9 ms·

After Surgery, Surprise $117,000 Medical Bill from Doctor He Didn't Know

84 points by jeswin 12y ago

zaroth 12y ago
There are a lot of really interesting things happening that this article looks at from exactly one angle -- the billing. What I want from NYT is an article which really examines the situation, and not just sensationalizing numbers. For example, Medicare would have paid only 1% for the assistant's work; that's the market rate that they set. This has all sorts of implications... I assume doctors must have some reason to accept those rates, other than out of some ethical responsibility. It sounds like private insurers are hugely subsidizing Medicare by paying 100x the price. If everyone paid the same rate, Medicare would have to pay a lot more, or there would be a lot less of these procedures. On the other hand, anyone who actually pays that list price is giving the doctor a gift. If they explained the median price patients pay the doctor out-of-pocket, I wonder if the examples would line up. It is interesting to read about some patients who went to extraordinary means to discover ahead of time what their costs would be, only to be basically assaulted with an outrageous bill in the end. For a planned procedure and even for an emergency, I think the doctor performing the work should find a way to work with their patient's insurance plan. And insurance plans should have reasonable coverage and customary payment terms which are accepted. The doctors shouldn't get to fleece the insurance companies either. The level of price discrimination is completely out of control, but I think the legal framework is in place, right now, to protect patients and insurers both from these bills. It's a tax on the rich and middle class, since the doctors collect some small fraction of total billings. It's like a lose-lose double lottery.
- oh_sigh 12y ago
  > It sounds like private insurers are hugely subsidizing Medicare by paying 100x the price More like they are billed 100x the price, negotiate down to 10x the price in general, and otherwise default to a point where the business collects .85x the price.
  - zaroth 12y ago
    In the example in the article, the private insurance DID pay the full amount. I don't understand why the private insurer would ever do that, but in this case that's what was reported.
- nols 12y ago
  You're mistaken on the Medicare only paying 1% for the assistant's work. They only pay 16% of the primary physician for the assistant, which in this case was 1% of Dr Mu's fee.
- guiambros 12y ago
  > What I want from NYT is an article which really examines the situation, and not just sensationalizing numbers. ... > For example, Medicare would have paid only 1% for the assistant's work... It sounds like private insurers are hugely subsidizing Medicare by paying 100x the price. I don't think they're sensationalizing the numbers. Private insurers are not paying 100x Medicare. They pay negotiated rates to in-network professionals, which is typically 20-100x lower than the list price. But doctors and companies are being creative, and using out-of-network services as a cover-up, so the private insurances can't enforce their negotiated rates. In some cases it's better to just settle with doctors, to avoid lawsuits and problems with patients' employers. But this rewards the bad behavior. With layers and more layers of companies, hospitals, consultants and lawyers, all trying to maximize their revenue targets, it's not a surprise that we're seeing six-digit bills for an assistant surgeon. The system is completely broken. Until we have a complete reform, and more strict laws like New York's Surprise Bill Law [1], I'm afraid we'll see more cases like this. The only solution is to (try to) stay healthy. If you can. [1] http://www.nyacp.org/files/public/169463_Health_Alert_3JUNE2014.pdf http://www.nyacp.org/files/public/169463_Health_Alert_3JUNE2...
- ThomPete 12y ago
  If you have the means already yes the legal system is in place if not you are out of luck. I was at one point presented with the option of either paying between 30-150.000USD for having a stage one melanoma removed or wait a year until the pre-existing condition clause was canceled out. Luckily I found another way but I have the resources to do so and I almost got screwed both financially and literally. What I don't understand is why the US doesn't adopt something like in Switzerland which have universal healthcare but it's privately insured. http://en.wikipedia.org/wiki/Health_care_in_Switzerland http://en.wikipedia.org/wiki/Health_care_in_Switzerland
- dalke 12y ago
  "What I want from NYT is an article which really examines the situation, and not just sensationalizing numbers." Steven Brill, in Time, wrote an excellent article on just that topic. The subscriber access is at http://time.com/198/bitter-pill-why-medical-bills-are-killing-us/ http://time.com/198/bitter-pill-why-medical-bills-are-killin... while a no cost version is at http://www.uta.edu/faculty/story/2311/Misc/2013,2,26,MedicalCostsDemandAndGreed.pdf http://www.uta.edu/faculty/story/2311/Misc/2013,2,26,Medical... . See also an interview with him at http://www.pbs.org/newshour/bb/health-jan-june13-healthcare_02-25/ http://www.pbs.org/newshour/bb/health-jan-june13-healthcare_... . Brill's thesis is that with most medical care it is impossible to do the comparison shopping that you emphasize should be possible "even in an emergency." You hypothesize that "private insurers are hugely subsidizing Medicare by paying 100x the price." As http://www.medscape.com/viewarticle/521175_2 http://www.medscape.com/viewarticle/521175_2 comments, "U.S. hospitals now receive abut [sic] 31 percent of their net revenues from Medicare." Moreover, if you start to read about the US system you would realize that Medicare is prevented, by US law, from negotiating drug prices. Private insurers, on the other hand, can do so. The Brill piece covers that detail. Since your hypothesis doesn't match reality, it must be incorrect. I am not well informed of this topic, and my knowledge is mostly limited to the popular press. I cannot therefore point to any critical research. There was a recent posting here on HN, at https://news.ycombinator.com/item?id=8304019 https://news.ycombinator.com/item?id=8304019 , concerning "The Cost of My Mother’s Cardiac Care in the United States and India." The actual article is at http://www.annfammed.org/content/12/5/470.long http://www.annfammed.org/content/12/5/470.long , which starts "When my mother fell ill while visiting me in the United States, I had the opportunity to compare costs of surgical cardiac care in the United States and India. I faced challenges in making