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California's ‘Surprise’ Billing Law Is Protecting Patients and Angering Doctors
- ChuckMcM 7y agotl;dr version, law works as expected and takes money out of the pockets of people who were over charging. They are mad and so they are throwing around as much FUD as they can dig up in an effort to keep this from spreading. I know, the question of "over charging" is a difficult one to answer. All of the evidence on people willing to be doctors in California suggests that there are plenty of suppliers who will work willingly in the new system. That says to me it is working as intended.
- ASalazarMX 7y agoGood. Free market doesn't work when refusing to pay for the product costs you in health or even life.
- privateSFacct 7y agoActually - this is an effort to bring the free market into the system. Ie, doctors have to tell you UP FRONT what they will charge you, and cannot just drop by your room while you are out and then bill you for the evaluation. You can then decide if the specialist out of network is worth it, or go in-network or to your medical / medicare provider and work with them. In particular (for those who don't know) California's law protects you ONLY if you go to an IN NETWORK facility. If you do, then if somehow an out of network doctor drops by or helps with the knock out gas or whatever, they can't then bill you for the "out of network" service. It turns out this was pretty common (my guess is some kind of kickback to the in-network facility to allow this). You can still be charged or over charged by any provider if you agree to be, and sometimes still even if you don't (ambulance ride to out of network)
- jniedrauer 7y agoPrices being known ahead of time is not an inherent property of a free market. Fair billing is not an inherent property of a free market.
- ZhuanXia 7y agoThe "free market" doesn't really exist. It is an ideal, and an ill defined one at best. What does exists are mechanisms. A law that forces prices to be visible is a mechanism that is likely to increase economic efficiency at little cost. In absence of a rent-seeking doctor's guild, it would not be needed, true, but it is certainly better than nothing.
- 333c 7y agoIn fact, full availability of information (including price and quality) is a key feature of a free market, at least as defined in my ECON 101 class.
- nostrademons 7y agoIt's generally called a "racket" rather than a "free market" in the absence of pricing information, free choice, and fair billing.
- standardUser 7y agoWithout accurate an available information, there is no free market. Just lots of betting. "I'm going to buy this great new car. I wonder if it will cost me $15k or $45k? Can't wait to find out!" Said no market participant ever.
- colejohnson66 7y agoIt’s more like: you get in a car accident and the mechanic forces you to get a new car. The only thing is: you won’t know the price of the car until you receive the dozens of bills for the different steps of manufacturing (one for the steel press factory, one for the leather factory, one for the aluminum factory, one for the person who put it together, one for the factory it was assembled in, etc.) You also can’t find the price of this new car online and the mechanic won’t (or sometimes can’t) tell you.
- deogeo 7y agoAnd even less when the seller refuses to disclose ahead of time what you will be charged.
- r00fus 7y agoThis is called inelastic demand.
- yunesj 7y ago> Free market doesn't work when refusing to pay for the product costs you in health or even life. The free market works great to provide food.
- duskwuff 7y agoFood is simple. Practically everyone understands what food is, knows where and when they can get it, and (usually) has plenty of choices of where to eat. All of these things are untrue of health care.
- munk-a 7y agoThis amuses me as I'm familiar with the quality and price of hospital food - both sold to visitors and given to patients. The food given to patients is nearly always of a decent quality since making people sicker really doesn't help, but it usually isn't nutritionally great and it's always over priced - for visitors the food is even more overpriced and the production of it is usually farmed out to a random restaurant in the area that can cater for it so quality will vary wildly. And just you try to find some competition in terms of food suppliers while you're in a hospital - it's the cafeteria or nothing.
- pxeboot 7y agoIf you are in the US, food is one of the most heavily subsidized items people typically buy.
- maximente 7y agowhich "free market" is that? in the US the "free market" for food continually gets porked up "Ag bills", leaves food deserts in low income areas, subsidizes complete and utter garbage used to feed livestock, and pays farmers directly even though it's not efficient by any means. despite all of this you almost certainly want this to continue because in the event the ol' "free market" decides that it's not worth, say, maintaining food infrastructure due to a few good years, you'll probably die in a famine or the chaos that comes as a result of it.
- duskwuff 7y agoPractically everything about the health care system makes it the opposite of a free market. Patients often lack the domain knowledge to know what care they need, or what it should cost; even when they do, they often have few choices of where to get it (due to geography and/or insurance restrictions), or no choice at all (if they're receiving emergency care, or if their care requirements change while they are hospitalized). All of this adds up to a marketplace where "customers" are largely forced to pay whatever they are charged, and have very little choice in the matter.
