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That it takes such effort to pass a bill like this - 80% public approval, banning a clearly predatory practice, has turned me from a pure free market thinking i

That it takes such effort to pass a bill like this - 80% public approval, banning a clearly predatory practice, has turned me from a pure free market thinking into a believer in single payer healthcare. The free market just doesn't work when there is very little elasticity in consumption. I've been on the receiving end of a $15K air ambulance bill (thankfully covered by insurance) as well as the out of network specialist at an in-network hospital. The latter is particularly galling. What are you supposed to do, interrogate every person that comes in the room?

mehrdadn 6y ago
> What are you supposed to do, interrogate every person that comes in the room? I'm curious too. Some people must have tried filing a lawsuit... what do judges think people should be doing?
- RHSeeger 6y ago
  I had to go into surgery last year and had to sign a "I will pay whatever my insurance doesn't" form. I wrote in a clause saying that any out of network elements (persons, etc) must be personally approved in writing by myself or my proxy before they can do anything they bill for. I don't know if it would have held up in court, but it made me feel a little safer.
- cmiles74 6y ago
  In my case it was the anesthesiologist who was out of network. Looking at the bill, they looked like just another practice. When I found their phone number and address, however, it turned out that their practice was part of the hospital. I called their number and ended up talking to someone in their office and they agreed to waive the fee. I wonder if this is part of their process: if there's pushback, waive the fee.
  - dr_orpheus 6y ago
    > I wonder if this is part of their process: if there's pushback, waive the fee. This is 100% how a lot of medical offices and/or insurance operates. For some practices that perform complicated procedures bills will get sent with a "catch-all" sort of approach of all possible scenarios that could have happened and you have to go back and tell them what treatment you actually got. Insurance companies will also just initially deny claims in the hopes that people won't spend the time to debate it. My wife had to get back injections for a bulged disk and insurance initially denied the claim on the basis that "it was not inhibiting her daily function". The original request from the doctor included the wording of "this is medically necessary because the pain is inhibiting her daily function" because he knew that was their criteria. Insurance still just rejected it because it is easier for them to do that and only accept the claims people fight for. Luckily in this case the doctors office was on our side and called the insurance company to get it approved. The doctor said that this kind of shit happened all the time.
    - ajtaylor 6y ago
      Huh. My wife is actually having the same procedure done for the second time after Christmas. Naturally the doctor is in-network, but his surgical facility (on the same floor, immediately adjacent to the doctor's offices) isn't. So it's fork out $1500 and fight insurance to reimburse us after the fact. In her case, the epidural really does give her life back by completely killing the pressure and migraines that otherwise plague her daily. Insurance can kiss my butt. Single payer would be fabulous in this case.
      - throwaway201103 6y ago
        There's this idea that "single payer" will pay for "anything I want" and it seems to me that evidence for this is sorely lacking.
        93po 6y ago
        Does the NHS not cover treatment for documented, debilitating migraines? I would be shocked to hear that it doesn't. In fact I think I would be surprised to hear if the NHS doesn't cover anything as long as it isn't something like cosmetic surgery. There is no reason single payer shouldn't or couldn't cover 99% of most medical needs.
cdjk 6y ago
The existing health insurance industry is far from free market. Try getting a price for a procedure or visit beforehand. Compare that to dental insurance. I’m always shocked when I get a treatment plant after 5 minutes that outlines exactly what the dentist needs to do, how much insurance will pay, and how much I will need to pay. Of course the set of possible treatments for dental work is a lot smaller, but it seems so much more straightforward.
- mehrdadn 6y ago
  > I’m always shocked when I get a treatment plant after 5 minutes that outlines exactly what the dentist needs to do, how much insurance will pay, and how much I will need to pay. What you don't know (unless you get 2nd/3rd/4th opinions from good dentists) is how necessary those truly are. Some dentists just work around things by recommending things you don't need. (Fill teeth, taking panorex, etc. unnecessarily)
  - HeyImAlex 6y ago
    Seriously, I’ve had dentists differ in opinions by an order of magnitude. Turns out “necessary” is a pretty broad grey area.
  - cdjk 6y ago
    True, but at least the dentist can tell me how much I will need to pay.
    - mehrdadn 6y ago
      Which one is better probably depends on if you value your money more, or your body.
    - learc83 6y ago
      That's because most common dental procedures are relatively straightforward and the mechanical processes of the mouth are relatively well understood compared to most of the rest of the body. Plus most dental procedures are elective in the sense that you can usually just have an offending tooth pulled if it gets too bad, so for most people there's a price ceiling that is much lower than say a lifesaving heart procedure.
c22 6y ago
It won't work. They'll still charge you for the interrogation!
- OkGoDoIt 6y ago
  Is this a snarky comment or is this an actual experience that’s happened to you or someone you know? I’m genuinely curious, I can definitely imagine hospitals trying something like this…
  - c22 6y ago
    I've never "interrogated" a medical professional about their in or out of network status, so I have no first hand knowledge. But I have been charged their ridiculous hourly rates for 5-10 minute "consultations" so I have no reason to believe they wouldn't charge you for this.
    - clownbaby 6y ago
      My wife was charged $65 "to meet the surgeon" that would be performing procedure if she went ahead with it (she didn't ask to meet him, btw). It was basically just "Hey Bill, can you come over here and say hi to this patient". She had the charges waived pretty easily, but, if you don't call and ask and/or complain, those charges stand.
baryphonic 6y ago
