5 ms·

> But is there room to distinguish emergency from non-emergency services? There absolutely must be, IMO. Emergency care is what insurance _should_ be for - the

by cheald 7y ago

> But is there room to distinguish emergency from non-emergency services? There absolutely must be, IMO. Emergency care is what insurance _should_ be for - the stuff you can't plan for, must have, and can't comparison shop for. IIRC, emergency healthcare spending accounts for around 2% of our annual totals. I just don't think we can justify our full medical pricing system on the basis of emergency care needs alone. For everything else, though, I'd be much happier if I could just have a price list up front and shop for the provider of my choice. I did it with Lasik, and it was easily the best medical experience I've ever had, not just in terms of "knowing what I'll pay", but the outfit I had it done by was actually competing to win my business. I felt like a customer they wanted to win, not just an account number that they were going to throw at my insurance company. By means of analogy, we carry car insurance in the case of accidents, but we don't expect car insurance to pay to refill our gas tank (even though gasoline has a lower price elasticity of demand than heathcare!) or pay for oil changes. Food has a lower price elasticity of demand than healthcare, too, but it's still cheap and we don't carry grocery insurance. Insurance makes sense to cover the unforeseen and unexpected. Why do we obfuscate prices and billing practices for routine, elective, and foreseeable care? "Don't have insurance cover routine care" is obviously insane if pricing were to remain unchanged, but I absolutely think the fundamental problem with the affordability of healthcare in the US isn't the availability (or lack thereof) of insurance, but the way we've completely separated services from prices. Hiding the prices doesn't mean they don't exist and don't get charged - they just eliminate the forces that would otherwise exert downwards price pressure. If we could get pricing transparency on everything, and then see providers start competing on uninsured pricing, I think that could open the door to "actual insurance" plans (at far lower cost than exists today), while actually reducing prices for everything else across the board.

