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"Rome said the companies seem to be maximizing prices while negotiating discounts behind the scenes with health and drug insurers and then setting yet another p

"Rome said the companies seem to be maximizing prices while negotiating discounts behind the scenes with health and drug insurers and then setting yet another price for direct-to-consumer cash-pay sales." This describes the biggest problem in US healthcare. No clear and consistent pricing. If we had a real market, you would get a prescription and then go to the seller with the lowest price. And everybody would get the same price. This whole business with PBMs that are owned by the insurance companies, discount cards and other shenanigans just invites corruption.

Uvix 10mo ago
Health insurance in general is the problem; PBMs/discount cards are just a cherry on top. Insurance is fundamentally incompatible with clear and consistent pricing.
- lotsofpulp 10mo ago
  Pharmaceutical companies, hospitals, and doctors are free to charge by the medicine, by the night, and by the minute. For example, this place does it: https://surgerycenterok.com/surgery-prices/ https://surgerycenterok.com/surgery-prices/ Insurance companies do not force the sellers to use complex billing practices, they would benefit from more transparent pricing (since they are seeking to pay less). The root cause is healthcare is inherently complicated and complex, it has a problem of supply being nowhere near demand, and since prices for things are so high (including liability), there is a lot of cover your ass and fraud prevention going on.
  - acdha 10mo ago
    Don’t do pro bono PR for those companies. Healthcare isn’t so complicated that every other country in the world hasn’t been able to solve it for significantly less money and far less stress for users, not to mention better health outcomes in most cases.
    - lotsofpulp 10mo ago
      Providing a chain of reasoning to support a logical conclusion is not “pro bono PR for those companies”. Claiming that someone doing that seems like an emotional kneejerk reaction to an idea that does not jive with the model of the world you would like to have. I even provided an example of a healthcare provider choosing to be more transparent. It is always Eli Lilly’s choice to sell their medicine at a flat price to everyone. But it is also in Eli Lilly’s benefit to engage in price discrimination, so that they get paid more by people who can pay more: https://en.wikipedia.org/wiki/Price_discrimination https://en.wikipedia.org/wiki/Price_discrimination Another example of this was when I was in college, US textbooks cost multiple times more than the international version of the textbook I could buy on Abe books or whatever website. Or, coupons for grocery stores. The insurance company has no hand in this. To be clear, insurance companies also cause waste, because the government does not audit them, and the insurance companies are not staffed appropriately to resolve disputes in a timely manner.
      - lenkite 10mo ago
        > it has a problem of supply being nowhere near demand, Get rid of the patents and this will solve itself in no time. > The insurance company has no hand in this. False. Insurance companies in the US own stock in big pharma firms like Pfizer, Johnson & Johnson, Eli Lilly, etc. They maintain substantial investment portfolios and generate returns on premiums and reserves. They also have voting rights as institutional investors.
        lotsofpulp 10mo ago
        Yes, no one is stopping US (or other countries’) taxpayers from paying for all the drug trials so that the resulting medicines are in the public domain. > False. Insurance companies in the US own stock in big pharma firms like Pfizer, Johnson & Johnson, Eli Lilly, etc. They maintain substantial investment portfolios and generate returns on premiums and reserves. They also have voting rights as institutional investors. This is a wild assertion. The sum total of all 7 publicly listed insurance companies’ market caps is less than Eli Lilly, just one pharmaceutical company. I would need some evidence before believing that health insurance company leaders have any influence on pharmaceutical companies. I would also be surprised to learn insurance companies hold specific stocks, seems like a risk insurance companies would not take, especially ones that have lots of routine cash expenses. They spend ~85% of their premiums on medical expenses, and probably at least 5% to 10% on their own staff, so they shouldn’t even have much extra cash left to invest for the long term. https://www.oliverwyman.com/our-expertise/insights/2023/mar/health-insurer-financial-insights-volume-11-p1.html https://www.oliverwyman.com/our-expertise/insights/2023/mar/... Edit: hit posting limit, so to respond to comment below about net income, that Yale link does not seem relevant as it is for all healthcare companies. All 7 publicly listed insurers’ combined annual net income is $35B or less for the previous 20 years, at a profit margin of 3% or less, which is peanuts. The pharmaceutical companies earn much more money than them, which is why the pharmaceutical companies have higher market caps. > Why are we using market cap as a metric ? Look at investment value. Because a company that owns influential portions of another company would have that reflected in their market cap. Like Berkshire Hathaway does. with the exception of UNH (due to its healthcare provider business), the other insurance companies are relatively tiny businesses compared to pharmaceutical companies and so cannot be holding any influential amount of stock.
