For someone who worked on price transparency in 2013 - I was personally affected with surprise billing - and spent long hours working on a price discovery / transparency tool called pricepain.com, I completely welcome this move. While it won’t solve all issues at once, shining some light into the medical billing mess can only be a good thing, allow market forces to enter the picture somewhat.
I really would love to hear your experience and some details about the work you did on price transparency.
Can you share some?
I have been beaten by the surprise billing so many times that I now dedicate some of my personal time to researching the root cause and taking action, one of which is sharing my thoughts with other people in a vain hope that things will get better and improve.
That sounds very familiar. At first I thought it was a mistake. The confusion when you get several bills, one larger than the other. Then the shock, when you get the final picture of what you owe. I went back and forth with the hospital and finally got an itemized bill (I didn’t know such a thing existed nor didn’t understand why all bills would be itemized.) A square gauze priced at the cost of an iPad,... And then the upcoding racket. It all leaves you confused. How is this possible? Why isn’t the media all over this or the state attorney? And why in the world is the insurance company part of the game? Then came the Time magazine front cover story (2013 I believe “Bills are killing us”) about hospital charge masters (why was nobody going after this decades ago?)... Finally I came across Dr. Keith Smith from the Oklahoma Surgery center and finally the puzzle pieces fell into place. So one does what one has to do: roll back the sleeves and get to work. Poured a couple of months into pricepain.com after hours (a friend working at hospitals in Wisconsin helped with some initial price finding), a NYT offspring that had gathered some medical prices send a cease and desist when we copied their ‘transparent prices for medical procedures in NY’ eye-roll. Eventually the government released Medicaid prices - a first big breakthrough. I had discussions on HN with Better Doctor who tried something similar - eventually they pivoted and focused on other things. We pitched to YC and a medical VC fund. Latter said in 2013 ‘there is at least 5 others that are working on this’ hahaha. Then came Obamacare and the future of free market / direct healthcare with price transparency became unclear - a super state nationalized Healthcare would have buried prices in yearly increasing taxes. So eventually I had to move on but always hoped that something like today’s news - more price transparency to allow for competition and improvements of quality/service - would eventually win out.
> A square gauze priced at the cost of an iPad,...
Absurd list prices were used to screw Medicaid and Medicate. Because they often paid at 85% of list price. When commercial payers had negotiated as much as 90% discounts. But that doesn't work anymore, I think.
> Industry groups are mobilizing to fight back, saying any requirement that hospitals and insurers disclose negotiated rates would go too far.
This kind of effort is what is required in order to allow for comparison shopping to occur. Maybe this even enables consumers to shop better for their insurance plans depending on their common needs. That would likely allow folks with certain recurring conditions to shop for the best insurance plan for them (thus also raising the risk level for that insurer and changing prices?) but that's a bit more like how a market is supposed to work.
I can't speak specifically to whether the order just increases legal ambiguity or whether it will be enforced, but I'm happy to see any initiative toward price transparency in medicine that will allow the public to start making better decisions.
> But the order doesn’t say if hospitals would have to disclose the average of all rates they get from insurers or the specific rate they get from an individual’s insurer. That detail matters: The average rates would have a milder effect on local markets as insurers and hospitals still wouldn’t get clarity on rivals’ specific secret rates.
PRECISELY. If everybody understands the negotiated rate, then any size organization can argue for that rate. This would make it easier for smaller-scale companies to get the same rates as larger plans and also reduce some of the incentives for large insurer / care company mergers that seem to be really rent-seeking given the industry comment on this order.
This is easier to solve by just passing a law that insurance companies move to reference pricing. Meaning that private insurance cost is always Medicare + 30%. This is what most private insurance negotiates anyway. It is completely unnecessary bloat to have all this maneuvering on price for no benefit. The insurers (payors) will push back because they see themselves as gatekeepers and this as their differentiation. They need to go back to only making their money on their float against premiums. Additionally, we should also add that paying cash means you get the Medicare price.
Medicare's reimbursement rates are already higher than every other developed nation. The idea that it doesn't pay enough is, frankly, bs.
Of course, reimbursement rates are hardly our only problem. We also use more expensive treatment options for the same conditions, give doctors (and thus patients) a level of flexibility unheard of elsewhere that allows to spend money on unnecessary medicine just to make a patient happy and have ridiculous administrative overhead costs.
> Medicare's reimbursement rates are already higher than every other developed nation. The idea that it doesn't pay enough is, frankly, bs.
Medicare's reimbursement rates could just as well be published by Gosplan. If you squint hard enough, they are almost an application of the Labor Theory of Value: There is an intrinsic value of everything determined by how much labor went into producing it. That, of course, leads to all sorts of fun stuff like seniors in Florida loading up on cosmetic surgery and ED medication on the backs of the younger generations.
The “price” is really just the unit cost. Companies seem to have no problem computing unit costs (and thus margins!), no gosplan-like apparatus is required for this beyond supply-chain management and accounting. The U.S. situation is complicated considerably by all the different parties involved which I guess is why this idea might work less well there.
Correspondingly I suppose the “true value” would be the value provided to the recipient of the procedure and society as a whole, and as you observe is much more subjective and probably best not even measured in dollars. I think “quality of life adjusted years” is a thing. The major problem is when the you and the state disagree on the value of a procedure and whether it justifies the costs...
Another way to look at it, “socialised medicine” is just health insurance collected by the state with full vertical integration; your insurer also runs the hospitals and provides the care. The upside is you’re covered, the downside is you don’t get to choose a plan.
We overtrain docs and we’ve built hospitals that focus on private rooms instead of wards. Both of those hugely increase the labor cost and will take a long time to undo.
> We overtrain docs and we’ve built hospitals that focus on private rooms instead of wards. Both of those hugely increase the labor cost and will take a long time to undo.
If I was a patient at a hospital, I would not be able to control this:
> We overtrain docs
That part is outside my control.
... but, I, as a patient at a hospital, would be able to control this:
> we’ve built hospitals that focus on private rooms instead of wards
Infact, some of hopitals in the U.S. do have ward deliveries - I believe Kaiser Permanente have shared rooms?
However, that is the rub - people are not explicitly requesting private rooms - hospitals just have them so they can charge as much as they can.
If you walk into a hospital, you cant ask to have a ward delivery. They take you to a private room by default - no questions asked. That's all they have.
Then the bill comes and the game begins - if the insurance company does not pay, the hospital will then come after you. They will put you on a payment plan.
If you can't make payments, they will sell you to collections. Some hospitals might settle for an upfront cash payment but then it cannot go through your insurance and you are out of money AND you did not meet your family deductible either.
If there was a choice to new parents between ward deliveries for $50k and private rooms for $150k, I know which one I would take.
I don't have that choice because my employer might not be offering care though Kaiser Permanente and the hospitals in network might only have private rooms.
So change employers because I prefer ward deliveries?
I did not mean exactly that, but this happens too.
Not every new parent can afford the expense of birth. So the hospitals try and squeeze out as much as they can from every party to try and even it out.
As a high income earner, I'm specially vulnerable to this practice.
No judge or newspaper or activist has particular empathy that I got charged $200k for a delivery or $6k for an 2 mile ambulance ride.
I can afford to pay it so why am I being so picky about it?
Price controls have been demonstrated to work in a number of other countries. I agree, in general, but when you have a proof by existence of efficacy, you can't really claim that they don't work in medicine.
Which countries? Price control doesn't work. It generates scarcity and supply problems. The case against price controls is not merely an academic exercise, restricted to economics textbooks. There is a four-thousand-year historical record of economic catastrophe after catastrophe caused by price controls. This record is partly documented in an excellent book entitled Forty Centuries of Wage and Price Controls by Robert Schuettinger and Eamon Butler, first published in 1979.
I live in Ontario where prices for medical care are negotiated by the provincial government, which you might regard to be a price control. The result is excellent, and one of several reasons I would never consider living in the United States.
The system is universal, but not complete. In fact, you should pay and that's how it works and it doesn't generate scarcity. There is 3 types of services in Switzerland: public with 2500 bed, subsidised private and private.
I will quote:
> The insured person pays the insurance premium for the basic plan up to 8% of their personal income. If a premium is higher than this, the government gives the insured person a cash subsidy to pay for any additional premium.
So, it's a basic insurance that doesn't cover everything. Also quoting:
> "Health insurance covers the costs of medical treatment and hospitalization of the insured. However, the insured person 'pays part of the cost of treatment' and 'For hospitalisation, one pays a contribution to room and service costs'."
As you can see, there's no 'free' but subsidizied basic healthcare treatments, but then you should pay everything.
Simple don't let doctors choose patient by insurance plan or negotiate a higher rate. Everyone pays the same. There are first world countries wherein the massive profit potential at every step between patient and care just doesn't exist and they in general have better health outcomes than we do.
What part of the Constitution covers medical billing? Doctors can get tort protection but patients can't get billing protection? Wages have been set by the U.S. government before so I'm not sure you could argue that, and there's no personal expression protection with accepting insurance. I'm really unsure of where this could possibly become Constitutional other than the right to life.
Perhaps it’s the ambiguity when I read the parents post about not allowing doctors to charge different rates. Does that mean not allowing me to charge more than you, or not allowing a doctor to charge one patient more than the former.
When I originally read it, it seemed like the former, but given everyone’s responses it must be the latter.
USA already has the common carrier law which states that certain services are not allowed to discriminate against specific customers, everyone pays the same price. So all you would need is institute a similar law for medical practice, like a "Common Health Provider" law. If you think that net neutrality is a good idea then you should also think that this is a good idea.
Why people downvoted this. Price control doesn't work. Just read any economic book and you will realize it's true. It hurts, but it's true. If price control works, then why prices never were freezed. Why don't freeze it forever? Because it doesn't work.
A theory that isn’t validated in practice isn’t much of a theory. I’ve lived in several countries with price controls (at least on reimbursements, you’re free to get price gouged at some doctor but not many people will follow) and things are fine.
If anything I ended up having issues at the few parts that _arent_ price controlled (eyecare in France is a pain, though I think mostly because supply of optometrists are limited)
You can read Forty Centuries of Wage and Price Controls by Robert Schuettinger and Eamon Butler, first published in 1979. The case against price controls is not merely an academic exercise, restricted to economics textbooks. There is a four-thousand-year historical record of economic catastrophe after catastrophe caused by price controls.
In the case of price controls for medical services and products, there are a bazillion cases of it working. Your theory goes up against the universe's facts on this specific case.
I'm not arguing for price controls on everything in general. I'm pointing out that _in this context_ price controls are a proven strategy and work and mean that people don't _die due to not affording their insulin_.
The best healthcare system in the world is private and it's made on Singapur. Every single citizen can afford it, since it starts from 16$/mo. I want to hear one case of those 'bazillion' of price-controlled system.
Price control is not a theory. There are several books, papers (Hayek, Mises, Friedman), topics that address this topic. If it is so good, why isn't implemented? It's the same argument than communism: if it is so good, why we don't implement it? Because it doesn't work. It never worked.
Price control generates scarcity. Because bureaus can't have all the information about the market, it's impossible. The moment a bureau determinate a price you're generating an impact on the different areas without having the possibility to address it. The gov. is not the market, the gov can't be an omnipotent entity that knows everything, that's why they screw everything.
It's more or less implemented for medical care in most other first-world countries and it seems to work better than ours* in all of them.
I lived in Canada for three years, and growing up in a fairly conservative area in the US, I was prepared for the worst - six-month wait times for life-saving procedures, etc. What I saw was more like Star Trek - people who needed medical care went to a clinic or hospital and got it, and they didn't have to worry about being bankrupted in the process.
After I moved back to the US, I got to see what it was like for most people - delaying or never getting critical procedures done, people with teeth rotting in their heads because they can't afford to go to the dentist, almost everyone 1 unexpected medical bill away from permanent financial ruin. Our system is objectively bad, and we deserve to feel bad for sticking with it.
You can cite all the market theory you want, but the US is a perfect empirical example of why those theories are wrong.
* Except for the tiny minority of the ultra-wealthy who can afford to pay any price for health care.
People call economics the dismal science but the truth is that it isn't even a science. Its predictive power is laughable and it seems to consist mostly of just so stories told after the fact.
You can't just claim something which is demonstrably functional somewhere doesn't in fact work because your half baked theory trumps actual reality. This is why this sort of comment is downvoted.
> You can't just claim something which is demonstrably functional somewhere doesn't in fact work because your half baked theory trumps actual reality. This is why this sort of comment is downvoted.
What actual reality? Because there's price controls doesn't mean it works. It generates scarcity, always.
Go to SF, put all rentals to 100 dollars and see the effects of the price controls. They will be the same there and in China.
I am not surprised people who deny the fact of economic science is downvoting this.
Now that advertising drugs to the public had ballooned marketing budgets beyond R&D is that still true?
I imagine that dollar-for-dollar a non-profit with the right incentives and oversight could out do the VC-backed leeches driving up prescription med prices.
The vast majority of pure research has funding generated directly from government funds. Medical funding is roughly half from public funds. This wouldn't change with price controls. More profits don't lead to more research.