> The free market just doesn't work when there is very little elasticity in consumption. Should we have single-payer markets for auto repairs, then? Or how about toilet paper, especially in a pandemic? Both of those are very inelastic, yet socialism has a particularly poor record of producing either reliably. > I've been on the receiving end of a $15K air ambulance bill (thankfully covered by insurance) as well as the out of network specialist at an in-network hospital. The latter is particularly galling. What are you supposed to do, interrogate every person that comes in the room? Yes, this is frustrating. It also has very little to do with a free market. Health care (and health care billing and insurance and medical devices etc.) have been regulated into oblivion, to the point that the prices make no sense and are more like Monopoly money than anything real. If I had my way, I'd have a high-deductible (at least $10k) universal single-payer system supplemented by individual private insurance. Most routine costs would be paid directly by patients at the point of care, and providers would have to suck it up to figure out what their prices actually were. That would actually give us much more of a free market than we have today, despite the large welfare-state component. EDIT: Meant to include a link to the classic Arrow paper about health economics.[1] My own comment about it is that third-party payers are the only robust reason for increases in health costs over time. We see that in every market where third parties subsidize transactions between first and second parties: health care/insurance, tuition/student loans, even housing/subsidized mortgages. [1] http://public.econ.duke.edu/~hf14/teaching/socialinsurance/readings/Arrow63(2.3).pdf http://public.econ.duke.edu/~hf14/teaching/socialinsurance/r...
- namdnay 6y ago
  > Should we have single-payer markets for auto repairs, then? Or how about toilet paper, especially in a pandemic? Both of those are very inelastic, yet socialism has a particularly poor record of producing either reliably. Why do you segue from single-payer to “socialism”? Btw not sure about the states, but here in Europe, Single-payer works fine for auto repair, it’s exactly what happens when your car breaks down during the initial warranty - the garage is paid by the car manufacturer, not you. Far less stress than having to tow your car from garage to garage to get quotes :)
  - 6y ago
jrumbut 6y ago
It's worse than that, my wife got one of these bills from a provider who was never in her hospital room. The bill ended up getting waived but it was for more than the rest of the stay.
- lacker 6y ago
  Yeah, we got a bill from the hospital once with a footnote saying, some of these procedures may have actually been for another patient, not for you, we don't have complete records. But your insurance agreed to pay it, so we recommend you don't worry about it.
  - colejohnson66 6y ago
    How is that not straight up fraud? If you don’t know if a procedure was for me or someone else, you’re lying by billing me!
    - jccooper 6y ago
      Insurance and hospitals basically do bulk deals. Insurance is probably paying for the service one way or another, so they don't care much to whom the record is attached. And if you're not out of pocket, doesn't matter much to you either.
      - 8note 6y ago
        I imagine that the charge can be used to raise your rates though?
bfieidhbrjr 6y ago
There's no "market" in healthcare in the US. Long ago, it became illegal to open a hospital without a 'certificate of need' from the State. That's why so many towns have only one hospital - it's a government granted monopoly like cable companies in the 80s. Differential pricing is also illegal. You fly cheap on Sunday at 3am, expensive on Monday at 9am. Healthcare providers are not allowed to charge less when it's cheap to do so, for example allowing you to do an MRI cheaper at 3am. Your employer picks a monopoly insurer for you to chose a plan from. The list goes on and on. There's no market here, it's a set of monopolies. It should be legal to open a hospital. Differential pricing should be legal. Your employer should let you chose from at least two insurers.
- andy_ppp 6y ago
  I find this idea interesting, but I'm extremely skeptical. If we are thinking about this as being a startup, how can we outsource the cost of building the hospital to the doctors and nurses? That way you might be able to build a billion dollar business by tricking people into owning all the downsides while you own all of the profits? I'm just joking of course... the idea that the market can optimise every problem is simply incorrect. There isn't a move fast and break things for doing startup hospitals, it's simply a problem that central planning can organise effectively. Unfortunately, the American allergy to government means your healthcare system costs twice as much per capita for the same outcomes.
  - pxeboot 6y ago
    >how can we outsource the cost of building the hospital to the doctors and nurses? This is almost reality in the US. Lookup "Ambulatory Surgical Center" investments.
- StreamBright 6y ago
  Exactly. Many people think that free market healthcare is bad because the US healthcare system. Once you are pointing out it is not a free market system they are surprised. The 20% profit cap also not very open market like.
comeonseriously 6y ago
Something is going to have to be done at some point. Even as much money as most of us make, HC will become too expensive for us in the next decade or so, especially for any of us with a family.
Causality1 6y ago
I think there's a difference between your philosophical ideal and the way you would set a society up and the approach you believe would best address the problems and situations we currently face.
lacker 6y ago
We don't have a free market in health care at all. In a free market you would be able to buy a coronavirus vaccine right now, instead of waiting months to get it for free. We haven't had a "free market" in health care in my lifetime.
- pbourke 6y ago
  > In a free market you would be able to buy a coronavirus vaccine right now, instead of waiting months to get it for free. Give it a few weeks ...
- comeonseriously 6y ago
  Instead, we have people like @marcorubio, who downplayed the virus, jumping to the head of the line.
- AlexandrB 6y ago
  Are you suggesting that it's better to distribute the vaccine in a way that keeps those most likely to get it vulnerable for longer (i.e. inefficiently)? What's exactly is the benefit of a free market in a situation where it's less efficient at allocating resources than central planning?
  - raunakdag 6y ago
    I don’t think he’s suggesting it insomuch as providing an example.
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iaw 6y ago
> has turned me from a pure free market thinking into a believer in single payer healthcare The current trend in 'free-market economics' is to call captured markets free and then argue for the relatively lax regulation. Most markets are not free markets and the healthcare definitely isn't. There's very little true choice, participants are typically under duress when seeking expensive services, and prices are hidden. If there was ala-carte transparent pricing and no insurer lockouts things may be a bit better. My suspicion is that Private Equity has been funneled in healthcare for two decades intentionally distorting the market behaviors for increased profitability which is why the US has such excessive healthcare costs without any apparent justification.
- annexrichmond 6y ago
