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My wife is the manager of budget and reimbursement at a hospital, and from many conversations with her, I can imagine that this article is accurate. However, if

My wife is the manager of budget and reimbursement at a hospital, and from many conversations with her, I can imagine that this article is accurate. However, if I were writing this, I would have given greater emphasis to the effect that Medicare has on these problems. The article does mention that Medicare typically pays fees that are below actual cost for the procedures, and that hospitals must therefore increase charges to other customers (the article says they must do this to make profit, but actually they must do this just to break even and stay in business). But the problem goes even farther than that. Because Medicare is essentially a monopsony and gets to call the shots as far as charges are concerned, it actually matters far less what the actual costs are. As a result, few hospitals today have modern cost accounting processes, and so they only have wild guesses as to what a given procedure costs. Obviously, then, their charge list is going to be made largely from guesswork, and so it's very much expected that two different hospitals will, at the micro per-item level at least, have very different charges. Medical care is the most highly regulated industry in the economy, and so nothing you see happening is going to bear very much resemblance to reality. And in the coming years this isn't going to get any better. What you are likely to see, though, is increased politicization of these charges, as the political process takes even greater control of the industry.

rdtsc 15y ago
> Medical care is the most highly regulated industry in the economy, and so nothing you see happening is going to bear very much resemblance to reality. You make it sound like one follows from the other in an obvious way. Can you expand on why that would be?
- CWuestefeld 15y ago
  You make it sound like one follows from the other in an obvious way. I think it does follow logically. I'm assuming that the regulations were intended to serve some purpose. If the system was working as the regulators/legislators wanted, there would have been no point in regulation. The regulations were created for the purpose of altering the way things would normally work out. By analogy, if we see a canal, it's probably a safe assumption that the waterway doesn't resemble the natural flow of water. The only reason to build the canal is that something was needed to be different from the water features that were present.
  - saucetenuto 15y ago
    Speaking as someone who doesn't know much about this stuff, your analogy reads more like, "the canal diverted the waterway, so tigers devoured the Pope". It may well be true, but you need to flesh it out more: explain how the new course flooded the tigers' habitat, forcing them to migrate to Rome.
    - jellicle 15y ago
      The person you're responding to believes that if medical charges are vastly different between providers it must be due to evil government regulation, because after all in other sorts of stores we never see wildly varying prices for the same item and healthcare, where people have plenty of time to comparison shop (even if you're choking on turkey, you still have a few minutes to contact the various local hospitals and determine which provides cheaper ER service before you pass out) is a perfect example of a transparent market.
      - CWuestefeld 15y ago
        The person you're responding to believes that The person he's talking to doesn't believe that putting a strawman argument into someone else's mouth is an honest debate tactic. This question has nothing to do with ideology. As a matter of pure logic, regulation changes what the market is doing naturally; that's the whole point of the regulation. This is a non-judgmental conclusion. One doesn't have to say that the market state was good or bad, or that the regulated state is good or bad. Simply that a regulated market differs from a free market. That's it. Now, given that the system is highly regulated, it's clear that the regulators have screwed up. However, this on its own doesn't tell us that the free market was good; it just tells us that the current regulatory regime is crap.
        intended 15y ago
        Bit late to the conversation, and somewhat pedantic, do forgive - Going from : >>This is a non-judgmental conclusion. One doesn't have to say that the market state was good or bad, or that the regulated state is good or bad. Simply that a regulated market differs from a free market. That's it. to >>Now, given that the system is highly regulated, it's clear that the regulators have screwed up. is making a jump. It is not a necessary that the regulators messed up - it is also possible that the parties being moderated, are actively subverting the system. /pedant I will agree with your point behind it all - ie that in such a system it is LIKELY that there is fault by the regulators. This type of fault, the extent of responsibility for the final outcome, these are complex questions which need more than just stating that the regulators were out of line. You could say that X and Y are responsible for crime A. The punishment/responsibility would depend on a variety of factors. That is the question that requires answering.
- deleted 15y ago
  [deleted]
- anamax 15y ago