- wisty 7y agoI think there is genuinely a libertarian argument that healthcare is partly expensive due to government over-regulation. A lot of what you said also applies to car mechanics. But they are less regulated, and there's unregulated alternatives, which makes things cheaper and more competitive. But since the US does have a high amount of government interference (apparently it's a big deal when a child dies, while a dodgy mechanic is something we just deal with), maybe it's best to just create a public system rather than a highly compromised hybrid with most of the cons of both public and private systems (the US actually has a higher tax burden due to healthcare than Canada, since the people who get it free on Medicare and Medicaid end up costing a fortune - the private sector can be way smarter than the government at the subsidies and incentives game).
- bart_spoon 7y agoVery little of what they said applies to auto mechanics, outside of consumers not having much domain knowledge.
- munk-a 7y agoWonderful, let's see these economic leeches burn their assets struggling to keep their do-nothing positions secure.
- JumpCrisscross 7y ago> the question of "over charging" is a difficult one to answer Not really. Just disclose the price up front. Prior to the procedure. The problem with these billing practices is the consumer has zero clue what they'll be billed by whom ex ante.
- munk-a 7y agoHonestly, let's go a step further - make those procedure prices publicly listed so that third parties can easily aggregate those list and let people find cheap care - then, finally, there will be market pressure to actually provide competitive services.
- inetknght 7y agoDo you mean "hide them away in a price list you must pay a fee and request by registered mail" when you say "publicly listed"?
- bskap 7y agoThat also only works if the patient can choose a different provider. If the only anesthesiologist authorized to assist in the only in-network hospital in the area equipped to do a particular urgent surgery charges an arm and a leg, there's not much knowing the price will do
- Fomite 7y agoThis gets into some murky areas as well though. For example, infectious disease physicians struggle a lot under pay for procedure-based schemes because so much of their work is supplementing existing teams and consults, rather than "Did Thing X".
- coolspot 7y agoI once got a surprise bill from in-network ER because they invited a specialist for consultation, That specialist sent me a separate bill later. No one told me upfront it will cost additional $450 to hear from the specialist that "sometimes kids are having stomach pain for no any reason". Edit: Additional information - Blue Shield CA HMO, Cedars-Sinai ER , circa 2012. $150 ER co-pay, later $10,000 bill fully paid by insurance + $450 specialist bill not covered by insurance.
- munk-a 7y agoOh, while I had mono and was pretty delusional my doctor sent me for an cat scan to make sure I didn't have appendicitis - 4000 dollars later... yup, just mono. And I was on vacation at the time and out of network so... fun.
- DollarGuru 7y agoI'm not familiar with US healthcare. As the customer in such a circumstance are you within your rights to refuse any such diagnosis tests when you reasonably believe they are unnecessary? e.g you have prior history of those symptoms. I have heard stories of some doctors and consultants making biased recommendations that are ultimately to line their pockets not cure the patient.
- xyzzyz 7y agoYes, you can deny any treatment, as long as you are able to comprehend reality and express your denial, which the parent suggests they weren’t able due to their illness.
- nraynaud 7y agodue to illness...and lack of medical degree.
- snagglegaggle 7y agoThese out-of-network bills have successfully been challenged and a law passed to address them in NY (https://www.dfs.ny.gov/insurance/health/OON_guidance.htm; https://www.dfs.ny.gov/insurance/health/OON_guidance.htm; I think). But, in the first place, these bills were never really valid: in no other market am I informed of the cost after I have received services. This fact is why the law was passed, though it shouldn't need to have been passed. The "contract" is already unenforceable.
- gok 7y agoYou had me at "angering doctors." If that was all the law did it would still be worth it.
- jorblumesea 7y agoI don't know why doctors receive so much ire. Most of the billing issues come from hospitals and insurers.
- munk-a 7y agoThey don't actually - some doctors are great but others are pretty bad actors that will bemoan the pricing publicly while advocating for higher prices privately. In our healthcare system no element is innocent of driving up those prices. Also, next time you're in your doctor's office ask if they accept medicaid or medicare - a lot don't because they end up with less take home for such patients.
- wetpaws 7y agoMost doctors don't event have an idea of how much the patient will pay, even if you ask them directly and they wish they knew the answer
- Gibbon1 7y agoDoctors and their lobbying organizations have be complicit in all this. Despite not getting that the over class sees them as 'the help' That said it's really only most but not all of the older generation of doctors that happily sold out their patients and younger doctors to the medical industrial complex.