  > and prices are hidden I believe the Trump administration is addressing this: https://www.hhs.gov/about/news/2019/11/15/trump-administration-announces-historic-price-transparency-and-lower-healthcare-costs-for-all-americans.html https://www.hhs.gov/about/news/2019/11/15/trump-administrati... https://www.hhs.gov/about/news/2020/10/29/trump-administration-finalizes-rule-requiring-health-insurers-disclose-price-and-cost-sharing.html https://www.hhs.gov/about/news/2020/10/29/trump-administrati... > The rule requires that most health plans and health insurers not only provide easy-to-understand personalized information on enrollee cost-sharing for healthcare services, but must also publicly disclose the rates they actually pay healthcare providers for specific services. > Through a shopping tool available through their plan or insurance company, consumers will be able to see the negotiated rate between their doctor and their plan or insurer, as well as the most accurate out-of-pocket cost estimate possible based on their health plan for procedures, drugs, durable medical equipment, and any other item or service they may need. > Consumers will also have access to accurate price and plan information that allows them to shop and compare costs between individual doctors before receiving care, so they can choose a healthcare provider that offers the most value and best suits their medical needs. But it'll be another couple years before it's all implemented it seems
  - zbrozek 6y ago
    We still need up-front transparency on what codes will be billed to whom, from whom, and for how much. I want a comprehensible restaurant-like menu. And we need to break up regional monopolies so that there's actually a choice of provider. Further, agreements to pay whatever, whenever, before any diagnosis need to be banned as contracts under duress. If we want the free market approach to work, we need to make it possible, easy even, to make informed decisions among competitors. But fixing this is increasingly feeling intractable, and this pushes me further and further towards believing a single-payer (maybe not exactly, but that's the buzzword) system is the better fix.
StreamBright 6y ago
> The free market just doesn't work And where did you experience free market healthcare out of curiosity? In the US there is no such thing.
ecf 6y ago
The only statistic you need to know to justify America being a shitty country with even shittier healthcare is that it is only one of two countries in the entire world that allow pharma companies to directly advertise to consumers.
- khuey 6y ago
  New Zealand is the other country that allows it and they seem generally satisfied with their healthcare system.
- FireBeyond 6y ago
  And that the other country only allowed it under pressure from the US for a trade agreement.
mauflows 6y ago
I've become more staunchly single payer after I had my first major medical hurdle of my adult life this year. I had switched insurance in January, but apparently my old insurance had a bug in their system. The effect was that they were accepting my claims, but then denying them. So I had to coordinate both insurances and get them on the same page. Then I had to call every one of my many providers, get them to understand, and then get them to reprocess the claim on their end. It was miserable and I had to deal with it while I was still dealing with a broken wrist and just hoping everything would work out. I feel awful for anyone who has to deal with that and has less time than me. I had to take notes during every phone call and get the numbers of customer reps so they could vouch for what I was saying
- jschwartzi 6y ago
  Imagine having to do this every time you change jobs.
  - pnutjam 6y ago
    Yup, last employer had me on a different plan then I signed up for. Went round and round with the employer and the insurer. Of course it was the others fault. Finally talked to DoL guy and they told me it's absolutely the employers responsibility. They kept going back and forth with me. This was about and $1800 difference in out of pocket max, not in my favor... Finally they fixed it, but only for my wife. Since she had the majority of the bills due to a surgery, the insurance clawed back a bunch of smaller stuff they had already paid. So that cost me about a $1k. I guess I'm going to have to sue in small claims, which is what the DoL guy recommended.
abootstrapper 6y ago
“The free market will solve everything” is a seductive idea because of its simplicity. “Just let the free market solve it. Oh, there’s a problem? It’s because the market is not ‘free’ enough.” The reality is more complicated. We need a balance of a healthy market forces and regulations to prevent the exploitation of people and the environment. But that’s a lot of work, and not as elegant sounding of a solution as, “let the market figure it out.”
nickthemagicman 6y ago
I've been saying this for a long time. Supply and demand don't apply to healthcare. You can only adjust supply. Peoples demand for their health is infinite.
dr_orpheus 6y ago
The out of network care at an in-network hospital, is the absolute worst. In a similar vein, my wife's insurance was supposed to cover "out-of-network" ER visits. So one night that we had to go the ER we went to an out-of-network hospital ER because there wasn't an in-network one close by. Turns out that the coverage of the out-of-network ER visit basically just covers the cost of the bed in the ER, every treatment that you get (IV, vitals check, medication) is considered out-of-network treatment. This resulted in an absolutely insane bill with charges like $250 for administering oxygen monitor (you know the things you can buy at Wallgreens for $30) or $300 for ibuprofen.
- jimbob45 6y ago
  Network scope existing at all baffles me. Insurance companies become the ultimate deciders of which hospitals are worthy and which aren’t instead of government certification agencies. Seems like an open door to malevolence.
ajtaylor 6y ago
While being only slightly sarcastic, maybe it's time to put a sign on the door "If you're not covered by health plan XXX, please do not come in this room." That we have to even joke about such things is beyond ridiculous.
javiramos 6y ago
>the out of network specialist at an in-network hospital The worst. After a $2k bill, I learned my lesson to check every doctor that attends me for coverage even if it is in an in-network hospital.
danielrhodes 6y ago
I don't have any opinions about what the perfect system here is, but I think it's safe to safe say that medicine does not work well as a free market. You don't get to access a free market within the confines of hospital walls when there is an emergency. Moreover, your decisions as a rational actor are impaired because you are being asked to put a price on your own life or quality of life. There is almost no way to make this business not predatory under those circumstances.
snarf21 6y ago
We just need to mandate reference based pricing. This automatically goes away and also removes other huge parts of the wasted health care spend. Additionally, it doesn't require new taxes at all.
Moodles 6y ago
