6 ms·

Yes, this non-transparent pricing, and weird discounts you can maybe ask for if you know how to ask (and if you figure out who to ask) drives me nuts. Sometimes

by mjn 14y ago

Yes, this non-transparent pricing, and weird discounts you can maybe ask for if you know how to ask (and if you figure out who to ask) drives me nuts. Sometimes you are better off being billed via your insurance; other times you're better off not using your insurance (even if you have one) and negotiating a cash price. And it's often hard to tell which one up front. Supposedly one of the downsides of more socialized systems are that they're bureaucratic, but I think the U.S. system, whatever you want to call it (it's not really either a functioning market or a properly socialized system) is somewhere near Peak Bureaucracy (certainly more than Denmark's, where I now live). It doesn't help that everyone bills separately: if you ever have to visit a hospital, you will get something like 15 different bills, because everyone from the anesthesiologist to the surgeon are apparently independent contractors, or at least bill that way. And you have to go through the same opaque negotiation process with each of them. And many of them are sloppy and contain errors, e.g. billing you for things that insurance actually should have covered. I'd be fine conceptually with a model where catastrophic care is insured and smaller expenses are paid for out of pocket. But then I'd like: 1) the catastrophic care to actually, 100%, guaranteed be covered, without loopholes, lifetime maxima, excluded conditions, etc.; and 2) the smaller expenses to be priced transparently up front.