well-informed decisions in the United States due to the lack of cost transparency and the minimal flexibility offered in choice of care, whereas in India costs are readily available and allow most people to freely choose their preferred type of care." It sounds like you are saying that NYT should, in every piece about a topic, give the full details to justify its arguments. That's not how newspapers work. They often give many different pieces; some of which examine the situation, and others which help flesh out details. This is one of the latter. You are supposed to read the newspaper over time to get a better sense of the whole. Otherwise, you need to look towards the specialist literature, like review papers on the economics of the US health system, to get the answers you're looking for. BTW, you like the word "should" - you used it three times. The many observations show that the US health care system isn't the way you think it should be. There is no legal framework like what you asserted. This suggests you are basing your opinions more on wishful thinking, rather than trying to understand what is actually a quite complex and well-discussed issue. I hope those links I gave help provide a beginning for you.
sachingulaya 12y ago
Ugh. Got hit by this. My insurance company listed a hospital as covered. I took my daughter to the ED...then got a $400 bill in the mail for a physician we saw for 2 minutes. The rest of the visit was covered. He wasn't. Apparently all doctors who work for the hospital are covered by the insurance...but he was a visiting physician. I hate health insurance.
torbit 12y ago
what a pile of shitty mess. tl;dr the assistant surgeon,whom he never meet, charged him separately and the price went from 6,200 to 117,000. why? because the assistant was an out-of-network doctor. " Insurance experts say surgeons and assistants sometimes share proceeds from operations, but Dr. Tindel’s office says he and Dr. Mu do not. Dr. Mu’s office did not respond to requests for comment." before you talk to anybody in a medical building yell "Are you in my network!?!?!"
- joesmo 12y ago
  That isn't enough. Most doctors have disclaimers that you sign stating that if it turns out they don't take your insurance, even if they say they're in your network, you are still responsible for out-of-network costs. You need to consult with your insurance company and get it in writing, ideally.
Shinkei 12y ago
Yet another example of the ridiculous arms race between payers and providers with patients caught in the middle.
grizzles 12y ago
It's a racket. There is one and only way of solving this problem for good. It's for your life insurer to also be your doctor. I wrote an article about it about 4 or so years ago (linked here): http://housecall.md http://housecall.md
- richmarr 12y ago
  While I think the subscription idea has some merit it's hardly "one and only way of solving this problem". I could maybe believe "one and only way of solving this problem without challenging preconceptions and accepting some nuance into free market ideology".
  - grizzles 12y ago
    Of course, you are right. There are other solutions, but I think this one is the best one. It's Google for health care. As an aside, I'm really glad Google is getting back into the field with Calico because cheap long tail health care (an obvious externality of the idea) is the ultimate positive use case / justification for their company's total information awareness philosophy / strategy.
HorizonXP 12y ago
So this practice is made more obvious in the US, simply because individuals are left with the bill. Although having a single-payer (i.e. universal health care) system might help to identify these patterns and reduce costs, the fact is that it occurs all the time, even in these systems. I'd be willing to bet that it happens more often in single-payer systems, simply because it's easier to justify and get away with. When I volunteered in the ER, I saw it all the time. In fact, I remember when I was preparing to apply for med school in Canada/Ontario, I had to read a number of articles, journals, and books about medical ethics, and one thing that stood out was the consistent push to have future physicians account for the impact of their decisions on the system as a whole. So not only was it imperative to promote patient health, but it was also important to balance that with the overall cost. A good example is a simple blood test. A full spectrum blood test may help identify potential problems in a patient, but it costs OHIP a lot of money to run those tests (especially since they're done in private for-profit labs). That's why your family doctor should really only order the required tests.
- jjoonathan 12y ago
  > the fact is that it occurs all the time, even in [single payer] systems The "single payer" has a hell of a lot more leverage than individuals in the US which, as far as I can tell, don't need to consent in any way (hell, they can even explicitly refuse to consent) and get stuck with the bill regardless. That trick wouldn't work so well on an organization the size of the government.
  - HorizonXP 12y ago
    I completely agree, but how likely is it that big government will be able to accurately audit whether a procedure was actually required or not? In fact, I'd prefer if big government would stay out of it and just pay for my healthcare to keep me healthy & alive. I am not an expert on the procedures I need, and neither is big government. We put our trust in medical practitioners to make those decisions for us. The problem is that they benefit financially from those decisions. If you ask me, the answer is to stop conducting these services as fee-for-service. Pay physicians a salary. Pay them well, but keep costs somewhat fixed.
dmishe 12y ago
Wait did I miss it, he did not have insurance? Otherwise he wouldn't pay 117k. Unless it is one of those EPO plans, but even then you can argue that you could not have known about the oon doctor. It is likely to take a couple of months though
- danbmil99 12y ago
  His insurer agreed to pay -- but the guy was just bothered by the ridiculous unethical situation and balked at reimbursing the overcharging physician. Read to the end bro!
  - dmishe 12y ago
    Ah thah crap missed that one paragraph, thanks
danbmil99 12y ago
Health care -- where Libertarian, free-market ideology goes to die. The free market simply doesn't work when there is zero price transparency, 3rd parties are often responsible for payment, and purchasers are often in great distress right when they need to be able to negotiate. Laissez faire market philosophy fails in this case for the same reason it fails during major crises and disasters. Purchasers are nearly powerless but have needs that they must meet immediately; vendors can price-gauge and make out like bandits. A climate of scarcity and desperation prevail over hypothetical rational actors participating in a stable market at equilibrium.
