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But do uninsured people actually really pay this? My impression was that you still can (and should) try to negotiate with hospitals/providers whenever possible

But do uninsured people actually really pay this? My impression was that you still can (and should) try to negotiate with hospitals/providers whenever possible and/or ask them to create a payment plan for you. But maybe that's not common knowledge? Since you're in the space, what do you think of the startup they mentioned in the thread, turquoise.health (or rather the idea behind it, not literally the startup)?

kgantchev 5y ago
No, uninsured people also don't pay it. They are offered a fraction of the cost if they pay "cash" once you're leaving. I went to the same ER in San Francisco with the same problem 3 months apart (kidney stones). The first time around I was uninsured and the bill was $2000- they told me that they'll cut it down to $500 if I paid on the spot, which I did. 3 months later I had the same problem, had purchased insurance, my bill came out to $8000 and my deductible was $2000.
- atlasunshrugged 5y ago
  Okay, interesting. I had read some articles about medical debt that alluded to those levels of savings for paying cash in one lump sum quickly but still, it's pretty striking that you get a 75% "discount" for cash on the spot.
  - pc86 5y ago
    And not to mention when they say "on the spot," they mean it. In the room, right there, as you're checking out. If you don't have access to any payment methods or you need to wait two days until you get paid or something, you're looking at a 50-100% increase over the final quoted "cash price" even if you're still paying cash.
- Rapzid 5y ago
  Can confirm. Had a procedure (hernia repair) and at the time of setting it up my insurance was in flux. I asked for the cash price to move things along and was quoted just ~7k all up. Insurance ended up covering it but received one of those invoices were it starts at over 20k before the magic "discount" gets applied. I have been assuming the magic discount is some sham the insurance companies push for to scare people into believing they would not get it if it weren't for the insurance. It's BS IMHO to not be advertising the ACTUAL cash amounts they would quote somebody..
- ta988 5y ago
  Can you just say "I don't want to use my insurance at this stage and I want the price from last time?"
  - pc86 5y ago
    As always, it depends. There is a certain point at which your visit is tied into your insurance so you can't just undo it. At that point the hospital is now fighting with the insurance company to pay and you're stuck in the middle.
- stefan_ 5y ago
  So you paid more on insurance? And the bill while on insurance just happened to be inflated so much that the deductible came out to be the price of the procedure the first time around? That sounds like fraud.
  - geerlingguy 5y ago
    Sounds like health insurance!
- bjornsing 5y ago
  If you delay payment you probably have to help pay for those that will not. One reason that stitching up minor cuts is so expensive could be that those who need that treatment (e.g. because they were in a fight) are statistically less likely to ever pay their bills…
  - pc86 5y ago
    Do you have a source that people getting small cuts stitched up are less likely to pay their bill?
- watwut 5y ago
  If you dont have 500 available at the time of health issue you pay more? But it still sounds scammy pricing tactic to me. That is not how stores or anything else works or should work.
  - jhauris 5y ago
    Or you pay nothing at all (they aren't going to repo your kidney), or end up working out a deal to pay whatever you can later. They offer the discount because on average they figure the discounted price is higher than what they'll get paid later.
- hasbot 5y ago
  That's not my experience. I was out of state and needed medical attention. I was on Medicaid. Urgent Care straight up wouldn't accept my out-of-state Medicaid plan and suggested I go to ER. They too didn't accept out-of-state Medicaid, listed me as having no insurance, and billed me full-price for the some of the services. There was no discount for paying on the spot. I paid for those initial services and got more bills from the doctor and other departments. They never accepted my out-of-state Medicaid but eventually "gave me a discount." I paid some of it myself but told them if they wanted the rest to bill Medicaid.s
deleted 5y ago
[deleted]
pc86 5y ago
The people who get screwed the hardest are the underinsured (in all cases) and those who have high-deductible plans with coinsurance and HSAs (and have some acute issue). I work in radiology and entered a few common procedures I see a lot in our data on https://turquoise.health/ https://turquoise.health/ (also linked in the Twitter thread). Then I entered information for our own HDHP+HSA plan. Guess what, having insurance costs you 40-60% more if it's an acute issue. So if you're healthy, you have zero incentive to use your insurance if you suddenly need a CT of something. The rub of course is if you pay cash, it doesn't count toward your multi-thousand dollar yearly deductible, so if it turns out to be a chronic issue you just shot yourself in the foot. But if it doesn't, you just burned thousands by using your insurance when you didn't have to. It's a complicated issue and anyone who says they have the solution, including "just make it free / just have the government pay for everything," is either being disingenuous or doesn't understand the problem. As was stated in the Twitter thread, running a hospital 24/7 is astronomically expensive. Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements. Attending physicians as resident-run hospitals will sleep overnight while getting paid literally half a million dollars a year. Insurance companies will just decide not to pay something and will spend years in court to defend their right to pay whatever they want, down to and including $0. Vendors will charge tens of millions of dollars to implement monolithic thick-client applications where everything is so configuration-heavy that you literally can't have a test environment because it won't match. Interoperability is managed by a text-based standard named HL7 that if you're not familiar with, will make you rip your hair out. The standard itself is ignored by every organization who ends up with their own flavor, so every app needs to be configured to support nearly any value in nearly any field. Hospital IT is staffed by people making $40k/yr who don't understand modern computing, and run by executives with no technical background. Every single entity and company involved in healthcare is complicit in the end result, which is skyrocketing patient costs with at best no change in patient care or patient outcomes.
- atlasunshrugged 5y ago
  Thank you for sharing this, really helpful to hear from someone inside the industry and of course, the issue is super nuanced and complex. I just wonder if/when something will give in the U.S. But you said something that stood out - "Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements." Given the rising prices, why isn't the pot getting bigger? What do you think of Epic systems and EHR stuff?
Redoubts 5y ago
You can negotiate the costs in bankruptcy

kgantchev 5y ago

No, uninsured people also don't pay it. They are offered a fraction of the cost if they pay "cash" once you're leaving. I went to the same ER in San Francisco with the same problem 3 months apart (kidney stones). The first time around I was uninsured and the bill was $2000- they told me that they'll cut it down to $500 if I paid on the spot, which I did. 3 months later I had the same problem, had purchased insurance, my bill came out to $8000 and my deductible was $2000.

