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It's also caused by absurd nonsense like how doctors can't tell you how much anything they're proposing to do actually will cost (a necessary condition for ente

It's also caused by absurd nonsense like how doctors can't tell you how much anything they're proposing to do actually will cost (a necessary condition for entering into a contract!), but then the system makes up arbitrary bills after the fact - with fraudulent amounts that nobody actually pays! No other industry works like that, as it's not the foundation of a market in the first place. Imagine if going to the grocery store involved "paying" some token amount at the cashier for their time to put your items in bags, then for the food you received shakedown bills for years afterwards, that you had to spend time going through your old documentation to refute and bargain down. Absurd. Regardless of "insurance", who is ultimately paying, or subsidies to provide a baseline of care - there needs to be reform that mandates simple up-front prices, constant per-provider regardless who is paying, and ruling out any other theory of billing. Doctors throw up their hands and act like they're dealing with some special problems, but there are plenty of other industries we can look at for the dynamics of how to handle routine procedures versus emergencies (and knowns vs unknowns) in a consensual and market-responsive manner.

nradov 2mo ago
That's all true, but from a practical standpoint providers really have no way to accurately estimate a patient's out-of-pocket financial responsibility in advance. The current HIPAA adopted standard transactions don't allow for sending a prospective claim. So all they can realistically do is perform the procedure, submit a claim to the patient's health plan, wait for it to (maybe) be paid, and then send a bill to the patient for the balance. https://www.cms.gov/priorities/key-initiatives/burden-reduction/administrative-simplification/hipaa/adopted-standards-operating-rules https://www.cms.gov/priorities/key-initiatives/burden-reduct... The good news is that CMS is working on an update to those standards which will at least make prospective claims technically possible. Although it may take years until that functionality is widely implemented.
- mindslight 2mo ago
  One can always craft some excuse, which is how the terrible system continues to perpetuate itself. Doctors cannot even tell you how much they themselves will charge for anything. The problem I'm describing originates completely with them - no escaping blame here. (And "might take years" lol. How about eliminate whatever flagrant regulatory capture is allowing providers to create and enforce post-facto and downright fraudulent bills in the first place, and watch the system reform itself overnight)
  - nradov 2mo ago
    Feel free to blame doctors if that makes you feel better but the reality is that in most cases they literally have no way to accurately calculate a patient's out-of-pocket cost in advance. Like there's just no technical way to do it. If you have specific suggestions for fixing the regulatory capture problem then you can submit a petition for rule making under the Administrative Procedures Act. https://www.govinfo.gov/content/pkg/USCODE-2011-title5/html/USCODE-2011-title5-partI-chap5-subchapII.htm https://www.govinfo.gov/content/pkg/USCODE-2011-title5/html/...
    - mindslight 2mo ago
      You keep misinterpreting "how much [a doctor] themselves will charge for something" as "patient's out-of-pocket cost". I'm certainly not asking for the doctor to get involved between the patient and their health plan [0], but rather what the doctor charges, regardless of who might pay. In other words, the straightforwardly-legible prices that exist in every other market - even markets where insurance companies often pay (eg auto repair). I don't know the specific legal details that allow doctors to make up these post-facto bills (often fraudulent) and send them to patients, but I feel it's probably at the state level rather than federal. Also the big problem with regulatory capture is that businesses paying off politicians makes that kind of citizen feedback meaningless. [0] in fact I think another good angle of reform would be "if a patient has a health plan, providers are prohibited from billing the patient directly". Any copays, outstanding balances, etc should flow through the health plan.
      - nradov 2mo ago
        Are you perhaps unfamiliar with existing price transparency rules? Patients paying cash already have the right to demand a Good Faith Estimate in advance. Those using a commercial health plan can see the negotiated rates for every participating provider. https://www.cms.gov/medical-bill-rights/help/guides/good-faith-estimate https://www.cms.gov/medical-bill-rights/help/guides/good-fai... https://www.cms.gov/priorities/healthplan-price-transparency/overview/consumers https://www.cms.gov/priorities/healthplan-price-transparency...
- _heimdall 2mo ago
  Nothing stops a doctor or an office from saying "treatment X costs $Y." Doctors can't say how much an insurance provider will cover or what a patient's out of pocket will therefore be, but that is a separate issue further downstream of clear pricing for treatment.
  - nradov 2mo ago
    Right, and as I already pointed out below, cash pay patients have the right to demand a Good Faith Estimate (GFE) from providers under federal price transparency rules.
    - _heimdall 2mo ago
      That shouldn't be limited to cash payers though. Insurance companies should not be part of the process of care providers pricing their service, nor should they be able to deny a charge after the fact. Today's model is great for the insurance company, it should be great for the patient. If one wants to offer an insurance product they should be considering average cost of care based on whatever factors their actuaries come up withz they shouldn't be demanding say into pricing so they can protect their bottom line.
_heimdall 2mo ago
Sure, I'd be all for such reform. Those are the kinda of changes we can and should make before even considering nationalizing an entire industry. If nothing else we'd want that setup anyway under a centralized system, and we could change pricing regulations now with much less controversy unless you ask the lobbyists who would fight it tooth and nail).