The US subsidizes drug development, that's about all. Other medical R&D doesn't really come out of any publicly funded research system, it comes from medical practitioners. The cost of US drug development subsidy is maybe $40 billion, accounting for basic research and development by pharmaceutical companies. This is pretty much peanuts compared to global healthcare spending. Also, this money is arguably not really that well spent, since most of drug development is useless, and nations can improve their health systems and outcomes much more through things like routine care and monitoring than they will through expensive research.
The private actors are the ones who pay for the R&D, to the tune of $70 billion/year. That's on the same order as total annual venture capital spending nationwide ($70-$80 billion/year from 2014-2017, though 2018 was an outlier at $130 billion).
These amounts are small enough where the U.S. government could pretty easily cover the expenditures. So by your logic, why do we need Silicon Valley venture capital? Why not just have the government pay for the R&D and make the results freely available to everyone?
Either the government is good at allocating capital for high-tech R&D or its not. Whether you're talking about medical tech or computer tech doesn't make a difference.
Price control doesn't work on healthcare. I give you an example: Spain, "free" healthcare: they realized people went to socialize to hospitals, making impossible to address the demand. People went to hospitals for headaches, colds, creating an incredible ammount of problems. How they solved it? They charged money (little) for any consult you wanted to do. This reduced instantly a big ammount of the consults and false positives. This was tested in Barcelona and in other provinces. This was also a case for Singapur, where everyone have access to healthcare (starting from 16$/mo) and healthcare is subsidised by demand.
Price controls force efficiency gains. If wages go up you don't stop paying your employee wages, you either train cheaper employees, find a way to get more work out of them, or find a better way to do it. The same applies to price controls.
This is not true. The moment you set a red line, you're making impossible for the lesser trained to join the wagon for getting a chance to climb the ladder. Also, you're making the capitalist not paying for not hiring lesser people, since none has to hire, there are not faults. The idea is that investors should fight to get you in, but if they're denied, they get the monopoly since no one can enter the market to compete with them by hiring people who is willing to work for less than the regulated wage price is meant is. Plus, wages will not go up easily, since you're killing the force supply by setting a line on it. Milton Friedman explained this properly, you can see his speech on Youtube.
Milton Friedman is only one school of economic thought. Nothing is proven in economics and likely won't be since it involves human psychology. When gas prices rose dramatically economists expected the US to move away from large vehicles. That's not what happened. The rational thought is almost never what happens in economics. People buy high and sell low, their purchases are often emotional, and investors pour money into acting blockchain.
> PRECISELY. If everybody understands the negotiated rate, then any size organization can argue for that rate. This would make it easier for smaller-scale companies to get the same rates as larger plans and also reduce some of the incentives for large insurer / care company mergers that seem to be really rent-seeking given the industry comment on this order.
The fallacy is assuming large insurer / care companies are interested in paying more to providers or keeping a lot for themselves.
Insurers work on margins, floats and risk pools.
More the better.
They would rather have more insured to have a larger float, a more diverse risk pool and lesser margins but more volume.
Also, why would a large insurer be OK with a smaller-scale company getting the same rate?
No market I know of works that way - a larger negotiating body always gets an advantage over a smaller negotiating body.
Which is WHY smaller companies want to become larger companies.
Otherwise it would not make sense - it's way easier and cheaper to run a smaller company than a larger company for example.
You and I can't start NewCo and demand the State of Alaska give us tax credits.
Nah, let's just replace the whole thing with Medicare for all. The federal government can then negotiate prices which will be far lower than any smaller org can do.
Works in Japan where prices are super low and the system is very good (far more private doctors per capita than in USA).
>> The federal government can then negotiate prices which will be far lower
I'm not convinced that the government can get a better rate - especially when you look at other sectors where government contracting has become a lucrative business like IT, military or space where the private sector does things much cheaper than what the government does.
>> Japan where prices are super low ... far more private doctors per capita than in US
I think the real reason in Japan might be that costs are low because there is more competition due to more private doctors. The cost of becoming a doctor are lower (lower education costs, lower malpractice insurances costs etc) and that incentivizes more people to become doctors and they are able to charge a lower fee as a result.
The US is an outlier, because the US system is broken.
IMO the US healthcare market either needs to be properly regulated, or it should be converted to single-payer (a system which many other countries use with great success) - other developed countries are spending significantly less per capita for better outcomes while still allowing private healthcare for those who want it and can afford it.
This is all interesting but not responsive to GP comment. It is in fact quite plausible that lower costs for physicians could lead to more physicians and more price competition among physicians, even in USA.
It is in fact quite plausible that lower costs for physicians could lead to more physicians and more price competition among physicians, even in USA.
It doesn't matter what seems plausible to you, what matters are the hard facts of how much is spent for what outcome, and as you'll see from those graphs, the evidence is overwhelming that the US spends a lot (both per capita and as % of GDP), and gets less in return.
How do you consider these observations to say anything about the topic of this sub-thread? Yes, we spend a lot on health care, and we're spending more all the time. That indicates that we should make some changes, but it doesn't indicate that this particular change wouldn't work. "Hard facts" that are completely irrelevant are not convincing.
How do you consider these observations to say anything about the topic of this sub-thread?
I thought it obvious, but the first hypothesis from the OP:
I'm not convinced that the government can get a better rate
From the data:
Single payer system countries have far lower costs for similar if not better outcomes.
The other hypothesis:
I think the real reason in Japan might be that costs are low because there is more competition due to more private doctors
From the data:
Japan has dramatically lower costs than the US, while having a radically different system far more similar to 'Medicare for all'. The far more private doctors comment was I think addressing irrational concerns that private healthcare would somehow disappear under medicare for all (instead of just being a lot cheaper). Japan is the proof that doesn't have to be the case.
" other developed countries are spending significantly less per capita for better outcomes "
What are better outcomes ? How are those measured ?
US is still the leader in healthtech, health quality, and health service timing.
Canadians are literally pouncing on new doctors like freshmen on beer, because existing doctors no longer take patients. The UK NHS has waiting times that are measured in months.
The only thing we struggle with is cost. So again, what are better outcomes ?
Govt wouldn’t run the hospitals and generally I don’t think govt contracting is super lucrative it’s just big dollars to match big costs. Also running hospitals is very different than running R&D from a cost perspective.
I'm interested to know why you think the government is incentivized to negotiate the best pricing for citizens. They would fill the same role as existing insurers, but instead of multiple black boxes there would be one. There is no way to tell if the price we are paying is at all good value for money compared to what it could cost. I'm not sure this solves our health care cost escalation problem, and the government would still be fighting against providers that would continue to grow and merge together so they would be able to negotiate with the government. This reduces overall service and competition.
We like to talk about healthcare like it's a free market but it's not. If I'm at the hospital I'm there for treatment. I'm not leaving until I get it, damn the cost. I will not consume less healthcare because the price is higher when the other option is death.
We need some price setting regulation to protect consumers from getting fleeced. When the hospital knows that I'm going to say yes, why not price every surgery at $100k?
We've tried letting the insurance companies regulate the price, but they've proven themselves incapable either because there are so many secrets making the market not fair or because they don't have an incentive. It is time to try something else. The government is our mechanism for regulation. Let's use it.
> We like to talk about healthcare like it's a free market but it's not.
Emergency medical care isn't.
But most other things are.
It should be possible to shop around for imaging and testing services. The regular "family doctor" is something families can (or at least should) be able to choose at will.
Heck people shop dentists all the time. They shop physical therapists, and even mental health providers.
If all the local X-Ray providers near me publish their prices online the fact is prices will drop, and that will likely carry over to what price is paid during emergency services as well. It will be hard to charge someone 5k for an X-Ray in the same imaging center that has a price of $120 listed on their website!
In Australia elective procedures on medicare are much more limited or not covered at all. A system can start by just covering the most essential and required care, then later expand to additional things.
My insurance company calls me after I schedule a service like lab/imaging to tell me of cheaper options. My doctors are attached to professional building at big local hospital chain, so I usually just go there because it’s easy, I know my way around, they are on same IT platform so I don’t have to chase down results, or long term they have all my medical history localized. Due to being attached to hospital though, cost of MRI for example is usually 10x versus competition. I still don’t care, because I have insurance and have no incentive to reduce the cost.
So if you want to make people price shop, it has to be coming out of their pockets for it to work. Dentists, PT, etc that you listed have much higher rates of cash/self pay.
You're describing inelasticity of demand, which has nothing to do with whether or not a market is free in the economic sense (that is, whether supplier competition and consumer substitution are possible). It's also incorrect to pretend that all healthcare goods have the same elasticity of demand, as well as to pretend that even emergency healthcare is perfectly inelastic.
The reason this matters is that we don't see the same problems in other inelastic markets - for example, automotive gasoline is highly inelastic (estimated to be at -0.02 - https://www.eia.gov/todayinenergy/detail.php?id=19191), but we don't have the same pricing pathology with it that we do with healthcare (emergency healthcare estimated to be at -0.04 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5600717/). Therefore, we can't conclude that the problems are specifically due to inelasticity.
> You're describing inelasticity of demand, which has nothing to do with whether or not a market is free in the economic sense (that is, whether supplier competition and consumer substitution are possible)
Next time when a bone in broken in your body, go comparison shopping because it's a free market and you should get the best deal while your bones hang freely.
Health care is a special case not comparable with any other market.
> Next time when a bone in broken in your body, go comparison shopping because it's a free market and you should get the best deal while your bones hang freely.
Or already know the price of how much it costs to get a bone set at different local providers and make your pick ahead of time.
Why assume people aren't going to shop around until something happens? "Hey ambulance driver, my preferred clinic is such and such take me there please."
Would you keep a mental record of every service at hospitals? Seems like a gigantic waste of effort for everyone to have to know that a bone fracture is cheapest at hospital A, but C is best for head injuries.
Unless of course you aren't conscious enough to direct the ambulance driver at all.
> Seems like a gigantic waste of effort for everyone to have to know that a bone fracture is cheapest at hospital A, but C is best for head injuries.
Imagine a world where prices are openly advertised, and as a result they start to drop.
Take laser eye surgery as an example. Prices are insanely competitive! They have been going down for years, and equipment manufacturers have been hard at work making more reliable and cheaper to operate equipment that has less side effects!
We have a free market for literally curing blindness and it works really well.
Now take more urgent but not life threatening cases. Last couple times I broke something, it was of the "well that sucks and it is kind of swollen but whatever" type, and I got to choose where to get an X-Ray at.
That is a perfect case where open pricing would drive the market price down and save me money.
As another example, physical therapy prices are often advertised on the open market. So are therapeutic massage prices. Both are price competitive markets.
Sure life threatening emergencies will still be subject to price gouging, but if the entire medical system is running more efficiently then even emergency services may see a reduction in costs in places. Maybe not for the trauma center, but for the hospital stay outside the ICU, why not?
They’re really not very competitive. In my experience there were discounts offered to people with mild myopia to get them in. People who need glasses to drive or see a blackboard pay more. People with large pupils pay much more. I think it’s likely the prices are suggested and discounted by the machine manufacturers who own patents.
The nominal price of Lasik is trending slightly down at the same time that the technology and procedure is getting better. It's a pretty stark contrast to most of the rest of the medical industry, IMO.
I definitely would, why wouldn't you? Broken bones are urgent but usually not life threatening - in that situation I'd definitely take a few minutes to decide how exactly to handle the situation - call an ambulance, or have a friend drive me to the hospital? ER, urgent care, or GP? Lots of options with different trade-offs, even if cost wasn't one of them!
Urgent, life and death situations are obviously a special case but are also a pretty small percentage of medical care at least IME. My wife has had quite a bit of medical care over the last few years including having 3 kids and several unrelated, important but not immediately life or death surgeries. In every case we evaluated several options before picking a Dr and a hospital. We looked at price, recs from friends, distance from home, reviews, etc just like picking a restaurant or a new car. Even in the few urgent life/death ER visits we've had we still picked where to go, we just picked ahead of time - when we get a new insurance plan we usually glance through it to make sure we know what are the closest ERs and urgent cares that are covered, and if there are multiple options we'll pick a default. Again I don't know why someone wouldn't do that, even if our healthcare were free we'd still compare on other metrics.
Cost should play a role but I don't think it should ever cross your mind or need to be a decision you have to make.
In your anecdotal situation let's say you fell and broke your arm and are now sitting in the back of the ambulance when they ask that question. North or South hospital?
With your one good arm are will you load up a cost comparison of services between the hospitals, checking what the procedure might be if the break is impacted, if muscle tissue is torn or needs to be repaired surgically, what followups or cast removal costs, and building a spreadsheet of possible scenarios based on the underlying medical statistics combined with the risk factors of your incident? Ar you comparing that against hospital ratings for those departments and doctors and their success rates combined with education or training in line with best practices or regulations? Then are you compiling this data to make a decision based on which hospital is the most viable economically vs the standard of care for your suspected injury and reaching a decision?
Are you going to do this for every viable healthcare situation in advance so you're aware of updated costs at South or the new star surgeon hired at North hospital?
There's certainly a market for that analysis but I don't think it's analogous to real life. Most people are going to call 911, get in the ambulance if needed, and go to the closest hospital with capacity. The price, quality, and other checks need to happen at a higher level while still be transparent and open. Medicare has tools to solve this just like how the FDA us meant to resolve food safety questions and other governing bodies are there to regulate and enforce standards. Unfortunately it's not as simple libertarian as "North or South?"