- NoMoreNicksLeft 12y ago
  There is no free market here. This isn't a price transparency thing either. This is about having created a culture where every doctor in the country is constantly hustling, committing borderline fraud. Sociologically, the idea that doctors and medical care workers are always looking out for what's best for their patients helps to mask the idea that they might be doing so from a health perspective but are ignoring any other consideration. And so bringing in a friend who's also a surgeon so he can get a little kickback doesn't really raise any ethical alarms. But this isn't the fault of the libertarians. Government has meddled in this industry and even with the ideas that the typical Americans think about for so long that this was inevitable. Nor can government fix it now... the AMA and other quasi-unions won't stand for it. They'll negotiate. And, as usual, our politicians will sell us down the river. If you want to fix this (and every other problem), the answer is simple (though not particularly libertarian): outlaw all health insurance. Make everyone pay for their own care. Make them pay out of pocket. In such a nation at that, none of these shenanigans could continue. Not that I expect anyone reading this to get it. You cry "But NoMoreNicksLeft, how could that man afford $117,000 out of pocket!" And the answer is that he couldn't. The doctor (if he billed after the fact) might sue, but winning a lawsuit doesn't make someone magically capable of paying. If the doctor insisted on payment up front, then the man would just forgo his particular service (which, since he was unaware that he needed it and it sound like bullshit... wouldn't have mattered). There aren't enough rich people who can afford to pay the current prices out of pocket for 100% of the doctors to continue to bill/earn what they do currently. Maybe just enough for 1% to continue like that... the other 99% are going to have to shape up, and in a hurry. They can't hold out prices where they are now (we can't pay that out of pocket), nor can they spitefully punish us and refuse to do it at lower prices. They have bills to pay just like the rest of us, they have mortgages, they need to buy groceries, etc. Nor will they decide to become plumbers and HVAC repairmen so that they don't have to give away their surgeries for less. But again, this is lost on anyone I've ever explained it to. You all think it will result in millions of deaths and untold suffering. > Laissez faire market philosophy fails Bullshit. There hasn't been a laissez fair in the healthcare industry in the United States in 100 years.
deleted 12y ago
[deleted]
- Untit1ed 12y ago
  I imagine he'd be dodging collections. EDIT: If his insurance hadn't paid it, obviously.
  - cookiecaper 12y ago
    They give up after a while and you can discharge the debt in a bankruptcy. More than half of all US bankruptcy cases are related to medical bills, so this is a very common issue. In the United States, having a major medical problem is synonymous with destroyed credit.
cookiecaper 12y ago
The US health system is FUBAR'd, but the right answer isn't a blank check from the government.
- chasing 12y ago
  Thank god nobody has actually proposed giving the healthcare industry a "blank check."
  - cookiecaper 12y ago
    That's effectively what Canada et al have done. Yes, I understand the government "negotiates great rates" for the citizens, but it's effectively the same thing as a blank check. It just takes a bit of shenanigans behind the scenes to sell the bureaucrats on your latest rate hikes. If you think pricing is bad now that the big insurance companies have to "negotiate great rates" for their clients, think how it'll be when there's only one party there. Government-negotiated rates places the pricing totally outside the realm of necessity or reality and makes it a purely political matter, and politics is a messy, fickle thing built on personal favors and tit-for-tat. Not having your political activity interpreted as corruption or bribery mostly depends on not pissing off someone with more power than you. Health care costs so much because of the insurance leech. The only way to restore sanity is to restore real competition and make the consumer pay directly. Doctors will have to charge reasonable fees to the patients, suppliers and vendors will have to charge reasonable fees to the doctors, etc. It will break the cycle of exorbitant cost in health care. That may be, in some senses, a painful transition, but it's the only sustainable thing in the long term. The cycle will not be broken by saying "Wow, health care sure costs a lot of money. Let's just get the government to print some extra cash and take care of that for us." Insurance is typically a highly regulated industry because when insurance is involved, people get screwed. The incentives are misaligned; the insurance company only makes money when they don't give you what you're paying for. Insurance only works in events that are very unlikely. It's extremely likely that everyone will go to the doctor or need medical assistance. Insurance is a very, very bad model for this service.
    - DanBC 12y ago
theworst 12y ago
Reasons I am dubious of the author's agenda, based on the structure of their arguments: 1. anchoring to high numbers, without contextualizing how big this issue is: "This contributes to the nation’s $2.8 trillion in annual health costs." How much does it contribute? 2. unequal metrics -- when discussing the expected charges: "Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee." When discussing the out-of-network bills: "Two plastic surgeons billed more than $250,000 to sew up the incision, a task done by a resident during previous operations for Ms. Kaufman’s chronic neurological condition." Now we're thinking $133k isn't so bad b/c he'll only pay part of it, but the $250k is frightening because there is no mention of an expected discount. As a counterpoint, the author mentions the insurance company pays the full amount to Dr. Mu for the other anecdote in the story. 3. fearful language -- 'He was blindsided, though, by a bill of about $117,000 from an “assistant surgeon,” a Queens-based neurosurgeon whom Mr. Drier did not recall meeting.' Sounds like a 24-hour-news-cycle headline: "Patients billed by doctors while under anesthesia". 4. mentioning there are marketing firms who specialize in helping maximize billing with insurance, as if it's an unethical business. This happens every time a provider of a service or product interacts with a bureaucracy -- there is a whole layer of these services for defense contracting, for example. 5. they mention how the US has more neurosurgeons per capita, then link that (by proximity in the same paragraph) to providing motive by mentioning how neurosurgeon compensation has decreased recently. A more honest article would have given absolute numbers about how the costs of neurosurgery relate to overall health care costs, rather than making the niche appear large relative to the story, so the reader implicitly compares that impact to the $2.8 trillion number. Medical billing is absurdly complex and byzantine. I'm don't doubt the veracity of the anecdotes, but the structure of the presentation make me suspect the intent of the author.
