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The True Cost of Healthcare in the US

97 points by felipellrocha 14y ago

ambiate 14y ago
After visiting the ER with a 108F temp due to pneumonia, I can attest to the fact that ER visits are a rip off. 3 unique doctor visits to the room + 1 IV + phlegm sample + 1 $60 pill + 1 prescription = $4200 for 50 minutes of office and 120 minutes of wait. Afterwards, I explained I did not have insurance. $60 pill was wrote off instantly. $4200 turned into $1200. Govt reimbursed 3/4ths of the bill instantly to the hospital. $1200 got wrote off after 3 months because it was not worth collecting... Edit: The interesting thing was each doctor had an individual bill of $600 sent to me. These are still in collections. The phlegm sample cost $120 and come from a separate clinical laboratories bill. My wife's birth control has a package value of $130/mo. Health insurance ($600 for wife, and kid), had a copay of $40 for this medication. I called the same clinic, requested generic and expressed my need to pay in cash. Instantly brought the price down to $8/mo. I did not sign up for health insurance this year. It is a complete waste. I usually pay more than just asking for generic and paying with cash. The 'poor' clinics here have a higher quality of care and staff, and are more affordable than my co-pays.
- jneal 14y ago
  I suppose you are prepared to starting paying the tax penalty for not having insurance under the PPACA?
  - ambiate 14y ago
    If necessary, I will pay the penalty. I assume the credit for health care costs and taxes charged on health care should make up for any penalties incurred by the PPACA. If I read correctly, my penalty should only be $950-1300. Inevitably, with my insurance rates, I would spend that on 2 months of health coverage for my small family. Just to break down costs: $600/mo health for wife/kid. $7200/yr. vs ~200/mo + 1000 penalty. $3400/yr. We're not exactly getting Xrays and CT scans on a daily basis in my household! If my wife was to get pregnant, I know most hospitals offer a specialized bundle plan for dealing with the pregnancy for a set flat rate. All check ups, ultrasounds, single doctor, etc, for $6000.
    - robinh 14y ago
      I'm not in the USA, but 'only $950-1300'? That's more or less what I pay for a whole year of health insurance in the NL. How much does insurance cost in the USA?
      - ambiate 14y ago
        $200/mo per kid. $350/mo for wife. $600 for wife and unlimited kids.
        roc 14y ago
        And for the record: that's what qualifies as "incredibly inexpensive" in the US. Many people pay well over $1000/mo for family care, not counting what their employer contributes.
        jneal 14y ago
        These costs are roughly what I'm faced with as well. I have insurance on myself but my kid is uninsured because I can't bring myself to pay so much per month when my child is only at the doctor 2-3 times a year and the cost is probably around $180 for a whole year, or less than the cost of a single month of insurance which I'd still be paying a copay on.
      - bhousel 14y ago
        Here is an example rate sheet for where I live (Northern NJ): http://www.horizon-bcbsnj.com/SiteGen/Uploads/Public/horizon_bcbsnj/pdf/Rate_Sheet_for_FF_Kits.pdf http://www.horizon-bcbsnj.com/SiteGen/Uploads/Public/horizon...
      - jes5199 14y ago
        when I left my last job, I had the option to continue the health insurance the company was paying for, for up to a year (this rule is called "COBRA"). It costs me about $1100 per month, to cover two people.
      - Ergomane 14y ago
        Unless you have low income, you pay more than that in the Netherlands. Payment for health care is composed of two parts: You pay about EUR 867 to 1,140 directly to an insurance company PER ADULT depending on how much you want to pay yourself in case of required care. Then there's the socialized income dependent part of the insurance that's either payed via your employer or by yourself, which, in the latter case, is 5,65% over up to EUR ~51 K. A family of two, each with an income > 51K then pays between EUR 7,480 to 8,026 (atm USD ~10K) each year for health insurance, subsidizing insurance for lower income groups.
- dschep 14y ago
  > My wife's birth control has a package value of $130/mo. Wow. My girlfriend's birth control is $9/month, without health insurance (Target's generic Ortho Tri-Cyclen).
- danielweber 14y ago
  ERs are expensive for two reasons: 1. You are paying for a standing army. 1 hour of scheduled doctor time is much different than 1 hour of doctor time ready to deploy in an instant. 2. The ERs need to cover all the non-paying clients. These two items probably feed on each other. Emergency departments are about 1% of total health care costs. They can be a good indicator of other symptoms that are wrong (medical billing is a maze, on purpose[1]), but fixing it won't really address health care costs. [1] http://www.thedailybeast.com/articles/2013/02/22/how-hospital-administrators-hide-the-umbrella.html http://www.thedailybeast.com/articles/2013/02/22/how-hospita...
- phren0logy 14y ago
  Not having health care works if you don't have a catastrophic injury, and/or you are willing to let the hospital write off services and pass the bills on the the rest of us. This isn't really a sustainable plan for the nation.
  - ambiate 14y ago
    There's a hidden truth in 'writing off'. Insurance companies wager paying the bill too. They say "We'll pay 60% of that $8000 ER visit." Guess who covers 25% of that leftover 40%? In a majority of cases, the government. (Source: My aunt has worked for a hospital performing these write-offs the majority of her 45 year life.)
- justsomedood 14y ago
  I'm in the same boat. My insurance premium changed this year to $950 a month. We have 3 younger kids and are all healthy. I would be paying almost $12,000k a year for the privilege of being able to pay "less" after the deductible is met. Paying around ~$120 for an office visit is so much less than premium + copay, and like you said a lot of services prices change once they know you don't have insurance. I wish health insurance were more like car insurance (accidental coverage, not maintenance) and I think we wouldn't have the same convoluted pricing we have now.
pstuart 14y ago
That's my doctor's site! The real takeaway (to me) is that single-payer health insurance would be the way to go.
- thatswrong0 14y ago