This greatly ignores the reality that in a community, when prices are known, there's a collective understanding of which places (regardless of industry) are more expensive than others. And whether the cost difference are justified based on, again, collective experience.
So, no, of course no one is going to fire up the equivalent of GasBuddy when they're in an ambulance. You no doubt already know this, so why make such a ludicrous argument?
Because deputizing the government to negotiate down prices is a saner alternative to keeping costs of emergency services down given that the actual cost depends on so many factors that your analysis is extremely faulty.
The only substantially cheaper across the board hospitals are those people go to die in because they are profoundly incompetent and understaffed.
Which is a form of government regulation allowing punishment of poor/illegal performance. Medicare for all or a universal solution could enforce quality across all healthcare providers while simplifying negotiation not only as the federal government would be the only client to barter with but could make policy restricting costs or overhead in a careful manner.
There would definitely be an app created for all that in no time. We will be able to do all that stuff with one finger and your smartphone. With the exception of the well-off and rich, people who are living on a budget are certainly going to look up costs for non-emergency medical treatment.
It's semantics, but they're important when you're talking about economics. You're describing inelasticity of demand, which is to say that I need the good irrespective of the price (and it may mean irrespective of the geographic inefficiency).
In a free market, I can open a hospital across the street from your hospital and charge whatever I want for similar (or completely different) services. Presumably, our hospitals would also have a brand reputation: I know lots of folks who say "I'll never go to X HMO again, it's so much better at Y public hospital" and would gladly drive an extra mile or two with their broken arm kid if it means they're fairly certain they'll save a few grand (or more).
A similar example is that I'm halfway down a 200 mile highway, and I need gasoline. There could be one gas station, there could be five, but the fact that I'm allowed to open a gas station next to the sole one that exists means it's a free market. If the government says "there shall be one [or two, or ten]" gas stations here, or that "all gas stations here shall charge this rate", then it's less of a free market.
You may be trying to describe the concept of perfect competition[1]. If so, I'd agree with you that health care can almost never achieve perfect competition because perfect information becomes harder to obtain as situations become more expedient or dire.
You're right, healthcare as I am describing it is a perfectly inelastic service. I cannot think of any other example where someone would show me an absurd price and I'd still take like. Like $1M absurd. I'd rather push my car than buy gas at some point. The same cannot be said about my health. There is no point at which I'd rather just die.
The government needs to regulate markets like this.
If healthcare is perfectly inelastic and inelasticity is the dominant factor in pricing, shouldn't we expect all procedures cost $LIFE_SAVINGS each already? I'm not trying to be glib; my point is that a) healthcare is _not_ perfectly inelastic, and b) even in the presence of high inelasticity, we can observe that market forces can exert downwards pressure on pricing. I think that arguing for a remedy solely on the basis of elasticity is misguided and potentially ignores larger problems within the market.
Consider the example of food, in general. Demand for food is wildly inelastic - without it provided regularly, for your entire life, you _will_ die. If elasticity were the only consideration in pricing, we should expect food to be break-the-bank expensive, but it clearly isn't. What else is different between the healthcare and food markets?
(To be clear, I'm not defending the current state of our healthcare system. It's broken in a lot of ways, and is way more expensive than it needs to be. I'm just arguing against the idea that the cause of its dysfunction is inelasticity of demand.)
> If elasticity were the only consideration in pricing, we should expect food to be break-the-bank expensive, but it clearly isn't.
Because welfare (and subsidy) programs exist so people aren't desperate for food, just like people who are covered under medicaid are not desperate to pay for health services.
I think that because it happened in Japan and other places. Japan has a single payer health insurance system called NHS. The government pays 70 percent of the cost of all health procedures, if you’re a low-income or elderly resident, it pays as much as 90 percent. The remaining 30 percent is covered by private health insurance.
The government is EXTREMELY good at negotiating prices. In other words, there are already examples of it working really well, so it's pretty clear it can work well here too with enough care.
Japan is known for really high-quality care that is insanely cheap and has more doctors per capita than in the USA. So the worry that overall service and competition would decline is unfounded.
So let's take really good working examples and try them here. The USA can do so much better, it's not even funny.
One issue that's talked about less frequently is how high US doctor incomes are compared to other countries. The average doctor in Japan made ~$105,000 USD [1] in 2014, whereas in the US the average primary care doctor made $195,000 and the average specialist made $284,000 [2]. Anecdotally, I had an eye infection in Mexico and was seen by an ophthalmologist the same day for an $8 consult fee and treated with antibiotics that cost $20, using the exact same techniques and equipment that would have cost me hundreds of dollars in the US.
We're paying our doctors sometimes double what they make in other countries and receiving inferior health outcomes. It's easy to vilify the AMA but our doctors also have an unusually high amount of risk and obligation when it comes to malpractice, which wouldn't go away if everyone magically was on Medicare For All tomorrow.
To reduce health care costs, someone needs to get squeezed... but who? Reducing doctor salaries will lead to a shortage of doctors unless there's some additional action on easing the education burden they presently have to take on.
The AMA most certainly needs to be vilified. It actively lobbied to limit the number of residency slots thus leading to doctor shortage and higher prices. It even indulged in price-fixing and opposed retail clinics that could offer competitive pricing.
I’d argue part of the cost of healthcare should be educating and training doctors. So there is control over number of doctors. Best way to reduce their salaries is increasing supply.
in the US, you are allowed to buy a ferrari or a geo.
in mexico, they only make geos. So prices reflect that.
in the US, you are only allowed to supply healthcare if you buy into $500,000 of loans and give up 6 years of your life. The AMA and government have mandated it to be so.
That's the price of a ferrari. US Medical salaries reflect that medical ferrari
High quality care in Japan? this claim is debunked when you see doctors dont spend more than 5 minutes with patients, barely do any tests before giving out medications by the dozen for most medical conditions. If that is high quality care it is seriously laughable.
==I'm interested to know why you think the government is incentivized to negotiate the best pricing for citizens.
I can think of two. First, so they can spend the money on other things they want (military, social security, education, etc.). Second, is so they can get re-elected by those same citizens.
==There is no way to tell if the price we are paying is at all good value for money compared to what it could cost.
We could look at the dozens of other developed countries who work like this, should give us some clues.
> I can think of two. First, so they can spend the money on other things they want (military, social security, education, etc.). Second, is so they can get re-elected by those same citizens.
Respectfully, is there any reason to think that the US government would actually do this, based on past behavior? Government spending is famously wasteful, both parties spend like it's going out of style when it aligns with their interests, government debt continues to explode, and spending continues to grow year-over-year effectively unchecked. I may just be overly cynical here, but I don't think that responsible spending is the primary election issue for hardly anyone today.
I don't think "frugal" fits the description of many or any of our lawmakers. With few exceptions, they all want either higher taxes or higher debt to pay for their favorite things.
Because HHS / CMS negotiates all of these rates I think it might be hard for voters to draw a path between rates / expenditures and their care, for the same reasons they fail to draw a line between their current insurer's negotiated rates and cost of care. A single negotiator will likely only make pricing more opaque, rather than less, so there will not be a strong incentive to perform better at the HHS level without transparency. Further, if Medicare for all is biased toward removing private plan competition there will be no incentive whatever for Medicare to be more efficient. Rate issues can be easily blamed on the providers.
==for the same reasons they fail to draw a line between their current insurer's negotiated rates and cost of care.==
Insurance companies are not subject to FOIA requests like the government. People tie Medicare to the Government, why would this be different?
==A single negotiator will likely only make pricing more opaque==
Not sure it's possible to be more opaque than today. All of the other country's who do it this way have far more transparent pricing than the US, so I'm not sure I buy this reasoning.
> Second, is so they can get re-elected by those same citizens.
American politicians are not elected by voters or citizens, they're elected by contributors. This unhinging is either a root or partial cause to many problems.
Sorry, that's total BS. Complain all you want about "campaign contributions", but the politicians absolutely are elected by voters on Election Day. The only thing contributors can do is try to change opinions by funding campaigns which goes to advertising. The final choice is made by the voters, and they are the ones ultimately to blame for the results.
That's fantastic, are they also to blame for the duopoly of political parties in America? Because the way our system is set up, first past the post, it is almost guaranteed. Are the voters to blame for the structure of our government which was written 250 years ago?
Yes, they absolutely are. If they didn't like it, they would fight to have it changed. They've fought to have many other things changed, and various Constitutional Amendments have been passed as a result. Did you forget the 18th Amendment, which was passed because of a bunch of Temperance activists? (and then the 21st that was passed because the result was a disaster) The system is set up this way because the voters don't want to change it.
> They would fill the same role as existing insurers, but instead of multiple black boxes there would be one.
Because larger purchasers have more leverage to negotiate better discounts/bulk rates. When your choice is, "take the offer or you don't get any payment", you take the offer.
We know it works because we have examples. It is quite frustrating to see you not even try to go and get those examples. It only takes a simple google search.
Here are three good ones: the UK, Japan and Canada. All different systems, all providing medical care for much less cost than we do in the US.
Additionally, your reasoning is flawed at best. The government can legislate that providers can only charge $x for y service, which private actors cannot. 300 million+ people is a very large market to leave just because you are slipping on profits. There are many other levers a single payer who is the government can pull as well.
"The U.S. has higher prices for most health care services and prescription drugs, according to available internationally comparable data."
"While available data are limited to select services and drugs, we find that higher prices – more so than utilization – explain the United States’ high health spending relative to other high-income countries." [1]
Perhaps the US is closer to those other countries than you claim.
Why is it unsustainable? Japan can run a deficit indefinitely. It's the magic of owning your own currency. There is hardly any inflation in Japan despite this, and they are trying hard.
I was just in Japan, and I saw no shortage of children and young people while I was there. In fact, I saw far more children than I ever do in cities here in the US.
The difference over there is that kids are born into families that are at least middle-class, while here in the US a huge number of children are born in poverty and raised by single parents. I don't think having a higher birthrate is going to turn out well in the long run when that's the case, compared to a country where children have a much better upbringing.
In Japan, they have to worry about the younger generations supporting the elderly.
In the US, we have to worry about the productive generations (the ones of working age) supporting both the elderly AND all the children and families in poverty and not having that bite us in the ass when those kids become adults (e.g., committing crimes, something that Japan doesn't have much trouble with).
" I was just in Japan, and I saw no shortage of children and young people while I was there. In fact, I saw far more children than I ever do in cities here in the US."
I would prefer to trust actual stats compared to your powers of observation. In this case 1.4 births per female in Japan vs 1.8 in the US. +0.7% annual population for the US vs -0.2% for Japan.
The point is that the Japanese system isn't inherently flawed its dealing with the consequences of there being fewer working age people supporting a greater number of older individuals. This has nothing to do with your opinion on the relative social mores of the 2 countries.
You "were just in Japan and saw X or Y" is a pretty poor argument vs actually knowing a thing or two about Japan by living here for a long time. Being a tourist somewhere does not make you knowledgeable in any way to comment about whole country trends.
Downvotes indicate that Modern Monetary Theory is unpopular on HN. Interesting - i would have thought that this is an audience that would have been receptive to it.
If one argues in favor of "free market" solutions for healthcare, then one MUST argue in favor of pricing transparency. A functioning free market requires the open and honest sharing of price information for consumers to make informed choices.
Now, whether or not health care should operate under free market principles is a different discussion entirely. But the established powers seem to consistently fall back on the free market argument, but continue to keep pricing as opaque and complicated as possible.
The US has long ago abandoned free market healthcare. I don't know why people keep calling it that.
It's some bastard child of socialized medicine where the poor and old are covered mixed with gov mandated private insurance coming from a few very large insurance companies capable of operating within the regulatory environment.
Which is basically one step removed from full blown single-payer public health insurance (as we have here in Canada) and about a hundred steps removed from "free market" health care.
I hope the US gov decides on single payer soon as I see no path towards going back to an actual market. Which would be better than the current system which features much of the worst of both worlds.
US health-care costs are out of this world. However, for the life of me I cannot begin to comprehend why every Canadian keeps using our healthcare system as example of success when incidents like these are becoming more and more common
It’s always lesser of evils when you’re dealing with critical gov services.
If you can’t provide a better alternative then it’s still an improvement.
The much larger UK NHS system where even hospitals are publicly run would be even harder to pull off in America. So single payer insurance is basically the lowest hurdle. Plus the simpler the better.
At some point the right in the US has to concede on healthcare because it’s already been gutted and killed by a thousand cuts. And I say that as a libertarian leaning person. You can’t honestly believe they can solve this problem by writing a thousand more small reform bills.
Plus if you give the mob public healthcare they will be much more tolerant of pro-economy policies and take a strong argument away from the people who want to gut even more industries so they function just as poorly as the pseudo healthcare market in the name of “fairness” and “equity” (mediocrity for all!). Lesser of evils.
I've been saying this for years. The only way that our healthcare is truly capitalistic is that someone makes a profit. When I got appendicitis a few months ago, it's not like I went on Yelp and searched for the best prices and and reviews; I went to the hospital that was closest, and prayed that it was covered by my insurance.