- eli 12y ago
  I don't understand what you're getting at. What do you suspect the author's agenda to be? What should we take away from this instead?
  - 12y ago
arjie 12y ago
How interesting. The patient is not in a position where consent is meaningful but is charged an exorbitant amount. At least a little unethical, I think.
- seanflyon 12y ago
  I would say that not only was this unethical, but also not a valid contract. Without some reasonable semblance of an agreement how can someone say that you owe them $117,000? I would bet that a court would disagree and would be interested to hear why.
  - milesskorpen 12y ago
    In the header of the article, it mentioned he signed many forms. Probably one of them agreed to this practice. Enforcement could still be tough though.
    - seanflyon 12y ago
      I get that, but if I sign a contract to buy a car and somewhere in the fine print is says that I owe an extra $117,000 that I am not aware of, that is not a valid contract.
raquo 12y ago
It's sad that the only surprising part is "He Didn't Know", not the actual price.
bambax 12y ago
The other weird thing is the billing happens after the fact with no visibility before hand. If you're building a house you don't start by saying «let's build a house» and then wait for bills from various contractors you've never met to arrive once the house is built. That would be considered crazy. Why is it acceptable in health care? What prevents praticians from establishing a budget? What prevents patients from demanding one?
- jonlucc 12y ago
  I had a recurrence of a medical complaint and have a high deductible insurance. I called around to several odficesbro find out what it would cost to treat if I was correct that it was a recurrence. In every case it took 30 minutes or longer for them to decipher their own costs.
- deleted 12y ago
  [deleted]
ar7hur 12y ago
To fellow startups claiming to "change healthcare": this is not about nicer online forms. This is about destroying this.
- drdeadringer 12y ago
  > this is not about nicer online forms. This is about destroying this. Thank you for clarifying this.
  - drdeadringer 12y ago
    ... not sure why an honest 'thank you' is downvote material, and am open to being educated on the matter.
verroq 12y ago
Shadowban test
deepsun 12y ago
By the way, in xUSSR free healthcare system multiple doctors _often_ discuss serious cases, unlike US. That's not something special for xUSSR doctors to discuss in a concilium complicated cases -- that's daily routine. That's their way to share expertise and improve professionally. In US you may have some chronic disease and one doctor would treat you as she/he believes is right, not discussing it with colleagues, and if you find another doctor, he/she might change the treatment, not even talking with previous doctor. So it's kinda strange to hear from famous US people that they "found an awesome doctor". I would prefer to find an awesome clinic, and have multiple doctors to discuss my case. That happens, of course, but money keeps that from being natural routine here.
- nobullet 12y ago
  Being a son of a physician from former USSR country I can say with the certain degree of certainty that this is not true in our times: you are lucky not to die in a line of 67 patients before you see a doctor in a state clinic. Not mentioning the MRI or X-Rays where patients wait up to 3-4 months in lines in order to get simple diagnosis. Money gives you the ability to go to private clinics and have these things done faster, often by more professional specialists. Doctors in state clinics are underpaid, often unprofessional and with lack of experience (graduated students).
peteretep 12y ago
Tangential but hopefully interesting: how much an extra year of life is worth to the NHS: http://m.bbc.com/news/health-28983924 http://m.bbc.com/news/health-28983924
interpol_p 12y ago
This almost feels like an Onion article where all the costs are multiplied by 20. What justifies such huge bills? The article makes it sound like a doctor walked in to ask "How are you feeling?" and then charged $20,000 for doing so. I've had a few private operations quoted in Australia and the full cost of the operation is usually in the $500-$2000 range. Even a pregnancy through a private hospital was quoted to us at about $4000. (Although we ended up having our first baby delivered for free through a public hospital, which was fantastic.)
- oliwarner 12y ago
  Completely agree. These prices are disgusting. Even if this consultant was there for an entire surgery, how can one person justify charging $1m/week? The US desperately needs to walk back the amount their doctors are paid.
- kamaal 12y ago
  >>doctor walked in to ask "How are you feeling?" and then charged $20,000 for doing so. It would have happened, why would you doubt it? It would have been like he was called in just in case any issue came up. The doctor walks in and asks the most obvious question to the patient "How are you feeling?". The operation ends without needing any inputs from him. But regardless he would have billed the patient for his time. The attitude is, he wouldn't have given any inputs but he did give them their time, which would otherwise be used else where to make the same money so you have to pay even if the actual value added by him was zero.
  - interpol_p 12y ago
    I understand the doctor gave her time — that's fine. It's that the cost for that time seems ludicrous. As I said, the pricing seems multiplied by 20.
anoirt56 12y ago
>“The notion is you can make end runs around price controls by increasing the number of things you do and bill for,” said Dr. Darshak Sanghavi, a health policy expert at the Brookings Institution until recently. .. like promoting and charging for unnecessary and damaging surgery on baby boys, robbing them of bodily integrity and killing ~200 infants a year from complications.