  - anthuswilliams 10mo ago
    Insurance companies absolutely benefit from the higher and opaque prices, because they negotiate rebates with providers. This allows them to maximize patient copays and ensures they hit their deductible, i.e. paying as much as possible under their respective insurance plans. Contrast this with a no-rebate world with cheaper/more transparent pricing. Fewer patients would hit their out of pocket maximum. They can use the rebates they get from the providers to subsidize the insured, allowing them to offer lower premiums and gain market share. This is what people mean when they say "In America, the sick people pay to subsidize the health care of the healthy people". Of course, that above only applies if there is competitive pressure. If there is no competitive pressure (e.g. in states with only one or two insurers), they can keep premiums high and book as profit the difference between what the patient paid out and what the patient would have paid out in a lower-cost no-rebate world.
    - vjvjvjvjghv 10mo ago
      Everybody in this system benefits from this insanity, except the patient.
    - lotsofpulp 10mo ago
      > Contrast this with a no-rebate world with cheaper/more transparent pricing. Fewer patients would hit their out of pocket maximum. And premiums would go up. Every insurer has to get their premium approved by every state’s insurance regulator, and every state’s insurance regulator is not going to allow them to have more than a few percent of profit. > They can use the rebates they get from the providers to subsidize the insured, allowing them to offer lower premiums and gain market share. This is what people mean when they say "In America, the sick people pay to subsidize the health care of the healthy people". I’ve never heard of this, and it’s legally not allowed. The ACA mandates insurers price plans so that old people only pay at most 3x what young people pay. And the ACA does not allow insurers to charge more to people likelier to need healthcare. Mathematically, that means younger and healthier people pay higher premiums so that older and sicker people can have lower premiums. NY state goes even further and says all ages pay the same premium, so young subsidizes old even more. MA has a 2x cap, I believe. And then of course, FICA taxes mean the young and working are paying for the healthcare for the old and non working, the vast majority of all healthcare spend in the US (Medicare).
  - Uvix 10mo ago
    Pharmaceutical companies, hospitals, and doctors are free to charge like that. But if I'm using insurance, it's irrelevant; that's the price to the insurer. It's the insurance company who determines the price I pay, using whatever arcane rituals they've chosen.
    - quietsegfault 10mo ago
      Unless the anesthesiologist is mysteriously out of network, or you failed to get some silly pre-approval, or…
- vjvjvjvjghv 10mo ago
  Germany has health insurances and they don’t do that nonsense. They fulfill their task which is to spread the risk over a wide range of people. That’s what insurance is for.
Workaccount2 10mo ago
Last year I needed to get blood work done, some of which may or may not be covered. It took me two weeks, dozens of phone calls, and multiple "escalations" to learn what would be covered and what the price would be if it wasn't Totally insane. The kicker is that after all that, the price I was billed wasn't even the price I was given (thankfully it was less though).
- juujian 10mo ago
  In practice, the whole system is set up in a way that discourages asking questions. Waste of time. It's truly the opposite of the transparent ideal market.
- olyjohn 10mo ago
  I just had some bloodwork done, myself. My provider accidentally billed insurance, which had lapsed due to being laid off. I got my "Explanation of benefits" and it was $1000 billed to them, but I was given a $500 "discount." So I only owed $500... Cash cost was $50. Makes no goddamn sense. Also I went in for a colonoscopy and an endoscopy. Insurance was billed for $14000. I got statements from 4 different doctors, and the facility where it was performed. None of the statements matched the explanation of benefits from the insurance company. And when I called each doctor, to pay them, they all told me that I didn't actually have to pay them what it said I owed. So I just ended up paying $2500 to the insurance company. It again, makes zero sense.
  - mothballed 10mo ago
    I don't think the hospital expects to actually ever get paid what they bill out, or anything at all, if it's not paid onsite or by insurance.
    - why-o-why 10mo ago
      >> I don't think the hospital expects to actually ever get paid what they bill out OH YES THEY ABSOLUTELY DO! When I was in-between jobs I had a medical emergency and I was on the ACA around the first year it was offered. I was billed above medicare rates so I was on the hook for ~40k after out of pocket max. They told me this limit is what insurance has to cover but hospitals can still bill above it. First they told me they could work on the prices and asked for my last 5 years tax returns. When they saw that I had dividend payments they said they couldn't help me and I owed them the $40k. I think that was the problem because even though I wasn't working in their mind if I had investments then technically I was not in need so they set up four-year payment plan and paid every penny with no cost reduction. I probably did something wrong but to this day I didn't know what I would have done differently. The only people I could talk to were the hospital and they only cared about the hospital.