- avocado4 7y agoMedical cartel (i.e. doctors) have successfully convinced the public to blame insurance, pharma, government, and whoever else for high prices of healthcare. The reality is that since the days of Flexner Report doctors are the supply side of healthcare by law, and a variety of medical associations and medical boards tightly control that supply on all levels of the system. Doctor is the one charging $1000 for a 10 minute consultation. There are enough leeches downstream too but the root issue is medical cartel. https://www.politico.com/agenda/story/2017/10/25/doctors-salaries-pay-disparities-000557 https://www.politico.com/agenda/story/2017/10/25/doctors-sal...
- Causality1 7y agoSocialized healthcare works. Capitalistic healthcare works. This ungodly mess we've created in the US that combines the worst aspects of both doesn't work. When everything is secret and there's no actual competition between providers but also no regulatory controls to prevent abuse you get the worst possible results.
- cma 7y agoIn which countries does capitalistic healthcare work well? Or do you mean just within your theory it works well and that there are none that actually do it?
- woofyman 7y agoPlastic surgery is capitalistic healthcare.
- elliekelly 7y agoThe incentives are very different. When the doctor says injections or implants will set you back $X it's not a matter of life and death. Or even health at all. You can choose to wait and save up. When the doctor says you need medical treatment that costs $X you're going to have to come up with a way to get the money even if you go broke trying. And that's assuming you're lucky/healthy enough to even be given a chance to price shop. It's hard to go broke getting boob jobs. It's exceedingly easy (in US) to go broke getting even the most basic of health care.
- woofyman 7y agoGood points. When I was taken by ambulance to an out of network trauma center, I had no choice.
- Causality1 7y agoIt worked well in the US until around 1990.
- 7y ago
- floatingatoll 7y agoHere’s the report the NYT drew much of their data from: https://health-access.org/wp-content/uploads/2019/09/ha-ab72report-092619.pdf https://health-access.org/wp-content/uploads/2019/09/ha-ab72...
- imgabe 7y agoIt should go further. End the in-network / out-of-network crap. One price per procedure that is the same for all customers. All providers should accept all insurances. The system we have is insane.
- maxcan 7y agoYES! MFN pricing would be a huge social benefit.
- geggam 7y agoGood luck with this. Those insurance contracts can keep you from paying cash for services. If they can do that the in and out of network is much simpler to defend in court. Recently had a situation where we were pressed for time and was waiting on insurance approval. I offered to pay cash and the Dr had to ask permission from the insurance company.
- lonelappde 7y agoWhat would it mean to have one insurance vs a different one then? That just sounds like nationalized done payer with extra steps
- burnte 7y agoAnything that gets the US to single payer is fine.
- WillPostForFood 7y agoYou could have a low cost high deductible plan, or high cost low deductible plan but the procedure would always be billed at the same price.
- subhobroto 7y agoUpvoted! The most efficient solution is an "all payer rate set system" - aka One price per procedure. YES, the system we have is insane. NO, unfortunately none of us are doing anything about it because we don't think beyond "single payer" system which itself has its own set of issues no one digs into because "single payer" is so awesome. Everytime I mention "all payer rate set system" the discussion halts as if I am an alien from outer space. If we are make ourselves go through an overhaul, and all the pain and suffering it entails, our sights should be on an "all payer rate set system" that's already proven to be way more effective than whatever people mean by "single payer" system.
- davidhyde 7y agoWhile I agree with the sentiment behind the article I think it is disgustingly and unnecessarily subjective. They have stripped their readers of the basic human desire to make up our own minds about what they read. Shame on them. The irony with my comment it that it is not in the least bit objective. Shame on me.
- sabujp 7y agohad a child born in a hospital in the bay area before this law and had the anaesthesiologist send a bill that looked he typed it on his typewriter. Wasn't even one of the official one's you see from a dr's group. No website, no email, just the guy's personal #.