nonamegiven 14y ago
"Yes, this non-transparent pricing," I have an appointment with my doctor soon. I asked them how much the appointment will cost. They called my insurance company. The got back to me, and the bottom line is nobody knows, and nobody will know until after the insurance company is actually billed. For any other service I'd just not buy it under those conditions, but if I don't go to the appointment then eventually I'll die.
- davefp 14y ago
  To be fair, you'll eventually die whether you go to the appointment or not.
  - nonamegiven 14y ago
    By "eventually" I mean a cascading series of events and degradations. I won't die the day after the missed appointment, but I'd almost certainly die within the year from that specific disease. Otherwise I'd die at a presumably much later date, barring accidents and other new health issues. I'd prefer the later date.
  - ctdonath 14y ago
    Most people understand there's a difference between "we're all gonna die someday from something" vs. "if I don't do X within a relatively few days and do ongoing maintenance treatments Y I'm gonna die of disease Z in short order." To imply there's not a meaningful difference between several decades' longevity vs. dead in a month isn't fair.
    - to3m 14y ago
      Depends. I don't think I have ever actually heard anybody say something like "if I don't do this, I'll eventually die", without some humorous intent. I had to read the post a couple of times to convince myself this wasn't the intention here.
      - maxerickson 14y ago
        Type I diabetics tend to be intensely aware of the consequences of neglecting their immediate care. (Looking at the above, I see that I should make it clear that just I'm bringing it up as an example of a group that approximately thinks like you say.)
- elmuchoprez 14y ago
  I run into this situation a lot: Doctors often have a cash price and an insurance price, with the former being significantly less. I have a high deductible insurance plan, which means I effectively pay for most stuff out of pocket. So when I call, I ask them what the cash price is. I then explain my situation and ask if they'll honor the cash price since I'm paying out of pocket anyways. They always tell me no. I mean, I get that they probably can't start discounting insurance claims because of my deductible or else they'd have to do it for all insurance claims, but it really grinds my gears that for all my insurance premiums, I essentially get the privilege of paying a higher rate.
  - mjn 14y ago
    I haven't tried it, but would it be possible to just not give them your insurance information, and pay cash? I realize then it wouldn't count against your deductible, but you could basically reserve the insurance for cases where you ended up in the hospital then. Or would that approach cause possible troubles with later coverage if something major ended up being a continuation of a visit that started initially "outside" the insurance?
    - tammer 14y ago
      This is possible, and I suggest it. You need to be one step ahead of both your insurer and your doctor, or they'll be ahead of you. Our 'system' is broken. When will it be fixed?
    - elmuchoprez 14y ago
      That would work. It just requires some planning (which is my fault for not doing). The problem is that my deductible is like $1300 or something. Now I don't remember the last time I spent $1300 on medical services in a year. On average, it's probably more like $500-$600 (I'm young-ish and reasonably healthy). So based on that data, I should probably get the highest deductible possible and just reserve using my health plan for catastrophic events. But my employer only offers one level of deductible, so I can't really shop for a higher deductible. And with my employers contribution to the current plan, it's still cheaper than if I were to buy an even higher deductible plan on my own. But still, if I have a $1300 deductible but only typically spend $600/year, I should still be paying cash. That said, I should probably be going to the doctor more than I do. I'm getting to an age where preventative care is becoming more important. I have some minor, non-life threatening issues that a doctor could probably help me out with if I was willing to go see a doctor. Under this way of thinking, I should probably commit myself to paying the annual deductible and just go to a doctor whenever I feel like it. But it's a pain to find time for the appointment, I don't enjoy the medical "process" any more than any red blooded American man, and the whole idea of "going to the doctor just because you can" bothers me on ideological levels... so I don't go. But I keep "using" my insurance because I hang onto the idea that I "should" go. So like I said, it's just bad planning on my part. That said, I know that's a giant whiny rant. I fully recognize that there are plenty of people who need legit medical care for serious things and can't get it, and here I am complaining that I can't find time in my day to schedule all the medical care I could ever want for $1300.
- Shivetya 14y ago
  I had a Doctors visit at the beginning of the year. Since I am on a HSA plan I have no deductible but rates are still negotiated. I have yet to receive a bill. This is for service rendered the first week of this year. I have received a NON BILL which denotes the costs of service and the negotiated rate having saved me money. I am still trying to find someone to pay. Now having talked to my Doctor before I have asked the questions about rates and such. The only points that stuck with me are, negotiated rates with government providers are too low for him cover his costs, insurance companies have rates which are more favorable because they need the business, and his higher base rates are because collections is rotten to deal with. One day I hope to pay my bill, I would have to have a collector show up but my Doctor cannot accept the payment as of yet and I legally cannot use my HSA funds for something I do not have a bill for.
- DanBC 14y ago
  How is this legal under contract law? They extend an offer, you agree the price, you agree to buy and they sell. But they're suggesting that you buy, and consume the product, before agreeing a price? Is it just that they don't know what's happening at the doctors? ie, they could offer a base price of $X per 15 minute appointment; $Y for writing a prescription; $Z for referring on for other tests? Or can they not even tell you how much a basic 15 minute consultation would cost?
  - nonamegiven 14y ago
    Like so many things, I probably could get my answer if I was prepared to fight for it. But since I have insurance, and I'll eventually pay out my deductible and out of pocket maximum, it's just not worth the fight, no matter how wrong this is. In a way it's a very small version of someone suing me, and I settle even though I know I could win. Cost/benefit, and the game is rigged against me. Insurance is the root of all health care evil.
  - lmm 14y ago
    >They extend an offer, you agree the price, you agree to buy and they sell. But they're suggesting that you buy, and consume the product, before agreeing a price? Pretty much anything custom-made works like that (have you never bought bespoke furniture?) - the seller will do the work and then bill you for how much it turned out to cost. You can sue them if it's unreasonable.
- eli_gottlieb 14y ago