mdorazio 7y ago
The problem with this is in how you classify different types of care. For example, is end of life care voluntary and thus should not be covered by insurance or is it emergency? If you say it’s the former and go to a national healthcare setup, people lose their minds shouting about death panels. If you say it’s the latter, healthcare costs go up 10-12%.
- cheald 7y ago
  Absolutely. There are a zillion different problems to solve like this, but I don't think they're necessarily unsolvable, though. On the one hand, you do really want people to be relatively insensitive to the cost of medical care they actually need. When you need it, you get it. On the other hand, that price insensitivity, applied indiscriminately, leads to the massive ballooning costs we've all seen. I don't think there's a way to have full price insensitivity and to keep prices in check - which means that we either just spend whatever our doctors ask (I'm not interested in that), or we start making people more price-sensitive to allow those downward pricing pressures to be exerted. Fundamentally, you don't get away with increased price sensitivity without someone yelling about death panels. Prices are how we allocate scarce resources, which means they determine who doesn't get things. We can either pretend prices don't exist (and get the status quo), or we can acknowledge that they do and that sometimes, people can't or won't pay those prices. Neither is emotionally attractive, but I think being realistic about the existence of prices and allowing consumers to actually exert some market pressures is preferable than just being held hostage to whatever the insurers demand we pay this year, just so that we don't have to think about costs at the point of service.
  - secabeen 7y ago
    > Absolutely. There are a zillion different problems to solve like this, but I don't think they're necessarily unsolvable, though. They are solvable, but with regulation, and they will sometimes get an edge case here or there wrong, which will inevitably result in a low-effort, sensationalist news article which will decry the situation, degrade people's support of the systems, and damage the institution.
  - anoncake 7y ago
    > I don't think there's a way to have full price insensitivity and to keep prices in check Maybe I've misunderstood you but how can there be no way to achieve what almost every other country has achieved?
    - cheald 7y ago
mehrdadn 7y ago
> For everything else, though, I'd be much happier if I could just have a price list up front and shop for the provider of my choice. Well the price list should be up front, but that's the case regardless of whether you're paying for all of the care or just some of it. > Emergency care is what insurance _should_ be for - the stuff you can't plan for, must have, and can't comparison shop for. Wouldn't that discourage preventative care?
- cheald 7y ago
  > Well the price list should be up front, but that's the case regardless of whether you're paying for all of the care or just some of it. Agreed. > Wouldn't that discourage preventative care? At the margin, yes. OTOH, paying less in insurance premiums and known/lower costs for services would leave more money for elective care (or whatever else you wanted to spend it on), which would apply pressure in the other direction. Most routine preventative care doesn't have to cost particularly much. Additionally, there's no reason why we couldn't have pooled cost systems for routine care like our existing insurance plans today for those that prefer to amortize their costs, but IMO, they should be separate from emergency care. Emergency care insurance isn't practically optional.
gremlinsinc 7y ago
What I don't get is how hospitals can justify the costs for a lot of the shit they charge for... Example if you have a baby and ask for an itemized list you might see something like $49 for chest to chest time with baby... they're fucking charging you to hold your damn baby. Or $35 for a single ibuprofin for pain. Seriously? 100x markup? I can get a bottle of 100 ibuprofin's for < $10. Some things should just be free because it's a hospitality industry right? I mean you go into a restaurant and ask for extra napkins they just give them to you. They don't charge $2/napkin. Or at the very least - at cost.
- harryh 7y ago
  Hospitals are "hiding the umbrella." Contracts prohibit them from raising prices on some items, so they shift price increases to other items sometimes in the ridiculous ways you list.
  - SilasX 7y ago
    Can you explain the metaphor "hiding the umbrella"? Google didn't turn up any obvious meaning. If I had to guess, it's a reference to the joke about turning in your expense report, after being told they won't reimburse you for the umbrella you lost, and so you overstaet expenses enough to cover the umbrella's cost. But that never made sense to me, since they demand receipts anyway...
    - harryh 7y ago
      Your guess is correct. And perhaps the metaphor isn't perfect (though many places don't require receipts below a certain value) but it gets the point across.
- noelsusman 7y ago
  The justification is that hospitals have enormous fixed costs, and somebody has to pay for care for people who don't pay and people on government plans that pay below cost. Also, nobody actually pays those prices, so hospitals have no incentive to give a shit about making them make sense.
pfranz 7y ago
I think Lasik is an outlier example. I couldn't find out how much of the population is a good candidate for Lasik, but 61% need corrective eyewear. The process is basically a commodity, it's almost exclusively a quality of life elective procedure, and it's basically a one-shot deal (I know people who traveled for it). I completely agree emergency care is one thing insurance is for, but I think more generally it's "catastrophic costs" which often includes ongoing things. A lot of issues require follow up costs (I've heard insurances are switching from itemized costs to a fixed cost for the whole procedure. Similarly, I see a lot more "continuity of care" in healthcare). As an example, let's say someone had vision loss for a couple minutes. An emergency room visit finds them to be ok in the immediate term, but it was because of a blockage in the heart causing a minor stroke. Which means there's a lot of follow up, with large costs. How do you best incentivize this? It's not "emergency care," there is time to research cost, but putting the cost burden on the patient is more than they can handle (hence insurance). Insurance tries to use cost signals like co-pays. An ongoing cost like dialysis will be optimized around convenience if you don't expose the cost, but exposing the cost may bankrupt them. I think tying healthcare to employment and pushing it as a benefit is the worst offender for the skewing of the market--masking the cost of routine care. Fixing that alone would make me much happier (I also think it would be an economic benefit because of people tied to their jobs and the drag on starting a small business).
notJim 7y ago
I think this misunderstands the point of insurance. Insurance covers rare, but high-cost situations by spreading the risk around to the entire population that's subject to that risk. It's not necessary that the situation be a surprise. People with chronic diseases aren't subject to an emergency, but they're far more expensive to provide medical services for than otherwise healthy people because they need so much more medical care. Same with people with cancer: cancer is not an emergency in the sense you're describing, but no amount of comparison shopping is going to make cancer treatment affordable for one person. What does make it affordable is that a huge pool of people are paying for it.
- LoSboccacc 7y ago
  > It's not necessary that the situation be a surprise setting aside the american/healthcare market with the inflated prices for the sake of the argument, wouldn't be more cost effective, for planned expenses, to go with savings or a loan?
  - notJim 7y ago
    No? Most people would struggle to save up hundreds of thousands of dollars to pay for the cancer or any chronic diseases they plan (?) to get at some point. Aside from that, you have no idea what medical conditions you're going to get, and when. Even if you can save the money, it's a massive amount of money sitting around in cash (can't invest it because you could need it any time), which would be a huge waste. And some people would save it all up and never end up needing it.

by cheald 7y ago

mdorazio 7y ago

The problem with this is in how you classify different types of care. For example, is end of life care voluntary and thus should not be covered by insurance or is it emergency? If you say it’s the former and go to a national healthcare setup, people lose their minds shouting about death panels. If you say it’s the latter, healthcare costs go up 10-12%.

cheald 7y ago
Absolutely. There are a zillion different problems to solve like this, but I don't think they're necessarily unsolvable, though. On the one hand, you do really want people to be relatively insensitive to the cost of medical care they actually need. When you need it, you get it. On the other hand, that price insensitivity, applied indiscriminately, leads to the massive ballooning costs we've all seen. I don't think there's a way to have full price insensitivity and to keep prices in check - which means that we either just spend whatever our doctors ask (I'm not interested in that), or we start making people more price-sensitive to allow those downward pricing pressures to be exerted. Fundamentally, you don't get away with increased price sensitivity without someone yelling about death panels. Prices are how we allocate scarce resources, which means they determine who doesn't get things. We can either pretend prices don't exist (and get the status quo), or we can acknowledge that they do and that sometimes, people can't or won't pay those prices. Neither is emotionally attractive, but I think being realistic about the existence of prices and allowing consumers to actually exert some market pressures is preferable than just being held hostage to whatever the insurers demand we pay this year, just so that we don't have to think about costs at the point of service.
- secabeen 7y ago
  > Absolutely. There are a zillion different problems to solve like this, but I don't think they're necessarily unsolvable, though. They are solvable, but with regulation, and they will sometimes get an edge case here or there wrong, which will inevitably result in a low-effort, sensationalist news article which will decry the situation, degrade people's support of the systems, and damage the institution.
- anoncake 7y ago
  > I don't think there's a way to have full price insensitivity and to keep prices in check Maybe I've misunderstood you but how can there be no way to achieve what almost every other country has achieved?
  - cheald 7y ago

mehrdadn 7y ago

> For everything else, though, I'd be much happier if I could just have a price list up front and shop for the provider of my choice. Well the price list should be up front, but that's the case regardless of whether you're paying for all of the care or just some of it. > Emergency care is what insurance _should_ be for - the stuff you can't plan for, must have, and can't comparison shop for. Wouldn't that discourage preventative care?