"The US has long ago abandoned free market healthcare."
Not true. Like literally every sector of a mixed economy, there is government interference. And sure, there is a lot more in the healthcare industry than most. But it does operate as a highly regulated market system wherein private enterprises compete and consumers make decisions.
And certainly it is not strictly "free market", but then again nothing is.
Competitors are tightly controlled, thus someone hiding their prices isn't easily supplanted by someone who is revealing them. A free market solution would be to let anyone choose to hide their prices but to not protect their market share from more customer friendly competitors.
The existing system is nothing like a free market and anyone trying to justify keeping things the way they are with that reasoning is either being intentionally dishonest or is completely naive about the situation.
>If one argues in favor of "free market" solutions for healthcare, then one MUST argue in favor of pricing transparency.
Indeed. And generally there is an enormous difference between "pro business" and "pro free market". In many cases they are the opposite. For example the information asymmetry you point out. Another is lack of enforcement of anti-trust.
Heaven help consumers and employees who live in the wrong one.
I don't think mandates can solve price transparency. I think in order for price transparency to happen we need to eliminate employer-provided insurance, and have insurance companies competing directly for consumers. Eliminating minimum coverage mandates could also help by allowing companies to compete on different levels of coverage.
Additionally, patents and the onerous burden of the FDA need to be reduced to encourage competition.
Why do you doubt mandates could solve price transparency? If you make the mandate correctly (e.g. “default price is $0, any other price must be disclosed upfront”) it would IMO cause complete price transparency pretty quickly...
How would eliminating employer insurance provide pricing transparency? Insurance companies don't typically disclose the prices they negotiate. They might disclose the prices a consumer pays but don't confuse this with the cost of healthcare. For an example say two options for a medical service have different cost. One charges $5000 and the other charges $8000. Say the insurance covers all but $500 no matter which choice is made. A consumer typically would only see the cost to them which is $500 and not the $3000 difference between the cost of the same service depending on provider.
I've noticed the more stridently someone identifies as a "free market" proponent, the more they seem to push back against the basic principals of a well-functioning free market.
> If one argues in favor of "free market" solutions for healthcare, then one MUST argue in favor of pricing transparency.
Absolutely not.
> A functioning free market requires the open and honest sharing of price information for consumers to make informed choices.
A free market does not require any of this. In a free market the producer can do whatever they want, in a free market the consumer is free to choose different options if given producer does not adhere to their personal standards thus driving other providers to either change their behavior or just losing business. A free market does not require a government ruling them to adhere to some business practices. That is regulation and not a free market.
In theory, no, but in practice market failure is usually due to information asymmetry and consolidation. The real world is, unfortunately, not full of that economists call "perfect competitors".
> in a free market the consumer is free to choose different options if given producer does not adhere to their personal standards
This requires information symmetry -- per Wikipedia, a free market is "a system in which the prices for goods and services are determined by the open market". How can the this work if pricing information isn't available to one side of the market?
> A free market does not require a government ruling them to adhere to some business practices
Free markets in practice require legal guardrails around things such as information symmetry and anticompetitive behavior, in order to protect against market failure. Again, per Wikipedia: "[free markets] require a framework that allows new market entrants".
This regulation is not for its own sake, but _to keep a market free (i.e., open to competition) by protecting it from the grasp of one extremely powerful entity going forward_.
You are incorrect. For a theoretical free market to exist, there must be perfect information. Otherwise, the optimal equilibrium points wouldn't be reached and so it would not be a free market, it would be a market failure.
I have good health insurance but recently my insurance declined payment for a lab test on grounds it was experimental. Turns out the insurance company was on solid grounds. At this point I was on the hook for the lab fees. But here’s the interesting part: because the insurance declined payment, negotiated rates no longer apply. This means the lab gets to charge me list price. The list price is a random high price that has no relation whatsoever to reality. In my case I was charged 3x the negotiated price! This executive order helps people in my situation—you can argue that the list price is unreasonable and that the negotiated price is all you should have to pay (even though you were not party to the negotiation).
This executive order is also useful for uninsured patients because you now have a basis for arguing for a lower bill. And the courts would be sympathetic because everyone knows list prices are random numbers!
I ran into a similarly infuriating issue with a hospital.
We have insurance. But we knew the procedure wasn't covered by insurance. So we would get the list price. We asked about the cash price. But they said we couldn't get the cash price because we have insurance.
They said that you cannot get the cash price if you have insurance because the hospital requires procedures always go through insurance if you have it. But we could lie and claim we don't have insurance. On the day of the procedure, they said, oh, if we bill it like this, your insurance would cover it! Sounded good to us.
They were wrong. So we ended up with the list price.
Most times its not definitive if the insurance will cover a procedure until after. I know for myself there is a fairly "cosmetic" produce I want, but no matter which surgeon or insurance I have I can't get an answer from either that isn't basically, "do the procedure and after it will be determined if its covered". While the procedure isn't life threatening it definitely would be quality of life improving. Unfortunately, its generally considered cosmetic, at least until later in life where the side effects of not having the procedure can become life threatening.
Your only choice is to change your employer or decline your employer provided insurance if you wanted to join an network that's receptive of your tests.
Just because InsCo1 treats a lab test as experimental does not mean InsCo2 treats the same lab test as experimental.
In your last sentence though, you seem to assume publicly listing prices would lead to a lower bill
If you are uninsured and receive a medical bill, unless the price was agreed upon before the medical procedure, you can go to court to argue that the bill is not fair or reasonable. List prices are random numbers. Having access to the actual prices paid by insurance companies helps you make your case in court as to what a realistic price should be.
> Having access to the actual prices paid by insurance companies helps you make your case in court as to what a realistic price should be
That's not public information. Even if that was available, that's useless.
Realistic price does not matter at all unless we are talking millions of dollars. Being in network or not does.
Let me explain why:
Have you been to court on this matter? I am interested in what your experience was.
Here is mine: the judge was tired from the previous case and really did not care what I nor the ambulance provider thought.
To her we were just sqabbling over prices: The ambulance provider wanted way more ($6k vs $600) than I thought was reasonable and I felt I had been taken advantage of when I was most vulnerable and it was not a honest way to make a living and we should not encourage it.
The judge had no interest in how I felt: it was all a matter of how to get us out both quickly and have the next hearing.
The ambulance provider said their 2 mile trip to the ER was worth $6k because blah blah blah.
Then I presented.
I had printouts that showed that ambulance providers that were in network with my plan typically charged $550 for the same exact service with the same level of staff in the ambulance.
I was hopeful that showing this and that there was no in network ambulance providers within a reasonable distance where I was injured would help me.
Nope.
I also said it was pretty unethical for the ambulance provider to have a business plan where they would be out of network by design with all insurance companies as way to extract as much as they could from people in distress.
I was with Anthem Blue Cross - they are a pretty big company, no small fish.
This ambulance provider clearly puts it on their website and all paperwork that they explicitly don't work with insurance companies because they don't get paid a fair price.
The judge asked me if I had signed the paperwork that said I would bear all expenses before I got into the ambulance.
I said yes.
Then she asked how much money I made and what payment plan I would be able to afford.
Maybe if the ambulance charged me a million dollars, then I could try with the "bill is not fair or reasonable" story, but I had the feeling the ambulance could have charged me $10k and I would have had to pay it because I'm a highly compensated individual in the top 1% income bracket in the country so I deserve to pay more.
I now always carry blankets and bags in my car so I can cover myself if I am bleeding and get into a taxi or Uber/Lyft/etc, without getting blood on the seat, to the nearest hospital if I can.
You could have refused to pay and offered them the original price or threatened to sue which you can do without benefit of a lawyer. The act of litigating it would almost certainly be higher than any differential.
That’s what I did after a surgical center told me that they spoke with my insurance company and everything was fine only to later send me a bill for $150,000 for a 1hr surgery to fix a broken hand. How are you supposed to deal with in-network / out of network hospitals when you have a bone coming through your hand? It eventually went away because balance billing was made illegal in california.
Simply refusing to pay or ignoring the bill results in the bill being sent to collection and your credit will be impacted. The only thing the lab was willing to do was to put me on a payment plan.
In the end I didn’t pay a penny. I have good insurance so if they declined payment that must be for a good reason. So I researched that angle. It turned out that the test the doctor ordered was FDA approved, but not as a cancer screen, which is what the doctor ordered it for. I threatened to sue the doctor for malpractice, and she worked with the manufacturer of the test and the lab and made the bill go away. The manufacturer was pushing the test as a cancer screen, but the doctor should have checked if it was FDA approved as a cancer screen.
This will help but until health insurance and healthcare is disconnected from employer provided, and instead consumer focused, the pricing will continue to be shrouded and fixed.
Healthcare and health insurance should almost be separate but should not be tied to a workplace. Disconnecting health insurance from work benefits in favor of payment will help the private market and public market pricing, whichever or a combination of both that it eventually goes.
Healthcare that is consumer focused and disconnected from employer provided:
- will have to be price transparent
- will make starting a business easier
- will make the US more business competitive as companies in other countries don't have to provide it
- will allow people to change jobs more easily
- will make ageism less of an issue
- will get companies out of your private health
- will allow bigger grouping by insurance companies across the nation not at the job level (right now small/medium/family/individual private insurance is seen as more risky because private insurance groups by employer and smaller is more risky)
Health insurance is personal and shouldn't be known by your employer, and re-signing up every year and anytime you get a new job is tedious, it needs to be like all other insurance (auto, home, life mostly) that it is a personal consumer choice and private.
Unbinding and de-coupling healthcare from the job is pro-business and pro-consumer health and will lead to true market price transparency.
I'm loving this. I shop around for my healthcare needs and it's very difficult to get a quote of any kind for any service. This will increase transparency and competition and that will hopefully lower prices.
That's kind of cool, though the devil is in the details and I'm not sure about the details for this case.
Essentially, free market relies on certain assumptions under which the supply/demand 'invisible hand' works properly and the benefits of free market are realized - the key economics 101 assumptions are (1) large amount of both suppliers and buyers; (2) small barriers of entry and exit; and (3) full and truthful information about market conditions. The further we get from these assumptions, the less free (and usually worse for the people) the market becomes, and often we need gov't intervention to ensure that these assumptions stay true and the market behavior stays close to theoretical free market instead of degenerating into an exploitative uncompetitive monopolistic market with hidden information - as the USA medical market is doing, and seems to need such intervention.
People I know who have worked in commercial aviation have claimed that it takes more paperwork to put a bolt on a plane than into a human body. While this may or may not be true, commercial aviation is a counter example of a tightly regulated industry that very much a free market that challenges your assumption that regulation alone are the reason for issues in healthcare.
Some regulation is key, like HIPPA or the drug approval process, or the lack of approval of medical devices leading to issues. We will never have a loosely regulated healthcare industry if we want privacy and safety for patients.
Whatever the system, the goal should be cost effective betterment of public health.
> The healthcare market isn't even close to free, it's the most tightly regulated industry. Until that changes, nothing will get better.
Agreed. I feel like people just like using the "socialism will solve everything" argument while not acknowledging that right or wrong - healthcare in the USA is anything but free market.
(4) buyers capable of making informed decisions (a) several nearby hospitals (b) enough expertise or impartial advice (c) not in an emergency situation, in pain, unconscious, intoxicated or otherwise unable to make good decisions (d) in a position where the price matters - not too poor, not too rich.
Since much of the above is not true in real life, a patient centered market for Healthcare does not work well.
The overwhelming majority of healthcare dollars are not spent in emergency situations. If you decide to go to the doctor because of some pain in your neck that's not an emergency decision. If the doctor tells you to get tests that's not an emergency decision, etc, etc.
You can go from healthy to cancer to treatment to more cancer (wash rinse repeat until you or the cancer is dead) without a single decision made under any meaningful time pressure.
And the guy who goes to the ER with a serious heart problem gets admitted and leaves bankrupt? Seems important to avoid that. Even for the cancer - you're in the most stressful situation of your life, you want to evaluate prices? What about your vulnerable grampa?
In the UK, where I'm originally from, I've never met anyone who wishes they had a role in evaluating healthcare pricing. In the US, I personally don't either.
I know larger cities are the norm but everyone else is acting like everyone has a choice. My town has an urgent care center and a hospital that serves the entire county. The next nearest hospital is two hours away. Even then we still have people Life Flighted out to Spokane on a regular basis from both hospitals.
All transparency will do is put a number in front of my single choice.
This would allow you to choose your insurer based on rates and copays for common treatments - that could be a win even if there is only a single provider.
Furthermore, if other competing providers see room to compete on price because of transparency you might actually get more providers.
If your employer is of smaller size, they will have greater leverage to match rates with larger plans because of transparency which could help you a great deal. Further, your company could have leverage with their insurance broker to provide better pricing / options based on public data.
If you cared enough, it might influence your choice of employer. Also some employers offer plans from multiple insurers. At my current employer I can choose between a Kaiser HMO and a Cigna PPO.
Even in the high demand field of software engineering the vast majority of people don't have the option to choose between multiple jobs to take. You take what you can get. Not unlike healthcare in which you usually have no say in what healthcare you get when you need it.