  Wow, really? That's impressively bad. Over here we have a Bismarck health system (baseline coverage is publicly funded, supplementary insurances are available from the same companies for a premium), and the last time I had to go see the doctor it was free. I think I paid 15 NIS (about $4 USD) to fill the antibiotic prescription my doctor gave me. America really needs to fix its health-care system, by now its decay has become incredibly low-hanging fruit. You have the rest of the civilized world to cherry-pick for efficient, caring health systems!
- xn 14y ago
  If you don't know what's going to be done during the appointment, they probably can't tell you what it's going to cost. But if you are going in for a specific procedure, you should be able to get the cost. Call the doctor and get the procedure code. Then ask for the amount that is going to be billed and the tax id of the person or company that will be sending the bill to the insurance company. You may need to get multiple procedure codes and talk to multiple billing departments. For example, I recently wanted to find out how much an MRI would cost. There's a fee to perform the MRI and a separate fee for reading the images. These are performed by different people, and therefore billed by different people. Next, call or livechat your insurance company. Ask them to run a test claim. Give them procedure code(s), the amount billed, and the tax id of party sending the bill. The insurance company can then tell you what the allowed amount is, that is, how much the insurance company and the medical provider have agreed upon for the specific procedure. If you have a deductible that you haven't yet met (and the procedure isn't something covered or partially covered before the deductible, such as preventative care), the allowed amount is the amount you will be billed by the medical provider. Obviously, this is a cumbersome process. Running the test claim took about 10 minutes in my case. This is apparently not a process that the insurance company has optimized for. But by going through the process, you are sending a signal that price transparency is important. With MRIs, it turns out that at least one local company has recognized the value of price transparency: https://twitter.com/xn/status/311886680145666048 https://twitter.com/xn/status/311886680145666048 (They also happen to be about $400 cheaper than the amount my insurance company negotiated with a large hospital.)
- pasbesoin 14y ago
  It seems to me that, ultimately, such practices should be investigated and perhaps prosecuted on some legal basis. The problem is so endemic and systemic that I can't help believing some degree of perhaps illegal (and, at least, it should be illegal) collusion is in place. One example: How can I know/believe that practices aren't widespread to deny myself and others coverage we are actually due per our contracts? There is also widespread, systemic spreading of cost that is outside of any contract (i.e. insurance) authorizing and mandating such. Widespread enough to warrant investigation for fraud. If the regulators weren't totally co-opted and owned by the industry, it would be rife for investigation and perhaps charges of corruption. Under existing laws -- no new laws needed.
yummyfajitas 14y ago
In extremely free market health care systems, pricing tends to be extremely transparent. I had surgery in India. The doctors could all quote a price to me, accurate to within about 5k INR (final price ranged from 85k-150k). A price list with common procedures (blood test, urine test) was usually printed on a sign behind the receptionist.
- VLM 14y ago
  Note the important point that "system" is not free market, merely at least some pre-planned surgery and common diagnostic procedures have a fixed price. I'm sure that the average purchaser is at an extreme knowledge disadvantage making comparison shopping nearly impossible, and critical care/emergency care does not allow the time for comparison shopping. Finally you did not elaborate on the competition... is there any? So its a free market in that some prices are posted, but not in pretty much any other way.
  - mjn 14y ago
    I'm not sure if he went to one of these kinds of facilities, but my impression there is a reasonably competitive market in medical tourism: there are hospitals in Jordan that target themselves at enticing foreigners to fly there for treatment, and compete directly against similar hospitals in Thailand, India, and other places. They generally target an upmarket crowd, though, with some increasingly specializing to target Americans specifically. (I've noticed some of their websites attempt to delicately telegraph, "this is a hospital for you, well-off foreigner; don't worry, it's not full of locals.")
    - VLM 14y ago
      The point I was kinda getting at is without a well informed consumer (good luck!) the best free market you can hope for is something rather like the process gamblers use to select a specific slot machine from a bank of slot machines. Or maybe a better analogy would be selecting a poker table in that you can select to sit down at the $5 ante table or the $10 ante table. Oddly enough given the strong asymmetry of knowledge and capital, the house always wins. Not much of a free market. Although I would agree that in the extremely limited area of price discovery of certain procedures, I'm sure they do better, mostly because we do so poorly its almost just statistically likely by random chance to be better.
eli_gottlieb 14y ago
I'd be fine conceptually with a model where catastrophic care is insured and smaller expenses are paid for out of pocket. But then I'd like: 1) the catastrophic care to actually, 100%, guaranteed be covered, without loopholes, lifetime maxima, excluded conditions, etc.; and 2) the smaller expenses to be priced transparently up front. No, for the sake of Return on Public Investment, I'd say we should not only cover catastrophic care but give full public support to preventative care as well.
- mjn 14y ago
  Good point, and a reasonable objection to my suggestion (not very deeply thought out, I must admit). I would need to look at some numbers, but I do seem to recall that "major" care, comprising stuff like hospital visits, surgeries, chronic conditions, and end-of-life care, takes such a large percentage of the total healthcare spending that scrimping on regular doctors' visits, which are quite cheap in comparison, may be counterproductive.
  - eli_gottlieb 14y ago
    Yeah, that's the same data I've seen. Life-saving and end-of-life care is usually the most expensive, so the long-term rational way to save money (private and public) ends up being to prevent major health problems from occurring at all.
    - Vivtek 14y ago
      Which starves the medical "industry" - an economic catastrophe, in American terms!
    - mjn 14y ago
      I can sort of buy that, but I think it might be complex to determine what is cheapest overall, if that is really the main goal to minimize. For example, someone dying of a heart attack in their home is much cheaper than someone dying of cancer after a prolonged 2-year battle. So it would actually cost more money if you successfully prevented the heart attack only for the same person to die of cancer 10 years later: preventative medicine can't keep someone from dying entirely, so it doesn't always necessarily save money, if it pushes back the death to one that turns out to be more expensive than the earlier death would've been. What you want cost-wise is for all ends to be quick and with minimal intervention, whether they're earlier or later ends (actually that's what some might want as the person in question too, but that's a much bigger debate).