seawsurf 10mo ago
Here in Brazil, we have something called 'Genéricos.' These are essentially the same medications as the brand-name versions, produced with the same chemical ingredients, but they often cost half the price, sometimes even cheaper than that. Insanely comical.
- itsdrewmiller 10mo ago
  Those are available in America too
  - seawsurf 10mo ago
    So this must be worldwide. It seems like the patents held by big pharma are the root of the corruption. What is the guarantee here? That the chemicals are pure, or just that the companies are getting their cut?
    - evilkorn 10mo ago
      Generic is the English word for it. The brand name drugs have a limited time patent and they are supposed to help cover the initial research and development costs of bringing that drug to market.
    - ebiester 10mo ago
      Generics can only be made after the patent expires. And due to pressure from western countries, these are enforced worldwide.
      - Forgeties79 10mo ago
        Which takes over a decade and can be extended multiple times if they find more uses for the drug.
  - ilamont 10mo ago
    But prices are going up. Look at the statements your insurance company provides about the reimbursed "cost" of covered generics: Some experts report that PBMs overcharge for generics; The Wall Street Journal estimated that Cigna and CVS Health, both of which own PBM services, are able to charge prices for specialty generic drugs that are 24 times higher than what manufacturers charge. https://www.americanprogress.org/article/5-things-to-know-about-pharmacy-benefit-managers/#:~:text=Accordingly%2C%20some%20experts%20report%20that,higher%20than%20what%20manufacturers%20charge. https://www.americanprogress.org/article/5-things-to-know-ab...
giantg2 10mo ago
"And everybody would get the same price. This whole business with PBMs that are owned by the insurance companies, discount cards and other shenanigans just invites corruption." It's hard to say that it isn't racketeering at this point. "Specifically, a racket was defined by this coinage as being a service that calls forth its own demand, and would not have been needed otherwise." There's demand for the meds, but the demand for discount cards, forcing people to use specific services/companies, and related programs is all invented by the companies themselves.
angarg12 10mo ago
As a european living in the US, the idea there is a market at all is laughable. I tried to get price quotes for treatments several time just to get a "well, it's hard to say" or "it's very complicated".
- vjvjvjvjghv 10mo ago
  There is a market but you aren't part of it :-)
dylan604 10mo ago
> "Rome said the companies seem to be maximizing prices while negotiating discounts behind the scenes with health and drug insurers and then setting yet another price for direct-to-consumer cash-pay sales." This sounds like typical negotiating 101. You know you are going to be forced to lower from your starting position, so increase your starting position so when you do negotiate down you are closer to where you wanted to be.
- refurb 10mo ago
  It’s not only a logical negotiating position, it has legal implications. Way back in the 50-60’s the government put in laws around “usual and customary price” in an attempt to rein in medical costs. What providers were doing is charging cash customer $10, then when an insured patient came in (back when insurance paid 100%) they charged $100. So a law was put into place to define what a “usual and customary price” is. The provider could not charge any customer more than this. Like most well intentioned laws it created perverse incentives to jack up the public price as high as possible - if someone paid it, great, otherwise offer a discount.
tzs 10mo ago
> This describes the biggest problem in US healthcare. No clear and consistent pricing. For anyone not in the US wondering if this is an exaggeration, here is my history of buying prescription drugs. 1. For years, when I had insurance through my employer, I'd go the the nearest in-network pharmacy, which was Rite-Aid, for them. Those insurance plans always had a copay which was typically $10-15. It was this way across several different insurance providers I had over the years at that employer. (For non-Americans wondering why my insurance company changed so often, it is common for employers to frequently switch providers to try to save money. Besides that being annoying because it means frequently changing coverage limits, it also means frequent changes in what doctors and dentists are in-network). 2. I saw something about Walmart's generic drug program. They were selling many generic drugs for a cash price of $4 for a month supply and $10 for a 3 month supply. Most of my drugs were included, so for those I switched my prescriptions to Walmart and didn't use insurance. 3. Later, for my drugs not in Walmart's generic drug program, I found that the GoodRx app or website could usually provide a discount coupon that would bring the cash price with coupon down below my insurance copay. The GoodRx discount could vary significantly from pharmacy to pharmacy so I had my prescriptions split across two pharmacies. 4. My employer downsized and could no longer afford to provide insurance. I switched to a plan purchased on my state's Affordable Care Act (ACA) marketplace. I made too much money to get a government subsidy on my premiums, but not enough to afford a marketplace plan in the top two of the three tiers of plans (gold and silver). I had to settle for the third tier, bronze. That basically meant bigger copays and/or bigger coinsurance on everything, including drugs, than I had when I was on plans through my employer. Walmart generics + GoodRx coupons continued to be how I bought drugs. 