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I expect the main difficulty this presents to hospitals isn't that their customers will be informed, or even that their competitors will be advantaged, but that

• bredren 5y ago
  Many, many medical bills go unpaid. Calculation of likelihood of payment based on customer attributes is being used to consider offering discounts to pay quickly. I don’t know how this wouldn’t act as de facto price discrimination but it is happening.
  • joenathanone 5y ago
    >Many, many medical bills go unpaid. Several years ago I ended up in the ICU, no insurance, got a ridiculous bill that would have taken the majority of my lifetime to pay down. In the end I decided not to even attempt to pay because it was so ridiculously high, decided to just wait the seven years for it to fall off my credit. If the price had been reasonable I would have paid outright or gotten on a payment plan.
    • MathCodeLove 5y ago
      What was the impact on your credit score? I imagine that had an effect on other parts of your life no?
      • joenathanone 5y ago
        It hurt my credit score(as in the number quite a bit), but not as much as I thought it would, I was really worried I wouldn’t get approved for things, but I was informed that when underwriters are reviewing credit reports, medical debt doesn’t carry much weight, as ‘everyone’ has it and it doesn’t reflect on how responsible or impulsive the debtor is.
        • dml2135 5y ago
          My worry is that as this happens more and more, the health care industry will come up with their own score, and will refuse to serve people that don’t pay their medical debts.
          • PaulDavisThe1st 5y ago
            A law signed by Ronald Reagan prevents denial of treatment based on ability to pay. However, it doesn't specify what treatment will be provided, so more likely, hospitals would use that sort of information to limit treatment to ER-level interventions and then recommend a wait-n-see approach as followup.
          • vel0city 5y ago
            The Emergency Medical Treatment and Active Labor Act prevents any hospital which accepts Medicare/Medicaid from turning away patients in critical conditions. They have to at least provide stabilization and some kind of basic medical screening services to everyone who arrives. https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_and_Active_Labor_Act https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an... As for other doctor's offices or planned procedures, I think they already can decide to not work with you if you don't pay them. Maybe there's something similar for general practice stuff related to Medicare/Medicaid as well but for exclusively private pay practices I can't imagine something forcing those providers to offer non-emergency services.
        • RealityVoid 5y ago
          As a non-US citizen, the more I read this thread, the more bonkers the whole system is. How the fuck does healthcare even work at all?
          • joenathanone 5y ago
            >How the fuck does healthcare even work at all? It doesn't, unless you are wealthy, otherwise you try and 'walk off' any issues until they become obviously life threatening, then you go to the hospital and if you have insurance, you hope the insurance will approve the operation you need, and if you don't have insurance you hope the cost wont bankrupt you.
      • xwdv 5y ago
        There comes a point where your credit score isn’t useful anymore. If you have a good house with a good mortgage and the best credit cards and have taken any other long term loans you need, then you’ve reached the end game. After that point maintaining a high score is just for bragging rights. It makes no sense to pay a massive hospital bill the rest of your life instead of just letting it fall off your credit reports in 7 years.
        • Retric 5y ago
          Jobs will also look at your credit score, but for a retired person it can quickly become meaningless.
          • EGreg 5y ago
            Why do employers care
            • greedo 5y ago
              Employers are looking for stability, so a poor credit score is a proxy for a risky hire (in their minds). Even if 50% of the low scores are due to either medical debt or student loans, it helps them weed out "undesirables."
            • relaxing 5y ago
              You might abuse your position for illicit gain in order to pay off debts.
            • xwdv 5y ago
              So they have an excuse to not hire minorities and people of color who have lower scores on average.
    • throwawaylinux 5y ago
      What does falling off your credit mean? Do you no longer owe anything? Did you go through bankruptcy?
      • joenathanone 5y ago
        It means it no longer appears on my credit report or effects my credit score.
        • throwawaylinux 5y ago
          You still owe the money though? Do they just stop chasing you after a while?
          • mcherm 5y ago
            All US states (I think) have some statute of limitations on debt collection, although each state is different. After this amount of time has passed (assuming that no court case has been filed), the courts can no longer be used to demand payment of a debt and the debt effectively ceases to exist legally. (Whether it ceases to exist morally depends on your personal moral system.)
            • throwawaylinux 5y ago
              Interesting, thanks. 3-6 years seems common.
            • lttlrck 5y ago
              But they will send collections after you long before that no? It happened to me (Scrips, CA), while we were trying to negotiate payment with the hospital and the bill was only $500 - I didn't want to pay it out of principal because we were told it was $150 flat rate at the time of service... they were very quick to pull the trigger. Is it at all advisable to ignore collections and risk court appearance?
              • 5y ago
• daniel-cussen 5y ago
  > charging different amounts to different customers, based on their willingness and ability to pay I haven't had that experience. That would be like a health dealership.
  • themitigating 5y ago
    I didn't have insurance and needed all my wisdom teeth out. I was able to negotiate a cash discount.
    • wjnc 5y ago
      How much did you pay if I may ask? It was € 428 a few months back in a Dutch hospital (under a system many people do not like, but I mostly do) with another € 30 for the dentist checking and referring. That’s an all-in price.