  >> Medical care is the most highly regulated industry in the economy, and so nothing you see happening is going to bear very much resemblance to reality. >You make it sound like one follows from the other in an obvious way. Can you expand on why that would be? Two factors: incentives and information. Regulators do not, by definition and intent, have the same incentives as participants. They're also not involved, so they lack information. Here's another way to think of it. When a biz goes bankrupt, employees lose their jobs, owners lose equity, and regulators go to lunch as usual. If a regulator mis-estimates costs by 1%, that's fantastic. If a supermarket mis-estimates costs by 1%, it goes out of biz (because their margins are less than 1%).
- Symmetry 15y ago
  As just one example, look at the RBRVS: http://www.slate.com/articles/news_and_politics/prescriptions/2009/09/the_fix_is_in.html http://www.slate.com/articles/news_and_politics/prescription... Paying people on a cost-plus basis provides them with an incentive to maximize costs, whether they're doctors or defense contractors. Then there's also the FDA's use of production quotas for drug production. We had a big shortage of Aderall recently because the FDA has to give permission ahead of time for a given amount of production of the drug for each company. And when the FDA decided that one of the producers wasn't up to snuff and was no longer allowed to make the drug, it failed to raise the quotas of the other producers to compensate. To the extent that you run a section of the economy like the USSR was run, you shouldn't expect it to be run efficiently. The US healthcare system would still have quite a ways to go before it becomes quite that bad, but its closer than most people seem to think.
  - llimllib 15y ago
    > We had a big shortage of Aderall recently because the FDA has to give permission ahead of time for a given amount of production of the drug for each company. As I understand it, the DEA, not the FDA, sets the quotas. They're currently arguing publicly over the shortage: http://www.nytimes.com/2012/01/01/health/policy/fda-is-finding-attention-drugs-in-short-supply.html?_r=2 http://www.nytimes.com/2012/01/01/health/policy/fda-is-findi... The DEA claims there is no shortage (insert Star Wars hand wave here) while the FDA wants them to raise the quotas. (How Soviet does that sound?) No disagreement on the rest of your comment.
  - _delirium 15y ago
    The Adderall example is due to our drug-war paranoia more than due to healthcare regulation; Adderall is a Schedule II controlled substance whose production and distribution is micromanaged as a result. My guess is that those problems would remain even if we completely deregulated healthcare otherwise, because there is very little political support for widespread drug declassification (maybe marijuana will happen in my lifetime, but I doubt much else).
- defen 15y ago
  I think part of the problem is that "highly regulated" is an ill defined term. For certain definitions of "highly regulated", the NASDAQ is highly regulated, yet we don't see much price distortion there. The "problem", I think, is with the nature of the regulation, and the nature of the supply/demand equation for medical care. One simple example, which I don't really have time to explain here, is the health insurance system which makes it so that people generally do not consider price when purchasing medical care. Of course that is going to lead to price distortions. Another simple example is the inflexibility in the supply of doctors, which is ultimately due to government regulations (many would argue that this is a good thing)
furyg3 15y ago
> Medical care is the most highly regulated industry in the economy, and so nothing you see happening is going to bear very much resemblance to reality. This is a pretty big logical jump. I'm American, but have been living in the Netherlands for a while. Health care is probably more regulated here than in the US, yet in all of the ER visits I've experienced (myself or friends/family) I've never seen bills like that. Regulation does not have to cause bills like that. Something is very wrong if sick people in life threatening situations are being charged hundreds (or thousands!) of times for the same care based on whether or not they have insurance. That screams "more regulation is necessary" to me.
- dsplittgerber 15y ago
  I'm from Germany and you do realize that over here (don't know about the exact differences) privately-insured patients (who opted out off the 'mandatory' insurance scheme) basically pay a LOT more for any given medical service just so that patients covered under the mandatory insurance can get treated at all? It's like a giant (inefficient) money redistribution scheme, in all the worst ways imaginable. Regulation does actually cause bills like that. It's just that in Europe, you don't ever see them.
  - tankenmate 15y ago
    Actually I think you'll find that billing like the kind you see in the US doesn't happen in Germany. The US spends nearly twice as much per capita than Germany for a comparable level of service[1]; this is hard to judge but life expectancy is a reasonable proxy, people in Germany on average live about the same. The UK with near mandatory, see below, universal healthcare the cost of per capita is lower still [1 ibid]. In the UK if you opt out of public healthcare you can't mix and match services beyond the GP level, this may change in the future. Obviously with a mandatory universal care the overall cost to the public at large stands a high chance of being lower; efficiencies of scale. The downside is that at the individual level you may be subject to "postcode lottery" healthcare. In many countries this leads to individualism raising the costs of healthcare for everyone. Everyone wants to be treated the best; the problem is that regardless of the system you chose this is impossible. [1] http://en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_(PPP)_per_capita http://en.wikipedia.org/wiki/List_of_countries_by_total_heal...