- subhobroto 7y agoThis is extremely welcome and much needed change BUT please, everyone reading this, pay attention to the fact that IF you get healthcare through your employer (aka "Group" health plan), this regulation MIGHT NOT APPLY to you and your plan if your employer did not purchase the plan through the ACA marketplace! Group health plans are, EXEMPT, from most state regulations. I know it does not make sense and sounds unbelievable but unfortunately your employer has more lobbying power than you do! As a result you, the employed, could still be on the hook for hundreds of thousands of dollars in surprise medical bills with little recourse (because you are employed and don't qualify for financial relief) and can have your wages garnished, which WILL be exercised by the provider if you refuse to pay the bill. The providers are OON precisely because they make more money that way and there's little reason for them to be in-network (they have nothing to gain by being in network!) So if you go to the ER today in an ambulance - that's highly likely to be OON - and have your XRays and/or CT scans read by a radiologist that's also highly likely to be OON and attended to by specialists that are also highly likely to be OON, you ARE on the hook for everything unless you're lucky enough to have a CA state regulated health plan. Most individual plans purchased through the ACA marketplace are required to be in compliance with the regulations of the state that the employee is resident of. Group health plans are not. If your employer did not purchase the plan through the ACA marketplace, even if the plan is ACA compliant, it might not be required to comply with the regulations of the state that the employee is resident of as long as it's in compliance with current federal regulation of health benefits. This can take a lot of employees by surprise, specially employees of multistate employers where the employer chooses the cheapest plan in compliance with current federal regulations without necessarily looking into state level details. I put in some details here: https://www.quora.com/In-the-US-the-majority-of-people-under-65-years-old-have-health-insurance-through-their-employers-What-is-the-logic-behind-tying-health-insurance-to-an-employer/answer/Subhobroto-Sinha-1 https://www.quora.com/In-the-US-the-majority-of-people-under... I really hope each of you take measures to decouple health insurance from employment. How do we, in this day and age, still think, an employer has the right to solely dictate the standard of care we receive? Please, if you think it's logical to so severely and tightly couple health insurance with your employer, let's have a discussion.
- jcrben 7y ago
- riahi 7y agoPhysician here. The problem with this law is it takes the medical reimbursement contract system and then shoots the physicians in the back. When insurance companies are trying to get people to join their network, they offer competitive rates. Once they are large enough, they start to exert downward pressure on physician reimbursement to both existing and new medical service providers (hospitals and physicians). The only way to counteract their pricing power is to be willing to walk. Physicians do not like going out of network; the insurance companies make it incredibly painful, refuse to pay you, and instead send the check to the patient who is expected to deposit it and forward it to the patient (if they pay at all). However, what has happened post-ACA is massive consolidation across the medical services sector so that large staffing companies would deliberately go out of network to force better rates strategically. It was no longer the individual physicians choice whether or not to out of network; rather their employers'. However, these laws are a huge gift to the insurance companies. They remove the physician/hospital's ability to negotiate, and already, we are seeing insurance carriers refuse to negotiate or offer rates greater than 125% of Medicare. It also completely eliminates the incentive for insurance carriers to even bother creating a provider network. This is not the intent of the law and fundamentally is acting as a wage-cap. Medicare rates are intentionally set by fiat and often below the cost of goods sold. 125% of Medicare is an arbitrary "sounds good" number that is not helping anyone but the insurance companies. Instead, a better version of the law would be to have payments indexed to the FAIR health claims database [https://www.fairhealth.org https://www.fairhealth.org]. Yes, I agree the medical reimbursement system in the US is not ideal; however, this is tantamount to price fixing which in EVERY thread on compensation for software engineers, people think what Google/Apple/et Al did to prevent wage increases and poaching was unethical and unfair to workers. I don't think this is any different.
- jcrben 7y agoIf physicians are not going to get on board with solving the problem, then I'm not too sympathetic when it doesn't work out well for them. Physicians who see patients while out-of-network without asking permission are outrageously unethical. And if someone is unconscious or dying, then you can't ask permission.
- zbsnsbskd 7y agoJust today I called my local hospital asking them how much they were going to charge me for an ultrasound Id already preformed. I’m in the middle of a qualifying life event and the new insurance retroactively kicks in. I need to know how much this will cost to decide which plan is better, mine or my spouses. The lady didn’t know how much they would charge. This is the only industry where they don’t know how much they’re going to chi argue me after the procedure An orange farmer has a price for his oranges months before his orange trees blossom. These geniuses can’t figure out the price after they delivered the product. BS
- g82918 7y ago> An orange farmer has a price for his oranges months before his orange trees blossom The futures market, how can we do that for people? Joke.
- test6554 7y agoSeriously though, if you applied cold rationality to healthcare and did not let human dignity get in the way, we would treat the healthcare industry more like an auto-repair shop or a veterinarian office.
- kova12 7y agoIt is only undignified in your mind. There's nothing wrong with being open about your prices, healthcare or not
- toast0 7y agoMy mechanic gives me a more or less binding estimate before he starts working, and calls me to confirm before doing anything that costs more. I understand that's not necessarily practical or helpful in an emergency or operating room, but if we could get that for office visits, it would be great.
- zbsnsbskd 7y agoIll be satisfied if I knew how much something will cost after I got it done. Its a first step. Then, maybe in a distant future, we can move on to reasonable estimates an hour before a non-emergency procedure. In this utopian future, I will have access to a chart with all the procedures atomistic broken down and codified with a corresponding prices for every code so can add up the cost myself. Of course this magical cost sheet already exists. I’m just not allowed to see it.