atlasunshrugged 5y ago
Okay, interesting. I had read some articles about medical debt that alluded to those levels of savings for paying cash in one lump sum quickly but still, it's pretty striking that you get a 75% "discount" for cash on the spot.
- pc86 5y ago
  And not to mention when they say "on the spot," they mean it. In the room, right there, as you're checking out. If you don't have access to any payment methods or you need to wait two days until you get paid or something, you're looking at a 50-100% increase over the final quoted "cash price" even if you're still paying cash.
Rapzid 5y ago
Can confirm. Had a procedure (hernia repair) and at the time of setting it up my insurance was in flux. I asked for the cash price to move things along and was quoted just ~7k all up. Insurance ended up covering it but received one of those invoices were it starts at over 20k before the magic "discount" gets applied. I have been assuming the magic discount is some sham the insurance companies push for to scare people into believing they would not get it if it weren't for the insurance. It's BS IMHO to not be advertising the ACTUAL cash amounts they would quote somebody..
ta988 5y ago
Can you just say "I don't want to use my insurance at this stage and I want the price from last time?"
- pc86 5y ago
  As always, it depends. There is a certain point at which your visit is tied into your insurance so you can't just undo it. At that point the hospital is now fighting with the insurance company to pay and you're stuck in the middle.
stefan_ 5y ago
So you paid more on insurance? And the bill while on insurance just happened to be inflated so much that the deductible came out to be the price of the procedure the first time around? That sounds like fraud.
- geerlingguy 5y ago
  Sounds like health insurance!
bjornsing 5y ago
If you delay payment you probably have to help pay for those that will not. One reason that stitching up minor cuts is so expensive could be that those who need that treatment (e.g. because they were in a fight) are statistically less likely to ever pay their bills…
- pc86 5y ago
  Do you have a source that people getting small cuts stitched up are less likely to pay their bill?
watwut 5y ago
If you dont have 500 available at the time of health issue you pay more? But it still sounds scammy pricing tactic to me. That is not how stores or anything else works or should work.
- jhauris 5y ago
  Or you pay nothing at all (they aren't going to repo your kidney), or end up working out a deal to pay whatever you can later. They offer the discount because on average they figure the discounted price is higher than what they'll get paid later.
hasbot 5y ago
That's not my experience. I was out of state and needed medical attention. I was on Medicaid. Urgent Care straight up wouldn't accept my out-of-state Medicaid plan and suggested I go to ER. They too didn't accept out-of-state Medicaid, listed me as having no insurance, and billed me full-price for the some of the services. There was no discount for paying on the spot. I paid for those initial services and got more bills from the doctor and other departments. They never accepted my out-of-state Medicaid but eventually "gave me a discount." I paid some of it myself but told them if they wanted the rest to bill Medicaid.s

deleted 5y ago

[deleted]

pc86 5y ago

The people who get screwed the hardest are the underinsured (in all cases) and those who have high-deductible plans with coinsurance and HSAs (and have some acute issue). I work in radiology and entered a few common procedures I see a lot in our data on https://turquoise.health/ https://turquoise.health/ (also linked in the Twitter thread). Then I entered information for our own HDHP+HSA plan. Guess what, having insurance costs you 40-60% more if it's an acute issue. So if you're healthy, you have zero incentive to use your insurance if you suddenly need a CT of something. The rub of course is if you pay cash, it doesn't count toward your multi-thousand dollar yearly deductible, so if it turns out to be a chronic issue you just shot yourself in the foot. But if it doesn't, you just burned thousands by using your insurance when you didn't have to. It's a complicated issue and anyone who says they have the solution, including "just make it free / just have the government pay for everything," is either being disingenuous or doesn't understand the problem. As was stated in the Twitter thread, running a hospital 24/7 is astronomically expensive. Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements. Attending physicians as resident-run hospitals will sleep overnight while getting paid literally half a million dollars a year. Insurance companies will just decide not to pay something and will spend years in court to defend their right to pay whatever they want, down to and including $0. Vendors will charge tens of millions of dollars to implement monolithic thick-client applications where everything is so configuration-heavy that you literally can't have a test environment because it won't match. Interoperability is managed by a text-based standard named HL7 that if you're not familiar with, will make you rip your hair out. The standard itself is ignored by every organization who ends up with their own flavor, so every app needs to be configured to support nearly any value in nearly any field. Hospital IT is staffed by people making $40k/yr who don't understand modern computing, and run by executives with no technical background. Every single entity and company involved in healthcare is complicit in the end result, which is skyrocketing patient costs with at best no change in patient care or patient outcomes.

atlasunshrugged 5y ago
Thank you for sharing this, really helpful to hear from someone inside the industry and of course, the issue is super nuanced and complex. I just wonder if/when something will give in the U.S. But you said something that stood out - "Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements." Given the rising prices, why isn't the pot getting bigger? What do you think of Epic systems and EHR stuff?

Redoubts 5y ago

You can negotiate the costs in bankruptcy