84 points by jeswin 12y ago

There are a lot of really interesting things happening that this article looks at from exactly one angle -- the billing. What I want from NYT is an article which really examines the situation, and not just sensationalizing numbers. For example, Medicare would have paid only 1% for the assistant's work; that's the market rate that they set. This has all sorts of implications... I assume doctors must have some reason to accept those rates, other than out of some ethical responsibility. It sounds like private insurers are hugely subsidizing Medicare by paying 100x the price. If everyone paid the same rate, Medicare would have to pay a lot more, or there would be a lot less of these procedures. On the other hand, anyone who actually pays that list price is giving the doctor a gift. If they explained the median price patients pay the doctor out-of-pocket, I wonder if the examples would line up. It is interesting to read about some patients who went to extraordinary means to discover ahead of time what their costs would be, only to be basically assaulted with an outrageous bill in the end. For a planned procedure and even for an emergency, I think the doctor performing the work should find a way to work with their patient's insurance plan. And insurance plans should have reasonable coverage and customary payment terms which are accepted. The doctors shouldn't get to fleece the insurance companies either. The level of price discrimination is completely out of control, but I think the legal framework is in place, right now, to protect patients and insurers both from these bills. It's a tax on the rich and middle class, since the doctors collect some small fraction of total billings. It's like a lose-lose double lottery.

oh_sigh 12y ago
> It sounds like private insurers are hugely subsidizing Medicare by paying 100x the price More like they are billed 100x the price, negotiate down to 10x the price in general, and otherwise default to a point where the business collects .85x the price.
- zaroth 12y ago
  In the example in the article, the private insurance DID pay the full amount. I don't understand why the private insurer would ever do that, but in this case that's what was reported.
nols 12y ago
You're mistaken on the Medicare only paying 1% for the assistant's work. They only pay 16% of the primary physician for the assistant, which in this case was 1% of Dr Mu's fee.
guiambros 12y ago
> What I want from NYT is an article which really examines the situation, and not just sensationalizing numbers. ... > For example, Medicare would have paid only 1% for the assistant's work... It sounds like private insurers are hugely subsidizing Medicare by paying 100x the price. I don't think they're sensationalizing the numbers. Private insurers are not paying 100x Medicare. They pay negotiated rates to in-network professionals, which is typically 20-100x lower than the list price. But doctors and companies are being creative, and using out-of-network services as a cover-up, so the private insurances can't enforce their negotiated rates. In some cases it's better to just settle with doctors, to avoid lawsuits and problems with patients' employers. But this rewards the bad behavior. With layers and more layers of companies, hospitals, consultants and lawyers, all trying to maximize their revenue targets, it's not a surprise that we're seeing six-digit bills for an assistant surgeon. The system is completely broken. Until we have a complete reform, and more strict laws like New York's Surprise Bill Law [1], I'm afraid we'll see more cases like this. The only solution is to (try to) stay healthy. If you can. [1] http://www.nyacp.org/files/public/169463_Health_Alert_3JUNE2014.pdf http://www.nyacp.org/files/public/169463_Health_Alert_3JUNE2...
ThomPete 12y ago
If you have the means already yes the legal system is in place if not you are out of luck. I was at one point presented with the option of either paying between 30-150.000USD for having a stage one melanoma removed or wait a year until the pre-existing condition clause was canceled out. Luckily I found another way but I have the resources to do so and I almost got screwed both financially and literally. What I don't understand is why the US doesn't adopt something like in Switzerland which have universal healthcare but it's privately insured. http://en.wikipedia.org/wiki/Health_care_in_Switzerland http://en.wikipedia.org/wiki/Health_care_in_Switzerland
dalke 12y ago
"What I want from NYT is an article which really examines the situation, and not just sensationalizing numbers." Steven Brill, in Time, wrote an excellent article on just that topic. The subscriber access is at http://time.com/198/bitter-pill-why-medical-bills-are-killing-us/ http://time.com/198/bitter-pill-why-medical-bills-are-killin... while a no cost version is at http://www.uta.edu/faculty/story/2311/Misc/2013,2,26,MedicalCostsDemandAndGreed.pdf http://www.uta.edu/faculty/story/2311/Misc/2013,2,26,Medical... . See also an interview with him at http://www.pbs.org/newshour/bb/health-jan-june13-healthcare_02-25/ http://www.pbs.org/newshour/bb/health-jan-june13-healthcare_... . Brill's thesis is that with most medical care it is impossible to do the comparison shopping that you emphasize should be possible "even in an emergency." You hypothesize that "private insurers are hugely subsidizing Medicare by paying 100x the price." As http://www.medscape.com/viewarticle/521175_2 http://www.medscape.com/viewarticle/521175_2 comments, "U.S. hospitals now receive abut [sic] 31 percent of their net revenues from Medicare." Moreover, if you start to read about the US system you would realize that Medicare is prevented, by US law, from negotiating drug prices. Private insurers, on the other hand, can do so. The Brill piece covers that detail. Since your hypothesis doesn't match reality, it must be incorrect. I am not well informed of this topic, and my knowledge is mostly limited to the popular press. I cannot therefore point to any critical research. There was a recent posting here on HN, at https://news.ycombinator.com/item?id=8304019 https://news.ycombinator.com/item?id=8304019 , concerning "The Cost of My Mother’s Cardiac Care in the United States and India." The actual article is at http://www.annfammed.org/content/12/5/470.long http://www.annfammed.org/content/12/5/470.long , which starts "When my mother fell ill while visiting me in the United States, I had the opportunity to compare costs of surgical cardiac care in the United States and India. I faced challenges in making well-informed decisions in the United States due to the lack of cost transparency and the minimal flexibility offered in choice of care, whereas in India costs are readily available and allow most people to freely choose their preferred type of care." It sounds like you are saying that NYT should, in every piece about a topic, give the full details to justify its arguments. That's not how newspapers work. They often give many different pieces; some of which examine the situation, and others which help flesh out details. This is one of the latter. You are supposed to read the newspaper over time to get a better sense of the whole. Otherwise, you need to look towards the specialist literature, like review papers on the economics of the US health system, to get the answers you're looking for. BTW, you like the word "should" - you used it three times. The many observations show that the US health care system isn't the way you think it should be. There is no legal framework like what you asserted. This suggests you are basing your opinions more on wishful thinking, rather than trying to understand what is actually a quite complex and well-discussed issue. I hope those links I gave help provide a beginning for you.

