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> It also completely eliminates the incentive for insurance carriers to even bother creating a provider network. This is extremely disingenuous. The reason fo

> It also completely eliminates the incentive for insurance carriers to even bother creating a provider network. This is extremely disingenuous. The reason for the regulation was precisely because most physicians never bothered joining a provider network knowing that doing so would cap their income and the ability to hold the patient hostage. Hey - it's ok to make money. But it's not OK to make it unethically. You are extremely lucky that people dont think too deeply about the root cause of the outrageous costs of healthcare in U.S. and get quickly distracted, blaming insurance companies and the govt. about their crippling medical debt - because when they do actually run the numbers, look at the statistics, the invoices, the claims, they realize the root cause are the providers themselves. It's very likely though, that some here in the HN crowd will come to this realization because they do think deeper. There is 0 reason for an insurance company to charge more than absolutely necessary. The cheaper the premiums are, more volume they have. Here are my thoughts: Nothing stops a provider from telling a patient "Hey, I will cost you $10000 at most. Do you want me to treat you?". The provider does not have to know what network the patient is in, what their deductible is. Whether the patient is employed or not. All they have to know is that the maximum they have charged for stitching a cut, that this patient in front of them, has, is $10000 and that is what they inform them. If a provider thinks that this question distracts them from providing the best of care, nothing stops them from joining an insurer's network and continue to do the good work. Provider does not want to handle money at all? Fine - work at a hospital that has someone willing to do that. To have the numbers ready. Or even have an estimate printout in a new minutes. Computers do that now. Do you, personally, think this is a fair expectation? No one is asking a provider to quote down to the last two decimal places what a visit might cost. The expectation is to know, atleast, what the maximum financial liability could be: $500? $2000? $10000? $50000? Crickets. Indifference at best. Instead - here's what providers have been doing: They explicitly try and stay OON to extract the maximal possible revenue from patients who were in a desperate situation with 0 leverage. > It was no longer the individual physicians choice The bulk of the individual physicians NEVER chose to be in network in the first place. Not when they were independent. Not now. The American people are hurting from the thousands of dollars in medical debt foisted on them without them even being told what they are getting into. Thousands of dollars in surprise bills from tens of different providers in addition to the tens of thousands of dollars from the hospital after spraining an ankle, dislocating an elbow, getting a cut. I am not talking about blood gushing out of an open wound. I am not talking about a head cracked open. Nickle, dimed and harassed by collection agencies that add on fees and interest rates multiples of prime if you can't settle in full. I understand the medical education system in the U.S. is expensive and long but I, as your customer, should have the ability to know, UP FRONT, how much seeing you, might get me into debt so I can make a decision whether I should work with you or not. NOT after the fact. Do you, personally, think this is a fair expectation? Not a SINGLE doctor in the WHOLE of California has ever come forward to answer this question of mine, which at this point is more than 3 years old: https://www.quora.com/How-do-I-find-a-general-physician-in-San-Diego-who-is-known-for-helping-people https://www.quora.com/How-do-I-find-a-general-physician-in-S... All this question asked (details can be found in comments for those logged in) was: Is there any general physician in San Diego that will provide an estimate (NOT a guarantee) of a visit planned weeks in advance with their staff. I have found tens of doctors in Mexico who were more than happy to provide a quote down to the last two decimal places and they went beyond what was expected of them. Yet, 0 responses so far from the WHOLE of California sans one extremely disingenuous, snarky Anonymous remark that stood up a strawman argument that I somehow wanted the estimate for free (which I did not and was more than happy to pay for) Every regulation is a response to societal pain. This pain has been cutting in too deep for far too long.