I don't think this is true for non immediate care though. If you had something that needed to be done in a number of weeks would you be willing to to to a different hospital to save.. a couple hundred? A couple thousand?
Depends. I can travel to another city, but do I go home to recover after a multi-hour car ride or do I recover in that city? If I have an issue post operation does my home city have the resources to handle it? Who's going to drive me if I need a driver?
The only argument I've heard that this is harmful comes from self-interested industry groups saying, in essence, "we make more money if patients are uninformed." That settles it for me.
This is awesome. I'm sure he will be opposed by congress, as they get a ton of money dumped in their pockets by pharma and insurance companies. Might be the first time I'll be on his side lol.
Great use of an executive order, the executive branch is so big that having no directives from the CEO is an odd way to run an organization that large
Overwhelming even
I dont think the constitution envisioned how big of an organization the executive branch is, all with independent sweeping rule making autonomy. Only industry enthusiasts know the specifics of one agency’s depth of rules. Someone elected by the people for totally unrelated reasons has no way of knowing everything these agencies are influencing
Is it though? I totally support the idea of the action, but it really feels like it should have come from congress. They are supposed to be the law makers. It feels like everytime congress fails, and we have to resort to executive actions to do every day legislation more power is being ceded to the executive branch.
The president is not a CEO; the executive branch is not a corporation. [0] Moreover, the executive branch does not need to be "run" from the top; instead, it operates in a distributed and semi-autonomous fashion. Think not of the Cartesian brain, but the octopus.
The Constitution outlines specific responsibilities of the President in Article Two. [1] Those responsibilities:
* Command the armed forces
* Have a Cabinet (have the heads of subbranches as direct reports)
* Conduct foreign diplomacy
* Give State-of-the-Union addresses
* Not be bad at carrying out the will of the law; "faithfully execute" whatever the law tells them to do
* Get impeached if Congress says so
There are some things that the President is enabled to do at a whim, but they are not as broad as you'd think:
* Issue pardons
* Appoint judges, diplomats, etc. with Congress's approval
* Call special sessions of Congress
I agree that, in order to be aware of the full nature of the law, the President needs to be surrounded with legal professionals who can advise them on how to not violate the law. But, in Article Two, it's clearly spelled out that the President should have a Cabinet in order to delegate day-to-day responsibilities further.
Finally, as a reminder, the President wasn't supposed to be chosen by the people, but by the Electoral College. [2] The Presidency should not be a popularity contest.
The president is, literally, the chief executive officer of the US government. He holds an office under the United States, and that office is executive in nature, and it is not subordinate to any other office.
You obviously are not familiar with the USA's Constitution. Please re-read it. In particular, Article Two, Section Four; "The President, Vice President and all civil Officers of the United States, shall be removed from Office on Impeachment for, and Conviction of, Treason, Bribery, or other high Crimes and Misdemeanors." This means that the President may be removed from office in certain circumstances.
In the time when the Constitution was framed, and in many times since, there is the meme of "checks and balances". [0] The overall idea is that no one branch of the Federal powers may be unilaterally or universally unabridged in its ability to act; other branches have powers which may check, veto, review, or otherwise neutralize certain actions.
So, why is the President sometimes called "chief"? Because, as Article Two also states, they are the "Commander in Chief" of the armed forces. When it comes to military decisions, yes, there is no office above the President's; however, note that the President's military powers are neither unilateral nor unlimited. Crucially, the President isn't able to declare war or allocate funds for military use without Congress' approval.
Hope this was informative. The USA's Constitution is a fascinating document worth reading, even for those not from the USA.
>The Presidency should not be a popularity contest.
Correct. Well, I mean, popular among the states, but not the people individually. I'm stunned how this is a difficult concept for people. I'd bet the people arguing for popular vote would change their mind in a hot second if LA and NYC went red.
The whole union's representative model is bent over backwards to keep consensus with the south eastern US for reasons that have little relevance this century, but are impossible to change.
The electoral college is from when there were 800,000 free white males in all the original states (US 1790 census), and the union still felt like it needed Georgia and South Carolina to agree to be a part of this contract for strategic reasons. I wonder how many of them were literate land owners!
Is that relevant today? Is ANY of that relevant today? Many other countries looked at the electoral college over the last 250 years and saw how it was a strategic compromise masqueraded as a feature. They decided not to do it and stick with popularity contests.
DO other countries not use it because they are not a collection of geographically / culturally / and relatively-recently separate states that have united so there is little reason to adopt a system that fairly treats unique states in relation to a larger unified federal body?
The people vote in thier states, the states vote for the president. Without it, all 48 other states get railroaded by the 2 with the highest population. We have a representative democracy because that's not fair.
You may even think you want NYC and LA to pick the president every year, but you don't.
For reference [0] I think you're going to have a bad time if you tell the people outside of NYC and LA that their voice, concerns, representation is totally irrelevant. We don't have a perfect system, but we have one that's been working for 240-some years.
> We don't have a perfect system, but we have one that's been working for 240-some years.
What does that mean?
Just because we haven't had a military coup then our system is good enough and the should not be questioned?
I'm really curious what you and other people mean by that
You know people laugh at ours right? People laugh at our religion of checks and balances, since they don't accomplish that in the most optimal way. I'm not promoting any alternative, only pointing out that accepting its flaws is missing in the collective conscious in the US. Practically all attempts at democracy over the last 200 years contain patches seen as improvements over what the US created and mostly stuck with.
> For reference [0] I think you're going to have a bad time
Youre going to have to be more specific.
> if you tell the people outside of NYC and LA that their voice, concerns, representation is totally irrelevant.
Nobody is saying anyones representation is irrelevant.
But how is it fair that the vote of someone living in Wyoming weighs 3.5x that of someone in New York or California?
"Thats just the way it is" is not a counter-argument.
Electoral college votes are not weighted by population, 20% of the votes are divided evenly between states and the remainder is weighted by population.
There is nothing intrinsic to representative democracy that requires this particular arrangement and practically no other developed country uses a system like the electoral college.
Plenty of fair elections occur with popular votes in developed nations; Brexit is a whole separate can of idiocy and just obscures the debate here.
> Without it, all 48 other states get railroaded by the 2 with the highest population.
You're viewing things from the point of view of the states instead of the people. Either
- The states get railroaded because each person gets an equal vote, OR
- The people get railroaded because each state gets an equal vote.
> DO other countries not use it because they are not a collection of geographically / culturally / and relatively-recently separate states that have united so there is little reason to adopt a system that fairly treats unique states in relation to a larger unified federal body?
There are plenty of countries with proportionally representative/popular-vote (or at the very least, mixed-member PR) models that are culturally and geographically diverse. Germany is the best example that comes to mind.
> The people vote in thier states, the states vote for the president. Without it, all 48 other states get railroaded by the 2 with the highest population. We have a representative democracy because that's not fair.
The alternative was shown in 2016. Trump lost the popular vote by millions, but won in three smaller states by ultra-thin margins. So instead of California, Texas, Florida, and NY dominating Presidential elections, we have Iowa, Pennsylvania, and Michigan dominating them. Considering that small states are already dangerously overrepresented in the Senate, it seems reasonable to have the one truly national official elected by true popular vote.
> We have a representative democracy because that's not fair.
This is wrong on two fronts. First, we have a representative democracy because southern states essentially held the Constitutional Convention hostage. Second, the truly "representative" part of government is already sufficiently exhibited in Congress. If you want empty space to have power, you already have that in the Senate (and the House, in which small states are also over-represented).
Is the motivating idea behind this that patients can demand the same price that insurance companies are getting and ultimately lessen the monopoly insurance companies have? Maybe even just get much cheaper insurance for true emergencies and pay out of pocket for everything else?
Because you cannot save enough cash to be able to afford every worthwhile treatment through up-front payment. If you don't have $150k in cash and don't have insurance, you can't get chemotherapy and die a preventable death. With insurance, the worst case is paying your out of pocket maximum, getting treatment, and then declaring bankruptcy or otherwise fighting attempts to balance bill you for hundreds of thousands of dollars.
Your assumption of $150k for chemotherapy treatment is exaggerated, especially in light of Trump's executive order to try to get price transparency at the level of actual insurance reimbursement.
$25k/year over ten years is $250,000, and compounded at 6% is $319,000.
So yeah, I'd easily be able to self insure for anything.
Because negotiated prices aren't actually low for a good chunk of treatments - especially for the health conditions that someone paying $20k+/year already in premiums is more likely to contract.
I pay $25k/year for family insurance with high deductible, and no pre-existing conditions.
Negotiated prices paid by insurance actually are pretty good, but could be even better with the price transparency that will come about with Trump's executive order.
This is a really important goal, but whether simple mandates can solve it, I'm not sure. The real problem is that consumers don't care about the prices, which is how all the various layers of providers and middlemen are able to jack up all the prices without limit.
High deductibles are one way that consumers can be made to care, but obviously that has its own problems. Single-payer would not fix the problem by itself, either... although using monopsony power could certainly help, if executed competently.
Merging a single-payer approach with a high deductible approach could work, and the deductibles could actually be paid via a government-filled HSA account that one could rollover into a retirement or college savings account, if unspent.
> The real problem is that consumers don't care about the prices
I think this is a trope in multiple areas trying to pose personal accountability as a solution where one actually needs systematic solutions. You see it with the climate crisis (make sure to buy only 100% organic recycled meat), or student loans (make sure to choose a major that has a 20 year postivive ROI), and medical expenses (make sure to price out and choose the most cost performant cancer chemo cocktail).
Really we need working institutions and controls those institutions can impose because the markets for industrial processes, or educational funding, or heathcare are vastly complex products with large capital, time, knowledge commitments needed to adequately check misperformance. The investments needed far exceed most time or money resources that make sense for any one person can put into single transaction. That's why collective institutions are needed to focus on developing the specialized information and policy needed to manage the poorly performing systems.
The economy is the sum of individual actions, which are all guided by incentives. Set up poor incentives, and each individual poor decision might not matter too much, but the collective result can be awful.
The idea that we ought to throw our trust in with bureaucrats is kind of ridiculous, particularly in the age of Trump.
But even if this were Scandinavia, incentives would still matter.
I’m not sure it’s a lack of “care” and more a lack of ability to take action.
If I have a broken arm I’m not going to price comparison shop amongst hospitals.
Anecdote: I attempted to comparison shop for an mri to diagnosis a potential rotator cuff injury. While I could get the actual scan fees I couldn’t get the fully burdened cost and during the visit it’s entirely opaque what things will be new line items on the bill.
And if you're taken in to the ER, you're possibly not even ABLE to consent to charges. You're at the whim of the hospital staff!
Did you know they charge for 'chaplain time' for having a chaplain stop by and say hi (you don't get to say yes or no, and this is obviously not medically necessary)?
Emergency care accounts for about 2% of total healthcare expenses. The issue you bring up about consent during an emergency is a real one, but it's not where all the money is going.
Note that your article cites at least 1 other study that says 5-6% or even as high as 10%. It would be interesting to see a breakdown here - does this include prescription medication? It seems like if you're talking about provider regulation, you shouldn't include that.
Unfortunately the article doesn't make it easy to figure this out.
Even assuming that the 10% number is the right one, it still seems good enough in my book if, in the beginning, only 90% of the expenses get addressed successfully.
While urgent care is a significant part of total medical expenses, it's not that large part - the vast majority of really expensive procedures are scheduled well in advance, and doing price comparison would be quite feasible if the institutions would allow that.
That's the "if institutions would allow that" part. Or, more accurately, if institutions would get legally forced to allow that. We didn't get price transparency and limits for ridiculously lying advertising in other consumer markets just by sheer goodwill of merchants, it required legal mandate and enforcement of it.
> If I have a broken arm I’m not going to price comparison shop amongst hospitals.
This gets mentioned in every healthcare thread. With transparent pricing we'll soon know which hospital costs 3x of the other, so we (or beforehand or family) can decide which one to go to for treatment.
This is a very urban/suburban mindset. There is a not insignificant portion of the population that has no choice and the one place they can get medical care is already over an hour away.
Most folks are moving to cities, the portion you mention is small and getting smaller.
Don't let perfect be the enemy of the good. People can make their own decisions. There is no ethical position for keeping pricing information secret. Just because one can imagine a rare scenario where it wouldn't be useful is hardly a reason to continue hiding it.
While true, 20% of a large number is still a large number. It's easy to disregard these people, but they should not be disregarded. They have suffered directly due to the privatization of hospitals and the requirement to satisfy stockholders.
Also, I'm not against price transparency, but I'm highly skeptical that it will improve anything. The reasons should be quite apparent but price setters will settle on or near the highest prices since everyone in the system is incentivized to do so. It also doesn't solve the problem that many people pay a $N copay noatter what the price is due to insurance. And the third issue is the in and out of network problem.
When you consider all these, along with the lack of choice for pretty much everyone, it isn't going to change anything.
Nobody wants to "disregard" rural patients. Rural patients would also like to know the price they'll be charged after driving 1.5 hours. Often we have a choice among several faraway towns to which we could drive. We've made our peace with the fact that living in the sticks requires driving further.
This argument is too dumb to qualify as sophistry.