5. I eventually switched to an HMO plan from the ACA marketplace, when rising costs made it so even the bronze non-HMO plans were too expensive. This meant I had to switch doctors to one that worked for the HMO (Kaiser), and the only in-network pharmacy was the one from the HMO. It remained cheaper for nearly everything to continue with Walmart and GoodRx. The only drug I regularly got through Kaiser's pharmacy was generic Lipitor. That was $0. I refilled one of my other prescripts at Kaiser once, and my out of pocket came to twice what that drug was at Safeway with a GoodRx coupon. I didn't try any of the others through Kaiser because there was no way that I could find to get the price other than actually getting the prescription filled there. Even though it was a Kaiser pharmacy, which is located in a Kaiser building and only takes Kaiser plans (and maybe people paying cash), they have no way apparently to answer the hypothetical "If I get drug X and I have Kaiser plan Y and my ID number is 12345678, what will my out of pocket cost be?". I would have expected that one of the benefits of an integrated system like Kaiser where it is one company basically providing all of your health care except for some special services they contract out for would be that they could tell you the damn costs. I would have expected that when I'm in the doctor's office and he gives me a new prescription that on his terminal it would have the cost of getting it filled in the Kaiser pharmacy that is in the same building. Nope. So I'd have to waste his time and mine getting out my phone, looking up the drug he's about to prescribe in the GoodRx app, and then decide where I want it. A nice thing about the GoodRx app was for Walmart if they did not have a GoodRx coupon because the drug was in Walmart's generic program GoodRx would still include it in the listing, showing the cash price so I didn't have to separately check Walmart's generics list. 6. It does get better when you get older. When I turned 65 and switched from a marketplace plan to Medicare I had to choose an insurance company that offered a Medicare drug plan. You can enter all your prescriptions on Medicare.gov and you can enter 5 pharmacies and the listing of available plans in your area will show you the annual total (premiums plug drugs) for each plan for both getting your drugs at the cheapest pharmacies on your pharmacy list and for getting them via mail order. By default it sorts the list by lowest total. You still have the hassle of plans possibly changing each year. My plan on my first year went away. It was a $0 premium and $0 for all my drugs. There is still a $0 premium and $0 for all my drugs plan available for 2026, but I'll have to change pharmacies to one less convenient. The above is if you choose regular Medicare when you enroll in Medicare. You can instead choose Medicare Advantage. The way Medicare Advantage works is instead of providing your medical coverage itself Medicare pays a private insurance company to do it. The plans offered by those private insurance companies broadly look a lot like the marketplace plans that offer on the ACA marketplaces or the plans they offer through employers. They are usually pretty cheap, often with no premium from the insurance company (although you still have to pay a premium to the government for Medicare). Some even have negative premium plans. They also have most of the annoyances of ACA marketplace and employer plans, but there are usually ones that include drug coverage similar to the part D plan coverage for people on regular Medicare.
duxup 10mo ago
Most of the non "cut everything" GOP plans still involve trying to get the consumer to shop around, but shopping around is impossible. The consumer can't be a consumer and impact the market if they don't know what is going on. The system is fundamentally broken. I go to the doctor and I have zero clue what will come back on the bills.
grafmax 10mo ago
Prices should be transparent, yes. But supply and demand isnt going to take down an oligopoly.
atoav 10mo ago
The US' main problem (seen from the outside) is that there seems to be no long term strategy just a sports-like us-versus-them mentality, where each team just thinks about how they can win more by making others lose. Winning the points is the goal, while all people forgot this was supposed to be a friendly game ans some even forgot which sport it is supposed to be. This may well be the end game of capitalism, no pun intended.
thrance 10mo ago
And when you get a broken leg you'd go shop around, comparing prices and looking up reviews? You can't have a "real" healthcare market. It is inelastic, people will always pay whatever is asked of them. It requires massive investments, naturally consolidating into a few large actors that are then easily able to join in a cartel, lobby the State for regulatory capture, etc. Price gouging and profiteering are just the end game of a free market functioning normally.
throw0101a 10mo ago
> This describes the biggest problem in US healthcare. No clear and consistent pricing. AIUI, this is one reason Kenneth Arrow argued (in 1963 [1][2]) that healthcare could not really use a market-oriented solution: information asymmetry. [1] https://assets.aeaweb.org/asset-server/files/9442.pdf https://assets.aeaweb.org/asset-server/files/9442.pdf [2] https://pubmed.ncbi.nlm.nih.gov/15042238/ https://pubmed.ncbi.nlm.nih.gov/15042238/