As an immigrant coming to America, honestly the most shocking and surprising thing (apart from the state of homeless in San Francisco being tolerated as normal) is the medical care expenses. How on Earth is it that I can walk into a doctor's office or hospital to get medical treatment and have no idea how much it's going to cost? $10? $100? $1000? Who knows. I had an ear infection once, went to the doctor who looked at it for a minute and said "give it a few days". I assumed this would cost maybe $20 or something? Nope. $400. There's just no way of even knowing. In no other industry would you buy something without knowing the price ahead of time. With medical care it's even more screwed up because, well, it's your health? You're generally more desperate for services now, so it's not like shopping around for clothes or something.
- 93po 6y ago
  It's safe to assume talking to a doctor is a minimum of $400. Any labs or testing, another $400. Surgery starts in the thousands. Life saving care is the same cost as a house.
  - Moodles 6y ago
    It's not though. Sometimes a simple visit is like $20 or even free.
    - 93po 6y ago
      If you have insurance that doesn't have a deductible or it's preventative care, sure. I'm talking paying cash or insurance with high deductible
darkwizard42 6y ago
As someone who is now figuring out how to deal with a 20K charge because one of the surgeons consulted was out-of-network (and EVERYTHING including the anesthesiologist, primary surgeon, hospital care was all in-network)... that last part is the most insane for me... Before my last surgery they offered me crutches and I asked if that was all covered by my insurance and specifically was it in-network with my provider. Imagine if it wasn't and some poor sap thinks... yes I should take crutches after a leg surgery and gets stacked with a massive upcharge
ApolloFortyNine 6y ago
15k for an airlift honestly sounds cheap all things considered, but the surprise out of network doctor is such bullshit it should have been fixed ages ago. It's one thing when you had to go to the ER, but even when your visit was planned they can spring you with that.
AnthonyMouse 6y ago
> into a believer in single payer healthcare. That isn't the part of the market which is broken though. The insurance companies want their vig, and they have no objection to cost increases because then they get the same percentage of a larger pot, but they're not actually where most of the money goes. It's really going to drug companies and medical devices companies and doctors and hospitals. Which all still exist even with single payer, and not only that but then have even less price sensitive customers (more unnecessary tests/treatments/procedures) and have a greater opportunity to have their lobbyists turn open the money spigot, because now it's tax dollars -- or government debt -- instead of insurance premiums that customers would balk at and switch to a less expensive plan when the price exceeds a given threshold. So you still need the very things they're lobbying against. You need something to make patients price sensitive enough to refuse over-treatment. You need some kind of price setting mechanism that works better than giving the most money to the company with the best lobbyists. Single payer doesn't get you that.
- 8note 6y ago
  What you're saying is that health care needs to stop being about health, I think. The price sensitivity you're looking for is "yeah, you can pay 5k less for your broken arm, but they'll be cutting it off instead of setting it"
sebastien_b 6y ago
I've been on the receiving end of a $15K air ambulance bill (thankfully covered by insurance) as well as the out of network specialist at an in-network hospital. The latter is particularly galling. What are you supposed to do, interrogate every person that comes in the room That could present a rather interesting legal challenge... Say you state "I can only allow care from in-network physicians/personnel" - will they take that as you outright refusing care if they're not in-network? And if they decide they're not going to care for you because of this, and you end up dying, what would be the recourse? Did the personnel (esp. doctors) still have a duty to care for you? Or else on what exact basis would they conclude you refused care and let you die?
hnracer 6y ago
It's good to keep in mind that not all medical services are price inelastic in the sense that ambulance costs or emergency hospital visits are. GP visits/non-emergency general surgeries/general medicines - just like food, are all necessities for survival, and are all locally price elastic, with the exception of medicines that have regulatory capture - not a free market, such as insulin which is many X the cost in the US because of a government-enforced oligopoly. This means that no single supplier (whether of food or non-emergency medicine) can raise their prices because consumers have time to find a cheaper alternative. Unless they collude, which is illegal, and impractical for many markets such as GP visits. For these particular goods, does your view differ, when compared to emergency services which we agree are price inelastic? And if not, how do such services differ to the foods market - holding aside regulatory capture of things such as insulin which we both probably agree is not a good thing?
powvans 6y ago
What if they don't even come into the room? I experienced this incredible phenomenon a couple years ago after taking my son to the ER while out of state on vacation. We were there for a few hours to have a very horror movie-esc swollen lymph node looked at. He needed a CT scan to confirm that it was not an abscess and some IV antibiotics for strep. The doctor and nurses were great, I paid up front, and additionally provided insurance. Seemed like everything went smoothly. Three months later we received a bill for $2500 from a doctor we had not seen. Insurance had adjusted it from $3800. Perhaps he was the attending physician and the doctor we saw consulted with him. I have no idea and no one told me anything about it. My wife, being the litigious trial attorney that she is, sent the physician's group a letter disputing the bill, requesting documentation that this doctor did in fact work on my son's case, and putting them on notice that she would fight them on principle over the amount of the bill. A couple of weeks later we got a letter stating that despite the fact that the charges were in fact valid, they would adjust the amount owed to $0. A friend I related this to commented, "yup, they just wrote you off because there are so many more people that they can go after and not fight with that it just isn't worth it to them." What a sad commentary on healthcare in America.
- spaetzleesser 6y ago
  So they are basically bullies that exploit the weak and defenseless and are afraid of people that fight back.
imaginenore 6y ago
Nothing is "free market" about a current system. • You're forced to buy health insurance. • You can't choose any doctor you like one you have the insurance. • You can't shop around for the best price, because the prices are not shown. • You're not given an estimate of how much a procedure would cost. • You can't choose which doctors visit your hospital room (and every time they do, you pay for it).