jbooth 15y ago
Hang on, so medicare told the hospitals and insurance companies to run their businesses that way? The transaction described in the article was entirely between private business entities. I get that they set their prices in a way that distorts the market to some extent but it seems that that distortion is far less than what the really-smart-guys-in-suits have been able to manage all by themselves. I understand the impulse that markets make things better. I really do. Look at computer parts for example, there's a robust market that keeps driving down prices and really delivers. But what about the healthcare industry resembles a sane market at all? There's effectively no market forces at work, due to the way that private sector businesses have structured it.
- CWuestefeld 15y ago
  I'll be honest. I don't get why hospitals continue to play the game. If I were running the place, I'd just pull out of Medicare. It seems that they're afraid of the millions of dollars of lost revenue, without considering the greater sum of expenses that they'd free up.
  - jbooth 15y ago
    I sincerely doubt that the bean-counters at hospital are losing a ton of money on medicare but are too confused by the large 'revenue' figure to subtract a larger 'expenses' figure and realize they're making a loss. As a matter of fact, I can't recall ever reading an op/ed or anything by a hospital administrator complaining that they're being fleeced by medicare and losing a bunch of money on it. But I've seen a billion op/eds in the same template as TFA, bemoaning the byzantine and obfuscatory private insurance regime as something that completely destroys any market forces that should exist in the industry. I mean, one hospital charged one thousand times as much as another for the same treatment. I have to conclude that bringing up medicare while the private insurance industry system is this flagrantly broken is nothing but a red herring.
    - CWuestefeld 15y ago
      And I'm telling you that my wife is that bean counter. Her job is (a) budgeting, and (b) getting reimbursement from Medicare and Medicaid. As well as anyone in the organization (which is to say, not too well, because of the deficiencies with cost accounting that I mentioned), she knows those numbers. I don't think a month goes by when I don't ask her this question. Something always comes up, where she's saying "Medicare just denied another $500K payment" or somesuch. And I'll say to her "you live by the sword, you die by the sword". She admits that the net profit via Medicare is negative. But the decisions makers don't want to consider it. In this case, it's possible that they consider it their mission because they are a Catholic hospital. I can't see any answer in the general case.
torontos 15y ago
That is a very good point re: medicare. I was a management consultant in the healthcare industry in a previous life. One interesting study I did found a direct correlation between percent of patients on medicare/medicaid and hospital profitability... The higher the percent of medicare and medicaid patients, the lower the profitability. The correlation was essentially a straight line.
Lagged2Death 15y ago
Medical care is the most highly regulated industry in the economy... Uh huh. Talk to the (quite profitable) utility companies about that.
- CWuestefeld 15y ago
  See, e.g., http://econlib.org/library/Enc/HealthCare.html http://econlib.org/library/Enc/HealthCare.html - - - - - Quote Regulation and the Health Care Market The health care industry is one of the most heavily regulated industries in the United States. These regulations stem from efforts to ensure quality, to facilitate the government’s role as purchaser of care, and to respond to provider efforts to increase the demand for their services. Hospitals and nursing homes are licensed by the state and must comply with quality and staffing requirements to maintain eligibility for participation in federal programs. Physicians and other health professionals are licensed by the states. Prescription drugs and medical devices are regulated by the Food and Drug Administration (see pharmaceuticals: economics and regulation). Some state governments require government permission before allowing a hospital or nursing home to be built or extensively changed. All of the above regulations restrict supply and raise the price of health care; interestingly, those who lobby for such regulations are medical providers, not consumers, presumably because they want to limit competition. Some state governments limit the extent to which managed care plans may selectively contract with providers. All state governments have imposed laws governing the content of insurance packages and the factors that may be used to determine insurance rates. While these may enhance quality, they do impose costs that raise the price of health insurance and increase the number of uninsured. In testimony before the Joint Economic Committee of the Congress, one analyst reported the annual net cost of regulation in the health care industry to be $128 billion.10
drumdance 15y ago
Here is a good article about how wildly Medicare costs can vary from place to place: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_... The second highest reimbursement district in the country is in Texas, which passed a draconinan tort reform law back in the 90s (if memory serves), so you can't blame courts or defensive medicine directly.
- tsotha 15y ago
  Texas is expensive for the same reason Southern California is expensive - a high percentage of the patient population is illegal aliens who a) can't afford the service and b) skip out on the bill.