From your anecdote you indicate that people will comparison shop among hospitals but are unable to do so. I have a similar story about a broken ankle where I couldn't even get an estimate for an X-ray and a cast.
According to DHS head (as heard on NPR this morning), something like 70% of hospital visits are non-emergency, meaning that people can at least exercise more cost comparison on those bases. But I think people already largely do that, by way of ensuring the provider they use is part of their insurance's network; after coverage, cost differences are pretty small (what's the difference between 10% of $5000 and 10% of $6000?).
The real issue is when people don't have coverage or when their insurance denies it. The latter is hopefully mitigated by Obamacare's "no pre-existing condition" exclusion. The former happening is pretty obvious: people can't afford it and their employers don't provide it (single-payer would help with this). Alternatively, some people just need _a lot_ of health care, and 10% of a million dollars is still a lot of fucking money.
But if you need the health care, what are you supposed to do? That's what we mean when we say "people don't care about prices". The prices aren't going to change that much because of this legislation. The real issues are 1) not everyone is paying into the insurance pool 2) there's a needless layer of gamesmanship between insurance and providers and 3) providers and insurance are working on a profit motive.
To fix healthcare: 1) Put everyone in the pool via taxation (aka single-payer), 2) Move healthcare to public or non-profit with lots of oversight to prevent fraud.
>People complain about 20U$S copays on doctor visits that bill 400U$S to insurance.
Well if that’s the case...it’s because the $400 bill isn’t the real cost for the service and insurance actually pays $0 of the bilked $400.
What happens is the patient pays $20 copay gets billed ~20% of the $400, or $80...then everyone but the patient is happy, Dr. gets his $100 for the visit and gets a $300 tax deduction, the insurance gets its premiums from the patient and gets their 80% waived by the provider effectively shifting 100% of the cost to the patient while still being able to account for the 80/20 split on the books.
Unless there's a weird provision I'm not aware of, you could be over representing the value of the deduction.
The best thing for the doctor is to get paid (and pay taxes on) $400. The $300 deduction is of no value to them because they never recognized the $300 as income. The deduction is basically "Hey, sorry you couldn't collect your billed amount. You don't need to pay taxes on money you didn't earn".
Sorry if you fully understand this already. The lack of understanding of basic taxes is a pet peeve of mine. People make statements like "Johnny was looking for one more tax deduction, so he donated to my charity". Johnny probably cares about the charity or at least looking good in the community, because he'd have a larger net worth if he just sucked it up and paid taxes rather than donating it.
>The best thing for the doctor is to get paid (and pay taxes on) $400.
No...the best thing is for the doctor to not upset the insurance company and get dropped from their network and lose all their patients.
Remember the famous line if you like your insurance/doctor you can keep your insurance/doctor. Turns out the president has no control over whether insurance will outright drop doctors from their networks.
As to your point on accounting, it simply depends on the doctors/hospitals accounting practices. It’s possible there is no deduction as you say (no big deal to the doctor, they got paid their fee anyway) or they can use an actual method of accounting and carry the loss forward.
In fact you may be understating it a bit. If the doctor uses cash accounting, then it's not that the $300 deduction is of no value, there is no $300 tax deduction.
As you point out, a cash basis taxpayer pays taxes on actual income received. Money you may have hoped to receive but didn't isn't income, so there is no tax and no deduction related to it.
If the doctor filed taxes using the accrual accounting method it would be different.
As I mention to a number of other comments...it simply depends on the accounting method.
It can be waived (not treated as income at all as you say) or it can be treated as income (taxes paid) and the loss carried forward for future deduction.
> Johnny probably cares about the charity or at least looking good in the community, because he'd have a larger net worth if he just sucked it up and paid taxes rather than donating it.
You are assuming that Johnny isn't the one that doesn't understand tax deductions.
The only way the doctor would get a $300 deduction is if they use accrual accounting and had already reported the $400 as taxable income. It's isn't a free deduction that comes out of nowhere.
With accrual, you report income when you bill for it, not when you receive it. Suppose you treat a patient on December 31 and bill the insurance $400 on same day. You report the $400 as income and pay taxes for the entire $400 in that year.
The next year, insurance only pays $100, so now you have a $300 loss to report in the new year. But you only have this loss because you've already reported the $300 as income.
If the doctor uses cash accounting, there would not be a $400 income entry on December. There wouldn't be any income to report until they are actually paid, and then the income is the actual amount they are paid, $100.
There is no opportunity cost deduction. Unless the doctor can show that he is losing money (amortized cost of office/staff overhead etc) on that $100 service, there is no deduction. They can't arbitrarily say they sell their services for a certain amount and deduct when they don't reach that amount.
If you have a widget that cost $50 to make/market/sell and you sell it for $100, then have a "sale" or "friends and family" discount to $60, you don't get to write $40 off your taxes. If you sold it for $40 you could write the $10 loss off of your taxes.
Just to add one more note to this lengthy thread... :-)
> Dr. gets his $100 for the visit and gets a $300 tax deduction
I think that is the phrase all of us have been jumping on. What you wrote there is simply not true. There is no scenario, regardless of whether the doctor uses cash or accrual accounting, where they get $100 for the visit and a $300 tax deduction.
There are three possible situations here:
1. Doctor uses cash accounting. The $400 invoice is not a taxable transaction. Doctor gets paid $100, reports it as income in the year it is paid, and that's that. There is no $300 deduction.
2. Doctor uses accrual accounting and is paid the same year. They report $400 of income along with a $300 loss in that year. Net income is $100, and doctor pays taxes on the $100 income. Their tax for this transaction is exactly the same as if they had used cash accounting.
3. Doctor uses accrual accounting and is paid in a subsequent year. They report $400 of income in the first year and pay taxes on the entire $400. Then, in the year they get paid, they report a $300 loss, because they were only paid $100 out of the $400 they previously declared as income. The only reason this $300 loss exists is that they already reported the entire $400 as income in the previous year and paid taxes on it. They aren't getting $100 income and a $300 deduction, they got $400 income in one year and a $300 deduction in a subsequent year.
As you mentioned in another comment, there may be reasons why a doctor would want to do this. Perhaps they just started their practice and are in a lower income bracket this year but expect to be in a higher bracket next year. In that situation the accrual method may help balance their income across those two years: they can pay taxes on the accrued (billed) income in the year that their tax rate is lower, and then take the loss in the next year at a higher tax bracket.
There may be other reasons to do this as well, but none of them change the fact that accrual accounting would mean they reported $400 in income along with the $300 loss, whichever years those happen to be.
It's not $100 in income combined with a $300 deduction, whichever way you account for it.
There is certainly a difference between a list price and a negotiated rate, but there isn't some sort of secret "we'll tell the patient in writing we're paying $400, but actually we'll pay you nothing" rate.
That’s insurance based healthcare in a nutshell. Insurance doesn’t negotiate just rates but the actual reimbursements.
The real fraud is the fact that insurance companies have been buying up health care practices/hospital systems and dropping all other providers from their networks and forcing the patients to go to the insurance owned providers (often times unbeknownst to the patients). Although there have been a couple successful large class actions by both doctors (who got dropped) and patients as well, but this hasn’t changed anything in practice just provided a little hush money.
I dont think that deduction idea makes sense. You would have had to actually report the income of the 400, pay taxes on that, and then deduct the next year. Unless there is trickery involved I'm not savvy of.
That’s exactly how it’s done under accrued accounting. And in health care paying taxes on uncollected Billings and carrying the loses forward can make a lot of financial sense.
> gets their 80% waived by the provider effectively shifting 100% of the cost to the patient while still being able to account for the 80/20 split on the books
On a macro scale, healthcare prices are a huge issue. On a micro scale, healthcare prices are a non-issue.
Perhaps the latter is part of what leads to the former, and perhaps full disclosure will change things, but generally there has been no point in even trying to shop around based on price, since there are no good options and very little information about prices.
What is the “micro scale” you’re referring to where healthcare prices are a non-issue? Medical bankruptcies are a pretty conspicuous problem in the United States.
I'm sick, I need to go to the doctor. In the USA, good luck figuring out how the price of anything in any way should affect the choices one makes at that moment.
Is there a difference between going to the CareNow clinic near my house or the Code3ER near my house? I have no idea. Should I go to a hospital instead? Is that cheaper or more expensive? I have no idea. Once I get there, are things going to cost me more or less depending on which arbitrary doctor I end up with? I have no idea. If they order further tests or a consult with someone else or some medicine I've never heard of, do I have the ability there to ask questions about price? No, I've tried. Doctors genuinely seem to have no idea whatsoever what things cost, by and large.
So at that scale, not the big picture but the individual scale, prices don't matter because if they did, I'd just stay home and hope I live through whatever ails me. Which is often what I do, in fact.
I hope forcing publication of prices makes a difference. I'm suspicious that companies will find a way to do so that protects their profits, but hey, I'm hopeful.
As for the physicians and pricing - I have some sympathy there. First, I'm happy that they are not making medical decisions based on overall price but instead based on risk. This seems to be the best way to treat me the patient and not me the line item.
That said, they also have to deal with liability (especially in an ER) so they have to treat any POSSIBLE thing that you might have before you leave since people often arrive with zero medical history and they have to rule out side effect things that may not be an issue. Further, the fact that their physicians often deal with advanced specialities and/or emergency medicine means you're paying for a specialty for something that could be simple. I try to stay out of ERs unless I'm worried about my life and instead use urgent care / clinic visits when my GP is not available. Their billing seems to be much more consistent, anyway, and there's less risk a physician won't be covered by your insurance just happening to stop by.
They are there but you more than likely don’t know anyone personally that has done it. Most people have insurance via group plans and don’t get that sick, it is the outliers that have huge problems. That is what makes the problem so hard to get people fired up about.
I have done that and seen all of those. I'm thinking at the systemic level. If everyone had to care about prices, then there would be more demand for transparency, and more competition in pricing, which would help even those who are unable or unwilling to price shop.
I also bring up single-payer in a related way because the need to find in-network providers within reasonable distance often is such a limiting factor that price shopping isn't possible.
With single-payer, one could actually choose between all of the providers... in addition to other benefits.
There are websites like ZocDoc which are like yelp for doctors, but they can only do so much because of the lack of price transparency, and lack of ability of consumers to choose doctors out of network.
There are some markets where price shopping is possible and does happen. For instance, LASIK prices plummeted as a result of competition and price shopping.
There could be many more, if not for various policies that impede this.
I think LASIK is probably closer to cosmetic surgery than "healthcare", at least as far as most of this discussion is concerned. If your arm is broken you can't really shop around.
It takes like 5 minutes, max, to shop around for a pizza. You can easily pull up prices, reviews, and so on.
If price transparency and quality comparison were made easily accessible, and one could actually choose options regardless of considerations like "in-network," then it would be entirely conceivable that the majority of medical procedures would involve price shopping.
And such shopping around based on price and quality would improve things even for those who do not price shop. Feeling the pressure of market discipline would force providers to compete on quality and price.
There are sites that try to be like yelp for healthcare, but you ultimately don't have any price transparency, not every doctor is listed, and you have to navigate a maze of insurance categories. In a saner world, we would have better transparency in healthcare than pizza delivery.
My employer’s healthcare plan includes Castlight. It’s a mobile app that shows nearby in-network providers. If I need a procedure, I can search for that and get average prices.
Dentistry is also like this. Lots of people have some dental insurance, but it doesn't cover enough of the really costly procedures to make most patients ignore costs.
I think this is it. Imho, you essentially have two populations of patients: those with good enough jobs to have good enough insurance that their fairly price insensitive in most cases, and those who are under-employed and/or under-insured who know going in they can't afford to pay for service regardless. Neither of these groups are particularly invested in effecting change to the status quo. On the flip side, though, there is a large population in the middle where price matters a lot ... but imho these voters are overwhelmed in their PR efforts by the big spenders at the top, and the under-insured are effectively disenfranchised anyway, so their voice doesn't matter much (Medicare/Medicaid & VA services are the exception here).
This order is about disclosing the prices that consumer pay (co-pays/co-insurance), not the total price with insurance reimbursement. Essentially it would force every clinic to be like Kaiser and MinuteClinic who tell you upfront how much you need to pay for the visit so there's no hidden fees.
HDHPs are rampant now. I have a $6500 deductible. It's absolutely miserable. I dump all the money I can into my HSA every year and inevitably I spend it all. The magic benefits of HSA as an investment vehicle for retirement or college are vastly overstated. Yes, if you basically never go to the doctor, it might work. Go to the ER or urgent care once a year and you're done. (Further, your investment options and the fees thereof are controlled by your employer's HSA servicer, and tend to suck.) Whenever I have a medical issue, I personally try to just suck it up and wait it out, because just to see a nurse practitioner to see is $150, let alone if they have to do anything. Every time my kids get sick I also have to make the same type of decision: is it worth it? This is an absolutely miserable place to be in, but this is exactly what HDHP proponents think is a great idea.
Meanwhile, my total annual premium cost is still > 20k.
I absolutely do care about prices (which doesn't matter right now, nobody will tell you what they are), and so does everyone I know, most of whom are on these same plans. The only people I know who aren't are unionized. But I have no way of finding out what they are beforehand. I don't even think this mandate will help. Yeah, sure, now the hospital posts the price - but what about the other dozen providers that involve themselves in a single procedure?
