10 ms·

When High Deductible Insurance was introduced the supposed concept was to "give employees a stake in their costs, and therefore lower them for both employer and

When High Deductible Insurance was introduced the supposed concept was to "give employees a stake in their costs, and therefore lower them for both employer and employee." However, even today doing so is very challenging, and before laws like this it was essentially impossible. There's no way to shop around American healthcare, with the system itself working against you at every turn (e.g. doctors prescribing named brand, and you not be allowed to switch back to generic without another $100+ appointment). You can try calling and getting quotes, but they'll just waste a bunch of time and then give you a RANGE with no assurances. Even getting the quote requires your doctor to write up the entire work-order, which itself can get pushback, and or cost money. Then you have random things like for-profit life flights, which are automatic bankruptcy machines. Imagine one minute driving down the road, then suddenly waking up in a hospital, and then getting billed $80K for just the trip to get there let alone your hospital treatment or recovery. And insurance doesn't cover it. Aside but all ambulances around me are "out of network" and don't work with insurance at all. So I guess I should shop around by moving cities..?

mancerayder 4y ago
I believe some states regulate that better than others. At the least, some prevent 'surprise bills' where the provider selected is out of network while the referer is in network. That's just not fair when you're unconscious or suffering.
- bbreier 4y ago
  It's complete nonsense even when you're conscious and fine!
- maxerickson 4y ago
  CMS took administrative action this year to try to improve those situations: https://www.cms.gov/nosurprises/consumers/new-protections-for-you https://www.cms.gov/nosurprises/consumers/new-protections-fo...
IncRnd 4y ago
The Pharmacist is a doctor and can offer the generic version. They do that regularly. There is no need to go back to the original doctor you saw.
- closewith 4y ago
  That depends on your state and country. It's certainly not universal.
briHass 4y ago
> doctors prescribing named brand, and you not be allowed to switch back to generic without another $100+ appointment I'm not sure this is that common, unless you have an adversarial relationship with your doctor. It's actually the opposite: in most states the Dr. must write DAW-dispense as written or 'name brand only' to get the expensive brand. Otherwise, the pharmacist can and will substitute a generic if available. I've always found docs to be very willing to work with you on budget issues. If there's a similar med that is available in generic where their original recommendation isn't, they're happy to switch.
- legitster 4y ago
  Fun fact, your pharmacist is allowed to change your prescription in some states! Try asking them if there are cheaper generics.
  - mikehotel 4y ago
    Good to know, thanks! BTW, Hopefully the last word is just a typo.
  - refurb 4y ago
    In most states they don’t have to ask. A generic is equivalent substitute for the brand name.
  - liotier 4y ago
    In France, the pharmacist is legally obliged to offer the cheaper generic. If the doctor wants the primary brand specifically, he has to write "non-substitutable" on the prescription and a shorthand mention of the reason.
    - mcv 4y ago
      "Non-substitutable -- otherwise I won't get my kickbacks"
      - pas 4y ago
shusaku 4y ago
> Aside but all ambulances around me are "out of network" and don't work with insurance at all. So I guess I should shop around by moving cities..? That’s rather disturbing, and from a purely pragmatic point of view, you might consider raising a fuss with your employer…
javajosh 4y ago
>So I guess I should shop around by moving cities No, the solution to most social ills in America is to simply not be poor. If you are poor, stop it. Then you don't have to worry about any of this. Consider abortion, a procedure now outlawed in many US states. If you're not poor, you can just pay to travel to another state or country, have the procedure, do some sight-seeing, and come home. The law has no de facto effect on you. Same with every aspect of healthcare. So, just don't be poor and you'll be fine. (Even better if you are connected to the wealthy and powerful in your city & state. It is very nice indeed to be a VIP in an American hospital, court, or anywhere else.)
- gumby 4y ago