Uvix 10mo ago

Health insurance in general is the problem; PBMs/discount cards are just a cherry on top. Insurance is fundamentally incompatible with clear and consistent pricing.

lotsofpulp 10mo ago
Pharmaceutical companies, hospitals, and doctors are free to charge by the medicine, by the night, and by the minute. For example, this place does it: https://surgerycenterok.com/surgery-prices/ https://surgerycenterok.com/surgery-prices/ Insurance companies do not force the sellers to use complex billing practices, they would benefit from more transparent pricing (since they are seeking to pay less). The root cause is healthcare is inherently complicated and complex, it has a problem of supply being nowhere near demand, and since prices for things are so high (including liability), there is a lot of cover your ass and fraud prevention going on.
- acdha 10mo ago
  Don’t do pro bono PR for those companies. Healthcare isn’t so complicated that every other country in the world hasn’t been able to solve it for significantly less money and far less stress for users, not to mention better health outcomes in most cases.
  - lotsofpulp 10mo ago
    Providing a chain of reasoning to support a logical conclusion is not “pro bono PR for those companies”. Claiming that someone doing that seems like an emotional kneejerk reaction to an idea that does not jive with the model of the world you would like to have. I even provided an example of a healthcare provider choosing to be more transparent. It is always Eli Lilly’s choice to sell their medicine at a flat price to everyone. But it is also in Eli Lilly’s benefit to engage in price discrimination, so that they get paid more by people who can pay more: https://en.wikipedia.org/wiki/Price_discrimination https://en.wikipedia.org/wiki/Price_discrimination Another example of this was when I was in college, US textbooks cost multiple times more than the international version of the textbook I could buy on Abe books or whatever website. Or, coupons for grocery stores. The insurance company has no hand in this. To be clear, insurance companies also cause waste, because the government does not audit them, and the insurance companies are not staffed appropriately to resolve disputes in a timely manner.
    - lenkite 10mo ago
      > it has a problem of supply being nowhere near demand, Get rid of the patents and this will solve itself in no time. > The insurance company has no hand in this. False. Insurance companies in the US own stock in big pharma firms like Pfizer, Johnson & Johnson, Eli Lilly, etc. They maintain substantial investment portfolios and generate returns on premiums and reserves. They also have voting rights as institutional investors.
      - lotsofpulp 10mo ago
        Yes, no one is stopping US (or other countries’) taxpayers from paying for all the drug trials so that the resulting medicines are in the public domain. > False. Insurance companies in the US own stock in big pharma firms like Pfizer, Johnson & Johnson, Eli Lilly, etc. They maintain substantial investment portfolios and generate returns on premiums and reserves. They also have voting rights as institutional investors. This is a wild assertion. The sum total of all 7 publicly listed insurance companies’ market caps is less than Eli Lilly, just one pharmaceutical company. I would need some evidence before believing that health insurance company leaders have any influence on pharmaceutical companies. I would also be surprised to learn insurance companies hold specific stocks, seems like a risk insurance companies would not take, especially ones that have lots of routine cash expenses. They spend ~85% of their premiums on medical expenses, and probably at least 5% to 10% on their own staff, so they shouldn’t even have much extra cash left to invest for the long term. https://www.oliverwyman.com/our-expertise/insights/2023/mar/health-insurer-financial-insights-volume-11-p1.html https://www.oliverwyman.com/our-expertise/insights/2023/mar/... Edit: hit posting limit, so to respond to comment below about net income, that Yale link does not seem relevant as it is for all healthcare companies. All 7 publicly listed insurers’ combined annual net income is $35B or less for the previous 20 years, at a profit margin of 3% or less, which is peanuts. The pharmaceutical companies earn much more money than them, which is why the pharmaceutical companies have higher market caps. > Why are we using market cap as a metric ? Look at investment value. Because a company that owns influential portions of another company would have that reflected in their market cap. Like Berkshire Hathaway does. with the exception of UNH (due to its healthcare provider business), the other insurance companies are relatively tiny businesses compared to pharmaceutical companies and so cannot be holding any influential amount of stock.
- anthuswilliams 10mo ago
  Insurance companies absolutely benefit from the higher and opaque prices, because they negotiate rebates with providers. This allows them to maximize patient copays and ensures they hit their deductible, i.e. paying as much as possible under their respective insurance plans. Contrast this with a no-rebate world with cheaper/more transparent pricing. Fewer patients would hit their out of pocket maximum. They can use the rebates they get from the providers to subsidize the insured, allowing them to offer lower premiums and gain market share. This is what people mean when they say "In America, the sick people pay to subsidize the health care of the healthy people". Of course, that above only applies if there is competitive pressure. If there is no competitive pressure (e.g. in states with only one or two insurers), they can keep premiums high and book as profit the difference between what the patient paid out and what the patient would have paid out in a lower-cost no-rebate world.
  - vjvjvjvjghv 10mo ago
    Everybody in this system benefits from this insanity, except the patient.
  - lotsofpulp 10mo ago
    > Contrast this with a no-rebate world with cheaper/more transparent pricing. Fewer patients would hit their out of pocket maximum. And premiums would go up. Every insurer has to get their premium approved by every state’s insurance regulator, and every state’s insurance regulator is not going to allow them to have more than a few percent of profit. > They can use the rebates they get from the providers to subsidize the insured, allowing them to offer lower premiums and gain market share. This is what people mean when they say "In America, the sick people pay to subsidize the health care of the healthy people". I’ve never heard of this, and it’s legally not allowed. The ACA mandates insurers price plans so that old people only pay at most 3x what young people pay. And the ACA does not allow insurers to charge more to people likelier to need healthcare. Mathematically, that means younger and healthier people pay higher premiums so that older and sicker people can have lower premiums. NY state goes even further and says all ages pay the same premium, so young subsidizes old even more. MA has a 2x cap, I believe. And then of course, FICA taxes mean the young and working are paying for the healthcare for the old and non working, the vast majority of all healthcare spend in the US (Medicare).
- Uvix 10mo ago
  Pharmaceutical companies, hospitals, and doctors are free to charge like that. But if I'm using insurance, it's irrelevant; that's the price to the insurer. It's the insurance company who determines the price I pay, using whatever arcane rituals they've chosen.
  - quietsegfault 10mo ago
    Unless the anesthesiologist is mysteriously out of network, or you failed to get some silly pre-approval, or…
vjvjvjvjghv 10mo ago
Germany has health insurances and they don’t do that nonsense. They fulfill their task which is to spread the risk over a wide range of people. That’s what insurance is for.