sachingulaya 12y ago

Ugh. Got hit by this. My insurance company listed a hospital as covered. I took my daughter to the ED...then got a $400 bill in the mail for a physician we saw for 2 minutes. The rest of the visit was covered. He wasn't. Apparently all doctors who work for the hospital are covered by the insurance...but he was a visiting physician. I hate health insurance.

torbit 12y ago

what a pile of shitty mess. tl;dr the assistant surgeon,whom he never meet, charged him separately and the price went from 6,200 to 117,000. why? because the assistant was an out-of-network doctor. " Insurance experts say surgeons and assistants sometimes share proceeds from operations, but Dr. Tindel’s office says he and Dr. Mu do not. Dr. Mu’s office did not respond to requests for comment." before you talk to anybody in a medical building yell "Are you in my network!?!?!"

joesmo 12y ago
That isn't enough. Most doctors have disclaimers that you sign stating that if it turns out they don't take your insurance, even if they say they're in your network, you are still responsible for out-of-network costs. You need to consult with your insurance company and get it in writing, ideally.

Shinkei 12y ago

Yet another example of the ridiculous arms race between payers and providers with patients caught in the middle.

grizzles 12y ago

It's a racket. There is one and only way of solving this problem for good. It's for your life insurer to also be your doctor. I wrote an article about it about 4 or so years ago (linked here): http://housecall.md http://housecall.md

richmarr 12y ago
While I think the subscription idea has some merit it's hardly "one and only way of solving this problem". I could maybe believe "one and only way of solving this problem without challenging preconceptions and accepting some nuance into free market ideology".
- grizzles 12y ago
  Of course, you are right. There are other solutions, but I think this one is the best one. It's Google for health care. As an aside, I'm really glad Google is getting back into the field with Calico because cheap long tail health care (an obvious externality of the idea) is the ultimate positive use case / justification for their company's total information awareness philosophy / strategy.

HorizonXP 12y ago

So this practice is made more obvious in the US, simply because individuals are left with the bill. Although having a single-payer (i.e. universal health care) system might help to identify these patterns and reduce costs, the fact is that it occurs all the time, even in these systems. I'd be willing to bet that it happens more often in single-payer systems, simply because it's easier to justify and get away with. When I volunteered in the ER, I saw it all the time. In fact, I remember when I was preparing to apply for med school in Canada/Ontario, I had to read a number of articles, journals, and books about medical ethics, and one thing that stood out was the consistent push to have future physicians account for the impact of their decisions on the system as a whole. So not only was it imperative to promote patient health, but it was also important to balance that with the overall cost. A good example is a simple blood test. A full spectrum blood test may help identify potential problems in a patient, but it costs OHIP a lot of money to run those tests (especially since they're done in private for-profit labs). That's why your family doctor should really only order the required tests.

jjoonathan 12y ago
> the fact is that it occurs all the time, even in [single payer] systems The "single payer" has a hell of a lot more leverage than individuals in the US which, as far as I can tell, don't need to consent in any way (hell, they can even explicitly refuse to consent) and get stuck with the bill regardless. That trick wouldn't work so well on an organization the size of the government.
- HorizonXP 12y ago
  I completely agree, but how likely is it that big government will be able to accurately audit whether a procedure was actually required or not? In fact, I'd prefer if big government would stay out of it and just pay for my healthcare to keep me healthy & alive. I am not an expert on the procedures I need, and neither is big government. We put our trust in medical practitioners to make those decisions for us. The problem is that they benefit financially from those decisions. If you ask me, the answer is to stop conducting these services as fee-for-service. Pay physicians a salary. Pay them well, but keep costs somewhat fixed.

dmishe 12y ago

Wait did I miss it, he did not have insurance? Otherwise he wouldn't pay 117k. Unless it is one of those EPO plans, but even then you can argue that you could not have known about the oon doctor. It is likely to take a couple of months though

danbmil99 12y ago
His insurer agreed to pay -- but the guy was just bothered by the ridiculous unethical situation and balked at reimbursing the overcharging physician. Read to the end bro!
- dmishe 12y ago
  Ah thah crap missed that one paragraph, thanks

danbmil99 12y ago

Health care -- where Libertarian, free-market ideology goes to die. The free market simply doesn't work when there is zero price transparency, 3rd parties are often responsible for payment, and purchasers are often in great distress right when they need to be able to negotiate. Laissez faire market philosophy fails in this case for the same reason it fails during major crises and disasters. Purchasers are nearly powerless but have needs that they must meet immediately; vendors can price-gauge and make out like bandits. A climate of scarcity and desperation prevail over hypothetical rational actors participating in a stable market at equilibrium.