mehrdadn 6y ago

> What are you supposed to do, interrogate every person that comes in the room? I'm curious too. Some people must have tried filing a lawsuit... what do judges think people should be doing?

RHSeeger 6y ago
I had to go into surgery last year and had to sign a "I will pay whatever my insurance doesn't" form. I wrote in a clause saying that any out of network elements (persons, etc) must be personally approved in writing by myself or my proxy before they can do anything they bill for. I don't know if it would have held up in court, but it made me feel a little safer.
cmiles74 6y ago
In my case it was the anesthesiologist who was out of network. Looking at the bill, they looked like just another practice. When I found their phone number and address, however, it turned out that their practice was part of the hospital. I called their number and ended up talking to someone in their office and they agreed to waive the fee. I wonder if this is part of their process: if there's pushback, waive the fee.
- dr_orpheus 6y ago
  > I wonder if this is part of their process: if there's pushback, waive the fee. This is 100% how a lot of medical offices and/or insurance operates. For some practices that perform complicated procedures bills will get sent with a "catch-all" sort of approach of all possible scenarios that could have happened and you have to go back and tell them what treatment you actually got. Insurance companies will also just initially deny claims in the hopes that people won't spend the time to debate it. My wife had to get back injections for a bulged disk and insurance initially denied the claim on the basis that "it was not inhibiting her daily function". The original request from the doctor included the wording of "this is medically necessary because the pain is inhibiting her daily function" because he knew that was their criteria. Insurance still just rejected it because it is easier for them to do that and only accept the claims people fight for. Luckily in this case the doctors office was on our side and called the insurance company to get it approved. The doctor said that this kind of shit happened all the time.
  - ajtaylor 6y ago
    Huh. My wife is actually having the same procedure done for the second time after Christmas. Naturally the doctor is in-network, but his surgical facility (on the same floor, immediately adjacent to the doctor's offices) isn't. So it's fork out $1500 and fight insurance to reimburse us after the fact. In her case, the epidural really does give her life back by completely killing the pressure and migraines that otherwise plague her daily. Insurance can kiss my butt. Single payer would be fabulous in this case.
    - throwaway201103 6y ago
      There's this idea that "single payer" will pay for "anything I want" and it seems to me that evidence for this is sorely lacking.
      - 93po 6y ago
        Does the NHS not cover treatment for documented, debilitating migraines? I would be shocked to hear that it doesn't. In fact I think I would be surprised to hear if the NHS doesn't cover anything as long as it isn't something like cosmetic surgery. There is no reason single payer shouldn't or couldn't cover 99% of most medical needs.

cdjk 6y ago

The existing health insurance industry is far from free market. Try getting a price for a procedure or visit beforehand. Compare that to dental insurance. I’m always shocked when I get a treatment plant after 5 minutes that outlines exactly what the dentist needs to do, how much insurance will pay, and how much I will need to pay. Of course the set of possible treatments for dental work is a lot smaller, but it seems so much more straightforward.

mehrdadn 6y ago
> I’m always shocked when I get a treatment plant after 5 minutes that outlines exactly what the dentist needs to do, how much insurance will pay, and how much I will need to pay. What you don't know (unless you get 2nd/3rd/4th opinions from good dentists) is how necessary those truly are. Some dentists just work around things by recommending things you don't need. (Fill teeth, taking panorex, etc. unnecessarily)
- HeyImAlex 6y ago
  Seriously, I’ve had dentists differ in opinions by an order of magnitude. Turns out “necessary” is a pretty broad grey area.
- cdjk 6y ago
  True, but at least the dentist can tell me how much I will need to pay.
  - mehrdadn 6y ago
    Which one is better probably depends on if you value your money more, or your body.
  - learc83 6y ago
    That's because most common dental procedures are relatively straightforward and the mechanical processes of the mouth are relatively well understood compared to most of the rest of the body. Plus most dental procedures are elective in the sense that you can usually just have an offending tooth pulled if it gets too bad, so for most people there's a price ceiling that is much lower than say a lifesaving heart procedure.

c22 6y ago

It won't work. They'll still charge you for the interrogation!

OkGoDoIt 6y ago
Is this a snarky comment or is this an actual experience that’s happened to you or someone you know? I’m genuinely curious, I can definitely imagine hospitals trying something like this…
- c22 6y ago
  I've never "interrogated" a medical professional about their in or out of network status, so I have no first hand knowledge. But I have been charged their ridiculous hourly rates for 5-10 minute "consultations" so I have no reason to believe they wouldn't charge you for this.
  - clownbaby 6y ago
    My wife was charged $65 "to meet the surgeon" that would be performing procedure if she went ahead with it (she didn't ask to meet him, btw). It was basically just "Hey Bill, can you come over here and say hi to this patient". She had the charges waived pretty easily, but, if you don't call and ask and/or complain, those charges stand.