  > No, the solution to most social ills in America is to simply not be poor. If you are poor, stop it. Those people deserve it. I mean, some people chose to be born to wealthy parents; if you were too lazy to do that why should I have to reward your laziness by paying to look after you? Really, some people can be so selfish! > It is very nice indeed to be a VIP in an American hospital My gf had a life threatening illness and went to Stanford hospital. They gave her the special blanket just for Stanford Faculty so she'd get the VIP treatment. Which in practice meant nothing. Thankfully she survived; now I wonder if I should be glad or not that VIPs get the same shitty health care there as everybody else.
  - javajosh 4y ago
    VIP treatment means a private room and doctors who personally really actually pay attention to your treatment because the administrator has reminded them to do that, or your friend from med school/business school has asked them to do that. It is not conferred by a blanket. BTW there is a carrot and a stick going on. Yes, the hospital admin wants to make VIP patients happy for donations, but they also want to avoid making the patient unhappy because they have resources to sue, and win. All of this is highly motivational.
    - OrvalWintermute 4y ago
      I don't really think the Mr/Mrs Moneybags "VIP patient" compares remotely to a board-certified member of La Cosa Nostra Medical Mafia with an iphone full of colleagues and professional acquaintances with a friend-of-an-attending across all specialties When you are a doctor, you're part of the club. Skipping the line and getting a consult in 30 seconds? Well, that is 15 seconds too long. Got a laceration on your child, and want a 3 layer closure by the head of Plastics? No issue there. Want to convene a board on your rare medical issue? Well, there is a doctors only Facebook group for that, with about 500 docs ready to chime in on their breaks. It goes way behind this too. Indepth knowledge and advice about who the actual locally best doctors and surgeons are, across specialties (not the popularity contest or bought magazine ones either). Early tracks on new promising studies. Handouts of non-scrip medical supplies like event swag. Pharma-reps wanting to market their novel products and spread the info on them. The amount of free stuff is off the charts. I've seen exponentially more over the top professional courtesy "Good Old Docs" club from my Dr. wife and the associated professional network, than I have in any other profession by far.
hotpotamus 4y ago
I feel like if your response when I ask you the price is, "I don't know", then my response is, "well then I don't know if I can/will pay that". A friend of mine with limited means says his medical plan is just to go the ER and give them a fake name - he came up with it after suffering a head injury (pool cue to the head) and being unable to remember the details of his treatment. I don't think it's a good system, but it seems to be the one we've got.
- ethbr0 4y ago
  For reference, the legal grounding of this is EMTALA: https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatment_and_Active_Labor_Act https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatment_... Which basically summarizes as "EDs that accept payments from Medicaid are required to at minimum stabilize all patients, regardless of their ability to pay or several named statuses."
oneoff786 4y ago
> When High Deductible Insurance was introduced the supposed concept was to "give employees a stake in their costs, and therefore lower them for both employer and employee." Funny, I always thought it was just squeezing every last penny out of customers without letting them feel like they didn’t have health insurance for big ones
duffpkg 4y ago
The primary cause today of doctors prescribing name brand medications without the ability for substitution of generics is a form of institutional stupidity. EMR prescribing systems are driven by a common "formulary" that has an entry for each drug and defaults. Often the people that define formularies are a weird mix of technological people that don't know anything about the drugs/medicine and medicine people that don't know anything about the technology. The checkbox for the formulary entry that defaults to "allow substititions" is not properly set or is defaulted to disallow them. Also this reminds me of one of the more evil things I have ever seen in healthcare. Practice Fusion gave doctors a "free EMR" because it was being paid by opiate pharmecuitcal companies to create an electronic EMR workflow that intentionally increased unecessary opiate prescribing. Absolute evil in my opinion. https://www.justice.gov/usao-vt/pr/electronic-health-records-vendor-pay-largest-criminal-fine-vermont-history-and-total-145 https://www.justice.gov/usao-vt/pr/electronic-health-records...