  I think it's a bit more complicated than that. It's easy to look at other countries and say, hey, that works there, therefore it will work here. But not all governments are created equal. If the government in the U.S. had a better track record, maybe it would be more palatable. But as is, I don't see single payer being the solution to our problems.
  - pstuart 14y ago
    It doesn't solve everything but it should help to simplify matters greatly. What would help too is ubiquitous electronic records management, e.g., any records from a visit with one doctor should be usable by the patient at another doctor. Add to that cheaper testing and more AI / self-help and that should take it even further. Lastly, kill the corn lobby and get some real sense into people about how their diet and lifestyle directly impact their health. What percentage of US healthcare costs are going towards diabetes and any related illnesses? And what percentage of that is directly related to obesity and a sedentary lifestyle?
    - epmatsw 14y ago
      Electronic Health Records are harder to implement than you'd expect. HIPAA sets really harsh penalties for violations that can occur much more easily if hospitals and doctors provide open access to other facilities. Organizations are also often reluctant to provide their data to other facilities because of a perception that it will lead to a loss of competitive advantage. Add to that the typical problems of cross-vendor interfacing between organizations. That said, EHRs are definitely the way to go, and we'll see much more of them in the future. Once Stage 2 of Meaningful Use[1] kicks in, you'll see a bunch of hospitals scrambling to upgrade their IT infrastructure to make sure they continue to receive the bonus Medicare/Medicaid payouts they're receiving now. 1. http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives http://www.healthit.gov/providers-professionals/meaningful-u...
ender7 14y ago
This Time article seems particularly apropos: http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/print/ http://healthland.time.com/2013/02/20/bitter-pill-why-medica...
- wiremine 14y ago
  Read it this weekend: I'd love to see a response from the health care industry that wasn't hand waiving. If he's right on 50% of his facts, it is disgusting how the system works.
  - Alex3917 14y ago
    "If he's right on 50% of his facts, it is disgusting how the system works." There were only a handful of actual statistics in there. The one thing he is wrong about though is that healthcare isn't "roughly 20% of the GDP", rather it's about 17.9%. The furthest out cms.gov gives yearly projections is to 2021, and even then healthcare is only supposed to be 19.6% of the GDP. And I think that might even include things like herbal supplements 'other non-durable medical supplies', I'm not positive about that though. Source: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2011PDF.pdf https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
    - Falling3 14y ago
      Facts are more than just statistics. There were numerous statements about (what seems to be) gross, gross overcharging on everything from pens to surgical gowns to diagnostic equipment. There were the exorbitant salaries and let's not forget the chargemaster.
      - wiremine 14y ago
        Exactly: that's the part I'd like to see a rebutted (if there is a rational rebuttal). The ad-hoc nature of their pricing model seems crazy.
    - 14y ago
zaidf 14y ago
We invited a dozen physicians for brunch this past weekend and they all had stories to share about how little they make per procedure compared to the amount the hospital makes. Example 1: A procedure costs $6,000 to be done at a hospital. It prices out patients paying out of pocket. The doctor realized that he himself gets about $700 from it. So the doctor reached out to another facility who agreed to do it for $1,800 instead of $6,000 for the exact same procedure. You can imagine how happy the doctor's patients are, particularly ones paying out of pocket. Example 2: A patient got upset a doctor's office wanted him to pay copay. The patient got the bill and felt the doctor already got paid $1,500. When the office informed the patient that out of the $1,500 the doctor only got about $300, the patient was shocked. Really what we need is a doctor compensation to everything else index. When we get that, we will realize the sham most of the efforts to reduce healthcare cost is. Most healthcare cost efforts focus on paying the doctor a little less, say $300 instead of $400. Problem is, bulk of the cost is not the doctor's fees. It is the cost of the bed, breakfast, Tylenol etc. We need regulation on those fees.
- specialp 14y ago
  For example 1: The reason why the hospital charges so much is the fact that it gets stiffed for a lot of emergecy patients without insurance. Many hospitals are on the brink of bankruptcy especially in poorer areas. This does not always reflect in the huge disparity in prices people pay, but is a big factor. Hospitals try to offset their losses by charging paying customers more. The real problems here especially with emergency care are that hospitals are forced to eat the cost of treating non insured patients, and that patients have no idea what something costs when they are there or if the people treating them will be covered by their insurance. Insurance companies spend a lot of time negotiating rates and making them somewhat uniform for them, but this is totally opaque to the patient. We need to make it more clear to the people being treated what things cost, and who is "in network". There have been times that I went to an emergency room "in network" and I was "balance billed" by nearly every doctor there due to them not being in network. What is a patient to do? Sit there with a book of providers and procedures?
  - pulledpork 14y ago
bdesimone 14y ago