For example, my wife underwent a routine procedure a few months ago. I am still receiving bills from different providers. So far I'm at 7. Never mind trying to even audit them to see if they really did anything!
At the same time, do we really want health care to be under intense price pressures? I'm not so sure. I imagine the medical bureaucracy will continue to expand unimpeded while actual quality of care will go down. That's what I already see happening as a result of cost-cutting.
Some cruel reality: you need to ration healthcare to reduce spending significantly. The iron triangle of healthcare: Quality, Access, Cost.
That said, there are definite things that increase the cost disproportionately, and the way the government subsidizes insurance through an employer makes a major disconnect between patients and providers. If the subsidy were eliminated and insurance untied to employer you would have a huge step in the direction of unleashing market forces.
The cruel reality appears to be that you ration health care without reducing spending, because medical administration and bureaucratic costs eat the savings and more.
Untying insurance from employment is a great idea, but it won't solve this. With HDHPs being so common the 'disconnect' between providers and patients is already not a real thing. Neither will single payer fix the underlying problem, although at least individuals will be better off.
At any rate, entrusting laymen to understand when they should and should not seek emergency medical attention means that people will die through entirely preventable causes in an attempt to ration their health care spending. Your cure sounds worse than the disease.
There are no effective market forces you can 'unleash' in the case of health care. It wouldn't matter if you removed all government regulation and subsidies tomorrow. Even in a world where it all somehow works out, do you want medical providers in a race to the bottom? In the absence of meaningful quality of care information (impossible), consumers are incredibly sensitive to one thing: price. What you will end up with is cheap(ish) providers providing incredibly substandard care by cutting corners and killing people.
I seem to remember a comment on here complaining about $30 pacifiers. Why do pacifiers cost $30 when they’re post paid from a hospital and not when they’re bought literally anywhere else if not for the presence of market forces? I can assure you this effect is not just limited to pacifiers.
> With HDHPs being so common the 'disconnect' between providers and patients is already not a real thing.
Long way to go for HDHP to take over the market. But its definitely the way to go. It will however attack mostly the primary care market, not the hospitals which are 40% of the national health spending.
> At any rate, entrusting laymen to understand when they should and should not seek emergency medical attention means that people will die through entirely preventable causes in an attempt to ration their health care spending. Your cure sounds worse than the disease.
Not my "cure" thats the economic reality. Unfettered access to healthcare will give you skyrocketing costs. You cant complain about both at the same time, they are a trade-off. I do think that cost is the single most important thing to attack, and the policies to do so are very easy to enact. They are just very unpopular, because the democratic party wants to increase the state, not make healthcare cheaper, and because republicas have their head up their ass on this topic for reasons I dont understand.
According to Kaiser, HDHPs are the second most common health insurance plan and account for 28% of all insurance plans.
> Not my "cure" thats the economic reality. Unfettered access to healthcare will give you skyrocketing costs. You cant complain about both at the same time, they are a trade-off.
Yes, if the problem is skyrocketing demand. But it isn't. Yes, if we waved a magic wand and provided unlimited free access to medical care, demand would rise somewhat. But demand is not the reason for the current high prices, and it's not the reason costs are outpacing inflation. Medical care in the US is much more expensive than in comparable countries, but demand is not appreciably different.
As long as people keep looking at this through a "market" lens, or through a "just make it single payer" lens, the problem will never be solved. The fundamental problem isn't that demand is too high. The problem is cost disease, the root of which consists of dozens of different factors. This is a decent article, albeit one that barely scratches the surface.
Look at those graphs! It's mindblowing! Medical costs have increased ten times more than inflation, while doctor and nurse salaries were flat (actually worse, since now their salary goes to paying off educational debt) over the same time period. If there's a demand problem, why aren't salaries of medical professionals rising faster than inflation?
Lastly, I think most people would disagree that cutting costs is the most important thing. Going bankrupt is better than dying of pneumonia because you were worried about wasting money on a doctor visit.
> As long as people keep looking at this through a "market" lens, or through a "just make it single payer" lens, the problem will never be solved
There is definitely a sort of impasse on both ideological positions. The forces that be for some reason have not agreed to test out their ideas: a public option and deregulation simultaneously. But neither policy is popular in neither party.
I disagree with your diagnosis, but I'm willing to do a policy that satisfies both your ideas and mine. Support a public option that will not have the issues you mention, and let me have my unlicensed, foreign, cash-pay, non-subsidized doctors, non-FDA meds and malpractice waivers.
Medicare for All will solve a lot of these issues. Look at the healthcare prices in Japan, which has a single payer system. Insanely cheap, high quality, and more doctors per capita than the USA.
The other part that someone like Sanders is pushing is tuition-free colleges. If doctors aren't burdened with half a million in student debt, maybe we can get cheaper care.
Medicare for All would help individuals, but does too little to stop rising costs - you get the benefit of government negotiation and annihilate insurance overhead, but it’s not enough. You help people in the short term, but ultimately you only delay the day of reckoning.
I already posted a link showing doctor and nurse compensation have been flat in the same time period that medical costs increased 10x faster than inflation. While free university might be a good idea for other reasons, this isn’t it.
> In the absence of meaningful quality of care information
Except that quality information gets provided quite satisfactorily in plenty of industries, even ones that might appear otherwise quite opaque. Sure, sometimes it is done in distorted and counterintuitive ways (many marketing practices, including many kinds of advertising, are ultimately reputational games that are designed to signal quality), but meaningful info is far from "absent"!
I'd be all in favor of that, but it's not quite as easy as it sounds. A lot of labor relations has resulted in health care being used as part of the total compensation package, a carefully negotiated, hard-fought conclusion. To wipe that benefit away would be a step backwards for a lot of people.
It should be possible to reopen those negotiations and reach a fair conclusion, but there's going to be a lot of fighting on a case-by-case basis (with a lot of cases). I believe it would ultimately work out better for everybody, but the "ultimate" would be years -- if not decades -- away.
> To wipe that benefit away would be a step backwards for a lot of people.
Welcome to vested interests.
> It should be possible to reopen those negotiations and reach a fair conclusion
As much as Uber can negotiate with taxis. The solution here is to cut all the bs out and dereg. Import free doctors from all the world for cheap, by allowing them to practice medicine and to apply to a Doctor visa. US can triple its doctoral staff in 5 years with no educational cost by simply doing less things.
> If the subsidy were eliminated and insurance untied to employer you would have a huge step in the direction of unleashing market forces.
That's exactly how things were in the 1930s. Healthcare was unaffordable to the degree of public outcry, which is why universal healthcare legislation was introduced repeatedly and stifled by the AMA every time. In fact, early health insurance programs were designed to bypass pay-as-you-go medical fees because they weren't meeting the needs of the hospital or patients. It wasn't a tenable system.
In 1930's the national spending of healthcare was like 4% of GDP, while now it is like 17%. If we could go back to the 1930's on that I'd take it.
The problem is not that the AMA was able to attack socialized healthcare, but that the AMA was able to dictate who would be able to practice medicine, what their education should be, how much they should charge and how they would organize.
Any american could go abroad to a country like say, Argentina, get free medical education and come back and treat patients without half a million dollars debt. But its illegal.
We live in an aging society, so the GDP metric is misleading.
Although, we certainly do spend irrational amounts on healthcare, partly because consumers don't bear consequences for going with the pricey procedures.
There's also numerous layers of regulatory capture, artificial scarcity, and rent-seeking in order to protect various industry-wide or regional cartels. The combination of that with consumers who have no reason to care about price is a potent recipe for price gouging.
The AMA is one of those. Hospital associations, medical device associations, phamaceutical associations, electronic medical record companies, and so on all take their cut.
The idea that debt is limiting the number of doctors is laughable.
I think public investment in educating medical providers is too small (it shouldn't be profitable to wrap a provider in like 5 people...), but doctors that aren't total fuck-ups are doing great by the time they are 45. We are likely in a supply constrained situation right now, prices would be nicer if there was excess supply.
Are you sure it's illegal? Like 80+ percent of the doctors in my metro area got their degrees in India (where they immigrated from). There is some form of reciprocity going on.
Foreign doctors still need a US residency. The number of slots for residencies is capped. I could imagine a world where the US signs reciprocal agreements with EU countries to honor their medical professional training without a residency. I cannot imagine the same for India or Argentina.
It isn't just unionized people that don't care about prices. Most people on Medicare or Medicaid do not care... that's like 1/3rd of the country right there. And among the highest per-capita consumers of healthcare.
There's plenty of people on Obamacare who are getting heavily subsidized low deductible policies, and paying very little.
The government is the largest employer, and most government employees do not care about prices.
Throw in those who are unionized or at cushy stable jobs with low deductible plans, which is innumerable millions more.
I'm thinking at least 75% of the country has little reason to care about prices, and even if they did the system is so byzantine that there isn't much they could do if they did. This is all an interlocking and self-reinforcing problem, which rewards the various layers of the healthcare industry with windfall gains irrespective of their own quality.
And all the staff at every specialist’s office dedicated to navigating the insurance & provider bureaucracy. Or every party having their own crappy payment & client portal - often created from scratch!
I think everyone here recognizes the insane inefficiencies of US healthcare. Maybe single payer could help streamline things. Or what if this price disclosure requirement could be wrapped into a more comprehensive system that allows all parties choice and visibility and interoperability?
FWIW, HDHP+HSA has worked great for me. Low premiums and I’ve built up a significant nest egg in the HSA over the 8 or so years I’ve had plans that used them.
I know it doesn’t work great for everyone though and I’ve seen some discussion that it doesn’t bring down costs because of the lack of transparency in pricing preventing comparison shopping (which is also my experience).
In the Japanese health care system, a government panel sets the prices for all medical goods and services. Private providers and private insurers must then manage their business to be profitable against known, fixed prices, and the panel is responsible for setting prices that allow for profitability while preventing gouging and rent-seeking.
They have private providers, employer-provided private insurance, and somehow manage to come in at around half the cost of the US system, for universal coverage and some of the best outcomes in the world.
If we used fixed prices, as Japan does, this sort of regulated transparency would be unnecessary.
Very hesitant that this is the actual problem of healthcare. What you care about is not how much the hospital bills, but how much is leftover after insurance. And that is unknown to all parties.
There is no "the" problem of healthcare. There are many, many interlocking issues that combine to drive up prices at every step of the way in every corner of the industry.
This might help a little bit, but there is no silver bullet.
I agree 100%, just that in the scope of price transparency this is not the real price, discounting all other economic effects that are not apparent in prices.
I disagree, I think the interlocking issue is that few industries have as much public support for its vested interests as healthcare and education. Anyone can get away with anything because the public is generally tricked by a simplistic understanding of what medicine is, and consequently support terrible policies.
You could drop the cost of care just de-regulating. But Milton Friedman failed, who would succeed today on that path?
"You could drop the cost of care just de-regulating"
That's a huge oversimplification and isn't true in many cases, for example when a single drug company owns the patent on a life saving drug. The laws of supply and demand are not in favor of those who require that drug to live.
> for example when a single drug company owns the patent on a life saving drug
Patents are a form of regulation. De-regulating would include voiding those patents. The government created that monopoly and all its attendant problems; there is absolutely no reason why it can't remove it just as easily.
In the USA, at least, there is a singular problem: In the early 70s, the HMO Act and similar legislation was passed, bringing in the HMO-oriented system of healthcare.
A silver bullet would consist of introducing a single-payer system and winding down the HMOs.
HMO's are very successful in terms of providing cost/care solutions. The fact that they are so unpopular reveals the american preference: they want to see any doctor, at any time, with as much access as possible.
Anecdata: A nuclear family member was the president of an HMO for a few years, as far as I know they successfully pooled Medicare resources and made group-wide decisions that saved a lot of money.
It's unknown right now. I don't think this problem is something that can be resolved in one all encompassing change.
We can start with the medical facilities, who will literally lose nothing by having transparency in their pricing. Now you can compare hospital prices; great!
Next we can expose the insurance companies policies per code, and we can apply them to each hospital. I could imagine tools where you select your plan, then select what you'll need.
Yes, I know there are well over 10k codes, and this can get complicated. But that doesn't mean we should just give up.
> Very hesitant that this is the actual problem of healthcare. What you care about is not how much the hospital bills, but how much is leftover after insurance. And that is unknown to all parties.
It's a start. Right now I have no idea what a hospital bill will be. If I know that I can figure out what will be left over after insurance (or even, what the cost will be when insurance company routinely denies a claim because they can.)
All progress is incremental. And pooh-poohing a small step forward is IMO what's holding us back.
This order targets negotiated prices, not hospital chargemaster prices.
Many (most?) hospitals will give you semi-accurate estimates if you hassle them long enough these days; I recently spent a month and a half and a dozen phone calls getting an accurate estimate from UCSF on a predictable medical procedure (cost: $3,300 OOP on a $10,000 negotiated rate).
To treat the problem, you have to go straight to the root.
And that problem is: The cost of free is too damn high.
Most people in the US don't pay for their medical care or their medical insurance. It's "free", at least in terms of money out of pocket.
We need to remove the corporate tax deduction for healthcare insurance from the tax law. This in turn will solve most other problems as market forces are brought back into the picture.