- jjoonathan 4y ago
  > institutional stupidity If you are a hospital, and you are shopping for an EMR to maximize revenue, is that a feature or is it a bug? Evil, yes, stupid, no.
  - pc86 4y ago
    I've worked with many, many hospital IT departments as a consultant, contractor, and vendor. It's absolutely stupidity.
    - Symmetry 4y ago
      From a doctor compaining about the difficulties faced by generic alternatives to EpiPens: If you know anything at all about doctors, you know that they have way too much institutional inertia to change from writing one word on a prescription pad to writing a totally different word on a prescription pad, especially if the second word is almost twice as long, and especially especially if it’s just to do something silly like save a patient money. I have an attending who, whenever we are dealing with anything other than a life-or-death matter, just dismisses it with “Nobody ever died from X”, and I can totally hear him saying “Nobody ever died from paying extra for an adrenaline injector”. So Adrenaclick continues to languish in obscurity. https://slatestarcodex.com/2016/08/29/reverse-voxsplaining-drugs-vs-chairs/ https://slatestarcodex.com/2016/08/29/reverse-voxsplaining-d...
colordrops 4y ago
> give employees a stake in their costs, and therefore lower them for both employer and employee The idea wasn't to get people to shop around, at least in my opinion, but rather to not use healthcare altogether unless absolutely necessary, because they feel the cost of the services more when they pay for the directly.
bsimpson 4y ago
I broke my foot recently. Calling around and asking for quotes ranged from a straight up "I don't know" to "Here is the cash price. We won't know your HDHP insurance price until after we bill them, which could be good for you or could be bad. It will probably be bad, because there are more middlemen." I tried paying the cash price. They inadvertently billed my insurance anyway. Turns out, I actually saved like 33% using the insurance price ($180 vs $120 for an xray + analysis). They said the only way to get a copy of the x-ray was to pay $5 for a CD. None of the computers I still use have a CD reader. The whole system is such a clusterfuck. I understand the aversion to giving a governmental bureaucracy more control (esp over something as important as healthcare); however, it's hard to imagine a worse way to pay for care than what we have now.
- dheera 4y ago
  I just got billed $5000 for a routine echocardiogram at Stanford, and in the process of fighting it. My insurance is supposed to cover preventative care 100% (not even a copay). They billed $18000 total (yes, for a 1-hour ultrasound) and insurance is leaving me to pay $5000. This is about the 6th time this has happened. It's always 15+ e-mails back and forth, then threatening lawyers, then they back off. I'm wondering if it would be faster if I just take it directly to a small claims court. I am insured and it is preventative care, so I believe I'm entitled to pay nothing. Advice welcome.
  - mrexroad 4y ago
    My son had strep throat. Stanford billed us just shy of $50K, but not before sending us a letter letting us know they had stopped accepting our insurance (BCBS) a few weeks prior. Obviously, more done than just a throat swab for the 50K, but whole thing was insane.
    - dheera 4y ago
      I really want to expose Stanford's ridiculous billing and shame them to no end, but I don't have enough Twitter followers. I know healthcare billing in the US is f-ed up but Stanford is particularly bad.
hnburnsy 4y ago
I belive that ACA plans must cover out of network emergency services.
throw123123123 4y ago
HDP is definitely in the right path, but you need to get rid of many layers of bureacracy and paperwork. Need an absolute de-reg. It's not going to happen, so the most likely scenario is innovation will be coming from fringe services.
CarbonCycles 4y ago
Me and my colleagues (actuaries by training) ran some very interesting what-if scenarios based on our companies insurance packages, and every single scenario indicated that going with the highest deductible (or HSA) was more cost effective for the employee...the employer (with the insurance companies) had stacked the deductibles and cost structure to shift the risk from the company to the employee. And the medical providers (not the insurance company) will always have discounts on their procedures...just have to ask for them. Makes one wonder how steep the mark-ups are.