I haven't read the whole site yet but I jumped to the topic I know fairly well, medical malpractice. Just some additional notes to consider: * 9 out of 10 physicians would discourage their children from becoming doctors.[3] There are many reasons for this. Malpractice insurance premiums are a factor. Not the only factor. * California physicians have the lowest insurance premiums in the country. This is directly the result of tort reform, and caps on pain and suffering payouts. His survey of physicians he knows in the area is subject to this sampling bias. Malpractice is a big issue in other states.[0] California is the model for tort reform for this reason, by not acknowledging this fact, he's missing a big aspect of the national (not just Californian) issues regarding healthcare. * California physicians also have some of the lowest reimbursement rates in the country. * As he indicated, internal medicine docs pay far less in premiums (as he noted) than other specialties. Surgeons pay much higher premiums. [1] * The California Department of Insurance does a good job of keeping most premium information public. It's not a secret what your average doctor pays in insurance.[2] [0] : https://en.wikipedia.org/wiki/Medical_Injury_Compensation_Reform_Act https://en.wikipedia.org/wiki/Medical_Injury_Compensation_Re... [1] : http://cl.ly/image/0m390m1F2D2D http://cl.ly/image/0m390m1F2D2D [2] : http://www.insurance.ca.gov/0250-insurers/0800-rate-filings/ http://www.insurance.ca.gov/0250-insurers/0800-rate-filings/ [3] : http://www.thedoctors.com/ecm/groups/public/@tdc/@web/documents/web_content/con_id_004676.pdf http://www.thedoctors.com/ecm/groups/public/@tdc/@web/docume...
- danielweber 14y ago
  Richard Thaler just had this op-ed in the NYT on ways to reduce costs, talking some about tort reform: http://www.nytimes.com/2013/02/24/business/overcoming-obstacles-to-better-health-care.html?_r=2&#38 http://www.nytimes.com/2013/02/24/business/overcoming-obstac...; I'm skeptical about tort reform as a panacea. However, lawsuits are incredibly expensive, and so doctors take steps that we would otherwise call economically unreasonable to avoid them. The amount of tort reform I think is really necessary is whatever would allow me to set up a private equivalent to the UK's NHS here. If someone thinks they are getting denied care that they deserve to have, the decision needs to be very cheap to adjudicate.
  - 14y ago
huhsamovar 14y ago
I am one of the lucky few who has insurance provided by their employer. Unfortunately, if I am in a car accident and rack up $100,000 in bills, I am bankrupt.
- nicholasjarnold 14y ago
  > Unfortunately, if I am in a car accident and rack up $100,000 in bills, I am bankrupt. ...or you just have to haggle with the hospital and refuse to pay their grossly inflated funny money prices. I have a good friend who incurred 30K in bills for a 2 day stay related to a broken femur. He has no insurance. Since seeing his bill, which wasn't itemized at all, he's basically refusing to pay anything until he sees what he's being charged for. In response to this demand the hospital reduced his bill by about 12K, magically, and still providing no itemization. He is still refusing to pay and only time will tell what the outcome will be. It's very clear, however, that he was grossly overcharged and that the hospital has no clue what they're really billing for. It's a game. Some people roll over, others fight. If someone really ends up with 100K+ in medical bills after adjustments then it might actually make sense to take 7 years of 'bad credit' after a bankruptcy. No easy answers here, but it's pretty clear we're all being swindled.
  - lotharbot 14y ago
    The rule of thumb that I've heard (from a health cost sharing ministry [0]) is that you should expect to be able to negotiate a discount of at least 40% if you're a self-pay patient. My sister shattered an ankle a while back, and was billed around $40,000. Between reductions, writeoffs, and charities the hospital connected her to, she ended up only paying about $5000. [0] http://www.chministries.org/whattodo.aspx http://www.chministries.org/whattodo.aspx under "general information"
- methehack 14y ago
  Can you elaborate? Do you think your employer provided health insurance is related? If so, how?
ohwp 14y ago
I'm not sure if this is true, but I heard that in some parts of China you only pay for health care when you are healthy because when you are not health care failed. Ofcourse this raises a lot of questions about responsibility. But in our society health care is making money when people are unhealthy. That is an unhealthy situation.
nirvana 14y ago
Back when he was alive, Milton Friedman did a study of the costs of health care in the US from 1900 to the 1970s. (I think the first study was in the 1970s, and it was updated in the 1990s) What he found was that the funding mechanism of health care over that time had shifted from patients paying out of pocket to government paying hospitals and government incentivized (by making it a tax write off for employers) and regulated (by preventing efficient pools of insured with state-by-state regulations) insurance. Consequently, not only did the availability of health care go down, but the costs went up 26fold. Or put another way, despite massive improvements in technology, medicine and productivity over 70+ years, costs skyrocketed from what you could afford out of pocket to what would bankrupt you. To put it in 2013 dollars, if you hypothesize a $100,000 surgery, in 1970[1] it would cost you $100,000, and you'd need insurance or go bankrupt, but in 1900 it would have cost you $3,846 (an amount you could put on credit cards today.) Command economies don't work, and the change in health care over the last century has been a centralization in control. I with Obamacare this has dramatically ramped up and now there are boards to decide who gets what care based on cost measures, rather than medical need. Whenever someone talks about the need for socialized medicine because "otherwise people would go bankrupt", remember it is the socialization of medicine that caused costs to rise to the point where people would go bankrupt. [1] The study was originally done in the 1970s, but I'm using 2013 dollars here so you can understand how cheap things would have been.
- myko 14y ago
  > now there are boards to decide who gets what care based on cost measures, rather than medical need. How is this different from insurance companies, or are those what you are referring to? I'm really confused by your statement.
  - kefka 14y ago
    You can thank Rush Limbaugh politik for the "government death panels" garbage.
  - danielweber 14y ago
    Hardly anyone is really approving or denying care based on cost-effectiveness. Which is why costs are out of control.
cpeterso 14y ago
Do other countries have employer-funded health insurance? Why doesn't my employer pay for, say, my car insurance? This system discourages people from leaving a job to start their own business because private health insurance can be very expensive.
- elemeno 14y ago