cheald 7y ago
> Well the price list should be up front, but that's the case regardless of whether you're paying for all of the care or just some of it. Agreed. > Wouldn't that discourage preventative care? At the margin, yes. OTOH, paying less in insurance premiums and known/lower costs for services would leave more money for elective care (or whatever else you wanted to spend it on), which would apply pressure in the other direction. Most routine preventative care doesn't have to cost particularly much. Additionally, there's no reason why we couldn't have pooled cost systems for routine care like our existing insurance plans today for those that prefer to amortize their costs, but IMO, they should be separate from emergency care. Emergency care insurance isn't practically optional.

gremlinsinc 7y ago

What I don't get is how hospitals can justify the costs for a lot of the shit they charge for... Example if you have a baby and ask for an itemized list you might see something like $49 for chest to chest time with baby... they're fucking charging you to hold your damn baby. Or $35 for a single ibuprofin for pain. Seriously? 100x markup? I can get a bottle of 100 ibuprofin's for < $10. Some things should just be free because it's a hospitality industry right? I mean you go into a restaurant and ask for extra napkins they just give them to you. They don't charge $2/napkin. Or at the very least - at cost.

harryh 7y ago
Hospitals are "hiding the umbrella." Contracts prohibit them from raising prices on some items, so they shift price increases to other items sometimes in the ridiculous ways you list.
- SilasX 7y ago
  Can you explain the metaphor "hiding the umbrella"? Google didn't turn up any obvious meaning. If I had to guess, it's a reference to the joke about turning in your expense report, after being told they won't reimburse you for the umbrella you lost, and so you overstaet expenses enough to cover the umbrella's cost. But that never made sense to me, since they demand receipts anyway...
  - harryh 7y ago
    Your guess is correct. And perhaps the metaphor isn't perfect (though many places don't require receipts below a certain value) but it gets the point across.
noelsusman 7y ago
The justification is that hospitals have enormous fixed costs, and somebody has to pay for care for people who don't pay and people on government plans that pay below cost. Also, nobody actually pays those prices, so hospitals have no incentive to give a shit about making them make sense.

pfranz 7y ago

I think Lasik is an outlier example. I couldn't find out how much of the population is a good candidate for Lasik, but 61% need corrective eyewear. The process is basically a commodity, it's almost exclusively a quality of life elective procedure, and it's basically a one-shot deal (I know people who traveled for it). I completely agree emergency care is one thing insurance is for, but I think more generally it's "catastrophic costs" which often includes ongoing things. A lot of issues require follow up costs (I've heard insurances are switching from itemized costs to a fixed cost for the whole procedure. Similarly, I see a lot more "continuity of care" in healthcare). As an example, let's say someone had vision loss for a couple minutes. An emergency room visit finds them to be ok in the immediate term, but it was because of a blockage in the heart causing a minor stroke. Which means there's a lot of follow up, with large costs. How do you best incentivize this? It's not "emergency care," there is time to research cost, but putting the cost burden on the patient is more than they can handle (hence insurance). Insurance tries to use cost signals like co-pays. An ongoing cost like dialysis will be optimized around convenience if you don't expose the cost, but exposing the cost may bankrupt them. I think tying healthcare to employment and pushing it as a benefit is the worst offender for the skewing of the market--masking the cost of routine care. Fixing that alone would make me much happier (I also think it would be an economic benefit because of people tied to their jobs and the drag on starting a small business).

notJim 7y ago

I think this misunderstands the point of insurance. Insurance covers rare, but high-cost situations by spreading the risk around to the entire population that's subject to that risk. It's not necessary that the situation be a surprise. People with chronic diseases aren't subject to an emergency, but they're far more expensive to provide medical services for than otherwise healthy people because they need so much more medical care. Same with people with cancer: cancer is not an emergency in the sense you're describing, but no amount of comparison shopping is going to make cancer treatment affordable for one person. What does make it affordable is that a huge pool of people are paying for it.

LoSboccacc 7y ago
> It's not necessary that the situation be a surprise setting aside the american/healthcare market with the inflated prices for the sake of the argument, wouldn't be more cost effective, for planned expenses, to go with savings or a loan?
- notJim 7y ago
  No? Most people would struggle to save up hundreds of thousands of dollars to pay for the cancer or any chronic diseases they plan (?) to get at some point. Aside from that, you have no idea what medical conditions you're going to get, and when. Even if you can save the money, it's a massive amount of money sitting around in cash (can't invest it because you could need it any time), which would be a huge waste. And some people would save it all up and never end up needing it.