mancerayder 4y ago

I believe some states regulate that better than others. At the least, some prevent 'surprise bills' where the provider selected is out of network while the referer is in network. That's just not fair when you're unconscious or suffering.

bbreier 4y ago
It's complete nonsense even when you're conscious and fine!
maxerickson 4y ago
CMS took administrative action this year to try to improve those situations: https://www.cms.gov/nosurprises/consumers/new-protections-for-you https://www.cms.gov/nosurprises/consumers/new-protections-fo...

IncRnd 4y ago

The Pharmacist is a doctor and can offer the generic version. They do that regularly. There is no need to go back to the original doctor you saw.

closewith 4y ago
That depends on your state and country. It's certainly not universal.

briHass 4y ago

> doctors prescribing named brand, and you not be allowed to switch back to generic without another $100+ appointment I'm not sure this is that common, unless you have an adversarial relationship with your doctor. It's actually the opposite: in most states the Dr. must write DAW-dispense as written or 'name brand only' to get the expensive brand. Otherwise, the pharmacist can and will substitute a generic if available. I've always found docs to be very willing to work with you on budget issues. If there's a similar med that is available in generic where their original recommendation isn't, they're happy to switch.

legitster 4y ago
Fun fact, your pharmacist is allowed to change your prescription in some states! Try asking them if there are cheaper generics.
- mikehotel 4y ago
  Good to know, thanks! BTW, Hopefully the last word is just a typo.
- refurb 4y ago
  In most states they don’t have to ask. A generic is equivalent substitute for the brand name.
- liotier 4y ago
  In France, the pharmacist is legally obliged to offer the cheaper generic. If the doctor wants the primary brand specifically, he has to write "non-substitutable" on the prescription and a shorthand mention of the reason.
  - mcv 4y ago
    "Non-substitutable -- otherwise I won't get my kickbacks"
    - pas 4y ago

shusaku 4y ago

> Aside but all ambulances around me are "out of network" and don't work with insurance at all. So I guess I should shop around by moving cities..? That’s rather disturbing, and from a purely pragmatic point of view, you might consider raising a fuss with your employer…

javajosh 4y ago

>So I guess I should shop around by moving cities No, the solution to most social ills in America is to simply not be poor. If you are poor, stop it. Then you don't have to worry about any of this. Consider abortion, a procedure now outlawed in many US states. If you're not poor, you can just pay to travel to another state or country, have the procedure, do some sight-seeing, and come home. The law has no de facto effect on you. Same with every aspect of healthcare. So, just don't be poor and you'll be fine. (Even better if you are connected to the wealthy and powerful in your city & state. It is very nice indeed to be a VIP in an American hospital, court, or anywhere else.)

gumby 4y ago
> No, the solution to most social ills in America is to simply not be poor. If you are poor, stop it. Those people deserve it. I mean, some people chose to be born to wealthy parents; if you were too lazy to do that why should I have to reward your laziness by paying to look after you? Really, some people can be so selfish! > It is very nice indeed to be a VIP in an American hospital My gf had a life threatening illness and went to Stanford hospital. They gave her the special blanket just for Stanford Faculty so she'd get the VIP treatment. Which in practice meant nothing. Thankfully she survived; now I wonder if I should be glad or not that VIPs get the same shitty health care there as everybody else.
- javajosh 4y ago
  VIP treatment means a private room and doctors who personally really actually pay attention to your treatment because the administrator has reminded them to do that, or your friend from med school/business school has asked them to do that. It is not conferred by a blanket. BTW there is a carrot and a stick going on. Yes, the hospital admin wants to make VIP patients happy for donations, but they also want to avoid making the patient unhappy because they have resources to sue, and win. All of this is highly motivational.
  - OrvalWintermute 4y ago
    I don't really think the Mr/Mrs Moneybags "VIP patient" compares remotely to a board-certified member of La Cosa Nostra Medical Mafia with an iphone full of colleagues and professional acquaintances with a friend-of-an-attending across all specialties When you are a doctor, you're part of the club. Skipping the line and getting a consult in 30 seconds? Well, that is 15 seconds too long. Got a laceration on your child, and want a 3 layer closure by the head of Plastics? No issue there. Want to convene a board on your rare medical issue? Well, there is a doctors only Facebook group for that, with about 500 docs ready to chime in on their breaks. It goes way behind this too. Indepth knowledge and advice about who the actual locally best doctors and surgeons are, across specialties (not the popularity contest or bought magazine ones either). Early tracks on new promising studies. Handouts of non-scrip medical supplies like event swag. Pharma-reps wanting to market their novel products and spread the info on them. The amount of free stuff is off the charts. I've seen exponentially more over the top professional courtesy "Good Old Docs" club from my Dr. wife and the associated professional network, than I have in any other profession by far.

hotpotamus 4y ago

I feel like if your response when I ask you the price is, "I don't know", then my response is, "well then I don't know if I can/will pay that". A friend of mine with limited means says his medical plan is just to go the ER and give them a fake name - he came up with it after suffering a head injury (pool cue to the head) and being unable to remember the details of his treatment. I don't think it's a good system, but it seems to be the one we've got.

ethbr0 4y ago
For reference, the legal grounding of this is EMTALA: https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatment_and_Active_Labor_Act https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatment_... Which basically summarizes as "EDs that accept payments from Medicaid are required to at minimum stabilize all patients, regardless of their ability to pay or several named statuses."

oneoff786 4y ago

> When High Deductible Insurance was introduced the supposed concept was to "give employees a stake in their costs, and therefore lower them for both employer and employee." Funny, I always thought it was just squeezing every last penny out of customers without letting them feel like they didn’t have health insurance for big ones

duffpkg 4y ago

The primary cause today of doctors prescribing name brand medications without the ability for substitution of generics is a form of institutional stupidity. EMR prescribing systems are driven by a common "formulary" that has an entry for each drug and defaults. Often the people that define formularies are a weird mix of technological people that don't know anything about the drugs/medicine and medicine people that don't know anything about the technology. The checkbox for the formulary entry that defaults to "allow substititions" is not properly set or is defaulted to disallow them. Also this reminds me of one of the more evil things I have ever seen in healthcare. Practice Fusion gave doctors a "free EMR" because it was being paid by opiate pharmecuitcal companies to create an electronic EMR workflow that intentionally increased unecessary opiate prescribing. Absolute evil in my opinion. https://www.justice.gov/usao-vt/pr/electronic-health-records-vendor-pay-largest-criminal-fine-vermont-history-and-total-145 https://www.justice.gov/usao-vt/pr/electronic-health-records...