baryphonic 6y ago

> The free market just doesn't work when there is very little elasticity in consumption. Should we have single-payer markets for auto repairs, then? Or how about toilet paper, especially in a pandemic? Both of those are very inelastic, yet socialism has a particularly poor record of producing either reliably. > I've been on the receiving end of a $15K air ambulance bill (thankfully covered by insurance) as well as the out of network specialist at an in-network hospital. The latter is particularly galling. What are you supposed to do, interrogate every person that comes in the room? Yes, this is frustrating. It also has very little to do with a free market. Health care (and health care billing and insurance and medical devices etc.) have been regulated into oblivion, to the point that the prices make no sense and are more like Monopoly money than anything real. If I had my way, I'd have a high-deductible (at least $10k) universal single-payer system supplemented by individual private insurance. Most routine costs would be paid directly by patients at the point of care, and providers would have to suck it up to figure out what their prices actually were. That would actually give us much more of a free market than we have today, despite the large welfare-state component. EDIT: Meant to include a link to the classic Arrow paper about health economics.[1] My own comment about it is that third-party payers are the only robust reason for increases in health costs over time. We see that in every market where third parties subsidize transactions between first and second parties: health care/insurance, tuition/student loans, even housing/subsidized mortgages. [1] http://public.econ.duke.edu/~hf14/teaching/socialinsurance/readings/Arrow63(2.3).pdf http://public.econ.duke.edu/~hf14/teaching/socialinsurance/r...

namdnay 6y ago
> Should we have single-payer markets for auto repairs, then? Or how about toilet paper, especially in a pandemic? Both of those are very inelastic, yet socialism has a particularly poor record of producing either reliably. Why do you segue from single-payer to “socialism”? Btw not sure about the states, but here in Europe, Single-payer works fine for auto repair, it’s exactly what happens when your car breaks down during the initial warranty - the garage is paid by the car manufacturer, not you. Far less stress than having to tow your car from garage to garage to get quotes :)
- 6y ago

jrumbut 6y ago

It's worse than that, my wife got one of these bills from a provider who was never in her hospital room. The bill ended up getting waived but it was for more than the rest of the stay.

lacker 6y ago
Yeah, we got a bill from the hospital once with a footnote saying, some of these procedures may have actually been for another patient, not for you, we don't have complete records. But your insurance agreed to pay it, so we recommend you don't worry about it.
- colejohnson66 6y ago
  How is that not straight up fraud? If you don’t know if a procedure was for me or someone else, you’re lying by billing me!
  - jccooper 6y ago
    Insurance and hospitals basically do bulk deals. Insurance is probably paying for the service one way or another, so they don't care much to whom the record is attached. And if you're not out of pocket, doesn't matter much to you either.
    - 8note 6y ago
      I imagine that the charge can be used to raise your rates though?

bfieidhbrjr 6y ago

There's no "market" in healthcare in the US. Long ago, it became illegal to open a hospital without a 'certificate of need' from the State. That's why so many towns have only one hospital - it's a government granted monopoly like cable companies in the 80s. Differential pricing is also illegal. You fly cheap on Sunday at 3am, expensive on Monday at 9am. Healthcare providers are not allowed to charge less when it's cheap to do so, for example allowing you to do an MRI cheaper at 3am. Your employer picks a monopoly insurer for you to chose a plan from. The list goes on and on. There's no market here, it's a set of monopolies. It should be legal to open a hospital. Differential pricing should be legal. Your employer should let you chose from at least two insurers.

andy_ppp 6y ago
I find this idea interesting, but I'm extremely skeptical. If we are thinking about this as being a startup, how can we outsource the cost of building the hospital to the doctors and nurses? That way you might be able to build a billion dollar business by tricking people into owning all the downsides while you own all of the profits? I'm just joking of course... the idea that the market can optimise every problem is simply incorrect. There isn't a move fast and break things for doing startup hospitals, it's simply a problem that central planning can organise effectively. Unfortunately, the American allergy to government means your healthcare system costs twice as much per capita for the same outcomes.
- pxeboot 6y ago
  >how can we outsource the cost of building the hospital to the doctors and nurses? This is almost reality in the US. Lookup "Ambulatory Surgical Center" investments.
StreamBright 6y ago
Exactly. Many people think that free market healthcare is bad because the US healthcare system. Once you are pointing out it is not a free market system they are surprised. The 20% profit cap also not very open market like.

comeonseriously 6y ago

Something is going to have to be done at some point. Even as much money as most of us make, HC will become too expensive for us in the next decade or so, especially for any of us with a family.

Causality1 6y ago

I think there's a difference between your philosophical ideal and the way you would set a society up and the approach you believe would best address the problems and situations we currently face.

lacker 6y ago

We don't have a free market in health care at all. In a free market you would be able to buy a coronavirus vaccine right now, instead of waiting months to get it for free. We haven't had a "free market" in health care in my lifetime.

pbourke 6y ago
> In a free market you would be able to buy a coronavirus vaccine right now, instead of waiting months to get it for free. Give it a few weeks ...
comeonseriously 6y ago
Instead, we have people like @marcorubio, who downplayed the virus, jumping to the head of the line.
AlexandrB 6y ago
Are you suggesting that it's better to distribute the vaccine in a way that keeps those most likely to get it vulnerable for longer (i.e. inefficiently)? What's exactly is the benefit of a free market in a situation where it's less efficient at allocating resources than central planning?
- raunakdag 6y ago
  I don’t think he’s suggesting it insomuch as providing an example.