Workaccount2 10mo ago

Last year I needed to get blood work done, some of which may or may not be covered. It took me two weeks, dozens of phone calls, and multiple "escalations" to learn what would be covered and what the price would be if it wasn't Totally insane. The kicker is that after all that, the price I was billed wasn't even the price I was given (thankfully it was less though).

juujian 10mo ago
In practice, the whole system is set up in a way that discourages asking questions. Waste of time. It's truly the opposite of the transparent ideal market.
olyjohn 10mo ago
I just had some bloodwork done, myself. My provider accidentally billed insurance, which had lapsed due to being laid off. I got my "Explanation of benefits" and it was $1000 billed to them, but I was given a $500 "discount." So I only owed $500... Cash cost was $50. Makes no goddamn sense. Also I went in for a colonoscopy and an endoscopy. Insurance was billed for $14000. I got statements from 4 different doctors, and the facility where it was performed. None of the statements matched the explanation of benefits from the insurance company. And when I called each doctor, to pay them, they all told me that I didn't actually have to pay them what it said I owed. So I just ended up paying $2500 to the insurance company. It again, makes zero sense.
- mothballed 10mo ago
  I don't think the hospital expects to actually ever get paid what they bill out, or anything at all, if it's not paid onsite or by insurance.
  - why-o-why 10mo ago
    >> I don't think the hospital expects to actually ever get paid what they bill out OH YES THEY ABSOLUTELY DO! When I was in-between jobs I had a medical emergency and I was on the ACA around the first year it was offered. I was billed above medicare rates so I was on the hook for ~40k after out of pocket max. They told me this limit is what insurance has to cover but hospitals can still bill above it. First they told me they could work on the prices and asked for my last 5 years tax returns. When they saw that I had dividend payments they said they couldn't help me and I owed them the $40k. I think that was the problem because even though I wasn't working in their mind if I had investments then technically I was not in need so they set up four-year payment plan and paid every penny with no cost reduction. I probably did something wrong but to this day I didn't know what I would have done differently. The only people I could talk to were the hospital and they only cared about the hospital.

seawsurf 10mo ago

Here in Brazil, we have something called 'Genéricos.' These are essentially the same medications as the brand-name versions, produced with the same chemical ingredients, but they often cost half the price, sometimes even cheaper than that. Insanely comical.