jjoonathan 4y ago
> institutional stupidity If you are a hospital, and you are shopping for an EMR to maximize revenue, is that a feature or is it a bug? Evil, yes, stupid, no.
- pc86 4y ago
  I've worked with many, many hospital IT departments as a consultant, contractor, and vendor. It's absolutely stupidity.
  - Symmetry 4y ago
    From a doctor compaining about the difficulties faced by generic alternatives to EpiPens: If you know anything at all about doctors, you know that they have way too much institutional inertia to change from writing one word on a prescription pad to writing a totally different word on a prescription pad, especially if the second word is almost twice as long, and especially especially if it’s just to do something silly like save a patient money. I have an attending who, whenever we are dealing with anything other than a life-or-death matter, just dismisses it with “Nobody ever died from X”, and I can totally hear him saying “Nobody ever died from paying extra for an adrenaline injector”. So Adrenaclick continues to languish in obscurity. https://slatestarcodex.com/2016/08/29/reverse-voxsplaining-drugs-vs-chairs/ https://slatestarcodex.com/2016/08/29/reverse-voxsplaining-d...

colordrops 4y ago

> give employees a stake in their costs, and therefore lower them for both employer and employee The idea wasn't to get people to shop around, at least in my opinion, but rather to not use healthcare altogether unless absolutely necessary, because they feel the cost of the services more when they pay for the directly.

bsimpson 4y ago

I broke my foot recently. Calling around and asking for quotes ranged from a straight up "I don't know" to "Here is the cash price. We won't know your HDHP insurance price until after we bill them, which could be good for you or could be bad. It will probably be bad, because there are more middlemen." I tried paying the cash price. They inadvertently billed my insurance anyway. Turns out, I actually saved like 33% using the insurance price ($180 vs $120 for an xray + analysis). They said the only way to get a copy of the x-ray was to pay $5 for a CD. None of the computers I still use have a CD reader. The whole system is such a clusterfuck. I understand the aversion to giving a governmental bureaucracy more control (esp over something as important as healthcare); however, it's hard to imagine a worse way to pay for care than what we have now.

dheera 4y ago
I just got billed $5000 for a routine echocardiogram at Stanford, and in the process of fighting it. My insurance is supposed to cover preventative care 100% (not even a copay). They billed $18000 total (yes, for a 1-hour ultrasound) and insurance is leaving me to pay $5000. This is about the 6th time this has happened. It's always 15+ e-mails back and forth, then threatening lawyers, then they back off. I'm wondering if it would be faster if I just take it directly to a small claims court. I am insured and it is preventative care, so I believe I'm entitled to pay nothing. Advice welcome.
- mrexroad 4y ago
  My son had strep throat. Stanford billed us just shy of $50K, but not before sending us a letter letting us know they had stopped accepting our insurance (BCBS) a few weeks prior. Obviously, more done than just a throat swab for the 50K, but whole thing was insane.
  - dheera 4y ago
    I really want to expose Stanford's ridiculous billing and shame them to no end, but I don't have enough Twitter followers. I know healthcare billing in the US is f-ed up but Stanford is particularly bad.

hnburnsy 4y ago

I belive that ACA plans must cover out of network emergency services.

throw123123123 4y ago

HDP is definitely in the right path, but you need to get rid of many layers of bureacracy and paperwork. Need an absolute de-reg. It's not going to happen, so the most likely scenario is innovation will be coming from fringe services.

CarbonCycles 4y ago

Me and my colleagues (actuaries by training) ran some very interesting what-if scenarios based on our companies insurance packages, and every single scenario indicated that going with the highest deductible (or HSA) was more cost effective for the employee...the employer (with the insurance companies) had stacked the deductibles and cost structure to shift the risk from the company to the employee. And the medical providers (not the insurance company) will always have discounts on their procedures...just have to ask for them. Makes one wonder how steep the mark-ups are.