      • Talanes 5y ago
        Does all-in mean all four wisdom teeth? Because I paid somewhere over $2000 out of pocket a few years back in San Francisco. And that was after insurance.
        • nicoburns 5y ago
          I paid £200 all-in for an initial check-up, and then a second appointment where a single tooth was removed here in the UK (this was a non-NHS dentist). I imagine they’d have charged more to remove 4 teeth, but not 4x more.
        • wjnc 5y ago
          It was for four teeth and with all-in I ment I had to pay for it out of pocket (first few hundred euro are at my own risk) and it (should) cover the whole price. No hidden subsidies. The insurer just billed me the full price they bargained for.
          • 5y ago
• Consultant32452 5y ago
  My kid recently needed a script. We had to go through a specialty pharmacy that ships directly to home because it apparently wasn't carried in the pharmacies like CVS. The script was over $400. Insurance denied the claim. They "applied a coupon" and the price magically became $35. In this one transaction there's multiple layers of corruption most likely starting with the prescribing doctor.
  • alphabettsy 5y ago
    Some doctors are certainly corrupt, but usually they have no way of knowing how much a particular medication costs since many do not buy or handle medication beyond what they would stock in their office. Your post lacks information such as whether or not the specialty medicine would’ve been approved with the proper paperwork from the doctor, but what likely happened is that someone at the pharmacy put in the effort to find a manufacturer coupon for the medicine for you. Interestingly the pharmacy doing that is generally forbidden in agreements with the insurance companies. That’s corruption imo. The insurance PBMs forcing you to use their designated specialty pharmacies is part of the massive healthcare consolidation over the last couple of decades and it’s full of corruption as well.
    • Consultant32452 5y ago
      Of course my post lacks information. It's not a persuasive essay, it's an internet post about an experience I had. Humans tend to prefer brevity over exactness, particularly on internet posts.
      • deleted 5y ago
        [deleted]
      • codewiz 5y ago
        I prefer brevity over irrelevant information, but mentioning the specific type of drug, the name of the insurance and the type of coupon being applied would be highly relevant in determining whether the story has merit. Leaving it deliberately unspecified triggers all my bullshit detectors.
• antisthenes 5y ago
  The main difficulty is that the penalty is laughable. $300/day doesn't even begin to cover a single well-paid IT professional who can handle this project, let alone a team with resources. It may seem trivial to HN audience to comply (hey, just do a SQL query and post the resulting CSV!), but hospital IT systems are oftentimes legacy dinosaurs, so a transparency project like this could cost millions of $ to undertake. Why pay millions, when you can simply pay a measly penalty of ~$109,000 year after year?
  • dml2135 5y ago
    100k is only this year, it goes up to $2mil tomorrow. Your point still stands though, even that is possibly not high enough
    • PaulDavisThe1st 5y ago
      If you can't extract pricing data from your existing IT infrastructure for less than US$2M, you've got deeper problems than this law (or you use one of the Big Three consulting companies for all your IT work)
• EamonnMR 5y ago
  Calling it price discrimination is generous. Usually you'd call such activity a confidence game.
• clsec 5y ago
  I don't agree that hospitals charge based on ability to pay. I believe that they generally charge the max and then, maybe, negotiate the price based on your ability to pay (more likely they put you on a payment plan). I had an accident in late 2010 where I needed to stay in the NICU for 14 days. In January 2011 I had major neck surgery and spent another week in the hospital. SFGH charged me $100K for the NICU stay and $200K for the surgery (plus a separate bill for $1K from SFFD for my initial ambulance ride). I had no job or insurance at the time and was in the process of moving out of my apartment. Luckily, it was a slip and fall type accident and I immediately hired a lawyer when I saw the bills. I was also approved for MediCal after my surgery and they initially covered the bill. But they put a lien on my lawsuit. I learned a lot during all of this, but my biggest takeaway was that MediCal paid $20K for a bill that was charging me $300K! Less than 10% of what I was being charged!
  • hedora 5y ago
    About 33% of total US healthcare spending goes to the people that haggle over prices for the doctor and the insurance company. That explains most of the bad pricing behavior in this space. For the law to have any real effect, it would need to force the hospitals to publish prices up front, and also ban discounting the charges after the fact. (I get the distinct impression high-cost insurance plans get the best deals from hospitals, but could be wrong. Either way, I don’t thing conventional price discrimination is a thing in this US healthcare market.)
    • vel0city 5y ago
      I still don't quite get how publishing prices up front is going to solve a lot of the problems. If I'm in an accident and bleeding out I'm not exactly going to whip out my phone and start comparison shopping which hospital to go to. What does it matter if they publish a 1,000 page PDF with tiny fonts of all their prices when I'm in need of emergency medical services and may not even begin to understand all the work I'll need? I guess it helps a bit when you're having a planned procedure done but often when you're planning out a procedure they can give you at least some kind of cost estimate. Don't get me wrong I do find it terrible that US healthcare pricing is incredibly opaque but it does not seem to immediately offer a lot of benefits. It will probably offer a good amount of indirect benefits as those who are paid to haggle will have more information to haggle with, but to me it seems like it wouldn't really force any of the changes needed.