itsdrewmiller 10mo ago
Those are available in America too
- seawsurf 10mo ago
  So this must be worldwide. It seems like the patents held by big pharma are the root of the corruption. What is the guarantee here? That the chemicals are pure, or just that the companies are getting their cut?
  - evilkorn 10mo ago
    Generic is the English word for it. The brand name drugs have a limited time patent and they are supposed to help cover the initial research and development costs of bringing that drug to market.
  - ebiester 10mo ago
    Generics can only be made after the patent expires. And due to pressure from western countries, these are enforced worldwide.
    - Forgeties79 10mo ago
      Which takes over a decade and can be extended multiple times if they find more uses for the drug.
- ilamont 10mo ago
  But prices are going up. Look at the statements your insurance company provides about the reimbursed "cost" of covered generics: Some experts report that PBMs overcharge for generics; The Wall Street Journal estimated that Cigna and CVS Health, both of which own PBM services, are able to charge prices for specialty generic drugs that are 24 times higher than what manufacturers charge. https://www.americanprogress.org/article/5-things-to-know-about-pharmacy-benefit-managers/#:~:text=Accordingly%2C%20some%20experts%20report%20that,higher%20than%20what%20manufacturers%20charge. https://www.americanprogress.org/article/5-things-to-know-ab...

giantg2 10mo ago

"And everybody would get the same price. This whole business with PBMs that are owned by the insurance companies, discount cards and other shenanigans just invites corruption." It's hard to say that it isn't racketeering at this point. "Specifically, a racket was defined by this coinage as being a service that calls forth its own demand, and would not have been needed otherwise." There's demand for the meds, but the demand for discount cards, forcing people to use specific services/companies, and related programs is all invented by the companies themselves.

angarg12 10mo ago

As a european living in the US, the idea there is a market at all is laughable. I tried to get price quotes for treatments several time just to get a "well, it's hard to say" or "it's very complicated".

vjvjvjvjghv 10mo ago
There is a market but you aren't part of it :-)

dylan604 10mo ago

> "Rome said the companies seem to be maximizing prices while negotiating discounts behind the scenes with health and drug insurers and then setting yet another price for direct-to-consumer cash-pay sales." This sounds like typical negotiating 101. You know you are going to be forced to lower from your starting position, so increase your starting position so when you do negotiate down you are closer to where you wanted to be.

refurb 10mo ago
It’s not only a logical negotiating position, it has legal implications. Way back in the 50-60’s the government put in laws around “usual and customary price” in an attempt to rein in medical costs. What providers were doing is charging cash customer $10, then when an insured patient came in (back when insurance paid 100%) they charged $100. So a law was put into place to define what a “usual and customary price” is. The provider could not charge any customer more than this. Like most well intentioned laws it created perverse incentives to jack up the public price as high as possible - if someone paid it, great, otherwise offer a discount.

