27 ms·

How much health insurers pay for almost everything is about to go public

766 points by nojito 4y ago

ageitgey 4y ago
I'm one of the co-founders of Turquoise Health, mentioned in the article here. We've been downloading and parsing this data all day. It's a really big deal in the industry that the prices that insurance companies pay doctors are now being shared publicly. It will have all sorts of positive impacts over time, hopefully making rate negotiations more consistent and fair between different insurance plans. Right now, 10x differences in prices paid for the same healthcare service from the same doctor between insurance plans is not uncommon.
- WFHRenaissance 4y ago
  What do you serve to gain from scraping all of this information?
  - jjoonathan 4y ago
    The information on their landing page was immediately relevant to me https://turquoise.health/ https://turquoise.health/ I hope they have a good business plan and manage to stick around!
    - ageitgey 4y ago
      Thanks! So far, so good. We don't sell anything to consumers. Our products are aimed at the healthcare industry which lets us post information for consumers for free and we have pretty good product-market fit. Obligatory "if anyone is interested in joining a fast growing, series A company doing impactful work, hit up our careers page!"
      - atlasunshrugged 4y ago
        Interesting, I'm curious since you're in the industry, why do you think medical tourism has never taken off in a big way in the U.S.? I feel like I saw more people willing to go to Poland or Ukraine for things like dental work when I lived in Europe than people in the U.S. willing to go to Mexico or some other destination.
        Red_Leaves_Flyy 4y ago
        Not the person you asked. I want my medical providers to be local to me so they’re liable to my local community. I also want to keep my organs and have insurance cover the costs.
        ageitgey 4y ago
        The US is really, really large and many people living there have never left it. There's also a belief that US healthcare is the gold standard (which is probably true at the very high end, but not necessarily on average). In other words, it's a hard sell to convince a factory worker to travel 5-10 hours on a plane to a place they have no familiarity with to get what they believe to be inferior treatment. They might not even have a passport. This is much less of an issue in Europe where countries are tiny and almost everyone travels between them on a regular basis. Also, medical tourism is mostly limited to what the industry calls Shoppable Services - outpatient treatments that are not emergent/not life threatening. There is a bit of a cottage industry in Mexico for some services, like bariatric surgery for obesity or dental work, but it isn't a huge volume. The really expensive stuff in the US is emergency treatment which you can't shop for anyway. All that said, I think the interest in buying prescriptions from overseas has never been higher.
        rootusrootus 4y ago
        Anecdotally, most of the people in my circle of friends and family are perfectly satisfied with what we get locally. If you have adequate insurance and no major medical issues, you don't save much by flying down to Mexico. I do have some extended family that have gone to Mexico for treatment, however, mostly of the dental variety. But it was major reconstruction, so it was worth the effort. I do remember reading a story a couple years back where an insurance company paid for their customer to fly to Mexico, flew down a US orthopedic surgeon, and paid him pretty well for his services. The cost of the flights, surgeon, and medical facility in Mexico were significantly less than it would cost them in the US, so everybody won except the US hospital. As I recall, the hospital in Mexico was collocated with a resort, so it was a nice place to recuperate as well. Not sure how common that really is, though, stories like that make the news for a reason. Edit: Pretty sure this is the story I was thinking about: https://www.advisory.com/daily-briefing/2019/08/13/cancun https://www.advisory.com/daily-briefing/2019/08/13/cancun
      - wildrhythms 4y ago
        How does the healthcare industry use this data typically?
  - ageitgey 4y ago
    Our industry-focused products are based on knowing how much every service costs at every healthcare provider. It's the underpinning of our products. We also post a lot of the rates publicly in a consumer-friendly searchable format, but we don't charge any money for that. But this data will let us greatly expand the scope of that free service.
  - dugmartin 4y ago
    I was guessing it was this bit at the bottom of their landing page: > Are you a transparent provider or payer? > There is a market for transparency. Let patients find you by claiming > your provider page and listing your services. It only takes 10 minutes. But following through that link says it is a free program.
    - ageitgey 4y ago
      We build products that help healthcare providers and insurance companies broker contracts between themselves based on actual market information instead of guessing at prices. The goal is to drive down prices by making the market more efficient. Part of that is assuming that prices will be public, so we encourage them to claim their own page and take control of the rates listed there.
- nullfield 4y ago
  Where is the - if it exists - list of locations where different entities have published their machine-readable files?
- elromulous 4y ago
  Could this backfire - similarly to how publicly traded companies' CEOs disclosing their pay caused their pay to skyrocket?
  - huitzitziltzin 4y ago
    This is a good question and the answer is absolutely yes. It could raise prices. Consumers have some incentive to care how much they are spending on health care, but they aren't generally the claimant on savings they realize for their insurance plans. (Obviously the incentives for uninsured or self-insured patients (to the extent that there's anyone in the latter category) are quite different, but those populations are small.) On the other hand, every hospital has a strong, strong incentive to care a lot about how much their competitors are getting for the same procedures. (Much more than consumers, for example.) It's possible that these disclosures lead to prices falling as hospitals seek to undercut each other. However, most US hospital markets feature a small number of competing hospital systems in an oligopoly. The price-cutting pressures in such markets are much, much weaker. There is a "mutually assured destruction" aspect to price competition in such markets which may keep prices from falling. The latter incentive can raise prices too. IF you know your competitors across town are getting an extra $5,000 for a knee replacement and you know that the two of you are the only game in town for hospitals, you may raise your prices rather than lowering them. On balance I think this is the right policy, in part because I want this data myself as a researcher. But it is not unambiguous that this will lead to price reductions. Source: am a health economist.
  - marricks 4y ago
    Can you support that claim? I couldn't find when CEO pay went public but it sounds very likely like one of those causes were correlation definitely doesn't imply causation.
    - zeruch 4y ago
      All CEO pay for public companies is exposed in the 10Ks. What I suspect the person was referring to is the change where compensation became more tied to equity valuation.
- sinab 4y ago
  Where are health providers hosting these data? Could you give an example? Thank you.
- treeman79 4y ago
  A few times I’ve seen a 10x price decrease when I asked to pay cash before. Sometimes the co-pay alone is more then cash for procedure. Weekly injections and MRIs is the worst offenders I’ve seen.
- snarf21 4y ago
  We really need to move to reference based pricing. We can cut so much waste out of the current system including brokers. Reference based pricing also get rids of the loopholes for things like anesthesiologists being "out of network" at a hospital/facility that is "in network". It also gets rid of the situation where if you offer cash you get one price but if you submit for the same code, it could be 3x or 10x or even more.
  - whatshisface 4y ago
    What's reference-based pricing?
    - antisthenes 4y ago
      It's basically price-controls. A regulatory body looks at how much something "should" cost based on its history of reimbursement and the cost of its inputs and then sets a cap of say, cost + 20%. The problem is having an independent body that is free of influence of health insurance companies and hospitals, both of which have perverse incentives to continue profiteering.
      - db48x 4y ago
        Not to mention the fact that it will eventually cause a supply shortage.
        alxhill 4y ago
        Germany has reference pricing for their drugs system and doesn't seem to have a supply issue. Genuine question, is there something that makes you think that wouldn't be true for the US?
        whatshisface 4y ago
        How would anyone notice a shortage when shortages came in the from of it not being standard practice to prescribe a medicine in a certain situation?
- tomrod 4y ago
  Very cool work! The article mentions that yall are working on hospital data. Is insurer data beginning to roll in?
- baby 4y ago
  Another proof that more transparency decreases corruption and improves efficiency?
  - BurningFrog 4y ago
    Once it's been shown to work it may be proof. The track record of healthcare reforms intended to cut costs is rather abysmal.
    - epgui 4y ago
      Does it really need to be proved? I'd argue that it's a mathematical/logical truth in principle, and that the only thing that requires proof is whether this particular implementation is successful at what it aims to do.
    - spaetzleesser 4y ago
      That may be true but the first prerequisite for functioning markets is price transparency for participants. Without that it will never work. There may be other problems but you absolutely need to know prices.
- antisthenes 4y ago
  Are you guys hiring?
  - missedthecue 4y ago
    Look like it https://turquoise.health/careers https://turquoise.health/careers
- jerry1979 4y ago
  How do you account for case-based charges?
- codegeek 4y ago
  I appreciate what you all are doing. We need people to try and really fix our Healthcare Industry. However, I do have a question. Are you trying to get rid of Insurance mafia at all for at least some things like basic preventive care etc because I am sure that drives costs up a lot if Insurance companies are always between a doctor and a patient. I really hope something can be done where I can just go to a doctor/hospital, ask how much and pay for it out of pocket instead of crazy premiums and all the other BS we have to go through everytime.
  - nradov 4y ago
    Most healthcare providers are happy to accept cash payments from patients. You can sometimes even negotiate a discount. If you have a medical plan subject to the Affordable Care Act then most preventive care is already fully covered at no cost to the patient. https://www.healthcare.gov/coverage/preventive-care-benefits/ https://www.healthcare.gov/coverage/preventive-care-benefits...