rdtsc 15y ago

> Medical care is the most highly regulated industry in the economy, and so nothing you see happening is going to bear very much resemblance to reality. You make it sound like one follows from the other in an obvious way. Can you expand on why that would be?

CWuestefeld 15y ago
You make it sound like one follows from the other in an obvious way. I think it does follow logically. I'm assuming that the regulations were intended to serve some purpose. If the system was working as the regulators/legislators wanted, there would have been no point in regulation. The regulations were created for the purpose of altering the way things would normally work out. By analogy, if we see a canal, it's probably a safe assumption that the waterway doesn't resemble the natural flow of water. The only reason to build the canal is that something was needed to be different from the water features that were present.
- saucetenuto 15y ago
  Speaking as someone who doesn't know much about this stuff, your analogy reads more like, "the canal diverted the waterway, so tigers devoured the Pope". It may well be true, but you need to flesh it out more: explain how the new course flooded the tigers' habitat, forcing them to migrate to Rome.
  - jellicle 15y ago
    The person you're responding to believes that if medical charges are vastly different between providers it must be due to evil government regulation, because after all in other sorts of stores we never see wildly varying prices for the same item and healthcare, where people have plenty of time to comparison shop (even if you're choking on turkey, you still have a few minutes to contact the various local hospitals and determine which provides cheaper ER service before you pass out) is a perfect example of a transparent market.
    - CWuestefeld 15y ago
      The person you're responding to believes that The person he's talking to doesn't believe that putting a strawman argument into someone else's mouth is an honest debate tactic. This question has nothing to do with ideology. As a matter of pure logic, regulation changes what the market is doing naturally; that's the whole point of the regulation. This is a non-judgmental conclusion. One doesn't have to say that the market state was good or bad, or that the regulated state is good or bad. Simply that a regulated market differs from a free market. That's it. Now, given that the system is highly regulated, it's clear that the regulators have screwed up. However, this on its own doesn't tell us that the free market was good; it just tells us that the current regulatory regime is crap.
      - intended 15y ago
        Bit late to the conversation, and somewhat pedantic, do forgive - Going from : >>This is a non-judgmental conclusion. One doesn't have to say that the market state was good or bad, or that the regulated state is good or bad. Simply that a regulated market differs from a free market. That's it. to >>Now, given that the system is highly regulated, it's clear that the regulators have screwed up. is making a jump. It is not a necessary that the regulators messed up - it is also possible that the parties being moderated, are actively subverting the system. /pedant I will agree with your point behind it all - ie that in such a system it is LIKELY that there is fault by the regulators. This type of fault, the extent of responsibility for the final outcome, these are complex questions which need more than just stating that the regulators were out of line. You could say that X and Y are responsible for crime A. The punishment/responsibility would depend on a variety of factors. That is the question that requires answering.
deleted 15y ago
[deleted]
anamax 15y ago
>> Medical care is the most highly regulated industry in the economy, and so nothing you see happening is going to bear very much resemblance to reality. >You make it sound like one follows from the other in an obvious way. Can you expand on why that would be? Two factors: incentives and information. Regulators do not, by definition and intent, have the same incentives as participants. They're also not involved, so they lack information. Here's another way to think of it. When a biz goes bankrupt, employees lose their jobs, owners lose equity, and regulators go to lunch as usual. If a regulator mis-estimates costs by 1%, that's fantastic. If a supermarket mis-estimates costs by 1%, it goes out of biz (because their margins are less than 1%).
Symmetry 15y ago
As just one example, look at the RBRVS: http://www.slate.com/articles/news_and_politics/prescriptions/2009/09/the_fix_is_in.html http://www.slate.com/articles/news_and_politics/prescription... Paying people on a cost-plus basis provides them with an incentive to maximize costs, whether they're doctors or defense contractors. Then there's also the FDA's use of production quotas for drug production. We had a big shortage of Aderall recently because the FDA has to give permission ahead of time for a given amount of production of the drug for each company. And when the FDA decided that one of the producers wasn't up to snuff and was no longer allowed to make the drug, it failed to raise the quotas of the other producers to compensate. To the extent that you run a section of the economy like the USSR was run, you shouldn't expect it to be run efficiently. The US healthcare system would still have quite a ways to go before it becomes quite that bad, but its closer than most people seem to think.
- llimllib 15y ago
  > We had a big shortage of Aderall recently because the FDA has to give permission ahead of time for a given amount of production of the drug for each company. As I understand it, the DEA, not the FDA, sets the quotas. They're currently arguing publicly over the shortage: http://www.nytimes.com/2012/01/01/health/policy/fda-is-finding-attention-drugs-in-short-supply.html?_r=2 http://www.nytimes.com/2012/01/01/health/policy/fda-is-findi... The DEA claims there is no shortage (insert Star Wars hand wave here) while the FDA wants them to raise the quotas. (How Soviet does that sound?) No disagreement on the rest of your comment.
- _delirium 15y ago
  The Adderall example is due to our drug-war paranoia more than due to healthcare regulation; Adderall is a Schedule II controlled substance whose production and distribution is micromanaged as a result. My guess is that those problems would remain even if we completely deregulated healthcare otherwise, because there is very little political support for widespread drug declassification (maybe marijuana will happen in my lifetime, but I doubt much else).
defen 15y ago
I think part of the problem is that "highly regulated" is an ill defined term. For certain definitions of "highly regulated", the NASDAQ is highly regulated, yet we don't see much price distortion there. The "problem", I think, is with the nature of the regulation, and the nature of the supply/demand equation for medical care. One simple example, which I don't really have time to explain here, is the health insurance system which makes it so that people generally do not consider price when purchasing medical care. Of course that is going to lead to price distortions. Another simple example is the inflexibility in the supply of doctors, which is ultimately due to government regulations (many would argue that this is a good thing)