  In the UK, it's not unusual for employers to offer private health insurance (or at least, it's pretty common for profesional jobs - I can't comment for other types of jobs!). From their point of view, it's comparatively inexpensive and the cost is probably easy recouped from their employees being able to get health problems dealt with faster than they might on the NHS so they're off work for less time. Edit - Given that we've got the NHS as well, losing your private coverage isn't such a big deal. It's nice to have, not a must have.
  - andrewaylett 14y ago
    I had private health insurance from a previous employer, and in my experience it was almost completely pointless. I'm not inclined to rate its provision as a substantial benefit for compensation purposes.
mlguenther 14y ago
The author missed a very important reason why hospitals are charging such high fees. In 1986 Reagan passed the "Emergency Medical Treatment and Active Labor Act". Since that time, hospitals are required to treat anyone, regardless of whether or not they have insurance, as if they were a fully insured patient. My wife, who is a physician in a busy hospital, consistently sees about 40% of her patients have no health insurance and are receiving free healthcare from that hospital. This may vary based on location, but I cant imagine by much. Hospitals foot the bill in this situation, and that is why costs to the insured are much higher. Everybody seems to think they are smarter than everyone else when it comes to healthcare reform, but in all of the "smoking gun" articles that are posted, none of them have ever touched on this fact. Even the new healthcare plan that passed does not address this directly, it assumes that the people who do not have healthcare will use a state healthcare exchange to get their own. I am a little pessimistic about this, and am assuming that only a small percentage of those people will do this.
- rogerbinns 14y ago
  Atul Gawande covered the issue in this article: http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...
- dave48 14y ago
  You should read my epilogue on why hospitals are going bankrupt: http://truecostofhealthcare.org/epilogue http://truecostofhealthcare.org/epilogue Or watch the video: https://www.youtube.com/watch?v=LieVr0QvkME https://www.youtube.com/watch?v=LieVr0QvkME No one is admitted to the hospital these days who doesn't qualify by a rather strict set of criteria. If you qualify and have nothing then, in most States, Medicaid picks up the tab. If you have anything, the hospital gets it.Hospitals give free care the way Heidi Fleiss gave free love.
mokash 14y ago
Call me naive but why doesn't the US simply switch to a healthcare system similar to the UK's NHS? I live in Britain and I live happy knowing that if I get a scratch, I won't go bankrupt.
- epmatsw 14y ago
  A significant portion of Americans don't trust their government to provide efficient services. In general, we'll trust other citizens and corporations to do a better job. On top of that, you have many people who are reasonably insured and don't have to worry about it, many people who don't want to pay for other people's healthcare, and many people who are scared of socialism. Once you combine those groups, you end up with a pretty significant chunk of the country that is opposed to single-payer for whatever reason. That said, the US healthcare system's problems go much much deeper than just single-payer vs private-public.
  - mokash 14y ago
    At the end of the day, my guess is it all boils down to your FREEDOM. right guys?
pstuart 14y ago
I pinged Dr. Belk about the dialog here and invited him to join this conversation.
dave48 14y ago
Hi, My name is David Belk and I wrote the website. I noticed a lot of traffic from here this Morning. I'd just like to say thank you and, are there any questions I can answer? I'm having a busy Morning but I'll be free in about an hour.
- guylhem 14y ago
  One question : just how would you prioritize actions to turn heathcare into a real market, or as close to it as possible ? I would go for: 1) full price transparency 2) making price discrimination illegal 3) attacking the information asymmetry by providing a free, subsidized first line triage Whether treatment is taken or the patient decides to do without it, making sure tests and diagnosis are performed could help proper self regulation of consumption It could also be made as a public service since it seems very close to a natural monopoly (due to the subadditivity of the cost function - see for ex http://www.clt.astate.edu/crbrown/eleven1.htm http://www.clt.astate.edu/crbrown/eleven1.htm - having big labs to process blood test gives economy of scales but require high fixed costs) It could therefore be politically defensible on grounds of efficient pricing (ie pricing at the marginal cost, which requires subsidizing for natural monopolies since average cost are above marginal costs), to avoid deadweight loss. The first line triage could then provide full price transparency (diagnosis -> probabilistic DRG), from which the patient could either decide to "wait and see", or to browse a catalog of hospital offering services (DRG -> prices) knowing the price paid would be no different with or without insurance. At that point, it might be possible to remove all price caps and floors, and let the market work. So basically, we could get a working market on the treatment side. Traditional monopoly and oligopoly management (watching the HHI before allowing fusions) could then keep it that way. I'm a bit out of idea however to have integral pure and perfect competition, at least until we get user-operable "all-in-one diagnosis devices" (like Star Trek tricoders) to remove the information asymmetry. My last rants on this topic were posted on http://news.ycombinator.com/item?id=5261137 http://news.ycombinator.com/item?id=5261137
  - dave48 14y ago
    Price transparency is good but, what's also missing in health care is value transparency. In other words, not only do most people (including most physicians) not know how much anything in health care really costs, they don't know how much anything should cost! The level of blindness in this business is truly unprecedented. What's also needed are a number of consumer protection laws that we take for granted in pretty much every other industry. Those alone would go a long way toward correcting many of the problems we have in health care.
d--b 14y ago
http://www.pbs.org/newshour/rundown/2012/10/health-costs-how-the-us-compares-with-other-countries.html http://www.pbs.org/newshour/rundown/2012/10/health-costs-how... US healthcare is broken. We are fools not to follow other countries.
deleted 14y ago
[deleted]