NoMoreNicksLeft 12y ago
There is no free market here. This isn't a price transparency thing either. This is about having created a culture where every doctor in the country is constantly hustling, committing borderline fraud. Sociologically, the idea that doctors and medical care workers are always looking out for what's best for their patients helps to mask the idea that they might be doing so from a health perspective but are ignoring any other consideration. And so bringing in a friend who's also a surgeon so he can get a little kickback doesn't really raise any ethical alarms. But this isn't the fault of the libertarians. Government has meddled in this industry and even with the ideas that the typical Americans think about for so long that this was inevitable. Nor can government fix it now... the AMA and other quasi-unions won't stand for it. They'll negotiate. And, as usual, our politicians will sell us down the river. If you want to fix this (and every other problem), the answer is simple (though not particularly libertarian): outlaw all health insurance. Make everyone pay for their own care. Make them pay out of pocket. In such a nation at that, none of these shenanigans could continue. Not that I expect anyone reading this to get it. You cry "But NoMoreNicksLeft, how could that man afford $117,000 out of pocket!" And the answer is that he couldn't. The doctor (if he billed after the fact) might sue, but winning a lawsuit doesn't make someone magically capable of paying. If the doctor insisted on payment up front, then the man would just forgo his particular service (which, since he was unaware that he needed it and it sound like bullshit... wouldn't have mattered). There aren't enough rich people who can afford to pay the current prices out of pocket for 100% of the doctors to continue to bill/earn what they do currently. Maybe just enough for 1% to continue like that... the other 99% are going to have to shape up, and in a hurry. They can't hold out prices where they are now (we can't pay that out of pocket), nor can they spitefully punish us and refuse to do it at lower prices. They have bills to pay just like the rest of us, they have mortgages, they need to buy groceries, etc. Nor will they decide to become plumbers and HVAC repairmen so that they don't have to give away their surgeries for less. But again, this is lost on anyone I've ever explained it to. You all think it will result in millions of deaths and untold suffering. > Laissez faire market philosophy fails Bullshit. There hasn't been a laissez fair in the healthcare industry in the United States in 100 years.

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Untit1ed 12y ago
I imagine he'd be dodging collections. EDIT: If his insurance hadn't paid it, obviously.
- cookiecaper 12y ago
  They give up after a while and you can discharge the debt in a bankruptcy. More than half of all US bankruptcy cases are related to medical bills, so this is a very common issue. In the United States, having a major medical problem is synonymous with destroyed credit.

cookiecaper 12y ago

The US health system is FUBAR'd, but the right answer isn't a blank check from the government.

chasing 12y ago
Thank god nobody has actually proposed giving the healthcare industry a "blank check."
- cookiecaper 12y ago
  That's effectively what Canada et al have done. Yes, I understand the government "negotiates great rates" for the citizens, but it's effectively the same thing as a blank check. It just takes a bit of shenanigans behind the scenes to sell the bureaucrats on your latest rate hikes. If you think pricing is bad now that the big insurance companies have to "negotiate great rates" for their clients, think how it'll be when there's only one party there. Government-negotiated rates places the pricing totally outside the realm of necessity or reality and makes it a purely political matter, and politics is a messy, fickle thing built on personal favors and tit-for-tat. Not having your political activity interpreted as corruption or bribery mostly depends on not pissing off someone with more power than you. Health care costs so much because of the insurance leech. The only way to restore sanity is to restore real competition and make the consumer pay directly. Doctors will have to charge reasonable fees to the patients, suppliers and vendors will have to charge reasonable fees to the doctors, etc. It will break the cycle of exorbitant cost in health care. That may be, in some senses, a painful transition, but it's the only sustainable thing in the long term. The cycle will not be broken by saying "Wow, health care sure costs a lot of money. Let's just get the government to print some extra cash and take care of that for us." Insurance is typically a highly regulated industry because when insurance is involved, people get screwed. The incentives are misaligned; the insurance company only makes money when they don't give you what you're paying for. Insurance only works in events that are very unlikely. It's extremely likely that everyone will go to the doctor or need medical assistance. Insurance is a very, very bad model for this service.
  - DanBC 12y ago

theworst 12y ago

Reasons I am dubious of the author's agenda, based on the structure of their arguments: 1. anchoring to high numbers, without contextualizing how big this issue is: "This contributes to the nation’s $2.8 trillion in annual health costs." How much does it contribute? 2. unequal metrics -- when discussing the expected charges: "Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee." When discussing the out-of-network bills: "Two plastic surgeons billed more than $250,000 to sew up the incision, a task done by a resident during previous operations for Ms. Kaufman’s chronic neurological condition." Now we're thinking $133k isn't so bad b/c he'll only pay part of it, but the $250k is frightening because there is no mention of an expected discount. As a counterpoint, the author mentions the insurance company pays the full amount to Dr. Mu for the other anecdote in the story. 3. fearful language -- 'He was blindsided, though, by a bill of about $117,000 from an “assistant surgeon,” a Queens-based neurosurgeon whom Mr. Drier did not recall meeting.' Sounds like a 24-hour-news-cycle headline: "Patients billed by doctors while under anesthesia". 4. mentioning there are marketing firms who specialize in helping maximize billing with insurance, as if it's an unethical business. This happens every time a provider of a service or product interacts with a bureaucracy -- there is a whole layer of these services for defense contracting, for example. 5. they mention how the US has more neurosurgeons per capita, then link that (by proximity in the same paragraph) to providing motive by mentioning how neurosurgeon compensation has decreased recently. A more honest article would have given absolute numbers about how the costs of neurosurgery relate to overall health care costs, rather than making the niche appear large relative to the story, so the reader implicitly compares that impact to the $2.8 trillion number. Medical billing is absurdly complex and byzantine. I'm don't doubt the veracity of the anecdotes, but the structure of the presentation make me suspect the intent of the author.