nradov 2mo ago

That's all true, but from a practical standpoint providers really have no way to accurately estimate a patient's out-of-pocket financial responsibility in advance. The current HIPAA adopted standard transactions don't allow for sending a prospective claim. So all they can realistically do is perform the procedure, submit a claim to the patient's health plan, wait for it to (maybe) be paid, and then send a bill to the patient for the balance. https://www.cms.gov/priorities/key-initiatives/burden-reduction/administrative-simplification/hipaa/adopted-standards-operating-rules https://www.cms.gov/priorities/key-initiatives/burden-reduct... The good news is that CMS is working on an update to those standards which will at least make prospective claims technically possible. Although it may take years until that functionality is widely implemented.

mindslight 2mo ago
One can always craft some excuse, which is how the terrible system continues to perpetuate itself. Doctors cannot even tell you how much they themselves will charge for anything. The problem I'm describing originates completely with them - no escaping blame here. (And "might take years" lol. How about eliminate whatever flagrant regulatory capture is allowing providers to create and enforce post-facto and downright fraudulent bills in the first place, and watch the system reform itself overnight)
- nradov 2mo ago
  Feel free to blame doctors if that makes you feel better but the reality is that in most cases they literally have no way to accurately calculate a patient's out-of-pocket cost in advance. Like there's just no technical way to do it. If you have specific suggestions for fixing the regulatory capture problem then you can submit a petition for rule making under the Administrative Procedures Act. https://www.govinfo.gov/content/pkg/USCODE-2011-title5/html/USCODE-2011-title5-partI-chap5-subchapII.htm https://www.govinfo.gov/content/pkg/USCODE-2011-title5/html/...
  - mindslight 2mo ago
    You keep misinterpreting "how much [a doctor] themselves will charge for something" as "patient's out-of-pocket cost". I'm certainly not asking for the doctor to get involved between the patient and their health plan [0], but rather what the doctor charges, regardless of who might pay. In other words, the straightforwardly-legible prices that exist in every other market - even markets where insurance companies often pay (eg auto repair). I don't know the specific legal details that allow doctors to make up these post-facto bills (often fraudulent) and send them to patients, but I feel it's probably at the state level rather than federal. Also the big problem with regulatory capture is that businesses paying off politicians makes that kind of citizen feedback meaningless. [0] in fact I think another good angle of reform would be "if a patient has a health plan, providers are prohibited from billing the patient directly". Any copays, outstanding balances, etc should flow through the health plan.
    - nradov 2mo ago
      Are you perhaps unfamiliar with existing price transparency rules? Patients paying cash already have the right to demand a Good Faith Estimate in advance. Those using a commercial health plan can see the negotiated rates for every participating provider. https://www.cms.gov/medical-bill-rights/help/guides/good-faith-estimate https://www.cms.gov/medical-bill-rights/help/guides/good-fai... https://www.cms.gov/priorities/healthplan-price-transparency/overview/consumers https://www.cms.gov/priorities/healthplan-price-transparency...
_heimdall 2mo ago
Nothing stops a doctor or an office from saying "treatment X costs $Y." Doctors can't say how much an insurance provider will cover or what a patient's out of pocket will therefore be, but that is a separate issue further downstream of clear pricing for treatment.
- nradov 2mo ago
  Right, and as I already pointed out below, cash pay patients have the right to demand a Good Faith Estimate (GFE) from providers under federal price transparency rules.
  - _heimdall 2mo ago
    That shouldn't be limited to cash payers though. Insurance companies should not be part of the process of care providers pricing their service, nor should they be able to deny a charge after the fact. Today's model is great for the insurance company, it should be great for the patient. If one wants to offer an insurance product they should be considering average cost of care based on whatever factors their actuaries come up withz they shouldn't be demanding say into pricing so they can protect their bottom line.

_heimdall 2mo ago

Sure, I'd be all for such reform. Those are the kinda of changes we can and should make before even considering nationalizing an entire industry. If nothing else we'd want that setup anyway under a centralized system, and we could change pricing regulations now with much less controversy unless you ask the lobbyists who would fight it tooth and nail).