    - indymike 4y ago
      > Most healthcare providers are happy to accept cash payments from patients. You can sometimes even negotiate a discount. Actually, if you don't have insurance, you get the special cash price of $Maximum. /been there //tried that.
      - adventured 4y ago
        I have also been there and tried that, extensively. That's the opposite experience of what I encountered in paying by cash for more than a decade. Typically I'd pay around half price via cash for healthcare services (routine doctor visits, scans, et al.) versus what they charged if you had insurance. I never ran into a situation where they wouldn't negotiate steep discounts for paying by cash.
        indymike 4y ago
        Yes, it works for routine stuff, but don't try to pay cash for abdominal surgery. You will get a very terrible, high price. After all, it's agree to our low price or die of appendicitis.
- FollowingTheDao 4y ago
  Sorry, but the only thing that will help is Medicare for all. We need to get rid of insurance companies completely.
  - KyeRussell 4y ago
    Non-American here: your healthcare system is so abysmal that you could stop short of implementing Medicare for all and still have a significantly improved system. You should obviously have Medicare for all, but let’s not kid ourselves about how far from that you are.
  - Steko 4y ago
    Lots of countries have great systems that aren't single payer.
  - refurb 4y ago
    Should Europe get rid of their insurers too?
    - hansel_der 4y ago
      as european i am not entirely convinced that it makes sense to have hundreds of companies providing the same heavily regulated service. if there were too few of those i would probably also object. idk about the situation where there are no private companies involved at all and the government takes over healthcare top to bottom because on the one hand i see a massive problem with for profit healtcare as it is and on the other hand i can see how incentives would wither away if there is no drive for efficiency at all.
- spaetzleesser 4y ago
  “Right now, 10x differences in prices paid for the same healthcare service from the same doctor between insurance plans is not uncommon.” Makes me wonder how things got to this point. How can a business perform any planning if they sell their services with such big differences between prices charged to customers?
  - pc86 4y ago
    Over time the higher paying ones subsidize the lower ones. Due to this we'll see some people's insurance premiums increase, some decrease, and some insurance providers probably go out of business (all good IMO).
  - 29athrowaway 4y ago
    Short answer is: because they can. And they can because there's a lack of transparency that makes people believe this is OK.
  - refurb 4y ago
    The honest answer is because that’s what insurer negotiation had led to with hospitals having using their negotiating position. If you’re a hospital in an area with standalone MRI clinics the negotiation pressure is high, insurers can say “ill send patients elsewhere”, so you give on price, maybe below cost. But that same hospital is the only cath lab in 100 miles. Great! We’ll just tell the insurer “we’re charging 300% the normal cost of a cath procedure, take it or leave it”. So the insurer takes it because how can you offer insurance and tell customer they have to drive 100 miles for a heart procedure? Hospital is happy because they’re profitable overall. Insurer just lives with paying 3x for cath procedures in that area.
    - datavirtue 4y ago
      Hospitals don't let you obtain imaging elsewhere. They force you to use their imaging services--full stop.
      - refurb 4y ago
- shostack 4y ago
  My dentist dropped my insurer (Delta Dental) because they claim they did not cover things as reliably as they should. When I saw a comparison bill of what it would be in and out of network for a recent service it looked like the 60% increase in price was purely because my dentist billed more, which they then claimed is due to the discount The insurer provides. None of this makes sense to me. How can I leverage this new data access to my advantage?
  - Akronymus 4y ago
    > When I saw a comparison bill of what it would be in and out of network for a recent service it looked like the 60% increase in price was purely because my dentist billed more, which they then claimed is due to the discount The insurer provides. Well, rebates kinda DO end up working like that. https://www.youtube.com/watch?v=uPa-RHVh97k https://www.youtube.com/watch?v=uPa-RHVh97k https://www.youtube.com/watch?v=_4_WNFPnmO8 https://www.youtube.com/watch?v=_4_WNFPnmO8
  - neycoda 4y ago
    People keep complaining government is too complicated and too expensive and bafoonish, yet they don't see how corporations are no different except their priority is maximizing profit not providing cost-efficient quality.
    - janekm 4y ago
      The point (in theory) is that in efficient markets you can choose between different companies offering a product/service and that competition drives down prices / costs. The healthcare market in the US is very much not a competitive market (in part due to transparency issues which this is trying to address, in part because of the perverse incentives in the health insurance system). It's not so easy to have a competitive marketplace for government services (though I would not be surprised if the US saw the emergence of private police forces now, for those parents who actually want police officers that have a duty to protect their kids...)
      - feet 4y ago
- Zenst 4y ago
  How well will their data be audited and enforced? For example if they charge one price and yet their public data purports another price? More so will they cut the drug prices internally and shift the difference onto an administration fee? That is one aspect I'm very mindful of.
Olreich 4y ago
> “What we’re learning from the hospital data is that insurers are really bad at negotiating” Do the insurers have any incentive to negotiate well? Since their customers are not very price-sensitive (since they aren't marketing directly to patients or doctors), I would imagine they don't have a huge incentive to do anything but apply a markup to whatever prices the hospital tells them it costs.
- MrFantastic 4y ago
  Private Healthcare is the Classic Agency Problem.
- jjoonathan 4y ago
  Well, if they can negotiate a particular incident down then they pay less for it, but in the long run big picture you're exactly right. So long as they can inject noise into the plan shopping channel and so long as they aren't doing worse than their competitors by that noise margin, they'll do fine. Which in practice means that they just pass along the costs.
- lotsofpulp 4y ago
  If insurers’ customers were not price sensitive, then they would have higher profit margins than 5%.
  - jjoonathan 4y ago
    The accusation here isn't that they are skimming a disproportionate amount, it's that they aren't doing their job, which is to put downwards pressure on provider prices.
    - lotsofpulp 4y ago
      The fact that there are at least 5 large insurers competing nationwide and all have 5% or less profit margins means there is lots of competition, and if they are not providing the best prices, their customers will go elsewhere. See pharmacy forums as an example for all the pharmacists complaining about how independent pharmacies are so tough to operate due to ever smaller payments from insurance companies for the past 10 years.
CoastalCoder 4y ago
I'm curious if this is a first step towards hospitals being required to charge the same prices to everyone, insured or otherwise.
- 31835843 4y ago
  This seems so sensible to me that I’m curious why the hell it wouldn’t work.
  - treis 4y ago
    Which price and who determines it?
    - CoastalCoder 4y ago
      I would think that hospitals could create price schedules similarly to how other businesses do. Although I imagine this gets really messy when dealing with Medicare and with the mandate to treat everyone regardless of their ability to pay. I'd expect those arrangements would need to change to make this work. I feel a bit silly pontificating about this. Hopefully someone who really understands the topic will weigh in.
      - deleted 4y ago
        [deleted]
    - spaetzleesser 4y ago
      The hospital determines a price and offers it to all comers. Most businesses work that way.
      - rootusrootus 4y ago
        I don't think it would work well. Hospitals are not a free market in most of the US. You have to get a Certificate of Need to set up a new one. Given the near monopoly they have in the local area, regulation is probably going to be required if nobody gets to negotiate.
rdxm 4y ago
daenz 4y ago
This is regulation everybody should be able to get behind. How are these markets supposed to function efficiently with healthy competition if critical information like this is hidden away?
- AdmiralAsshat 4y ago
  That would get in the way of unadulterated profit, you see.
  - ch4s3 4y ago
    Health insurers in the US have a cap on how much of premiums can go to profits.
    - wccrawford 4y ago
      Doesn't that just mean that they have an interest in keeping these costs high? The higher the costs, the larger that % is for the in absolute dollars. If all the costs come down, they are allowed to make less money.
      - nimish 4y ago
        Bingo. This is why they loved the ACA. Only allowed one scoop of ice cream? Great I'll use an enormous scoop.
        lotsofpulp 4y ago
        That enormous scoop results in 5% or less profit margins. Compare to tech companies’ profit margins.
        CogitoCogito 4y ago
        So? They're insurance companies. Why should they have high profit margins?
chevman 4y ago
Wait till you find out how much it actually costs doctors/providers to render some of these services! Do you like 90% margins? Doctors sure do! :)
- rr888 4y ago
  Doctors and Surgeons in America are incredibly highly paid. People love hating insurance and drug companies but the cost of people is driving much of the price.
  - haldujai 4y ago
    Disclaimer: I am a physician. Physician salaries represent a small fraction of overall healthcare costs. Nursing/allied health salaries make up the bulk of any hospital’s costs and are often bloated due to powerful unions physicians don’t have. For comparison, Canadian physicians are on average better compensated than American physicians. I practice radiology, a specialty often considered “overpaid” yet my compensation is only high because of the amount of advanced studies ordered in modern medicine. On a per study basis I get paid less and less every year yet scans are getting more and more complex (many studies on this). In addition the standard to which I am held to keeps rising and I spend a significant amount of time doing unpaid QA, following up on my reports to improve my ROC, and at least a few hours every week reading the latest publications in my sub specialty. The average diagnostic radiologist in the USA is grossing around 400k (no retirement fund, pension, and commonly no benefits). What is reasonable compensation in your opinion for someone who has finished 10+ years of post-undergrad training and accepts significant liability for every report (a radiologist at HMS missed a lung nodule on an X-ray and lost 16 million in court)?