eli 12y ago
I don't understand what you're getting at. What do you suspect the author's agenda to be? What should we take away from this instead?
- 12y ago

arjie 12y ago

How interesting. The patient is not in a position where consent is meaningful but is charged an exorbitant amount. At least a little unethical, I think.

seanflyon 12y ago
I would say that not only was this unethical, but also not a valid contract. Without some reasonable semblance of an agreement how can someone say that you owe them $117,000? I would bet that a court would disagree and would be interested to hear why.
- milesskorpen 12y ago
  In the header of the article, it mentioned he signed many forms. Probably one of them agreed to this practice. Enforcement could still be tough though.
  - seanflyon 12y ago
    I get that, but if I sign a contract to buy a car and somewhere in the fine print is says that I owe an extra $117,000 that I am not aware of, that is not a valid contract.

raquo 12y ago

It's sad that the only surprising part is "He Didn't Know", not the actual price.

bambax 12y ago

The other weird thing is the billing happens after the fact with no visibility before hand. If you're building a house you don't start by saying «let's build a house» and then wait for bills from various contractors you've never met to arrive once the house is built. That would be considered crazy. Why is it acceptable in health care? What prevents praticians from establishing a budget? What prevents patients from demanding one?

jonlucc 12y ago
I had a recurrence of a medical complaint and have a high deductible insurance. I called around to several odficesbro find out what it would cost to treat if I was correct that it was a recurrence. In every case it took 30 minutes or longer for them to decipher their own costs.
deleted 12y ago
[deleted]

ar7hur 12y ago

To fellow startups claiming to "change healthcare": this is not about nicer online forms. This is about destroying this.

drdeadringer 12y ago
> this is not about nicer online forms. This is about destroying this. Thank you for clarifying this.
- drdeadringer 12y ago
  ... not sure why an honest 'thank you' is downvote material, and am open to being educated on the matter.

verroq 12y ago

Shadowban test

deepsun 12y ago

By the way, in xUSSR free healthcare system multiple doctors _often_ discuss serious cases, unlike US. That's not something special for xUSSR doctors to discuss in a concilium complicated cases -- that's daily routine. That's their way to share expertise and improve professionally. In US you may have some chronic disease and one doctor would treat you as she/he believes is right, not discussing it with colleagues, and if you find another doctor, he/she might change the treatment, not even talking with previous doctor. So it's kinda strange to hear from famous US people that they "found an awesome doctor". I would prefer to find an awesome clinic, and have multiple doctors to discuss my case. That happens, of course, but money keeps that from being natural routine here.

nobullet 12y ago
Being a son of a physician from former USSR country I can say with the certain degree of certainty that this is not true in our times: you are lucky not to die in a line of 67 patients before you see a doctor in a state clinic. Not mentioning the MRI or X-Rays where patients wait up to 3-4 months in lines in order to get simple diagnosis. Money gives you the ability to go to private clinics and have these things done faster, often by more professional specialists. Doctors in state clinics are underpaid, often unprofessional and with lack of experience (graduated students).

peteretep 12y ago

Tangential but hopefully interesting: how much an extra year of life is worth to the NHS: http://m.bbc.com/news/health-28983924 http://m.bbc.com/news/health-28983924

interpol_p 12y ago

This almost feels like an Onion article where all the costs are multiplied by 20. What justifies such huge bills? The article makes it sound like a doctor walked in to ask "How are you feeling?" and then charged $20,000 for doing so. I've had a few private operations quoted in Australia and the full cost of the operation is usually in the $500-$2000 range. Even a pregnancy through a private hospital was quoted to us at about $4000. (Although we ended up having our first baby delivered for free through a public hospital, which was fantastic.)

oliwarner 12y ago
Completely agree. These prices are disgusting. Even if this consultant was there for an entire surgery, how can one person justify charging $1m/week? The US desperately needs to walk back the amount their doctors are paid.
kamaal 12y ago
>>doctor walked in to ask "How are you feeling?" and then charged $20,000 for doing so. It would have happened, why would you doubt it? It would have been like he was called in just in case any issue came up. The doctor walks in and asks the most obvious question to the patient "How are you feeling?". The operation ends without needing any inputs from him. But regardless he would have billed the patient for his time. The attitude is, he wouldn't have given any inputs but he did give them their time, which would otherwise be used else where to make the same money so you have to pay even if the actual value added by him was zero.
- interpol_p 12y ago
  I understand the doctor gave her time — that's fine. It's that the cost for that time seems ludicrous. As I said, the pricing seems multiplied by 20.

anoirt56 12y ago

>“The notion is you can make end runs around price controls by increasing the number of things you do and bill for,” said Dr. Darshak Sanghavi, a health policy expert at the Brookings Institution until recently. .. like promoting and charging for unnecessary and damaging surgery on baby boys, robbing them of bodily integrity and killing ~200 infants a year from complications.