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iaw 6y ago

> has turned me from a pure free market thinking into a believer in single payer healthcare The current trend in 'free-market economics' is to call captured markets free and then argue for the relatively lax regulation. Most markets are not free markets and the healthcare definitely isn't. There's very little true choice, participants are typically under duress when seeking expensive services, and prices are hidden. If there was ala-carte transparent pricing and no insurer lockouts things may be a bit better. My suspicion is that Private Equity has been funneled in healthcare for two decades intentionally distorting the market behaviors for increased profitability which is why the US has such excessive healthcare costs without any apparent justification.

annexrichmond 6y ago
> and prices are hidden I believe the Trump administration is addressing this: https://www.hhs.gov/about/news/2019/11/15/trump-administration-announces-historic-price-transparency-and-lower-healthcare-costs-for-all-americans.html https://www.hhs.gov/about/news/2019/11/15/trump-administrati... https://www.hhs.gov/about/news/2020/10/29/trump-administration-finalizes-rule-requiring-health-insurers-disclose-price-and-cost-sharing.html https://www.hhs.gov/about/news/2020/10/29/trump-administrati... > The rule requires that most health plans and health insurers not only provide easy-to-understand personalized information on enrollee cost-sharing for healthcare services, but must also publicly disclose the rates they actually pay healthcare providers for specific services. > Through a shopping tool available through their plan or insurance company, consumers will be able to see the negotiated rate between their doctor and their plan or insurer, as well as the most accurate out-of-pocket cost estimate possible based on their health plan for procedures, drugs, durable medical equipment, and any other item or service they may need. > Consumers will also have access to accurate price and plan information that allows them to shop and compare costs between individual doctors before receiving care, so they can choose a healthcare provider that offers the most value and best suits their medical needs. But it'll be another couple years before it's all implemented it seems
- zbrozek 6y ago
  We still need up-front transparency on what codes will be billed to whom, from whom, and for how much. I want a comprehensible restaurant-like menu. And we need to break up regional monopolies so that there's actually a choice of provider. Further, agreements to pay whatever, whenever, before any diagnosis need to be banned as contracts under duress. If we want the free market approach to work, we need to make it possible, easy even, to make informed decisions among competitors. But fixing this is increasingly feeling intractable, and this pushes me further and further towards believing a single-payer (maybe not exactly, but that's the buzzword) system is the better fix.

StreamBright 6y ago

> The free market just doesn't work And where did you experience free market healthcare out of curiosity? In the US there is no such thing.

ecf 6y ago

The only statistic you need to know to justify America being a shitty country with even shittier healthcare is that it is only one of two countries in the entire world that allow pharma companies to directly advertise to consumers.

khuey 6y ago
New Zealand is the other country that allows it and they seem generally satisfied with their healthcare system.
FireBeyond 6y ago
And that the other country only allowed it under pressure from the US for a trade agreement.

mauflows 6y ago

I've become more staunchly single payer after I had my first major medical hurdle of my adult life this year. I had switched insurance in January, but apparently my old insurance had a bug in their system. The effect was that they were accepting my claims, but then denying them. So I had to coordinate both insurances and get them on the same page. Then I had to call every one of my many providers, get them to understand, and then get them to reprocess the claim on their end. It was miserable and I had to deal with it while I was still dealing with a broken wrist and just hoping everything would work out. I feel awful for anyone who has to deal with that and has less time than me. I had to take notes during every phone call and get the numbers of customer reps so they could vouch for what I was saying

jschwartzi 6y ago
Imagine having to do this every time you change jobs.
- pnutjam 6y ago
  Yup, last employer had me on a different plan then I signed up for. Went round and round with the employer and the insurer. Of course it was the others fault. Finally talked to DoL guy and they told me it's absolutely the employers responsibility. They kept going back and forth with me. This was about and $1800 difference in out of pocket max, not in my favor... Finally they fixed it, but only for my wife. Since she had the majority of the bills due to a surgery, the insurance clawed back a bunch of smaller stuff they had already paid. So that cost me about a $1k. I guess I'm going to have to sue in small claims, which is what the DoL guy recommended.

abootstrapper 6y ago

“The free market will solve everything” is a seductive idea because of its simplicity. “Just let the free market solve it. Oh, there’s a problem? It’s because the market is not ‘free’ enough.” The reality is more complicated. We need a balance of a healthy market forces and regulations to prevent the exploitation of people and the environment. But that’s a lot of work, and not as elegant sounding of a solution as, “let the market figure it out.”

nickthemagicman 6y ago

I've been saying this for a long time. Supply and demand don't apply to healthcare. You can only adjust supply. Peoples demand for their health is infinite.

dr_orpheus 6y ago

The out of network care at an in-network hospital, is the absolute worst. In a similar vein, my wife's insurance was supposed to cover "out-of-network" ER visits. So one night that we had to go the ER we went to an out-of-network hospital ER because there wasn't an in-network one close by. Turns out that the coverage of the out-of-network ER visit basically just covers the cost of the bed in the ER, every treatment that you get (IV, vitals check, medication) is considered out-of-network treatment. This resulted in an absolutely insane bill with charges like $250 for administering oxygen monitor (you know the things you can buy at Wallgreens for $30) or $300 for ibuprofen.

jimbob45 6y ago
Network scope existing at all baffles me. Insurance companies become the ultimate deciders of which hospitals are worthy and which aren’t instead of government certification agencies. Seems like an open door to malevolence.

ajtaylor 6y ago

While being only slightly sarcastic, maybe it's time to put a sign on the door "If you're not covered by health plan XXX, please do not come in this room." That we have to even joke about such things is beyond ridiculous.

javiramos 6y ago

>the out of network specialist at an in-network hospital The worst. After a $2k bill, I learned my lesson to check every doctor that attends me for coverage even if it is in an in-network hospital.

danielrhodes 6y ago

I don't have any opinions about what the perfect system here is, but I think it's safe to safe say that medicine does not work well as a free market. You don't get to access a free market within the confines of hospital walls when there is an emergency. Moreover, your decisions as a rational actor are impaired because you are being asked to put a price on your own life or quality of life. There is almost no way to make this business not predatory under those circumstances.

snarf21 6y ago

We just need to mandate reference based pricing. This automatically goes away and also removes other huge parts of the wasted health care spend. Additionally, it doesn't require new taxes at all.