    - rr888 4y ago
      My brother and his wife both are doctors in the UK. At 400k you earn about the same pay as 3 or 4 doctors there. https://www.bmj.com/careers/article/the-complete-guide-to-nhs-pay-for-doctors https://www.bmj.com/careers/article/the-complete-guide-to-nh.... To me that is a lot of money. I realize lots of tech wages are crazy high too, I dont understand that either.
logicalmonster 4y ago
Question to somebody who might know as this seems like a relevant thread to ask in. If a person wants to pay directly in cash/credit-card for services rendered by a doctor, do doctors' agreements with insurance companies generally prevent them from offering a cash discount to cash-paying patiences lower than the insurance company negotiated price?
- coredog64 4y ago
  If a doctor accepts Medicare patients, that sets a price floor for cash. Legally, if you accept Medicare money, you cannot offer anyone a better price than you charge Medicare.
- yardie 4y ago
  Yes, not only do they offer it but some insurers will give you credit card gift cards to help pay for treatment. That is how dysfunctional our medical system is at this moment. Providers will lock insurers at one rate, negotiate a different rate for self-insured that could be lower/higher. And insurers get wind of this and try to sneak pay the self rate.
  - Consultant32452 4y ago
    I use one of the "health share" providers instead of insurance. They have negotiated rates with providers but they literally instruct you not to reveal that, get the cash price invoice, and then they will take care of further negotiations if applicable. Presumably getting the cash price first lets them pick which they would prefer to pay: cash price or the negotiated rate. "Oh yeah, our customer forgot to inform you they qualify for this negotiated rate."
- pishpash 4y ago
  Sometimes they aren't allowed to offer a cash option at all, if you've told them you have insurance.
  - jjeaff 4y ago
    I have come across quite a few doctors that will not treat you at all if you don't have insurance.
dontcare007 4y ago
Thanks again President Trump!
- kstrauser 4y ago
  I'll admit, this is one thing, perhaps literally the only thing, he did that I think is excellent for individual Americans.
  - nicodjimenez 4y ago
    Yep. That, and space force, and cheap energy, and renegotiating trade agreements, and not starting any new wars.
    - BurningFrog 4y ago
      This is rapidly becoming a Monty Python sketch :)
    - sodality2 4y ago
      "Cheap energy" is not the boon you think it is. You have to consider other factors - deregulating the food industry and getting rid of the FDA would save millions of taxpayer's money, would lower prices of the supply chain and let consumers pay significantly less for food, yet would have drastic side effects. Cheap energy that requires deregulation, more alarming and precarious climate effects, etc might not be a net positive. Likewise, "not starting any new wars" can be perceived as bowing to foreign nations by anyone who wants to frame it negatively, or vice versa as an amazing success for diplomacy.
      - 0des 4y ago
        > "not starting any new wars" can be perceived as bowing to foreign nations This is an interesting take on peace in the middle east.
        sodality2 4y ago
pkaye 4y ago
Next step is pharmacies. Find out which step in the chain is overpricing. The manufacturers, PBMs or local pharmacies, etc.
- uoaei 4y ago
  I think we all already know it's all of them.
  - quarantaseih 4y ago
    Agreed, but admin is probably the greediest and while adding the least value.
  - corrral 4y ago
    I've been reading about healthcare systems off and on, sometimes fairly seriously, for over 15 years, and my conclusion about the entire US system is that "the problem" is "literally everyone involved". It's why various schemes that target one thing (say, excessively-expensive doctor liability insurance, which gets talked up as some super-big deal and a huge part of the problem in certain circles) are typically expected, on sober analysis, to have only a tiny effect on prices—everyone is taking too much money, at every level, so at most steps the % increase over what's reasonable isn't huge, but by the time you filter through a few layers of that with everyone piling atop the other layers, sure enough, it's a solid 30%-40% more expensive than it has any reason to be. But there's no one, or two, or even three things you can point at and say "if we fix this, we fix almost the entire problem". Every part of it needs a shake-up. It's like 20 different, though interrelated, problems, contributing to the bad result we see. Addressing most or all of the problem will take tens of measures, or else one big, sweeping, fundamental overhaul (M4A or what have you)
- fragmede 4y ago
  Hopefully this approach will help the situation: https://costplusdrugs.com/ https://costplusdrugs.com/
AceJohnny2 4y ago
Anecdote: I recently had my yearly glasses update. Cost was $188 to me + $20 of insurance copay, so the glasses provider charged $208 for the glasses. That's not too bad, so I asked how much it would be to replace/update the lenses on my old frames, entirely at my charge. It would've been $450. Just for the lenses. I passed. I find it scandalous how much they can charge when just before they were perfectly happy to accept less than half that amount. Instead I got another pair on EyeBuyDirect for $80. It's not just the insurers themselves, but the whole system. Burn it all down.
- zdragnar 4y ago
  They likely had lenses already available for the frames they had in stock, or were frequently making batches of them. OTOH the frames you already owned may be out of style, so they would have needed to grind a totally custom pair of lenses, just for you.
  - deleted 4y ago
    [deleted]
  - lostcolony 4y ago
    Nah. Outside of the vision cartel you can get replacement lenses for any pair of frames < $100, with all the various coatings and special shit for low hundreds. Likewise, using insurance to just replace the lenses, if a plan includes that, is often $50 or less. It's just shopping at the vision cartel without insurance = huge sticker price.
    - sib 4y ago
      Any tips for how to stay "outside the vision cartel"? (In the US, if that is relevant...)
      - atrus 4y ago
        zenni optical. I mostly use contacts, but I have several 'backup' glasses. You can get decent looks frame for like $11 shipped.
nonrandomstring 4y ago
"Doctors hate this simple trick to reduce <illness>." That's the strange spam message I could never understand. Surely doctors would be delighted at any method to improve health? So I always assumed the "trick" to be quackery with dangerous side effects. After all, why else would "doctors hate it"? Eventually I realised these messages are exclusively US American, the only place on the planet where doctors could plausibly resent people improving their health at the expense of their profits (or at least that's the implication that seems to rest on an entrenched cultural cynicism). Am I totally wrong?
- kube-system 4y ago
  You're overcomplicating your analysis. The purpose of ads is to generate attention. The message is effective for Americans for the same way that it is effective for you. It leaves the reader with multiple questions, which is more effective than an alternative phrasing which may leave someone with one or zero questions. Those ads are not posted by medical professionals, they're posted by scam operations. Healthcare in the US uses specialized labor just like any other developed nation. US doctors are not concerned with financial operations, they're focused on clinical duties. For any typical hospital, the people who do anything with finance or billing are not even in the same building as doctors.
- vorpalhex 4y ago
  You are totally wrong. Quackery exists all over the EU and other socialized systems. The idea that you can fix issues by drinking water or vinegar instead of going through Chemo or surgery has always been an easy sell to the gullible.
  - nonrandomstring 4y ago
    So you're saying my initial interpretation is the correct one? "Doctors hate this" because it's fake and leads people to false hope and ineffective outcomes? But I'm still confused. Other than as an arresting "attention grab" (as another commenter says) why would someone advertise a product by denigrating it, even semi-ironically?
macksd 4y ago
I've lost count of all the problems I've had with medical billing. I can't understand an argument against public pricing because it seems like a clear win if you believe in free market dynamics or progressive reformation of the health care system. But it seems to me the system is just rotten to the core anyway. It makes even my Libertarian self want single-payer healthcare, but I have no expectation the set of people currently working in the system would do anything but keep it rotten. In the most recent case I tried to get a written quote for procedures because of past problems. I was given the run-around until all I could get was a verbal quote over the phone. But if that wasn't good enough, my only recourse was to delay getting a suspicious lump examined. I was then charged more than I was quoted, and I was even billed for procedures they didn't do. I actually heard one of the employees say "I added that because I thought he was using insurance". Still - hours of phone calls over several weeks before they would even bill me correctly without adding tests that they had no results from. And even then - more expensive than they told me because the person I was transferred to over the phone was in a different state than the clinic I called in the first place. Absolutely rotten.
- bushbaba 4y ago
  Don’t forget all that time spent on the healthcare side. Easily 10%+ of the cost of operation.
BryanBeshore 4y ago
Now tell me about the relationship between health insurers and hospitals, and how they engage in pricing.
smm11 4y ago
Very soon we'll have Congressional hearings after oil companies see profits climb 7000 percent over last year, and they'll look sad and do nothing. I expect much the same from health insurance companies.
- pkaye 4y ago
  I'd be curious how their profits compare to pre covid profits given then many oil companies were losing a lot during covid due to sharp drop in demand.
  - boston_clone 4y ago
    Thankfully, that data is public. [0] And it's still damning. Billions of dollars of profit were made, every single quarter. I have absolutely no sympathy for these companies, especially when they also likely received huge sums of cash from the federal government for this "sharp drop in demand". >Over 10 percent of the more than 7,000 oil, gas, and petrochemical companies that received PPP funds totaling between $3 billion and $6 billion reported no jobs retained as a result of the loan. The CEOs of Exxon and Chevron got raises in 2020, while Exxon announced that it is suspending the company’s contribution to the US employee retirement savings plan beginning in October and Chevron is cutting 6,700 workers around the globe [1] 0. https://www.macrotrends.net/stocks/charts/XOM/exxon/gross-profit https://www.macrotrends.net/stocks/charts/XOM/exxon/gross-pr... 1. https://www.sierraclub.org/sierra/bailout-billions-dollars-federal-covid-19-relief-money-flow-oil-industry https://www.sierraclub.org/sierra/bailout-billions-dollars-f...