furyg3 15y ago

> Medical care is the most highly regulated industry in the economy, and so nothing you see happening is going to bear very much resemblance to reality. This is a pretty big logical jump. I'm American, but have been living in the Netherlands for a while. Health care is probably more regulated here than in the US, yet in all of the ER visits I've experienced (myself or friends/family) I've never seen bills like that. Regulation does not have to cause bills like that. Something is very wrong if sick people in life threatening situations are being charged hundreds (or thousands!) of times for the same care based on whether or not they have insurance. That screams "more regulation is necessary" to me.

dsplittgerber 15y ago
I'm from Germany and you do realize that over here (don't know about the exact differences) privately-insured patients (who opted out off the 'mandatory' insurance scheme) basically pay a LOT more for any given medical service just so that patients covered under the mandatory insurance can get treated at all? It's like a giant (inefficient) money redistribution scheme, in all the worst ways imaginable. Regulation does actually cause bills like that. It's just that in Europe, you don't ever see them.
- tankenmate 15y ago
  Actually I think you'll find that billing like the kind you see in the US doesn't happen in Germany. The US spends nearly twice as much per capita than Germany for a comparable level of service[1]; this is hard to judge but life expectancy is a reasonable proxy, people in Germany on average live about the same. The UK with near mandatory, see below, universal healthcare the cost of per capita is lower still [1 ibid]. In the UK if you opt out of public healthcare you can't mix and match services beyond the GP level, this may change in the future. Obviously with a mandatory universal care the overall cost to the public at large stands a high chance of being lower; efficiencies of scale. The downside is that at the individual level you may be subject to "postcode lottery" healthcare. In many countries this leads to individualism raising the costs of healthcare for everyone. Everyone wants to be treated the best; the problem is that regardless of the system you chose this is impossible. [1] http://en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_(PPP)_per_capita http://en.wikipedia.org/wiki/List_of_countries_by_total_heal...

jbooth 15y ago

Hang on, so medicare told the hospitals and insurance companies to run their businesses that way? The transaction described in the article was entirely between private business entities. I get that they set their prices in a way that distorts the market to some extent but it seems that that distortion is far less than what the really-smart-guys-in-suits have been able to manage all by themselves. I understand the impulse that markets make things better. I really do. Look at computer parts for example, there's a robust market that keeps driving down prices and really delivers. But what about the healthcare industry resembles a sane market at all? There's effectively no market forces at work, due to the way that private sector businesses have structured it.