by mjn 14y ago

nonamegiven 14y ago

"Yes, this non-transparent pricing," I have an appointment with my doctor soon. I asked them how much the appointment will cost. They called my insurance company. The got back to me, and the bottom line is nobody knows, and nobody will know until after the insurance company is actually billed. For any other service I'd just not buy it under those conditions, but if I don't go to the appointment then eventually I'll die.

davefp 14y ago
To be fair, you'll eventually die whether you go to the appointment or not.
- nonamegiven 14y ago
  By "eventually" I mean a cascading series of events and degradations. I won't die the day after the missed appointment, but I'd almost certainly die within the year from that specific disease. Otherwise I'd die at a presumably much later date, barring accidents and other new health issues. I'd prefer the later date.
- ctdonath 14y ago
  Most people understand there's a difference between "we're all gonna die someday from something" vs. "if I don't do X within a relatively few days and do ongoing maintenance treatments Y I'm gonna die of disease Z in short order." To imply there's not a meaningful difference between several decades' longevity vs. dead in a month isn't fair.
  - to3m 14y ago
    Depends. I don't think I have ever actually heard anybody say something like "if I don't do this, I'll eventually die", without some humorous intent. I had to read the post a couple of times to convince myself this wasn't the intention here.
    - maxerickson 14y ago
      Type I diabetics tend to be intensely aware of the consequences of neglecting their immediate care. (Looking at the above, I see that I should make it clear that just I'm bringing it up as an example of a group that approximately thinks like you say.)
elmuchoprez 14y ago
I run into this situation a lot: Doctors often have a cash price and an insurance price, with the former being significantly less. I have a high deductible insurance plan, which means I effectively pay for most stuff out of pocket. So when I call, I ask them what the cash price is. I then explain my situation and ask if they'll honor the cash price since I'm paying out of pocket anyways. They always tell me no. I mean, I get that they probably can't start discounting insurance claims because of my deductible or else they'd have to do it for all insurance claims, but it really grinds my gears that for all my insurance premiums, I essentially get the privilege of paying a higher rate.
- mjn 14y ago
  I haven't tried it, but would it be possible to just not give them your insurance information, and pay cash? I realize then it wouldn't count against your deductible, but you could basically reserve the insurance for cases where you ended up in the hospital then. Or would that approach cause possible troubles with later coverage if something major ended up being a continuation of a visit that started initially "outside" the insurance?
  - tammer 14y ago
    This is possible, and I suggest it. You need to be one step ahead of both your insurer and your doctor, or they'll be ahead of you. Our 'system' is broken. When will it be fixed?
  - elmuchoprez 14y ago
    That would work. It just requires some planning (which is my fault for not doing). The problem is that my deductible is like $1300 or something. Now I don't remember the last time I spent $1300 on medical services in a year. On average, it's probably more like $500-$600 (I'm young-ish and reasonably healthy). So based on that data, I should probably get the highest deductible possible and just reserve using my health plan for catastrophic events. But my employer only offers one level of deductible, so I can't really shop for a higher deductible. And with my employers contribution to the current plan, it's still cheaper than if I were to buy an even higher deductible plan on my own. But still, if I have a $1300 deductible but only typically spend $600/year, I should still be paying cash. That said, I should probably be going to the doctor more than I do. I'm getting to an age where preventative care is becoming more important. I have some minor, non-life threatening issues that a doctor could probably help me out with if I was willing to go see a doctor. Under this way of thinking, I should probably commit myself to paying the annual deductible and just go to a doctor whenever I feel like it. But it's a pain to find time for the appointment, I don't enjoy the medical "process" any more than any red blooded American man, and the whole idea of "going to the doctor just because you can" bothers me on ideological levels... so I don't go. But I keep "using" my insurance because I hang onto the idea that I "should" go. So like I said, it's just bad planning on my part. That said, I know that's a giant whiny rant. I fully recognize that there are plenty of people who need legit medical care for serious things and can't get it, and here I am complaining that I can't find time in my day to schedule all the medical care I could ever want for $1300.
Shivetya 14y ago