imperio59 4y ago
Not to get political, but pretty sure this is thanks to one of Trump's last executive orders while he was in office. Correct me if I'm wrong
- deleted 4y ago
  [deleted]
- UberFly 4y ago
  You are correct.
bushbaba 4y ago
This will be huge! I’ve found that self paying can be 1/nth the cost of paying through my insurance. But you need to request self pay up front. Being able to better understand prices before hand will drastically help people reduce their healthcare costs.
- dwringer 4y ago
  I've seen the exact opposite of this - the self pay option would cost (for example) $300 while insurance would only get billed $150 for the exact same procedure. In the case I saw it, that meant the insurance paid out something like $12 and I was on the hook for the remaining $138. Which is roughly the same I would have owed if insurance had been billed the full amount and paid out the remaining $162.
benreesman 4y ago
This would be great news in a world where healthcare company revenue (which never quite trickles all the way down to retail shareholders) wasn’t just a one-way wratchet. More opaque: costs more. More transparent: costs more. Want a better deal? Choose better parents pleb.
dimal 4y ago
I'm not a fan of Trump, but I have to admit, the executive order [0] that forced this disclosure looks fantastic, really fantastic. But if I'm reading it right, it seems like it's just an order to _enforce_ requirements ObamaCare that were intended to increase transparency.[1] Obama and Trump actually accomplished something _together_! [0] https://www.federalregister.gov/documents/2017/10/17/2017-22677/promoting-healthcare-choice-and-competition-across-the-united-states https://www.federalregister.gov/documents/2017/10/17/2017-22... [1] https://www.federalregister.gov/documents/2020/11/12/2020-24591/transparency-in-coverage#footnote-9-p72160 https://www.federalregister.gov/documents/2020/11/12/2020-24...
- yieldcrv 4y ago
imwillofficial 4y ago
I hope this becomes the norm all over
nazka 4y ago
Do you think this can have med to long term effect on revenues earnings and so stocks?
epgui 4y ago
IMO, as a non-affected Canadian, this is one of the (very few) good outcomes of the Trump presidency.
alanfriedman 4y ago
For anyone looking to download the data, here are a few links: Empire Blue (Anthem): https://www.empireblue.com/machine-readable-file/search/ https://www.empireblue.com/machine-readable-file/search/ United Healthcare: https://transparency-in-coverage.uhc.com/ https://transparency-in-coverage.uhc.com/ Aetna (Seems like the right page, but I don't see any download links — possibly because they haven't been posted yet): https://health1.aetna.com/app/public/#/one/insurerCode=AETNACVS_I&brandCode=ALICSI/machine-readable-transparency-in-coverage?searchTerm=279439&lock=true https://health1.aetna.com/app/public/#/one/insurerCode=AETNA... Search keywords: https://www.google.com/search?q=machine+readable+files+transparency+in+coverage https://www.google.com/search?q=machine+readable+files+trans...
- nope96 4y ago
  Blue Cross https://www.bcbsil.com/member/policy-forms/machine-readable-file https://www.bcbsil.com/member/policy-forms/machine-readable-... So are there programs I can use to parse this? It looks like a json file with links to more gziped json files...
  - throwaway743 4y ago
    ...it is unfortunately. If you know a language you could run through it. Otherwise ypu might be able to find something like a json to csv converter online
  - loxias 4y ago
    > It looks like a json file with links to more gziped json files Yup! Should be pretty easy to whip up a parser, it's just JSON and HTTP, you could do it in shell if you cared to. The challenge is what are you parsing it _to_. That is to say, what's your data model. I'd choose that first, then worry about parsing.
- loxias 4y ago
  Thank you thank you thank you! Here's Cigna: https://www.cigna.com/legal/compliance/machine-readable-files https://www.cigna.com/legal/compliance/machine-readable-file... UCLA Health keeps theirs: https://uclahealth.s3-us-west-1.amazonaws.com/price-transparency/rr-sm-machine-readable-2022.json https://uclahealth.s3-us-west-1.amazonaws.com/price-transpar... But sadly, still can't find my insurance company's download links. I can't wait to lose a weekend doing something with this data, it's a dream dataset and a perfect example of a very narrow type of project I love doing. Is there a canonical list of the major insurance companies?
PaulDavisThe1st 4y ago
Can anyone provide any hints on the search keywords to find this data at a given insurer's website?
stevebmark 4y ago
This happened for hospitals too, and not much has changed. Cryptic billing codes will make this data hard to understand.
deleted 4y ago
[deleted]
kazinator 4y ago
> Even after the pricing data is public, “I don’t think things will change overnight,” said Leibach. “Patients are still going to make care decisions based on their doctors and referrals, a lot of reasons other than price.” Ah, but in the USA, there are a lot of uninsured people who end up paying cash for stuff. And there is a corruption problem in that individuals who pay for services and materials get ripped off compared to what insurance pays behalf of an insured patient. I would expect that this will have an almost instant beneficial effect for some of the uninsured or under-insured. It will be harder to charge them $500 for something that insurance pays $250 for in plain view. People will go back and complain, asking for rebates even after paying.
IG_Semmelweiss 4y ago
I work in healthcare. Here is an exchange I had with a major hospital about standard surgery (one of those deemed "Shoppable services") earlier this year. This exchange was possible after I was able to get an email recipient, following a 30min conversation. >>>> Hello! I was told by the very helpful Ms. XXX, that you would be able to provide patient responsibility amount , related to CPT codes for XXX procedure. I am attaching front and back of my insurance card (Payor). The member DOB is MM/DD/YY The specific 2 codes in question are : CPT 12345 CPT 01234 Can you please provide the total cost and patient resp. for the CPTs above? ___________________________________________________________ Response: Good morning, >>>>>The hospital does not process estimates for patients with insurance coverage. However, our web portal contains charges under the Hospital Price Transparency link. I have included the link in the subject line for easy access. [comment: This link was broken. After much browsing.. I was able to find an alternate route. The linked file turned out to be a JSON. I couldn't figure that one out] As far as out-pocket responsibility, your insurance company is the best source for that information; they will advise if you have any copay for the encounter. _______ Read the 1st sentence of the reply again. My blood still boils from that...
- JohnBjorge 4y ago
  This sounds about right. I've worked in the healthcare tech world for about 5 years on both sides (for providers and payors). I totally empathize with how annoying it is that essentially no one processes estimates for patients with insurance. There are some places though that do, and it tends to be small/medium size specialty practices (think orthopedics, ophthalmology, radiology) in forward thinking places (Seattle, Minneapolis, etc). I can give some technical reasons as to "why" they can't/won't give you an estimate. I'm not saying these are legitimate reasons, just stating what I've seen. One reason they may not want to give you an estimate is because depending on what happens during your visit/procedure, the codes that get billed could change quite a bit. Because of this their initial estimate could be wildly different. In addition to the procedure codes changing, there are modifiers/adjustments that can get applied to a procedure code depending on what happens during the procedure (which adds another level of uncertainty). For example, anesthesia often bills based on time and complexity. If the procedure runs long then it will cost more, if something goes wrong and the complexity increases then it will cost more, if a nurse anesthetist (CRNA) does your anesthesia rather than an MD it will cost less, etc. Another reason they may not want to give you an estimate is because they have no idea. This is in my experience the case most of the time. A given clinic/hospital is going to have many many contracts with many payors. There's a ton of nuance in these contracts and they are sometimes extremely complicated. I've read hundreds of these contracts and written software to try to scale price estimate tools for patients. It's really hard, happy to dive into it more if there's interest. I often see comments on hackernews along the lines of "it's just a fee schedule, how hard is it to put it in a database and select amount from feeschedule where procedure = 99215". The big wrinkle here is the contracts. The contracts are often times super complicated, dependent on many many different fee schedules and pricing methodologies. The fee schedules/pricing methodologies may be from the payor, they may be from 3rd party vendors, they may be proprietary, they may be based on medicare, etc. Then there's a whole slew of adjustments/modifiers that can trigger depending on tons of different events and combinations of procedures codes that may appear on a claim. Another reason they may not want to give you an estimate is because it's not straightforward to verify your insurance. There are clearinghouses that aggregate benefits data from major payors, but the data is kind of shoddy. It may return your insurance is active when it really is inactive. It may have bad data on what is covered vs not covered, what your deductible, coinsurance, etc are so given all this data is kind of unreliable then giving an estimate becomes pretty unreliable. Anyway, these were a few reasons off the top of my head. Again, I want to emphasize I'm 100% with you on how annoying it is that we can't get estimates. I spent 3 years literally trying to solve this problem, and we actually made really good progress if it gives you any hope that things will maybe (fingers crossed) get better overtime. I just wanted to give some context / spark some conversation around these contracts and why they are challenging from a technical perspective to automate price estimates.
kkrbalam 4y ago
Why nobody ever talks about how much doctors are overpaid and over valued in this country? Why always demonize insurance companies? I was in an ER for 7 days, I only saw the doctor 2 times for less than 5 mins each. In the final bill, the most expensive line item was doctor consultation.