nwallin 7y ago
> Every regulation is a response to societal pain. This pain has been cutting in too deep for far too long. I feel like the societal pain and the regulatory response cycle in healthcare in the US is out of control. We have an itch, and we've been scratching it aggressively since the Kennedy Administration. We've scratched so deep we're not scratching, we're digging deep to the bone. Everything that's good about the free market is gone from this system. Prices are not dictated by supply and demand: to the contrary, the suppliers (doctors) and consumers (patients) are the ones farthest from the negotiation of price. Everything that's good about a regulated market is gone from this system. The system is so complex that the only people knowledgeable enough to write regulations are the ones whose profits need to be reigned in the most. The fox is guarding the henhouse. The system is fucked. More regulation will make the system more fucked. Less regulation will make the system more fucked. We're fucked.
- bart_spoon 7y ago
  > More regulation will make the system more fucked. Less regulation will make the system more fucked. That’s pretty ridiculous given that it essentially concludes there is no way to create a viable healthcare system, when most other first world countries are not having these problems. The issue is that the US system insists on clinging to the idea of a “free market solution”, without any of the crucial ingredients for making a free market solution work. The information regarding who pays what for what services is as opaque as any industry out there. People receiving the health care are different from the people paying for the healthcare, and the how the costs trickle between parties is unapparent until after services are rendered, and even then it’s fairly inscrutable. How is a free market supposed to work when people can’t actually shop around and compare prices? On the other hand, you have massive consolidation and monopoly creation occurring in both the hospital administration field, as well as for insurers and PBMs. Barrier of entry is also sky high, so in reality there is little to no competition going on, which is crucial for any free market solution. The reality is that people need to accept that the functional “free market solutions” simply don’t exist for certain industries, chief among them healthcare.
riahi 7y ago
> This is extremely disingenuous. The reason for the regulation was precisely because most physicians never bothered joining a provider network knowing that doing so would cap their income and the ability to hold the patient hostage. I'm sorry but this is incorrect. The opposite is the case. Post-ACA, insurance companies deliberately pruned their provider networks to be so narrow so as to restrict access to care, in direct hopes that patients would go outside the network out of frustration. I can tell you personally as someone applying to be in network, I have been frequently denied as "they have too many people in their network already of my specialty" (exact quote). [0] https://www.modernhealthcare.com/article/20181204/NEWS/181209976/most-aca-exchange-plans-feature-a-narrow-network https://www.modernhealthcare.com/article/20181204/NEWS/18120... [1] https://www.nytimes.com/2016/10/18/upshot/savings-yes-but-narrow-health-networks-also-show-troubling-signs.html https://www.nytimes.com/2016/10/18/upshot/savings-yes-but-na... [2] https://www.npr.org/2017/11/26/566634747/aca-s-narrow-networks-leave-big-gaps-in-health-care-coverage https://www.npr.org/2017/11/26/566634747/aca-s-narrow-networ... [3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547685/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547685/ [4] https://www.firstquotehealth.com/health-insurance-news/narrow-network-health-insurance-plans https://www.firstquotehealth.com/health-insurance-news/narro... > You are extremely lucky that people dont think too deeply about the root cause of the outrageous costs of healthcare in U.S. and get quickly distracted, blaming insurance companies and the govt. about their crippling medical debt - because when they do actually run the numbers, look at the statistics, the invoices, the claims, they realize the root cause are the providers themselves. It's very likely though, that some here in the HN crowd will come to this realization because they do think deeper. There is 0 reason for an insurance company to charge more than absolutely necessary. The cheaper the premiums are, more volume they have. I'd like to split this into three topics: Insurers, Physicians, and Hospitals. For insurers, profits are capped at 20% of premiums by the ACA. The only way they can increase profits is to increase premiums or increase subscribers. That's it. Insurance companies do not make up anything on volume. Occasionally, an insurance carrier will make too much money and be forced to refund premiums. [0] https://www.healthinsurance.org/obamacare/billions-in-aca-rebates-show-80-20-rules-impact/ https://www.healthinsurance.org/obamacare/billions-in-aca-re... Physicians cost at most 20% of total health expenditures from CMS data, even though this number is at the high end and does not include individual practice overhead. However, the really outrageous bills that get people up in arms are frequently hospital bills (where people love to complain about overpriced tylenol). [1] https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html https://www.cms.gov/research-statistics-data-and-systems/sta... > Here are my thoughts: Nothing stops a provider from telling a patient "Hey, I will cost you $10000 at most. Do you want me to treat you?". If a provider thinks that this question distracts them from providing the best of care, nothing stops them from joining a insurer's network and continue to do the good work. Do you, personally, think this is a fair expectation? No one is asking a provider to quote down to the last two decimal places what a visit might cost. The expectation is to know, atleast, what the maximum financial liability could be: $2000? $10000? $50000? Crickets. Indifference at best. Instead - here's what providers are doing: They explicitly try and stay OON to extract the maximal possible revenue from patients who were in a desperate situation with 0 leverage. We don't like staying or going out of network, because it is hell to get paid. However, there are national private equity staffing groups that deliberately will go OON to force better rates across a state; since these are PE backed, they can stomach the pain it takes to get payment from angry patients. This is not a physician decision; the staffing group makes this decision. I personally think it should be illegal for non physicians to own physician groups like it is with legal practices, but currently, it is legal. As I mentioned in a sibling comment, we can always provide a charge master rate, but it's usually extraordinarily high (because we have to charge a single rate to all payers) and people want to know what their insurance will pay. Can't easily just query the BCBS API as much as I wish I could. > It was no longer the individual physicians choice The bulk of the individual physicians NEVER chose to be in network in the first place. Not when they were independent. Not now. The American people are hurting from the thousands of dollars in medical debt foisted on them without them even being told what they are getting into. Thousands of dollars in surprise bills from tens of providers in addition to the tens of thousands of dollars from the hospital after spraining an ankle, dislocating an elbow, getting a cut. I am not talking about blood gushing out of an open wound. I am not talking about a head cracked open. Nickle, dimed and harassed by collection agencies that add on fees and interest rates multiples of prime if you can't settle in full. I understand the medical education system in the U.S. is expensive and long but I, as your customer, should have the ability to know, UP FRONT, how much seeing you, might get me into debt so I can make a decision whether I should work with you or not. NOT after the fact. Do you, personally, think this is a fair expectation? I think this is a fair expectation; why not make it so insurance companies actually stop hiding this information? > Not a SINGLE doctor in the WHOLE of California has ever come forward to answer this question of mine, which at this point is more than 3 years old: https://www.quora.com/How-do-I-find-a-general-physician-in-S.. https://www.quora.com/How-do-I-find-a-general-physician-in-S.... All this question asked (details can be found in comments for those logged in) was: Is there any general physician in San Diego that will provide an estimate (NOT a guarantee) of a visit planned weeks in advance with their staff. I have found tens of doctors in Mexico who were more than happy to provide a quote down to the last two decimal places and they went beyond what was expected of them. Yet, 0 responses so far from the WHOLE of California sans one extremely disingenuous, snarky Anonymous remark that stood up a strawman argument that I somehow wanted the estimate for free (which I did not and was more than happy to pay for) Every regulation is a response to societal pain. This pain has been cutting in too deep for far too long. I'd suggest you seek out a concierge or direct primary care practice. It's not absurd to just pay for people's time. If I were in primary care, I'd probably just set an hourly rate for people to purchase medical advice consultation and bypass insurance entirely. Of all specialties, I'm the most sympathetic to billing issues because our billing is very predictable: an imaging examination is an encapsulated episode of care. However, the problem is that a lot of hospitals own imaging equipment and use it to cross-subsidize their other departments.