tzs 10mo ago

> This describes the biggest problem in US healthcare. No clear and consistent pricing. For anyone not in the US wondering if this is an exaggeration, here is my history of buying prescription drugs. 1. For years, when I had insurance through my employer, I'd go the the nearest in-network pharmacy, which was Rite-Aid, for them. Those insurance plans always had a copay which was typically $10-15. It was this way across several different insurance providers I had over the years at that employer. (For non-Americans wondering why my insurance company changed so often, it is common for employers to frequently switch providers to try to save money. Besides that being annoying because it means frequently changing coverage limits, it also means frequent changes in what doctors and dentists are in-network). 2. I saw something about Walmart's generic drug program. They were selling many generic drugs for a cash price of $4 for a month supply and $10 for a 3 month supply. Most of my drugs were included, so for those I switched my prescriptions to Walmart and didn't use insurance. 3. Later, for my drugs not in Walmart's generic drug program, I found that the GoodRx app or website could usually provide a discount coupon that would bring the cash price with coupon down below my insurance copay. The GoodRx discount could vary significantly from pharmacy to pharmacy so I had my prescriptions split across two pharmacies. 4. My employer downsized and could no longer afford to provide insurance. I switched to a plan purchased on my state's Affordable Care Act (ACA) marketplace. I made too much money to get a government subsidy on my premiums, but not enough to afford a marketplace plan in the top two of the three tiers of plans (gold and silver). I had to settle for the third tier, bronze. That basically meant bigger copays and/or bigger coinsurance on everything, including drugs, than I had when I was on plans through my employer. Walmart generics + GoodRx coupons continued to be how I bought drugs. 5. I eventually switched to an HMO plan from the ACA marketplace, when rising costs made it so even the bronze non-HMO plans were too expensive. This meant I had to switch doctors to one that worked for the HMO (Kaiser), and the only in-network pharmacy was the one from the HMO. It remained cheaper for nearly everything to continue with Walmart and GoodRx. The only drug I regularly got through Kaiser's pharmacy was generic Lipitor. That was $0. I refilled one of my other prescripts at Kaiser once, and my out of pocket came to twice what that drug was at Safeway with a GoodRx coupon. I didn't try any of the others through Kaiser because there was no way that I could find to get the price other than actually getting the prescription filled there. Even though it was a Kaiser pharmacy, which is located in a Kaiser building and only takes Kaiser plans (and maybe people paying cash), they have no way apparently to answer the hypothetical "If I get drug X and I have Kaiser plan Y and my ID number is 12345678, what will my out of pocket cost be?". I would have expected that one of the benefits of an integrated system like Kaiser where it is one company basically providing all of your health care except for some special services they contract out for would be that they could tell you the damn costs. I would have expected that when I'm in the doctor's office and he gives me a new prescription that on his terminal it would have the cost of getting it filled in the Kaiser pharmacy that is in the same building. Nope. So I'd have to waste his time and mine getting out my phone, looking up the drug he's about to prescribe in the GoodRx app, and then decide where I want it. A nice thing about the GoodRx app was for Walmart if they did not have a GoodRx coupon because the drug was in Walmart's generic program GoodRx would still include it in the listing, showing the cash price so I didn't have to separately check Walmart's generics list. 6. It does get better when you get older. When I turned 65 and switched from a marketplace plan to Medicare I had to choose an insurance company that offered a Medicare drug plan. You can enter all your prescriptions on Medicare.gov and you can enter 5 pharmacies and the listing of available plans in your area will show you the annual total (premiums plug drugs) for each plan for both getting your drugs at the cheapest pharmacies on your pharmacy list and for getting them via mail order. By default it sorts the list by lowest total. You still have the hassle of plans possibly changing each year. My plan on my first year went away. It was a $0 premium and $0 for all my drugs. There is still a $0 premium and $0 for all my drugs plan available for 2026, but I'll have to change pharmacies to one less convenient. The above is if you choose regular Medicare when you enroll in Medicare. You can instead choose Medicare Advantage. The way Medicare Advantage works is instead of providing your medical coverage itself Medicare pays a private insurance company to do it. The plans offered by those private insurance companies broadly look a lot like the marketplace plans that offer on the ACA marketplaces or the plans they offer through employers. They are usually pretty cheap, often with no premium from the insurance company (although you still have to pay a premium to the government for Medicare). Some even have negative premium plans. They also have most of the annoyances of ACA marketplace and employer plans, but there are usually ones that include drug coverage similar to the part D plan coverage for people on regular Medicare.

duxup 10mo ago

Most of the non "cut everything" GOP plans still involve trying to get the consumer to shop around, but shopping around is impossible. The consumer can't be a consumer and impact the market if they don't know what is going on. The system is fundamentally broken. I go to the doctor and I have zero clue what will come back on the bills.

grafmax 10mo ago

Prices should be transparent, yes. But supply and demand isnt going to take down an oligopoly.

atoav 10mo ago

The US' main problem (seen from the outside) is that there seems to be no long term strategy just a sports-like us-versus-them mentality, where each team just thinks about how they can win more by making others lose. Winning the points is the goal, while all people forgot this was supposed to be a friendly game ans some even forgot which sport it is supposed to be. This may well be the end game of capitalism, no pun intended.

thrance 10mo ago

And when you get a broken leg you'd go shop around, comparing prices and looking up reviews? You can't have a "real" healthcare market. It is inelastic, people will always pay whatever is asked of them. It requires massive investments, naturally consolidating into a few large actors that are then easily able to join in a cartel, lobby the State for regulatory capture, etc. Price gouging and profiteering are just the end game of a free market functioning normally.

throw0101a 10mo ago

> This describes the biggest problem in US healthcare. No clear and consistent pricing. AIUI, this is one reason Kenneth Arrow argued (in 1963 [1][2]) that healthcare could not really use a market-oriented solution: information asymmetry. [1] https://assets.aeaweb.org/asset-server/files/9442.pdf https://assets.aeaweb.org/asset-server/files/9442.pdf [2] https://pubmed.ncbi.nlm.nih.gov/15042238/ https://pubmed.ncbi.nlm.nih.gov/15042238/