766 points by nojito 4y ago

I'm one of the co-founders of Turquoise Health, mentioned in the article here. We've been downloading and parsing this data all day. It's a really big deal in the industry that the prices that insurance companies pay doctors are now being shared publicly. It will have all sorts of positive impacts over time, hopefully making rate negotiations more consistent and fair between different insurance plans. Right now, 10x differences in prices paid for the same healthcare service from the same doctor between insurance plans is not uncommon.

WFHRenaissance 4y ago
What do you serve to gain from scraping all of this information?
- jjoonathan 4y ago
  The information on their landing page was immediately relevant to me https://turquoise.health/ https://turquoise.health/ I hope they have a good business plan and manage to stick around!
  - ageitgey 4y ago
    Thanks! So far, so good. We don't sell anything to consumers. Our products are aimed at the healthcare industry which lets us post information for consumers for free and we have pretty good product-market fit. Obligatory "if anyone is interested in joining a fast growing, series A company doing impactful work, hit up our careers page!"
    - atlasunshrugged 4y ago
      Interesting, I'm curious since you're in the industry, why do you think medical tourism has never taken off in a big way in the U.S.? I feel like I saw more people willing to go to Poland or Ukraine for things like dental work when I lived in Europe than people in the U.S. willing to go to Mexico or some other destination.
      - Red_Leaves_Flyy 4y ago
        Not the person you asked. I want my medical providers to be local to me so they’re liable to my local community. I also want to keep my organs and have insurance cover the costs.
      - ageitgey 4y ago
        The US is really, really large and many people living there have never left it. There's also a belief that US healthcare is the gold standard (which is probably true at the very high end, but not necessarily on average). In other words, it's a hard sell to convince a factory worker to travel 5-10 hours on a plane to a place they have no familiarity with to get what they believe to be inferior treatment. They might not even have a passport. This is much less of an issue in Europe where countries are tiny and almost everyone travels between them on a regular basis. Also, medical tourism is mostly limited to what the industry calls Shoppable Services - outpatient treatments that are not emergent/not life threatening. There is a bit of a cottage industry in Mexico for some services, like bariatric surgery for obesity or dental work, but it isn't a huge volume. The really expensive stuff in the US is emergency treatment which you can't shop for anyway. All that said, I think the interest in buying prescriptions from overseas has never been higher.
      - rootusrootus 4y ago
        Anecdotally, most of the people in my circle of friends and family are perfectly satisfied with what we get locally. If you have adequate insurance and no major medical issues, you don't save much by flying down to Mexico. I do have some extended family that have gone to Mexico for treatment, however, mostly of the dental variety. But it was major reconstruction, so it was worth the effort. I do remember reading a story a couple years back where an insurance company paid for their customer to fly to Mexico, flew down a US orthopedic surgeon, and paid him pretty well for his services. The cost of the flights, surgeon, and medical facility in Mexico were significantly less than it would cost them in the US, so everybody won except the US hospital. As I recall, the hospital in Mexico was collocated with a resort, so it was a nice place to recuperate as well. Not sure how common that really is, though, stories like that make the news for a reason. Edit: Pretty sure this is the story I was thinking about: https://www.advisory.com/daily-briefing/2019/08/13/cancun https://www.advisory.com/daily-briefing/2019/08/13/cancun
    - wildrhythms 4y ago
      How does the healthcare industry use this data typically?
- ageitgey 4y ago
  Our industry-focused products are based on knowing how much every service costs at every healthcare provider. It's the underpinning of our products. We also post a lot of the rates publicly in a consumer-friendly searchable format, but we don't charge any money for that. But this data will let us greatly expand the scope of that free service.
- dugmartin 4y ago
  I was guessing it was this bit at the bottom of their landing page: > Are you a transparent provider or payer? > There is a market for transparency. Let patients find you by claiming > your provider page and listing your services. It only takes 10 minutes. But following through that link says it is a free program.
  - ageitgey 4y ago
    We build products that help healthcare providers and insurance companies broker contracts between themselves based on actual market information instead of guessing at prices. The goal is to drive down prices by making the market more efficient. Part of that is assuming that prices will be public, so we encourage them to claim their own page and take control of the rates listed there.
nullfield 4y ago
Where is the - if it exists - list of locations where different entities have published their machine-readable files?
elromulous 4y ago
Could this backfire - similarly to how publicly traded companies' CEOs disclosing their pay caused their pay to skyrocket?
- huitzitziltzin 4y ago
  This is a good question and the answer is absolutely yes. It could raise prices. Consumers have some incentive to care how much they are spending on health care, but they aren't generally the claimant on savings they realize for their insurance plans. (Obviously the incentives for uninsured or self-insured patients (to the extent that there's anyone in the latter category) are quite different, but those populations are small.) On the other hand, every hospital has a strong, strong incentive to care a lot about how much their competitors are getting for the same procedures. (Much more than consumers, for example.) It's possible that these disclosures lead to prices falling as hospitals seek to undercut each other. However, most US hospital markets feature a small number of competing hospital systems in an oligopoly. The price-cutting pressures in such markets are much, much weaker. There is a "mutually assured destruction" aspect to price competition in such markets which may keep prices from falling. The latter incentive can raise prices too. IF you know your competitors across town are getting an extra $5,000 for a knee replacement and you know that the two of you are the only game in town for hospitals, you may raise your prices rather than lowering them. On balance I think this is the right policy, in part because I want this data myself as a researcher. But it is not unambiguous that this will lead to price reductions. Source: am a health economist.
- marricks 4y ago
  Can you support that claim? I couldn't find when CEO pay went public but it sounds very likely like one of those causes were correlation definitely doesn't imply causation.
  - zeruch 4y ago
    All CEO pay for public companies is exposed in the 10Ks. What I suspect the person was referring to is the change where compensation became more tied to equity valuation.
sinab 4y ago
Where are health providers hosting these data? Could you give an example? Thank you.
treeman79 4y ago
A few times I’ve seen a 10x price decrease when I asked to pay cash before. Sometimes the co-pay alone is more then cash for procedure. Weekly injections and MRIs is the worst offenders I’ve seen.
snarf21 4y ago
We really need to move to reference based pricing. We can cut so much waste out of the current system including brokers. Reference based pricing also get rids of the loopholes for things like anesthesiologists being "out of network" at a hospital/facility that is "in network". It also gets rid of the situation where if you offer cash you get one price but if you submit for the same code, it could be 3x or 10x or even more.
- whatshisface 4y ago
  What's reference-based pricing?
  - antisthenes 4y ago
    It's basically price-controls. A regulatory body looks at how much something "should" cost based on its history of reimbursement and the cost of its inputs and then sets a cap of say, cost + 20%. The problem is having an independent body that is free of influence of health insurance companies and hospitals, both of which have perverse incentives to continue profiteering.
    - db48x 4y ago
      Not to mention the fact that it will eventually cause a supply shortage.
      - alxhill 4y ago
        Germany has reference pricing for their drugs system and doesn't seem to have a supply issue. Genuine question, is there something that makes you think that wouldn't be true for the US?
        whatshisface 4y ago
        How would anyone notice a shortage when shortages came in the from of it not being standard practice to prescribe a medicine in a certain situation?
tomrod 4y ago
Very cool work! The article mentions that yall are working on hospital data. Is insurer data beginning to roll in?
baby 4y ago
Another proof that more transparency decreases corruption and improves efficiency?
- BurningFrog 4y ago
  Once it's been shown to work it may be proof. The track record of healthcare reforms intended to cut costs is rather abysmal.
  - epgui 4y ago
    Does it really need to be proved? I'd argue that it's a mathematical/logical truth in principle, and that the only thing that requires proof is whether this particular implementation is successful at what it aims to do.
  - spaetzleesser 4y ago
    That may be true but the first prerequisite for functioning markets is price transparency for participants. Without that it will never work. There may be other problems but you absolutely need to know prices.
antisthenes 4y ago
Are you guys hiring?
- missedthecue 4y ago
  Look like it https://turquoise.health/careers https://turquoise.health/careers
jerry1979 4y ago
How do you account for case-based charges?
codegeek 4y ago
I appreciate what you all are doing. We need people to try and really fix our Healthcare Industry. However, I do have a question. Are you trying to get rid of Insurance mafia at all for at least some things like basic preventive care etc because I am sure that drives costs up a lot if Insurance companies are always between a doctor and a patient. I really hope something can be done where I can just go to a doctor/hospital, ask how much and pay for it out of pocket instead of crazy premiums and all the other BS we have to go through everytime.
- nradov 4y ago
  Most healthcare providers are happy to accept cash payments from patients. You can sometimes even negotiate a discount. If you have a medical plan subject to the Affordable Care Act then most preventive care is already fully covered at no cost to the patient. https://www.healthcare.gov/coverage/preventive-care-benefits/ https://www.healthcare.gov/coverage/preventive-care-benefits...
  - indymike 4y ago
    > Most healthcare providers are happy to accept cash payments from patients. You can sometimes even negotiate a discount. Actually, if you don't have insurance, you get the special cash price of $Maximum. /been there //tried that.
    - adventured 4y ago
      I have also been there and tried that, extensively. That's the opposite experience of what I encountered in paying by cash for more than a decade. Typically I'd pay around half price via cash for healthcare services (routine doctor visits, scans, et al.) versus what they charged if you had insurance. I never ran into a situation where they wouldn't negotiate steep discounts for paying by cash.
      - indymike 4y ago
        Yes, it works for routine stuff, but don't try to pay cash for abdominal surgery. You will get a very terrible, high price. After all, it's agree to our low price or die of appendicitis.
FollowingTheDao 4y ago
Sorry, but the only thing that will help is Medicare for all. We need to get rid of insurance companies completely.
- KyeRussell 4y ago
  Non-American here: your healthcare system is so abysmal that you could stop short of implementing Medicare for all and still have a significantly improved system. You should obviously have Medicare for all, but let’s not kid ourselves about how far from that you are.
- Steko 4y ago
  Lots of countries have great systems that aren't single payer.
- refurb 4y ago
  Should Europe get rid of their insurers too?
  - hansel_der 4y ago
    as european i am not entirely convinced that it makes sense to have hundreds of companies providing the same heavily regulated service. if there were too few of those i would probably also object. idk about the situation where there are no private companies involved at all and the government takes over healthcare top to bottom because on the one hand i see a massive problem with for profit healtcare as it is and on the other hand i can see how incentives would wither away if there is no drive for efficiency at all.
spaetzleesser 4y ago
“Right now, 10x differences in prices paid for the same healthcare service from the same doctor between insurance plans is not uncommon.” Makes me wonder how things got to this point. How can a business perform any planning if they sell their services with such big differences between prices charged to customers?
- pc86 4y ago
  Over time the higher paying ones subsidize the lower ones. Due to this we'll see some people's insurance premiums increase, some decrease, and some insurance providers probably go out of business (all good IMO).
- 29athrowaway 4y ago
  Short answer is: because they can. And they can because there's a lack of transparency that makes people believe this is OK.
- refurb 4y ago
  The honest answer is because that’s what insurer negotiation had led to with hospitals having using their negotiating position. If you’re a hospital in an area with standalone MRI clinics the negotiation pressure is high, insurers can say “ill send patients elsewhere”, so you give on price, maybe below cost. But that same hospital is the only cath lab in 100 miles. Great! We’ll just tell the insurer “we’re charging 300% the normal cost of a cath procedure, take it or leave it”. So the insurer takes it because how can you offer insurance and tell customer they have to drive 100 miles for a heart procedure? Hospital is happy because they’re profitable overall. Insurer just lives with paying 3x for cath procedures in that area.
  - datavirtue 4y ago
    Hospitals don't let you obtain imaging elsewhere. They force you to use their imaging services--full stop.
    - refurb 4y ago
shostack 4y ago
My dentist dropped my insurer (Delta Dental) because they claim they did not cover things as reliably as they should. When I saw a comparison bill of what it would be in and out of network for a recent service it looked like the 60% increase in price was purely because my dentist billed more, which they then claimed is due to the discount The insurer provides. None of this makes sense to me. How can I leverage this new data access to my advantage?
- Akronymus 4y ago
  > When I saw a comparison bill of what it would be in and out of network for a recent service it looked like the 60% increase in price was purely because my dentist billed more, which they then claimed is due to the discount The insurer provides. Well, rebates kinda DO end up working like that. https://www.youtube.com/watch?v=uPa-RHVh97k https://www.youtube.com/watch?v=uPa-RHVh97k https://www.youtube.com/watch?v=_4_WNFPnmO8 https://www.youtube.com/watch?v=_4_WNFPnmO8
- neycoda 4y ago
  People keep complaining government is too complicated and too expensive and bafoonish, yet they don't see how corporations are no different except their priority is maximizing profit not providing cost-efficient quality.
  - janekm 4y ago
    The point (in theory) is that in efficient markets you can choose between different companies offering a product/service and that competition drives down prices / costs. The healthcare market in the US is very much not a competitive market (in part due to transparency issues which this is trying to address, in part because of the perverse incentives in the health insurance system). It's not so easy to have a competitive marketplace for government services (though I would not be surprised if the US saw the emergence of private police forces now, for those parents who actually want police officers that have a duty to protect their kids...)
    - feet 4y ago
Zenst 4y ago
How well will their data be audited and enforced? For example if they charge one price and yet their public data purports another price? More so will they cut the drug prices internally and shift the difference onto an administration fee? That is one aspect I'm very mindful of.