97 points by felipellrocha 14y ago

After visiting the ER with a 108F temp due to pneumonia, I can attest to the fact that ER visits are a rip off. 3 unique doctor visits to the room + 1 IV + phlegm sample + 1 $60 pill + 1 prescription = $4200 for 50 minutes of office and 120 minutes of wait. Afterwards, I explained I did not have insurance. $60 pill was wrote off instantly. $4200 turned into $1200. Govt reimbursed 3/4ths of the bill instantly to the hospital. $1200 got wrote off after 3 months because it was not worth collecting... Edit: The interesting thing was each doctor had an individual bill of $600 sent to me. These are still in collections. The phlegm sample cost $120 and come from a separate clinical laboratories bill. My wife's birth control has a package value of $130/mo. Health insurance ($600 for wife, and kid), had a copay of $40 for this medication. I called the same clinic, requested generic and expressed my need to pay in cash. Instantly brought the price down to $8/mo. I did not sign up for health insurance this year. It is a complete waste. I usually pay more than just asking for generic and paying with cash. The 'poor' clinics here have a higher quality of care and staff, and are more affordable than my co-pays.

jneal 14y ago
I suppose you are prepared to starting paying the tax penalty for not having insurance under the PPACA?
- ambiate 14y ago
  If necessary, I will pay the penalty. I assume the credit for health care costs and taxes charged on health care should make up for any penalties incurred by the PPACA. If I read correctly, my penalty should only be $950-1300. Inevitably, with my insurance rates, I would spend that on 2 months of health coverage for my small family. Just to break down costs: $600/mo health for wife/kid. $7200/yr. vs ~200/mo + 1000 penalty. $3400/yr. We're not exactly getting Xrays and CT scans on a daily basis in my household! If my wife was to get pregnant, I know most hospitals offer a specialized bundle plan for dealing with the pregnancy for a set flat rate. All check ups, ultrasounds, single doctor, etc, for $6000.
  - robinh 14y ago
    I'm not in the USA, but 'only $950-1300'? That's more or less what I pay for a whole year of health insurance in the NL. How much does insurance cost in the USA?
    - ambiate 14y ago
      $200/mo per kid. $350/mo for wife. $600 for wife and unlimited kids.
      - roc 14y ago
        And for the record: that's what qualifies as "incredibly inexpensive" in the US. Many people pay well over $1000/mo for family care, not counting what their employer contributes.
      - jneal 14y ago
        These costs are roughly what I'm faced with as well. I have insurance on myself but my kid is uninsured because I can't bring myself to pay so much per month when my child is only at the doctor 2-3 times a year and the cost is probably around $180 for a whole year, or less than the cost of a single month of insurance which I'd still be paying a copay on.
    - bhousel 14y ago
      Here is an example rate sheet for where I live (Northern NJ): http://www.horizon-bcbsnj.com/SiteGen/Uploads/Public/horizon_bcbsnj/pdf/Rate_Sheet_for_FF_Kits.pdf http://www.horizon-bcbsnj.com/SiteGen/Uploads/Public/horizon...
    - jes5199 14y ago
      when I left my last job, I had the option to continue the health insurance the company was paying for, for up to a year (this rule is called "COBRA"). It costs me about $1100 per month, to cover two people.
    - Ergomane 14y ago
      Unless you have low income, you pay more than that in the Netherlands. Payment for health care is composed of two parts: You pay about EUR 867 to 1,140 directly to an insurance company PER ADULT depending on how much you want to pay yourself in case of required care. Then there's the socialized income dependent part of the insurance that's either payed via your employer or by yourself, which, in the latter case, is 5,65% over up to EUR ~51 K. A family of two, each with an income > 51K then pays between EUR 7,480 to 8,026 (atm USD ~10K) each year for health insurance, subsidizing insurance for lower income groups.
dschep 14y ago
> My wife's birth control has a package value of $130/mo. Wow. My girlfriend's birth control is $9/month, without health insurance (Target's generic Ortho Tri-Cyclen).
danielweber 14y ago
ERs are expensive for two reasons: 1. You are paying for a standing army. 1 hour of scheduled doctor time is much different than 1 hour of doctor time ready to deploy in an instant. 2. The ERs need to cover all the non-paying clients. These two items probably feed on each other. Emergency departments are about 1% of total health care costs. They can be a good indicator of other symptoms that are wrong (medical billing is a maze, on purpose[1]), but fixing it won't really address health care costs. [1] http://www.thedailybeast.com/articles/2013/02/22/how-hospital-administrators-hide-the-umbrella.html http://www.thedailybeast.com/articles/2013/02/22/how-hospita...
phren0logy 14y ago
Not having health care works if you don't have a catastrophic injury, and/or you are willing to let the hospital write off services and pass the bills on the the rest of us. This isn't really a sustainable plan for the nation.
- ambiate 14y ago
  There's a hidden truth in 'writing off'. Insurance companies wager paying the bill too. They say "We'll pay 60% of that $8000 ER visit." Guess who covers 25% of that leftover 40%? In a majority of cases, the government. (Source: My aunt has worked for a hospital performing these write-offs the majority of her 45 year life.)
justsomedood 14y ago
I'm in the same boat. My insurance premium changed this year to $950 a month. We have 3 younger kids and are all healthy. I would be paying almost $12,000k a year for the privilege of being able to pay "less" after the deductible is met. Paying around ~$120 for an office visit is so much less than premium + copay, and like you said a lot of services prices change once they know you don't have insurance. I wish health insurance were more like car insurance (accidental coverage, not maintenance) and I think we wouldn't have the same convoluted pricing we have now.