I had a Doctors visit at the beginning of the year. Since I am on a HSA plan I have no deductible but rates are still negotiated. I have yet to receive a bill. This is for service rendered the first week of this year. I have received a NON BILL which denotes the costs of service and the negotiated rate having saved me money. I am still trying to find someone to pay. Now having talked to my Doctor before I have asked the questions about rates and such. The only points that stuck with me are, negotiated rates with government providers are too low for him cover his costs, insurance companies have rates which are more favorable because they need the business, and his higher base rates are because collections is rotten to deal with. One day I hope to pay my bill, I would have to have a collector show up but my Doctor cannot accept the payment as of yet and I legally cannot use my HSA funds for something I do not have a bill for.
DanBC 14y ago
How is this legal under contract law? They extend an offer, you agree the price, you agree to buy and they sell. But they're suggesting that you buy, and consume the product, before agreeing a price? Is it just that they don't know what's happening at the doctors? ie, they could offer a base price of $X per 15 minute appointment; $Y for writing a prescription; $Z for referring on for other tests? Or can they not even tell you how much a basic 15 minute consultation would cost?
- nonamegiven 14y ago
  Like so many things, I probably could get my answer if I was prepared to fight for it. But since I have insurance, and I'll eventually pay out my deductible and out of pocket maximum, it's just not worth the fight, no matter how wrong this is. In a way it's a very small version of someone suing me, and I settle even though I know I could win. Cost/benefit, and the game is rigged against me. Insurance is the root of all health care evil.
- lmm 14y ago
  >They extend an offer, you agree the price, you agree to buy and they sell. But they're suggesting that you buy, and consume the product, before agreeing a price? Pretty much anything custom-made works like that (have you never bought bespoke furniture?) - the seller will do the work and then bill you for how much it turned out to cost. You can sue them if it's unreasonable.
eli_gottlieb 14y ago
Wow, really? That's impressively bad. Over here we have a Bismarck health system (baseline coverage is publicly funded, supplementary insurances are available from the same companies for a premium), and the last time I had to go see the doctor it was free. I think I paid 15 NIS (about $4 USD) to fill the antibiotic prescription my doctor gave me. America really needs to fix its health-care system, by now its decay has become incredibly low-hanging fruit. You have the rest of the civilized world to cherry-pick for efficient, caring health systems!
xn 14y ago
If you don't know what's going to be done during the appointment, they probably can't tell you what it's going to cost. But if you are going in for a specific procedure, you should be able to get the cost. Call the doctor and get the procedure code. Then ask for the amount that is going to be billed and the tax id of the person or company that will be sending the bill to the insurance company. You may need to get multiple procedure codes and talk to multiple billing departments. For example, I recently wanted to find out how much an MRI would cost. There's a fee to perform the MRI and a separate fee for reading the images. These are performed by different people, and therefore billed by different people. Next, call or livechat your insurance company. Ask them to run a test claim. Give them procedure code(s), the amount billed, and the tax id of party sending the bill. The insurance company can then tell you what the allowed amount is, that is, how much the insurance company and the medical provider have agreed upon for the specific procedure. If you have a deductible that you haven't yet met (and the procedure isn't something covered or partially covered before the deductible, such as preventative care), the allowed amount is the amount you will be billed by the medical provider. Obviously, this is a cumbersome process. Running the test claim took about 10 minutes in my case. This is apparently not a process that the insurance company has optimized for. But by going through the process, you are sending a signal that price transparency is important. With MRIs, it turns out that at least one local company has recognized the value of price transparency: https://twitter.com/xn/status/311886680145666048 https://twitter.com/xn/status/311886680145666048 (They also happen to be about $400 cheaper than the amount my insurance company negotiated with a large hospital.)
pasbesoin 14y ago
It seems to me that, ultimately, such practices should be investigated and perhaps prosecuted on some legal basis. The problem is so endemic and systemic that I can't help believing some degree of perhaps illegal (and, at least, it should be illegal) collusion is in place. One example: How can I know/believe that practices aren't widespread to deny myself and others coverage we are actually due per our contracts? There is also widespread, systemic spreading of cost that is outside of any contract (i.e. insurance) authorizing and mandating such. Widespread enough to warrant investigation for fraud. If the regulators weren't totally co-opted and owned by the industry, it would be rife for investigation and perhaps charges of corruption. Under existing laws -- no new laws needed.