Olreich 4y ago

> “What we’re learning from the hospital data is that insurers are really bad at negotiating” Do the insurers have any incentive to negotiate well? Since their customers are not very price-sensitive (since they aren't marketing directly to patients or doctors), I would imagine they don't have a huge incentive to do anything but apply a markup to whatever prices the hospital tells them it costs.

MrFantastic 4y ago
Private Healthcare is the Classic Agency Problem.
jjoonathan 4y ago
Well, if they can negotiate a particular incident down then they pay less for it, but in the long run big picture you're exactly right. So long as they can inject noise into the plan shopping channel and so long as they aren't doing worse than their competitors by that noise margin, they'll do fine. Which in practice means that they just pass along the costs.
lotsofpulp 4y ago
If insurers’ customers were not price sensitive, then they would have higher profit margins than 5%.
- jjoonathan 4y ago
  The accusation here isn't that they are skimming a disproportionate amount, it's that they aren't doing their job, which is to put downwards pressure on provider prices.
  - lotsofpulp 4y ago
    The fact that there are at least 5 large insurers competing nationwide and all have 5% or less profit margins means there is lots of competition, and if they are not providing the best prices, their customers will go elsewhere. See pharmacy forums as an example for all the pharmacists complaining about how independent pharmacies are so tough to operate due to ever smaller payments from insurance companies for the past 10 years.

CoastalCoder 4y ago

I'm curious if this is a first step towards hospitals being required to charge the same prices to everyone, insured or otherwise.

31835843 4y ago
This seems so sensible to me that I’m curious why the hell it wouldn’t work.
- treis 4y ago
  Which price and who determines it?
  - CoastalCoder 4y ago
    I would think that hospitals could create price schedules similarly to how other businesses do. Although I imagine this gets really messy when dealing with Medicare and with the mandate to treat everyone regardless of their ability to pay. I'd expect those arrangements would need to change to make this work. I feel a bit silly pontificating about this. Hopefully someone who really understands the topic will weigh in.
    - deleted 4y ago
      [deleted]
  - spaetzleesser 4y ago
    The hospital determines a price and offers it to all comers. Most businesses work that way.
    - rootusrootus 4y ago
      I don't think it would work well. Hospitals are not a free market in most of the US. You have to get a Certificate of Need to set up a new one. Given the near monopoly they have in the local area, regulation is probably going to be required if nobody gets to negotiate.

rdxm 4y ago

daenz 4y ago

This is regulation everybody should be able to get behind. How are these markets supposed to function efficiently with healthy competition if critical information like this is hidden away?

AdmiralAsshat 4y ago
That would get in the way of unadulterated profit, you see.
- ch4s3 4y ago
  Health insurers in the US have a cap on how much of premiums can go to profits.
  - wccrawford 4y ago
    Doesn't that just mean that they have an interest in keeping these costs high? The higher the costs, the larger that % is for the in absolute dollars. If all the costs come down, they are allowed to make less money.
    - nimish 4y ago
      Bingo. This is why they loved the ACA. Only allowed one scoop of ice cream? Great I'll use an enormous scoop.
      - lotsofpulp 4y ago
        That enormous scoop results in 5% or less profit margins. Compare to tech companies’ profit margins.
        CogitoCogito 4y ago
        So? They're insurance companies. Why should they have high profit margins?

chevman 4y ago

Wait till you find out how much it actually costs doctors/providers to render some of these services! Do you like 90% margins? Doctors sure do! :)

rr888 4y ago
Doctors and Surgeons in America are incredibly highly paid. People love hating insurance and drug companies but the cost of people is driving much of the price.
- haldujai 4y ago
  Disclaimer: I am a physician. Physician salaries represent a small fraction of overall healthcare costs. Nursing/allied health salaries make up the bulk of any hospital’s costs and are often bloated due to powerful unions physicians don’t have. For comparison, Canadian physicians are on average better compensated than American physicians. I practice radiology, a specialty often considered “overpaid” yet my compensation is only high because of the amount of advanced studies ordered in modern medicine. On a per study basis I get paid less and less every year yet scans are getting more and more complex (many studies on this). In addition the standard to which I am held to keeps rising and I spend a significant amount of time doing unpaid QA, following up on my reports to improve my ROC, and at least a few hours every week reading the latest publications in my sub specialty. The average diagnostic radiologist in the USA is grossing around 400k (no retirement fund, pension, and commonly no benefits). What is reasonable compensation in your opinion for someone who has finished 10+ years of post-undergrad training and accepts significant liability for every report (a radiologist at HMS missed a lung nodule on an X-ray and lost 16 million in court)?
  - rr888 4y ago
    My brother and his wife both are doctors in the UK. At 400k you earn about the same pay as 3 or 4 doctors there. https://www.bmj.com/careers/article/the-complete-guide-to-nhs-pay-for-doctors https://www.bmj.com/careers/article/the-complete-guide-to-nh.... To me that is a lot of money. I realize lots of tech wages are crazy high too, I dont understand that either.