nwallin 7y ago

> Every regulation is a response to societal pain. This pain has been cutting in too deep for far too long. I feel like the societal pain and the regulatory response cycle in healthcare in the US is out of control. We have an itch, and we've been scratching it aggressively since the Kennedy Administration. We've scratched so deep we're not scratching, we're digging deep to the bone. Everything that's good about the free market is gone from this system. Prices are not dictated by supply and demand: to the contrary, the suppliers (doctors) and consumers (patients) are the ones farthest from the negotiation of price. Everything that's good about a regulated market is gone from this system. The system is so complex that the only people knowledgeable enough to write regulations are the ones whose profits need to be reigned in the most. The fox is guarding the henhouse. The system is fucked. More regulation will make the system more fucked. Less regulation will make the system more fucked. We're fucked.

bart_spoon 7y ago
> More regulation will make the system more fucked. Less regulation will make the system more fucked. That’s pretty ridiculous given that it essentially concludes there is no way to create a viable healthcare system, when most other first world countries are not having these problems. The issue is that the US system insists on clinging to the idea of a “free market solution”, without any of the crucial ingredients for making a free market solution work. The information regarding who pays what for what services is as opaque as any industry out there. People receiving the health care are different from the people paying for the healthcare, and the how the costs trickle between parties is unapparent until after services are rendered, and even then it’s fairly inscrutable. How is a free market supposed to work when people can’t actually shop around and compare prices? On the other hand, you have massive consolidation and monopoly creation occurring in both the hospital administration field, as well as for insurers and PBMs. Barrier of entry is also sky high, so in reality there is little to no competition going on, which is crucial for any free market solution. The reality is that people need to accept that the functional “free market solutions” simply don’t exist for certain industries, chief among them healthcare.