pstuart 14y ago

That's my doctor's site! The real takeaway (to me) is that single-payer health insurance would be the way to go.

thatswrong0 14y ago
I think it's a bit more complicated than that. It's easy to look at other countries and say, hey, that works there, therefore it will work here. But not all governments are created equal. If the government in the U.S. had a better track record, maybe it would be more palatable. But as is, I don't see single payer being the solution to our problems.
- pstuart 14y ago
  It doesn't solve everything but it should help to simplify matters greatly. What would help too is ubiquitous electronic records management, e.g., any records from a visit with one doctor should be usable by the patient at another doctor. Add to that cheaper testing and more AI / self-help and that should take it even further. Lastly, kill the corn lobby and get some real sense into people about how their diet and lifestyle directly impact their health. What percentage of US healthcare costs are going towards diabetes and any related illnesses? And what percentage of that is directly related to obesity and a sedentary lifestyle?
  - epmatsw 14y ago
    Electronic Health Records are harder to implement than you'd expect. HIPAA sets really harsh penalties for violations that can occur much more easily if hospitals and doctors provide open access to other facilities. Organizations are also often reluctant to provide their data to other facilities because of a perception that it will lead to a loss of competitive advantage. Add to that the typical problems of cross-vendor interfacing between organizations. That said, EHRs are definitely the way to go, and we'll see much more of them in the future. Once Stage 2 of Meaningful Use[1] kicks in, you'll see a bunch of hospitals scrambling to upgrade their IT infrastructure to make sure they continue to receive the bonus Medicare/Medicaid payouts they're receiving now. 1. http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives http://www.healthit.gov/providers-professionals/meaningful-u...

ender7 14y ago

This Time article seems particularly apropos: http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/print/ http://healthland.time.com/2013/02/20/bitter-pill-why-medica...

wiremine 14y ago
Read it this weekend: I'd love to see a response from the health care industry that wasn't hand waiving. If he's right on 50% of his facts, it is disgusting how the system works.
- Alex3917 14y ago
  "If he's right on 50% of his facts, it is disgusting how the system works." There were only a handful of actual statistics in there. The one thing he is wrong about though is that healthcare isn't "roughly 20% of the GDP", rather it's about 17.9%. The furthest out cms.gov gives yearly projections is to 2021, and even then healthcare is only supposed to be 19.6% of the GDP. And I think that might even include things like herbal supplements 'other non-durable medical supplies', I'm not positive about that though. Source: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/Proj2011PDF.pdf https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
  - Falling3 14y ago
    Facts are more than just statistics. There were numerous statements about (what seems to be) gross, gross overcharging on everything from pens to surgical gowns to diagnostic equipment. There were the exorbitant salaries and let's not forget the chargemaster.
    - wiremine 14y ago
      Exactly: that's the part I'd like to see a rebutted (if there is a rational rebuttal). The ad-hoc nature of their pricing model seems crazy.
  - 14y ago

zaidf 14y ago

We invited a dozen physicians for brunch this past weekend and they all had stories to share about how little they make per procedure compared to the amount the hospital makes. Example 1: A procedure costs $6,000 to be done at a hospital. It prices out patients paying out of pocket. The doctor realized that he himself gets about $700 from it. So the doctor reached out to another facility who agreed to do it for $1,800 instead of $6,000 for the exact same procedure. You can imagine how happy the doctor's patients are, particularly ones paying out of pocket. Example 2: A patient got upset a doctor's office wanted him to pay copay. The patient got the bill and felt the doctor already got paid $1,500. When the office informed the patient that out of the $1,500 the doctor only got about $300, the patient was shocked. Really what we need is a doctor compensation to everything else index. When we get that, we will realize the sham most of the efforts to reduce healthcare cost is. Most healthcare cost efforts focus on paying the doctor a little less, say $300 instead of $400. Problem is, bulk of the cost is not the doctor's fees. It is the cost of the bed, breakfast, Tylenol etc. We need regulation on those fees.

specialp 14y ago
For example 1: The reason why the hospital charges so much is the fact that it gets stiffed for a lot of emergecy patients without insurance. Many hospitals are on the brink of bankruptcy especially in poorer areas. This does not always reflect in the huge disparity in prices people pay, but is a big factor. Hospitals try to offset their losses by charging paying customers more. The real problems here especially with emergency care are that hospitals are forced to eat the cost of treating non insured patients, and that patients have no idea what something costs when they are there or if the people treating them will be covered by their insurance. Insurance companies spend a lot of time negotiating rates and making them somewhat uniform for them, but this is totally opaque to the patient. We need to make it more clear to the people being treated what things cost, and who is "in network". There have been times that I went to an emergency room "in network" and I was "balance billed" by nearly every doctor there due to them not being in network. What is a patient to do? Sit there with a book of providers and procedures?
- pulledpork 14y ago