CWuestefeld 15y ago
I'll be honest. I don't get why hospitals continue to play the game. If I were running the place, I'd just pull out of Medicare. It seems that they're afraid of the millions of dollars of lost revenue, without considering the greater sum of expenses that they'd free up.
- jbooth 15y ago
  I sincerely doubt that the bean-counters at hospital are losing a ton of money on medicare but are too confused by the large 'revenue' figure to subtract a larger 'expenses' figure and realize they're making a loss. As a matter of fact, I can't recall ever reading an op/ed or anything by a hospital administrator complaining that they're being fleeced by medicare and losing a bunch of money on it. But I've seen a billion op/eds in the same template as TFA, bemoaning the byzantine and obfuscatory private insurance regime as something that completely destroys any market forces that should exist in the industry. I mean, one hospital charged one thousand times as much as another for the same treatment. I have to conclude that bringing up medicare while the private insurance industry system is this flagrantly broken is nothing but a red herring.
  - CWuestefeld 15y ago
    And I'm telling you that my wife is that bean counter. Her job is (a) budgeting, and (b) getting reimbursement from Medicare and Medicaid. As well as anyone in the organization (which is to say, not too well, because of the deficiencies with cost accounting that I mentioned), she knows those numbers. I don't think a month goes by when I don't ask her this question. Something always comes up, where she's saying "Medicare just denied another $500K payment" or somesuch. And I'll say to her "you live by the sword, you die by the sword". She admits that the net profit via Medicare is negative. But the decisions makers don't want to consider it. In this case, it's possible that they consider it their mission because they are a Catholic hospital. I can't see any answer in the general case.

torontos 15y ago

That is a very good point re: medicare. I was a management consultant in the healthcare industry in a previous life. One interesting study I did found a direct correlation between percent of patients on medicare/medicaid and hospital profitability... The higher the percent of medicare and medicaid patients, the lower the profitability. The correlation was essentially a straight line.

Lagged2Death 15y ago

Medical care is the most highly regulated industry in the economy... Uh huh. Talk to the (quite profitable) utility companies about that.

CWuestefeld 15y ago
See, e.g., http://econlib.org/library/Enc/HealthCare.html http://econlib.org/library/Enc/HealthCare.html - - - - - Quote Regulation and the Health Care Market The health care industry is one of the most heavily regulated industries in the United States. These regulations stem from efforts to ensure quality, to facilitate the government’s role as purchaser of care, and to respond to provider efforts to increase the demand for their services. Hospitals and nursing homes are licensed by the state and must comply with quality and staffing requirements to maintain eligibility for participation in federal programs. Physicians and other health professionals are licensed by the states. Prescription drugs and medical devices are regulated by the Food and Drug Administration (see pharmaceuticals: economics and regulation). Some state governments require government permission before allowing a hospital or nursing home to be built or extensively changed. All of the above regulations restrict supply and raise the price of health care; interestingly, those who lobby for such regulations are medical providers, not consumers, presumably because they want to limit competition. Some state governments limit the extent to which managed care plans may selectively contract with providers. All state governments have imposed laws governing the content of insurance packages and the factors that may be used to determine insurance rates. While these may enhance quality, they do impose costs that raise the price of health insurance and increase the number of uninsured. In testimony before the Joint Economic Committee of the Congress, one analyst reported the annual net cost of regulation in the health care industry to be $128 billion.10

drumdance 15y ago

Here is a good article about how wildly Medicare costs can vary from place to place: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_... The second highest reimbursement district in the country is in Texas, which passed a draconinan tort reform law back in the 90s (if memory serves), so you can't blame courts or defensive medicine directly.

tsotha 15y ago
Texas is expensive for the same reason Southern California is expensive - a high percentage of the patient population is illegal aliens who a) can't afford the service and b) skip out on the bill.