Moodles 6y ago

As an immigrant coming to America, honestly the most shocking and surprising thing (apart from the state of homeless in San Francisco being tolerated as normal) is the medical care expenses. How on Earth is it that I can walk into a doctor's office or hospital to get medical treatment and have no idea how much it's going to cost? $10? $100? $1000? Who knows. I had an ear infection once, went to the doctor who looked at it for a minute and said "give it a few days". I assumed this would cost maybe $20 or something? Nope. $400. There's just no way of even knowing. In no other industry would you buy something without knowing the price ahead of time. With medical care it's even more screwed up because, well, it's your health? You're generally more desperate for services now, so it's not like shopping around for clothes or something.

93po 6y ago
It's safe to assume talking to a doctor is a minimum of $400. Any labs or testing, another $400. Surgery starts in the thousands. Life saving care is the same cost as a house.
- Moodles 6y ago
  It's not though. Sometimes a simple visit is like $20 or even free.
  - 93po 6y ago
    If you have insurance that doesn't have a deductible or it's preventative care, sure. I'm talking paying cash or insurance with high deductible

darkwizard42 6y ago

As someone who is now figuring out how to deal with a 20K charge because one of the surgeons consulted was out-of-network (and EVERYTHING including the anesthesiologist, primary surgeon, hospital care was all in-network)... that last part is the most insane for me... Before my last surgery they offered me crutches and I asked if that was all covered by my insurance and specifically was it in-network with my provider. Imagine if it wasn't and some poor sap thinks... yes I should take crutches after a leg surgery and gets stacked with a massive upcharge

ApolloFortyNine 6y ago

15k for an airlift honestly sounds cheap all things considered, but the surprise out of network doctor is such bullshit it should have been fixed ages ago. It's one thing when you had to go to the ER, but even when your visit was planned they can spring you with that.

AnthonyMouse 6y ago

> into a believer in single payer healthcare. That isn't the part of the market which is broken though. The insurance companies want their vig, and they have no objection to cost increases because then they get the same percentage of a larger pot, but they're not actually where most of the money goes. It's really going to drug companies and medical devices companies and doctors and hospitals. Which all still exist even with single payer, and not only that but then have even less price sensitive customers (more unnecessary tests/treatments/procedures) and have a greater opportunity to have their lobbyists turn open the money spigot, because now it's tax dollars -- or government debt -- instead of insurance premiums that customers would balk at and switch to a less expensive plan when the price exceeds a given threshold. So you still need the very things they're lobbying against. You need something to make patients price sensitive enough to refuse over-treatment. You need some kind of price setting mechanism that works better than giving the most money to the company with the best lobbyists. Single payer doesn't get you that.

8note 6y ago
What you're saying is that health care needs to stop being about health, I think. The price sensitivity you're looking for is "yeah, you can pay 5k less for your broken arm, but they'll be cutting it off instead of setting it"

sebastien_b 6y ago

I've been on the receiving end of a $15K air ambulance bill (thankfully covered by insurance) as well as the out of network specialist at an in-network hospital. The latter is particularly galling. What are you supposed to do, interrogate every person that comes in the room That could present a rather interesting legal challenge... Say you state "I can only allow care from in-network physicians/personnel" - will they take that as you outright refusing care if they're not in-network? And if they decide they're not going to care for you because of this, and you end up dying, what would be the recourse? Did the personnel (esp. doctors) still have a duty to care for you? Or else on what exact basis would they conclude you refused care and let you die?

hnracer 6y ago

It's good to keep in mind that not all medical services are price inelastic in the sense that ambulance costs or emergency hospital visits are. GP visits/non-emergency general surgeries/general medicines - just like food, are all necessities for survival, and are all locally price elastic, with the exception of medicines that have regulatory capture - not a free market, such as insulin which is many X the cost in the US because of a government-enforced oligopoly. This means that no single supplier (whether of food or non-emergency medicine) can raise their prices because consumers have time to find a cheaper alternative. Unless they collude, which is illegal, and impractical for many markets such as GP visits. For these particular goods, does your view differ, when compared to emergency services which we agree are price inelastic? And if not, how do such services differ to the foods market - holding aside regulatory capture of things such as insulin which we both probably agree is not a good thing?

powvans 6y ago

What if they don't even come into the room? I experienced this incredible phenomenon a couple years ago after taking my son to the ER while out of state on vacation. We were there for a few hours to have a very horror movie-esc swollen lymph node looked at. He needed a CT scan to confirm that it was not an abscess and some IV antibiotics for strep. The doctor and nurses were great, I paid up front, and additionally provided insurance. Seemed like everything went smoothly. Three months later we received a bill for $2500 from a doctor we had not seen. Insurance had adjusted it from $3800. Perhaps he was the attending physician and the doctor we saw consulted with him. I have no idea and no one told me anything about it. My wife, being the litigious trial attorney that she is, sent the physician's group a letter disputing the bill, requesting documentation that this doctor did in fact work on my son's case, and putting them on notice that she would fight them on principle over the amount of the bill. A couple of weeks later we got a letter stating that despite the fact that the charges were in fact valid, they would adjust the amount owed to $0. A friend I related this to commented, "yup, they just wrote you off because there are so many more people that they can go after and not fight with that it just isn't worth it to them." What a sad commentary on healthcare in America.

spaetzleesser 6y ago
So they are basically bullies that exploit the weak and defenseless and are afraid of people that fight back.

imaginenore 6y ago

Nothing is "free market" about a current system. • You're forced to buy health insurance. • You can't choose any doctor you like one you have the insurance. • You can't shop around for the best price, because the prices are not shown. • You're not given an estimate of how much a procedure would cost. • You can't choose which doctors visit your hospital room (and every time they do, you pay for it).