logicalmonster 4y ago

Question to somebody who might know as this seems like a relevant thread to ask in. If a person wants to pay directly in cash/credit-card for services rendered by a doctor, do doctors' agreements with insurance companies generally prevent them from offering a cash discount to cash-paying patiences lower than the insurance company negotiated price?

coredog64 4y ago
If a doctor accepts Medicare patients, that sets a price floor for cash. Legally, if you accept Medicare money, you cannot offer anyone a better price than you charge Medicare.
yardie 4y ago
Yes, not only do they offer it but some insurers will give you credit card gift cards to help pay for treatment. That is how dysfunctional our medical system is at this moment. Providers will lock insurers at one rate, negotiate a different rate for self-insured that could be lower/higher. And insurers get wind of this and try to sneak pay the self rate.
- Consultant32452 4y ago
  I use one of the "health share" providers instead of insurance. They have negotiated rates with providers but they literally instruct you not to reveal that, get the cash price invoice, and then they will take care of further negotiations if applicable. Presumably getting the cash price first lets them pick which they would prefer to pay: cash price or the negotiated rate. "Oh yeah, our customer forgot to inform you they qualify for this negotiated rate."
pishpash 4y ago
Sometimes they aren't allowed to offer a cash option at all, if you've told them you have insurance.
- jjeaff 4y ago
  I have come across quite a few doctors that will not treat you at all if you don't have insurance.

dontcare007 4y ago

Thanks again President Trump!

kstrauser 4y ago
I'll admit, this is one thing, perhaps literally the only thing, he did that I think is excellent for individual Americans.
- nicodjimenez 4y ago
  Yep. That, and space force, and cheap energy, and renegotiating trade agreements, and not starting any new wars.
  - BurningFrog 4y ago
    This is rapidly becoming a Monty Python sketch :)
  - sodality2 4y ago
    "Cheap energy" is not the boon you think it is. You have to consider other factors - deregulating the food industry and getting rid of the FDA would save millions of taxpayer's money, would lower prices of the supply chain and let consumers pay significantly less for food, yet would have drastic side effects. Cheap energy that requires deregulation, more alarming and precarious climate effects, etc might not be a net positive. Likewise, "not starting any new wars" can be perceived as bowing to foreign nations by anyone who wants to frame it negatively, or vice versa as an amazing success for diplomacy.
    - 0des 4y ago
      > "not starting any new wars" can be perceived as bowing to foreign nations This is an interesting take on peace in the middle east.
      - sodality2 4y ago

pkaye 4y ago

Next step is pharmacies. Find out which step in the chain is overpricing. The manufacturers, PBMs or local pharmacies, etc.

uoaei 4y ago
I think we all already know it's all of them.
- quarantaseih 4y ago
  Agreed, but admin is probably the greediest and while adding the least value.
- corrral 4y ago
  I've been reading about healthcare systems off and on, sometimes fairly seriously, for over 15 years, and my conclusion about the entire US system is that "the problem" is "literally everyone involved". It's why various schemes that target one thing (say, excessively-expensive doctor liability insurance, which gets talked up as some super-big deal and a huge part of the problem in certain circles) are typically expected, on sober analysis, to have only a tiny effect on prices—everyone is taking too much money, at every level, so at most steps the % increase over what's reasonable isn't huge, but by the time you filter through a few layers of that with everyone piling atop the other layers, sure enough, it's a solid 30%-40% more expensive than it has any reason to be. But there's no one, or two, or even three things you can point at and say "if we fix this, we fix almost the entire problem". Every part of it needs a shake-up. It's like 20 different, though interrelated, problems, contributing to the bad result we see. Addressing most or all of the problem will take tens of measures, or else one big, sweeping, fundamental overhaul (M4A or what have you)
fragmede 4y ago
Hopefully this approach will help the situation: https://costplusdrugs.com/ https://costplusdrugs.com/

AceJohnny2 4y ago

Anecdote: I recently had my yearly glasses update. Cost was $188 to me + $20 of insurance copay, so the glasses provider charged $208 for the glasses. That's not too bad, so I asked how much it would be to replace/update the lenses on my old frames, entirely at my charge. It would've been $450. Just for the lenses. I passed. I find it scandalous how much they can charge when just before they were perfectly happy to accept less than half that amount. Instead I got another pair on EyeBuyDirect for $80. It's not just the insurers themselves, but the whole system. Burn it all down.

zdragnar 4y ago
They likely had lenses already available for the frames they had in stock, or were frequently making batches of them. OTOH the frames you already owned may be out of style, so they would have needed to grind a totally custom pair of lenses, just for you.
- deleted 4y ago
  [deleted]
- lostcolony 4y ago
  Nah. Outside of the vision cartel you can get replacement lenses for any pair of frames < $100, with all the various coatings and special shit for low hundreds. Likewise, using insurance to just replace the lenses, if a plan includes that, is often $50 or less. It's just shopping at the vision cartel without insurance = huge sticker price.
  - sib 4y ago
    Any tips for how to stay "outside the vision cartel"? (In the US, if that is relevant...)
    - atrus 4y ago
      zenni optical. I mostly use contacts, but I have several 'backup' glasses. You can get decent looks frame for like $11 shipped.

nonrandomstring 4y ago

"Doctors hate this simple trick to reduce <illness>." That's the strange spam message I could never understand. Surely doctors would be delighted at any method to improve health? So I always assumed the "trick" to be quackery with dangerous side effects. After all, why else would "doctors hate it"? Eventually I realised these messages are exclusively US American, the only place on the planet where doctors could plausibly resent people improving their health at the expense of their profits (or at least that's the implication that seems to rest on an entrenched cultural cynicism). Am I totally wrong?

kube-system 4y ago
You're overcomplicating your analysis. The purpose of ads is to generate attention. The message is effective for Americans for the same way that it is effective for you. It leaves the reader with multiple questions, which is more effective than an alternative phrasing which may leave someone with one or zero questions. Those ads are not posted by medical professionals, they're posted by scam operations. Healthcare in the US uses specialized labor just like any other developed nation. US doctors are not concerned with financial operations, they're focused on clinical duties. For any typical hospital, the people who do anything with finance or billing are not even in the same building as doctors.
vorpalhex 4y ago
You are totally wrong. Quackery exists all over the EU and other socialized systems. The idea that you can fix issues by drinking water or vinegar instead of going through Chemo or surgery has always been an easy sell to the gullible.
- nonrandomstring 4y ago
  So you're saying my initial interpretation is the correct one? "Doctors hate this" because it's fake and leads people to false hope and ineffective outcomes? But I'm still confused. Other than as an arresting "attention grab" (as another commenter says) why would someone advertise a product by denigrating it, even semi-ironically?

macksd 4y ago

I've lost count of all the problems I've had with medical billing. I can't understand an argument against public pricing because it seems like a clear win if you believe in free market dynamics or progressive reformation of the health care system. But it seems to me the system is just rotten to the core anyway. It makes even my Libertarian self want single-payer healthcare, but I have no expectation the set of people currently working in the system would do anything but keep it rotten. In the most recent case I tried to get a written quote for procedures because of past problems. I was given the run-around until all I could get was a verbal quote over the phone. But if that wasn't good enough, my only recourse was to delay getting a suspicious lump examined. I was then charged more than I was quoted, and I was even billed for procedures they didn't do. I actually heard one of the employees say "I added that because I thought he was using insurance". Still - hours of phone calls over several weeks before they would even bill me correctly without adding tests that they had no results from. And even then - more expensive than they told me because the person I was transferred to over the phone was in a different state than the clinic I called in the first place. Absolutely rotten.

bushbaba 4y ago
Don’t forget all that time spent on the healthcare side. Easily 10%+ of the cost of operation.