bdesimone 14y ago

I haven't read the whole site yet but I jumped to the topic I know fairly well, medical malpractice. Just some additional notes to consider: * 9 out of 10 physicians would discourage their children from becoming doctors.[3] There are many reasons for this. Malpractice insurance premiums are a factor. Not the only factor. * California physicians have the lowest insurance premiums in the country. This is directly the result of tort reform, and caps on pain and suffering payouts. His survey of physicians he knows in the area is subject to this sampling bias. Malpractice is a big issue in other states.[0] California is the model for tort reform for this reason, by not acknowledging this fact, he's missing a big aspect of the national (not just Californian) issues regarding healthcare. * California physicians also have some of the lowest reimbursement rates in the country. * As he indicated, internal medicine docs pay far less in premiums (as he noted) than other specialties. Surgeons pay much higher premiums. [1] * The California Department of Insurance does a good job of keeping most premium information public. It's not a secret what your average doctor pays in insurance.[2] [0] : https://en.wikipedia.org/wiki/Medical_Injury_Compensation_Reform_Act https://en.wikipedia.org/wiki/Medical_Injury_Compensation_Re... [1] : http://cl.ly/image/0m390m1F2D2D http://cl.ly/image/0m390m1F2D2D [2] : http://www.insurance.ca.gov/0250-insurers/0800-rate-filings/ http://www.insurance.ca.gov/0250-insurers/0800-rate-filings/ [3] : http://www.thedoctors.com/ecm/groups/public/@tdc/@web/documents/web_content/con_id_004676.pdf http://www.thedoctors.com/ecm/groups/public/@tdc/@web/docume...

danielweber 14y ago
Richard Thaler just had this op-ed in the NYT on ways to reduce costs, talking some about tort reform: http://www.nytimes.com/2013/02/24/business/overcoming-obstacles-to-better-health-care.html?_r=2&#38 http://www.nytimes.com/2013/02/24/business/overcoming-obstac...; I'm skeptical about tort reform as a panacea. However, lawsuits are incredibly expensive, and so doctors take steps that we would otherwise call economically unreasonable to avoid them. The amount of tort reform I think is really necessary is whatever would allow me to set up a private equivalent to the UK's NHS here. If someone thinks they are getting denied care that they deserve to have, the decision needs to be very cheap to adjudicate.
- 14y ago

huhsamovar 14y ago

I am one of the lucky few who has insurance provided by their employer. Unfortunately, if I am in a car accident and rack up $100,000 in bills, I am bankrupt.

nicholasjarnold 14y ago
> Unfortunately, if I am in a car accident and rack up $100,000 in bills, I am bankrupt. ...or you just have to haggle with the hospital and refuse to pay their grossly inflated funny money prices. I have a good friend who incurred 30K in bills for a 2 day stay related to a broken femur. He has no insurance. Since seeing his bill, which wasn't itemized at all, he's basically refusing to pay anything until he sees what he's being charged for. In response to this demand the hospital reduced his bill by about 12K, magically, and still providing no itemization. He is still refusing to pay and only time will tell what the outcome will be. It's very clear, however, that he was grossly overcharged and that the hospital has no clue what they're really billing for. It's a game. Some people roll over, others fight. If someone really ends up with 100K+ in medical bills after adjustments then it might actually make sense to take 7 years of 'bad credit' after a bankruptcy. No easy answers here, but it's pretty clear we're all being swindled.
- lotharbot 14y ago
  The rule of thumb that I've heard (from a health cost sharing ministry [0]) is that you should expect to be able to negotiate a discount of at least 40% if you're a self-pay patient. My sister shattered an ankle a while back, and was billed around $40,000. Between reductions, writeoffs, and charities the hospital connected her to, she ended up only paying about $5000. [0] http://www.chministries.org/whattodo.aspx http://www.chministries.org/whattodo.aspx under "general information"
methehack 14y ago
Can you elaborate? Do you think your employer provided health insurance is related? If so, how?

ohwp 14y ago

I'm not sure if this is true, but I heard that in some parts of China you only pay for health care when you are healthy because when you are not health care failed. Ofcourse this raises a lot of questions about responsibility. But in our society health care is making money when people are unhealthy. That is an unhealthy situation.

nirvana 14y ago

Back when he was alive, Milton Friedman did a study of the costs of health care in the US from 1900 to the 1970s. (I think the first study was in the 1970s, and it was updated in the 1990s) What he found was that the funding mechanism of health care over that time had shifted from patients paying out of pocket to government paying hospitals and government incentivized (by making it a tax write off for employers) and regulated (by preventing efficient pools of insured with state-by-state regulations) insurance. Consequently, not only did the availability of health care go down, but the costs went up 26fold. Or put another way, despite massive improvements in technology, medicine and productivity over 70+ years, costs skyrocketed from what you could afford out of pocket to what would bankrupt you. To put it in 2013 dollars, if you hypothesize a $100,000 surgery, in 1970[1] it would cost you $100,000, and you'd need insurance or go bankrupt, but in 1900 it would have cost you $3,846 (an amount you could put on credit cards today.) Command economies don't work, and the change in health care over the last century has been a centralization in control. I with Obamacare this has dramatically ramped up and now there are boards to decide who gets what care based on cost measures, rather than medical need. Whenever someone talks about the need for socialized medicine because "otherwise people would go bankrupt", remember it is the socialization of medicine that caused costs to rise to the point where people would go bankrupt. [1] The study was originally done in the 1970s, but I'm using 2013 dollars here so you can understand how cheap things would have been.

myko 14y ago
> now there are boards to decide who gets what care based on cost measures, rather than medical need. How is this different from insurance companies, or are those what you are referring to? I'm really confused by your statement.
- kefka 14y ago
  You can thank Rush Limbaugh politik for the "government death panels" garbage.
- danielweber 14y ago
  Hardly anyone is really approving or denying care based on cost-effectiveness. Which is why costs are out of control.

cpeterso 14y ago

Do other countries have employer-funded health insurance? Why doesn't my employer pay for, say, my car insurance? This system discourages people from leaving a job to start their own business because private health insurance can be very expensive.