yummyfajitas 14y ago

In extremely free market health care systems, pricing tends to be extremely transparent. I had surgery in India. The doctors could all quote a price to me, accurate to within about 5k INR (final price ranged from 85k-150k). A price list with common procedures (blood test, urine test) was usually printed on a sign behind the receptionist.

VLM 14y ago
Note the important point that "system" is not free market, merely at least some pre-planned surgery and common diagnostic procedures have a fixed price. I'm sure that the average purchaser is at an extreme knowledge disadvantage making comparison shopping nearly impossible, and critical care/emergency care does not allow the time for comparison shopping. Finally you did not elaborate on the competition... is there any? So its a free market in that some prices are posted, but not in pretty much any other way.
- mjn 14y ago
  I'm not sure if he went to one of these kinds of facilities, but my impression there is a reasonably competitive market in medical tourism: there are hospitals in Jordan that target themselves at enticing foreigners to fly there for treatment, and compete directly against similar hospitals in Thailand, India, and other places. They generally target an upmarket crowd, though, with some increasingly specializing to target Americans specifically. (I've noticed some of their websites attempt to delicately telegraph, "this is a hospital for you, well-off foreigner; don't worry, it's not full of locals.")
  - VLM 14y ago
    The point I was kinda getting at is without a well informed consumer (good luck!) the best free market you can hope for is something rather like the process gamblers use to select a specific slot machine from a bank of slot machines. Or maybe a better analogy would be selecting a poker table in that you can select to sit down at the $5 ante table or the $10 ante table. Oddly enough given the strong asymmetry of knowledge and capital, the house always wins. Not much of a free market. Although I would agree that in the extremely limited area of price discovery of certain procedures, I'm sure they do better, mostly because we do so poorly its almost just statistically likely by random chance to be better.

eli_gottlieb 14y ago

I'd be fine conceptually with a model where catastrophic care is insured and smaller expenses are paid for out of pocket. But then I'd like: 1) the catastrophic care to actually, 100%, guaranteed be covered, without loopholes, lifetime maxima, excluded conditions, etc.; and 2) the smaller expenses to be priced transparently up front. No, for the sake of Return on Public Investment, I'd say we should not only cover catastrophic care but give full public support to preventative care as well.

mjn 14y ago
Good point, and a reasonable objection to my suggestion (not very deeply thought out, I must admit). I would need to look at some numbers, but I do seem to recall that "major" care, comprising stuff like hospital visits, surgeries, chronic conditions, and end-of-life care, takes such a large percentage of the total healthcare spending that scrimping on regular doctors' visits, which are quite cheap in comparison, may be counterproductive.
- eli_gottlieb 14y ago
  Yeah, that's the same data I've seen. Life-saving and end-of-life care is usually the most expensive, so the long-term rational way to save money (private and public) ends up being to prevent major health problems from occurring at all.
  - Vivtek 14y ago
    Which starves the medical "industry" - an economic catastrophe, in American terms!
  - mjn 14y ago
    I can sort of buy that, but I think it might be complex to determine what is cheapest overall, if that is really the main goal to minimize. For example, someone dying of a heart attack in their home is much cheaper than someone dying of cancer after a prolonged 2-year battle. So it would actually cost more money if you successfully prevented the heart attack only for the same person to die of cancer 10 years later: preventative medicine can't keep someone from dying entirely, so it doesn't always necessarily save money, if it pushes back the death to one that turns out to be more expensive than the earlier death would've been. What you want cost-wise is for all ends to be quick and with minimal intervention, whether they're earlier or later ends (actually that's what some might want as the person in question too, but that's a much bigger debate).