BryanBeshore 4y ago

Now tell me about the relationship between health insurers and hospitals, and how they engage in pricing.

smm11 4y ago

Very soon we'll have Congressional hearings after oil companies see profits climb 7000 percent over last year, and they'll look sad and do nothing. I expect much the same from health insurance companies.

pkaye 4y ago
I'd be curious how their profits compare to pre covid profits given then many oil companies were losing a lot during covid due to sharp drop in demand.
- boston_clone 4y ago
  Thankfully, that data is public. [0] And it's still damning. Billions of dollars of profit were made, every single quarter. I have absolutely no sympathy for these companies, especially when they also likely received huge sums of cash from the federal government for this "sharp drop in demand". >Over 10 percent of the more than 7,000 oil, gas, and petrochemical companies that received PPP funds totaling between $3 billion and $6 billion reported no jobs retained as a result of the loan. The CEOs of Exxon and Chevron got raises in 2020, while Exxon announced that it is suspending the company’s contribution to the US employee retirement savings plan beginning in October and Chevron is cutting 6,700 workers around the globe [1] 0. https://www.macrotrends.net/stocks/charts/XOM/exxon/gross-profit https://www.macrotrends.net/stocks/charts/XOM/exxon/gross-pr... 1. https://www.sierraclub.org/sierra/bailout-billions-dollars-federal-covid-19-relief-money-flow-oil-industry https://www.sierraclub.org/sierra/bailout-billions-dollars-f...

imperio59 4y ago

Not to get political, but pretty sure this is thanks to one of Trump's last executive orders while he was in office. Correct me if I'm wrong

deleted 4y ago
[deleted]
UberFly 4y ago
You are correct.

bushbaba 4y ago

This will be huge! I’ve found that self paying can be 1/nth the cost of paying through my insurance. But you need to request self pay up front. Being able to better understand prices before hand will drastically help people reduce their healthcare costs.

dwringer 4y ago
I've seen the exact opposite of this - the self pay option would cost (for example) $300 while insurance would only get billed $150 for the exact same procedure. In the case I saw it, that meant the insurance paid out something like $12 and I was on the hook for the remaining $138. Which is roughly the same I would have owed if insurance had been billed the full amount and paid out the remaining $162.

benreesman 4y ago

This would be great news in a world where healthcare company revenue (which never quite trickles all the way down to retail shareholders) wasn’t just a one-way wratchet. More opaque: costs more. More transparent: costs more. Want a better deal? Choose better parents pleb.

dimal 4y ago

I'm not a fan of Trump, but I have to admit, the executive order [0] that forced this disclosure looks fantastic, really fantastic. But if I'm reading it right, it seems like it's just an order to _enforce_ requirements ObamaCare that were intended to increase transparency.[1] Obama and Trump actually accomplished something _together_! [0] https://www.federalregister.gov/documents/2017/10/17/2017-22677/promoting-healthcare-choice-and-competition-across-the-united-states https://www.federalregister.gov/documents/2017/10/17/2017-22... [1] https://www.federalregister.gov/documents/2020/11/12/2020-24591/transparency-in-coverage#footnote-9-p72160 https://www.federalregister.gov/documents/2020/11/12/2020-24...

yieldcrv 4y ago

imwillofficial 4y ago

I hope this becomes the norm all over

nazka 4y ago

Do you think this can have med to long term effect on revenues earnings and so stocks?

epgui 4y ago

IMO, as a non-affected Canadian, this is one of the (very few) good outcomes of the Trump presidency.

alanfriedman 4y ago

For anyone looking to download the data, here are a few links: Empire Blue (Anthem): https://www.empireblue.com/machine-readable-file/search/ https://www.empireblue.com/machine-readable-file/search/ United Healthcare: https://transparency-in-coverage.uhc.com/ https://transparency-in-coverage.uhc.com/ Aetna (Seems like the right page, but I don't see any download links — possibly because they haven't been posted yet): https://health1.aetna.com/app/public/#/one/insurerCode=AETNACVS_I&brandCode=ALICSI/machine-readable-transparency-in-coverage?searchTerm=279439&lock=true https://health1.aetna.com/app/public/#/one/insurerCode=AETNA... Search keywords: https://www.google.com/search?q=machine+readable+files+transparency+in+coverage https://www.google.com/search?q=machine+readable+files+trans...

nope96 4y ago
Blue Cross https://www.bcbsil.com/member/policy-forms/machine-readable-file https://www.bcbsil.com/member/policy-forms/machine-readable-... So are there programs I can use to parse this? It looks like a json file with links to more gziped json files...
- throwaway743 4y ago
  ...it is unfortunately. If you know a language you could run through it. Otherwise ypu might be able to find something like a json to csv converter online
- loxias 4y ago
  > It looks like a json file with links to more gziped json files Yup! Should be pretty easy to whip up a parser, it's just JSON and HTTP, you could do it in shell if you cared to. The challenge is what are you parsing it _to_. That is to say, what's your data model. I'd choose that first, then worry about parsing.
loxias 4y ago
Thank you thank you thank you! Here's Cigna: https://www.cigna.com/legal/compliance/machine-readable-files https://www.cigna.com/legal/compliance/machine-readable-file... UCLA Health keeps theirs: https://uclahealth.s3-us-west-1.amazonaws.com/price-transparency/rr-sm-machine-readable-2022.json https://uclahealth.s3-us-west-1.amazonaws.com/price-transpar... But sadly, still can't find my insurance company's download links. I can't wait to lose a weekend doing something with this data, it's a dream dataset and a perfect example of a very narrow type of project I love doing. Is there a canonical list of the major insurance companies?

PaulDavisThe1st 4y ago

Can anyone provide any hints on the search keywords to find this data at a given insurer's website?

stevebmark 4y ago

This happened for hospitals too, and not much has changed. Cryptic billing codes will make this data hard to understand.

deleted 4y ago

[deleted]

kazinator 4y ago

> Even after the pricing data is public, “I don’t think things will change overnight,” said Leibach. “Patients are still going to make care decisions based on their doctors and referrals, a lot of reasons other than price.” Ah, but in the USA, there are a lot of uninsured people who end up paying cash for stuff. And there is a corruption problem in that individuals who pay for services and materials get ripped off compared to what insurance pays behalf of an insured patient. I would expect that this will have an almost instant beneficial effect for some of the uninsured or under-insured. It will be harder to charge them $500 for something that insurance pays $250 for in plain view. People will go back and complain, asking for rebates even after paying.

IG_Semmelweiss 4y ago

I work in healthcare. Here is an exchange I had with a major hospital about standard surgery (one of those deemed "Shoppable services") earlier this year. This exchange was possible after I was able to get an email recipient, following a 30min conversation. >>>> Hello! I was told by the very helpful Ms. XXX, that you would be able to provide patient responsibility amount , related to CPT codes for XXX procedure. I am attaching front and back of my insurance card (Payor). The member DOB is MM/DD/YY The specific 2 codes in question are : CPT 12345 CPT 01234 Can you please provide the total cost and patient resp. for the CPTs above? ___________________________________________________________ Response: Good morning, >>>>>The hospital does not process estimates for patients with insurance coverage. However, our web portal contains charges under the Hospital Price Transparency link. I have included the link in the subject line for easy access. [comment: This link was broken. After much browsing.. I was able to find an alternate route. The linked file turned out to be a JSON. I couldn't figure that one out] As far as out-pocket responsibility, your insurance company is the best source for that information; they will advise if you have any copay for the encounter. _______ Read the 1st sentence of the reply again. My blood still boils from that...

JohnBjorge 4y ago
This sounds about right. I've worked in the healthcare tech world for about 5 years on both sides (for providers and payors). I totally empathize with how annoying it is that essentially no one processes estimates for patients with insurance. There are some places though that do, and it tends to be small/medium size specialty practices (think orthopedics, ophthalmology, radiology) in forward thinking places (Seattle, Minneapolis, etc). I can give some technical reasons as to "why" they can't/won't give you an estimate. I'm not saying these are legitimate reasons, just stating what I've seen. One reason they may not want to give you an estimate is because depending on what happens during your visit/procedure, the codes that get billed could change quite a bit. Because of this their initial estimate could be wildly different. In addition to the procedure codes changing, there are modifiers/adjustments that can get applied to a procedure code depending on what happens during the procedure (which adds another level of uncertainty). For example, anesthesia often bills based on time and complexity. If the procedure runs long then it will cost more, if something goes wrong and the complexity increases then it will cost more, if a nurse anesthetist (CRNA) does your anesthesia rather than an MD it will cost less, etc. Another reason they may not want to give you an estimate is because they have no idea. This is in my experience the case most of the time. A given clinic/hospital is going to have many many contracts with many payors. There's a ton of nuance in these contracts and they are sometimes extremely complicated. I've read hundreds of these contracts and written software to try to scale price estimate tools for patients. It's really hard, happy to dive into it more if there's interest. I often see comments on hackernews along the lines of "it's just a fee schedule, how hard is it to put it in a database and select amount from feeschedule where procedure = 99215". The big wrinkle here is the contracts. The contracts are often times super complicated, dependent on many many different fee schedules and pricing methodologies. The fee schedules/pricing methodologies may be from the payor, they may be from 3rd party vendors, they may be proprietary, they may be based on medicare, etc. Then there's a whole slew of adjustments/modifiers that can trigger depending on tons of different events and combinations of procedures codes that may appear on a claim. Another reason they may not want to give you an estimate is because it's not straightforward to verify your insurance. There are clearinghouses that aggregate benefits data from major payors, but the data is kind of shoddy. It may return your insurance is active when it really is inactive. It may have bad data on what is covered vs not covered, what your deductible, coinsurance, etc are so given all this data is kind of unreliable then giving an estimate becomes pretty unreliable. Anyway, these were a few reasons off the top of my head. Again, I want to emphasize I'm 100% with you on how annoying it is that we can't get estimates. I spent 3 years literally trying to solve this problem, and we actually made really good progress if it gives you any hope that things will maybe (fingers crossed) get better overtime. I just wanted to give some context / spark some conversation around these contracts and why they are challenging from a technical perspective to automate price estimates.

kkrbalam 4y ago

Why nobody ever talks about how much doctors are overpaid and over valued in this country? Why always demonize insurance companies? I was in an ER for 7 days, I only saw the doctor 2 times for less than 5 mins each. In the final bill, the most expensive line item was doctor consultation.