riahi 7y ago

> This is extremely disingenuous. The reason for the regulation was precisely because most physicians never bothered joining a provider network knowing that doing so would cap their income and the ability to hold the patient hostage. I'm sorry but this is incorrect. The opposite is the case. Post-ACA, insurance companies deliberately pruned their provider networks to be so narrow so as to restrict access to care, in direct hopes that patients would go outside the network out of frustration. I can tell you personally as someone applying to be in network, I have been frequently denied as "they have too many people in their network already of my specialty" (exact quote). [0] https://www.modernhealthcare.com/article/20181204/NEWS/181209976/most-aca-exchange-plans-feature-a-narrow-network https://www.modernhealthcare.com/article/20181204/NEWS/18120... [1] https://www.nytimes.com/2016/10/18/upshot/savings-yes-but-narrow-health-networks-also-show-troubling-signs.html https://www.nytimes.com/2016/10/18/upshot/savings-yes-but-na... [2] https://www.npr.org/2017/11/26/566634747/aca-s-narrow-networks-leave-big-gaps-in-health-care-coverage https://www.npr.org/2017/11/26/566634747/aca-s-narrow-networ... [3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547685/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547685/ [4] https://www.firstquotehealth.com/health-insurance-news/narrow-network-health-insurance-plans https://www.firstquotehealth.com/health-insurance-news/narro... > You are extremely lucky that people dont think too deeply about the root cause of the outrageous costs of healthcare in U.S. and get quickly distracted, blaming insurance companies and the govt. about their crippling medical debt - because when they do actually run the numbers, look at the statistics, the invoices, the claims, they realize the root cause are the providers themselves. It's very likely though, that some here in the HN crowd will come to this realization because they do think deeper. There is 0 reason for an insurance company to charge more than absolutely necessary. The cheaper the premiums are, more volume they have. I'd like to split this into three topics: Insurers, Physicians, and Hospitals. For insurers, profits are capped at 20% of premiums by the ACA. The only way they can increase profits is to increase premiums or increase subscribers. That's it. Insurance companies do not make up anything on volume. Occasionally, an insurance carrier will make too much money and be forced to refund premiums. [0] https://www.healthinsurance.org/obamacare/billions-in-aca-rebates-show-80-20-rules-impact/ https://www.healthinsurance.org/obamacare/billions-in-aca-re... Physicians cost at most 20% of total health expenditures from CMS data, even though this number is at the high end and does not include individual practice overhead. However, the really outrageous bills that get people up in arms are frequently hospital bills (where people love to complain about overpriced tylenol). [1] https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html https://www.cms.gov/research-statistics-data-and-systems/sta... > Here are my thoughts: Nothing stops a provider from telling a patient "Hey, I will cost you $10000 at most. Do you want me to treat you?". If a provider thinks that this question distracts them from providing the best of care, nothing stops them from joining a insurer's network and continue to do the good work. Do you, personally, think this is a fair expectation? No one is asking a provider to quote down to the last two decimal places what a visit might cost. The expectation is to know, atleast, what the maximum financial liability could be: $2000? $10000? $50000? Crickets. Indifference at best. Instead - here's what providers are doing: They explicitly try and stay OON to extract the maximal possible revenue from patients who were in a desperate situation with 0 leverage. We don't like staying or going out of network, because it is hell to get paid. However, there are national private equity staffing groups that deliberately will go OON to force better rates across a state; since these are PE backed, they can stomach the pain it takes to get payment from angry patients. This is not a physician decision; the staffing group makes this decision. I personally think it should be illegal for non physicians to own physician groups like it is with legal practices, but currently, it is legal. As I mentioned in a sibling comment, we can always provide a charge master rate, but it's usually extraordinarily high (because we have to charge a single rate to all payers) and people want to know what their insurance will pay. Can't easily just query the BCBS API as much as I wish I could. > It was no longer the individual physicians choice The bulk of the individual physicians NEVER chose to be in network in the first place. Not when they were independent. Not now. The American people are hurting from the thousands of dollars in medical debt foisted on them without them even being told what they are getting into. Thousands of dollars in surprise bills from tens of providers in addition to the tens of thousands of dollars from the hospital after spraining an ankle, dislocating an elbow, getting a cut. I am not talking about blood gushing out of an open wound. I am not talking about a head cracked open. Nickle, dimed and harassed by collection agencies that add on fees and interest rates multiples of prime if you can't settle in full. I understand the medical education system in the U.S. is expensive and long but I, as your customer, should have the ability to know, UP FRONT, how much seeing you, might get me into debt so I can make a decision whether I should work with you or not. NOT after the fact. Do you, personally, think this is a fair expectation? I think this is a fair expectation; why not make it so insurance companies actually stop hiding this information? > Not a SINGLE doctor in the WHOLE of California has ever come forward to answer this question of mine, which at this point is more than 3 years old: https://www.quora.com/How-do-I-find-a-general-physician-in-S.. https://www.quora.com/How-do-I-find-a-general-physician-in-S.... All this question asked (details can be found in comments for those logged in) was: Is there any general physician in San Diego that will provide an estimate (NOT a guarantee) of a visit planned weeks in advance with their staff. I have found tens of doctors in Mexico who were more than happy to provide a quote down to the last two decimal places and they went beyond what was expected of them. Yet, 0 responses so far from the WHOLE of California sans one extremely disingenuous, snarky Anonymous remark that stood up a strawman argument that I somehow wanted the estimate for free (which I did not and was more than happy to pay for) Every regulation is a response to societal pain. This pain has been cutting in too deep for far too long. I'd suggest you seek out a concierge or direct primary care practice. It's not absurd to just pay for people's time. If I were in primary care, I'd probably just set an hourly rate for people to purchase medical advice consultation and bypass insurance entirely. Of all specialties, I'm the most sympathetic to billing issues because our billing is very predictable: an imaging examination is an encapsulated episode of care. However, the problem is that a lot of hospitals own imaging equipment and use it to cross-subsidize their other departments.