elemeno 14y ago
In the UK, it's not unusual for employers to offer private health insurance (or at least, it's pretty common for profesional jobs - I can't comment for other types of jobs!). From their point of view, it's comparatively inexpensive and the cost is probably easy recouped from their employees being able to get health problems dealt with faster than they might on the NHS so they're off work for less time. Edit - Given that we've got the NHS as well, losing your private coverage isn't such a big deal. It's nice to have, not a must have.
- andrewaylett 14y ago
  I had private health insurance from a previous employer, and in my experience it was almost completely pointless. I'm not inclined to rate its provision as a substantial benefit for compensation purposes.

mlguenther 14y ago

The author missed a very important reason why hospitals are charging such high fees. In 1986 Reagan passed the "Emergency Medical Treatment and Active Labor Act". Since that time, hospitals are required to treat anyone, regardless of whether or not they have insurance, as if they were a fully insured patient. My wife, who is a physician in a busy hospital, consistently sees about 40% of her patients have no health insurance and are receiving free healthcare from that hospital. This may vary based on location, but I cant imagine by much. Hospitals foot the bill in this situation, and that is why costs to the insured are much higher. Everybody seems to think they are smarter than everyone else when it comes to healthcare reform, but in all of the "smoking gun" articles that are posted, none of them have ever touched on this fact. Even the new healthcare plan that passed does not address this directly, it assumes that the people who do not have healthcare will use a state healthcare exchange to get their own. I am a little pessimistic about this, and am assuming that only a small percentage of those people will do this.

rogerbinns 14y ago
Atul Gawande covered the issue in this article: http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...
dave48 14y ago
You should read my epilogue on why hospitals are going bankrupt: http://truecostofhealthcare.org/epilogue http://truecostofhealthcare.org/epilogue Or watch the video: https://www.youtube.com/watch?v=LieVr0QvkME https://www.youtube.com/watch?v=LieVr0QvkME No one is admitted to the hospital these days who doesn't qualify by a rather strict set of criteria. If you qualify and have nothing then, in most States, Medicaid picks up the tab. If you have anything, the hospital gets it.Hospitals give free care the way Heidi Fleiss gave free love.

mokash 14y ago

Call me naive but why doesn't the US simply switch to a healthcare system similar to the UK's NHS? I live in Britain and I live happy knowing that if I get a scratch, I won't go bankrupt.

epmatsw 14y ago
A significant portion of Americans don't trust their government to provide efficient services. In general, we'll trust other citizens and corporations to do a better job. On top of that, you have many people who are reasonably insured and don't have to worry about it, many people who don't want to pay for other people's healthcare, and many people who are scared of socialism. Once you combine those groups, you end up with a pretty significant chunk of the country that is opposed to single-payer for whatever reason. That said, the US healthcare system's problems go much much deeper than just single-payer vs private-public.
- mokash 14y ago
  At the end of the day, my guess is it all boils down to your FREEDOM. right guys?

pstuart 14y ago

I pinged Dr. Belk about the dialog here and invited him to join this conversation.

dave48 14y ago

Hi, My name is David Belk and I wrote the website. I noticed a lot of traffic from here this Morning. I'd just like to say thank you and, are there any questions I can answer? I'm having a busy Morning but I'll be free in about an hour.

guylhem 14y ago
One question : just how would you prioritize actions to turn heathcare into a real market, or as close to it as possible ? I would go for: 1) full price transparency 2) making price discrimination illegal 3) attacking the information asymmetry by providing a free, subsidized first line triage Whether treatment is taken or the patient decides to do without it, making sure tests and diagnosis are performed could help proper self regulation of consumption It could also be made as a public service since it seems very close to a natural monopoly (due to the subadditivity of the cost function - see for ex http://www.clt.astate.edu/crbrown/eleven1.htm http://www.clt.astate.edu/crbrown/eleven1.htm - having big labs to process blood test gives economy of scales but require high fixed costs) It could therefore be politically defensible on grounds of efficient pricing (ie pricing at the marginal cost, which requires subsidizing for natural monopolies since average cost are above marginal costs), to avoid deadweight loss. The first line triage could then provide full price transparency (diagnosis -> probabilistic DRG), from which the patient could either decide to "wait and see", or to browse a catalog of hospital offering services (DRG -> prices) knowing the price paid would be no different with or without insurance. At that point, it might be possible to remove all price caps and floors, and let the market work. So basically, we could get a working market on the treatment side. Traditional monopoly and oligopoly management (watching the HHI before allowing fusions) could then keep it that way. I'm a bit out of idea however to have integral pure and perfect competition, at least until we get user-operable "all-in-one diagnosis devices" (like Star Trek tricoders) to remove the information asymmetry. My last rants on this topic were posted on http://news.ycombinator.com/item?id=5261137 http://news.ycombinator.com/item?id=5261137
- dave48 14y ago
  Price transparency is good but, what's also missing in health care is value transparency. In other words, not only do most people (including most physicians) not know how much anything in health care really costs, they don't know how much anything should cost! The level of blindness in this business is truly unprecedented. What's also needed are a number of consumer protection laws that we take for granted in pretty much every other industry. Those alone would go a long way toward correcting many of the problems we have in health care.

d--b 14y ago

http://www.pbs.org/newshour/rundown/2012/10/health-costs-how-the-us-compares-with-other-countries.html http://www.pbs.org/newshour/rundown/2012/10/health-costs-how... US healthcare is broken. We are fools not to follow other countries.

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