Once people start selecting and paying for their own policy, they will be more price conscious on their claims, as most people already are on their auto insurance.
Once people are more price conscious, medical facilities will begin to complete again on price and insurance companies will focus on individual plans.
It all has to start with the consumer though, and currently the consumer doesn't care what the price is. They don't pay for the medical care and they don't the insurance premiums.
It’s crazy that a drug that prevents the spread of HIV (Truvada) is nearly $2000/month. Even if you had insurance with a high deductible plan you’d potentially need to pay $6-7k before having it covered.
The government should be giving this away for free.
>The government should be giving this away for free.
The government has no money. So you're saying the tax payers should be paying $2000/mo/recipient.
In this scenario you've made nothing cheaper. You've only externalized the costs on to us. You could argue this is for my/public good, but you didn't ask me, you didn't get a representative vote from me. In your scenario you've just decided how to spend my money. I hope you understand you've only just made the problem worse because nothing has preventing it from being $4000/mo now that they know the gov will buy an unlimited supply.
edit: To be clear since posts below don't seem to get it... You're missing a step. You've done nothing to solve the $2000/mo problem, just shifted the costs to everyone. This is the issue with healthcare, the off the cuff solutions don't actually fix the root problems.
> The government has no money. So you're saying the tax payers should be paying $2000/mo/recipient.
The government is able to achieve economies of scale that the private sector can't. I think you know damn well "the government should be giving this away for free" is just a simplified way to describe the economics.
> You could argue this is for my/public good, but you didn't ask me, you didn't get a representative vote from me. In your scenario you've just decided how to spend my money.
Right, you got yours, so you're rationalizing away your part of the cost burden.
You're participating in a society. The consent is implied. If you don't like the terms of the contract, feel free to stop enjoying all the fruits of civilization.
>Right, you got yours, so you're rationalizing away your part of the cost burden.
No. I earned mine. And now here you want to come along and have it spent on something we all agree is a scam at $2000/mo/user.
I reject the premise that any money spent on the social good is money well spent by default. I argue that money spent wisely the goal, GP had no plan for wisely, just spend to spend. That is why ACA failed, it did nothing to adjust costs, just signed everyone up into a broken system.
At the same time most people here are just saying "it's been invented, patent expired and should be free now!" which is another way to say "I want remove incentives for new drug research by making it very high risk and low reward". So I disagree with that too. I wonder how many people understand why the USA is the center of pharmaceutical research and in general healthcare research?
Feel free to attack me for just not caring about people selfishly, surely I'm a greedy monster. That seems ineffective to me, but what do I know!?
Uh, no. Truvada is a generic drug in many countries around the world and cost maybe $10/month not $2000/month. The US just allows Gilead to profit massively from something that is generic and in the public health interest of all Americans to be as cheap as possible. In fact, Gilead agreed to speed up the expiration of their exclusivity so that it will become generic in 2020 due to public outcry, but the fact that a life saving drug will still be $2000/month for a year or more when it could be $10 tomorrow is terrible.
I think you are technically correct that Truvada is a life saving drug but I feel you are being dishonest. If you exclude occupations where you could be exposed to HIV, most of the US users of Truvada could choose to change their behaviors and reduce their chance of contracting HIV to <1%.
There is also the general trend that US companies pay large amounts of money to develop drugs, charge US customers enough to cover R&D costs and then sell the drugs at cost internationally. Does that suck for us? Yes, but it helps the rest of the world significantly.
Wow, this is a bad take. You could literally say that about any disease. Why don’t all obese people just change their behavior and then we don’t need to worry about cheap insulin anymore! Why don’t men stop having sex with each other and then they won’t be at risk for HIV?
>Why don’t all obese people just change their behavior and then we don’t need to worry about cheap insulin anymore!
For type 2 diabetics, behavior changes should be a part of the treatment plan. That said, if you currently have diabetics and you don't get insulin you will die thus it does qualify as life saving medicine.
>Why don’t men stop having sex with each other and then they won’t be at risk for HIV?
While it is not pleasant, people are not going to die just because they have to stay abstinent. You don't even have to be abstinent, you can find a group of 10 or even 50 guys, make sure everyone is HIV negative and then you can do what ever you want, as often as you want, with no need for drugs.
Calling it a "life saving drug" is correct in many cases (NGO worker in parts of Africa) using the term "life saving drug" to advocate for people to be able to cheaply have unprotected sex with strangers is dishonest rhetoric.
If those filthy citizens would just wash their hands, we wouldn’t need to waste money developing flu treatment either. You’re a genius! We can save so much money.
And we can stop working on making cars safer - all we have to do is tell everyone to follow the rules of the road and almost all collisions will be prevented!
While you are taking the idea to the extreme to make a point, I agree with the underlying argument that we should work to modify behavior to improve outcomes.
A lot of money has been spent reducing tobacco use which has paid for itself in better health outcomes.
When there are multiple cost-effective public health measures that can achieve the same end, we should pursue all of them.
In the case of Truvada, we already did the hard part (inventing it). Now it’s just a chemical that can be infinitely duplicated a low cost. It would be a huge wasted opportunity, a moral crime really, not to give it away for free to everyone that can benefit from it.
And the same is true for the flu vaccine, the birth control pill, the seat belt, etc. These are miraculous technological advances. If you support the use of these advances, but not Truvada, I would take a hard look at what factors might be playing into that.
> Why don’t men stop having sex with each other and then they won’t be at risk for HIV?
OK, you seem to have some misunderstandings about HIV. Through an accident of history, HIV in the US spread through the gay population first. That is not the case for HIV generally, and any thought that not having sex with other men is going to protect you is totally wrong.
The overwhelming majority of new HIV infections are men having sex with men. Having unprotected anal sex with a man is absolutely the highest risk category for HIV.
USA also does a huge majority of the research and development for most drugs and developing new drugs is insanely expensive. The profit is the reason why there is incentive to do this research and there also won't be any money left to research and develop new ones. If there was no profit to be made, there would be no reason to develop new drugs.
It is out of patent, the government could manufacture it. These manufacturers are cutting deals with generic manufacturers to delay the introduction of generic drugs to the market in order to maintain a monopoly.
It also cheaper to put people on prep than to pay for their HIV treatment. Who is paying for all the HIV treatment to opiate addicts? Medicaid is which is the government.
> The wholesale cost in the developing world is about US$6.06 to US$7.44 per month.[5] In the United States, as of 2016, the wholesale cost is about US$1,415.00 per month.
Considering that the alternative is simply not having unprotected sex, it is hard to convince people that they should subsidize this in rich countries. This is by design, or else we won't have drugs at all
>the alternative is simply not having unprotected sex
What about being born to a parent with HIV? Or not making a one-time mistake? Or being raped by someone who has HIV? The issue with HIV (unlike with other health issues that could stem from lifestyle habits, e.g., obesity or diabetes, to a certain degree) is that one slip is enough to get your life depending on that drug for the rest of your days.
Even if I disagree with the whole "make people pay for their mistakes, to amortize the costs for the rest of the society", I at least understand the logical train of thought occurring there. But there is no real lifestyle change for someone who got HIV that will cure them, and it doesn't even necessitate to have a certain "wrong" lifestyle to get HIV.
I believe its use is for pre-exposure? Anyway its not about passing judgements about lifestyles, but since there is a much cheaper alternative, people won't be persuaded to subsidize the expensive stuff.
I agree with your sentiment, and there is a large program doing that right now. In May the current administration got Gilead to agree to give 200,000 uninsured people Truvada per year for free. It's not enough, although it is a start.
The Preventive Services Task Force also just put new obligations on insurers in the past two weeks - through an A rating on PrEPs - to provide people with private insurance the drugs at no cost (a mechanism the ACA put into place).
In an effort to eradicate HIV in the US, Trump has secured a donation of this drug from the Canadian producer Gilead for up to 200k Americans for 11 years. And they have a generic hitting market in 2020 afaik.
I’ve been getting free Truvada since Obama was president. Nobody pays for Truvada - Gilead reimburses you if your insurance doesn’t cover it. Sounds like just another example of Trump claiming credit for something that was already happening.
Someone definitely pays for it. If Gilead reimburses the full amount, then those who pay insurance premiums are paying for those that don't.
Maybe those free doses are being distributed to clinics for people who are not capable of initially paying for or even filling out forms for reimbursement.
If you’re uninsured, Gilead will give you a voucher you can take to a pharmacy to get it for free.
I don’t believe this press release is actually announcing any change in the situation on the ground for people who need Truvada - I’m saying that as a person who’s on Truvada, and who’s helped other people get it. If there’s any change, it’s not mentioned in that press release.
I think it’s just like all the press releases where Trump claims credit for some growing business’s hiring plans. It’s a cheap way companies can curry favor from the administration. Kind of slimy but of no great consequence.
The entire exercise is pointless because the health care market isn't actually a free and open market. There's lots of regulation on health services (obviously, as there should be, because safety is important), but more importantly, when a person is sick or injured, they usually are not able to comparison shop. Emergencies make it impossible, but even a relatively common illness makes comparison shopping unrealistic. What we have is not a market and efforts to help comparison shopping really do almost nothing to fix things.
Has anyone else had a doctor or nurse filed the wrong paperwork for a blood test, and then you get stuck footing the bill for an obscenely expensive test you didn't need or want? It's happened to me several times. And you have to pay whatever price the test facility sets, period.
The system is broken and until the insurance industry's grip is broken, we are not going to get relief.
>when a person is sick or injured, they usually are not able to comparison shop
You argument seems to be that since this doesn't work in all situations, it is useless. I strongly disagree.
On my current commute to work, I drive by at least 2 major hospitals and know that a 3rd is not far out of the way. If I was willing to drive up to 2 hours, I could choose from at least 7 major hospitals. For emergencies I don't have time to shop. If it is something important but planned (fixing a torn ACL) it would be nice to be able to look up the price at the 7 different hospitals. If one is 1/3 the price of the others, I know which one I am picking. Current rules make it impossible to price shop for fixing an ACL this would make it at least possible.
Oh come on. This has got to be a bad faith argument.
Most of us either choose the lowest cost option on the public market that suits our needs for emergency care or take our employers options, of which there are one or two. Even if you had previously made a choice, which again is not something most people can or want to do, when an emergency happens, it’s an emergency! You will have to be taken somewhere.
There are many times when an ER is full, you are outside of your home area, maybe just traffic, that would push you to another hospital in an emergency. Your argument is not only poorly made, I find it hysterically obtuse. Most people don’t want to get to or even have to choose their damned emergency care. To assert otherwise is disingenuous
That doesn't always help. As an example, the only level 1 trauma center in SF - Zuckerberg SF General - where you'd be taken if you were unconscious and in bad condition after a bad car wreck, is out of network for every insurer in the area. If I'm not mistaken, that means that you'd be balance billed for an enormous amount when you regained consciousness.
And for most major health care issues, the primary concern of the patient isn't price, but rather outcomes - quality of care. Do we choose the cheapest doctor, or the doctor with the best reputation?
My wife, who is a dancer, tore her ACL last year. Not getting it fixed, and fixed right, was the difference between being able to continue dancing, and having to give up the thing she loves the most. So when decisions like "Use transplant tissue, or cadaver tissue?" came up, there was zero thought given to "Which one costs the most?" It was all "Which one is most likely to get her back on her feet and allow her to continue dancing?"
My reasoning still applies, though. My spouse wasn't going to base her decision on who should fix her torn ACL based on cost, no matter what the price difference. If you have life-threatening cancer, do you go to the cheapest oncologist, or the one you think is mostly likely to save your life?
The real financial decision isn't on price comparison, but rather whether or not to get the treatment at all. I made a cost-based decision on treatment a while back. I was being treated for an eye problem where I was at risk of permanent blindness in my right eye. Treatment involved monthly injections of a quite inexpensive drug (about $27 iirc), that was inexpensive because it was developed for other, more common conditions and had been around for a long time. My doctor wanted to try a new, specialized drug, hoping for better results. It cost $8000 a dose. With 90% coverage, I would have been paying $800/mo out of pocket. I decided to stick with the cheap drug that seemed to be working.
But that's the sort of cost difference that matters, not the "This doctor is 5% cheaper!" dream of idealized free markets.
I would like to point out that you have a very privileged position in life to be able to say that cost is no object to the quality of care you receive. Not every has that luxury. Also, there are some people in some situations that would be willing to sacrifice quality of care on price.
Don't belittle the point by calling it "privilege". I'm in the same situation as most Americans with employer-provided health insurance. The real cost decision, as I pointed out in another comment, is whether or not to get care at all, rather than to choose between Doctor A, or Doctor B who costs 5% less.
This is exacerbated by the fact that our insurance hides most of the cost variation from us anyway, and health care networks turn potentially cheaper care into probably much more expensive care. Writing this all off as "privilege" is a gross, lazy oversimplification.
Your argument seems to be that since you live within range of many health provider options, that everyone does. I strongly disagree (for the obvious reason: not everyone does).
Sorry, no. Not only do doctors and surgeons vary dramatically in competency, specialty groups within a facility can vary a lot. Further - even if we take it to the seemingling simple, like where to get an MRI - how are you able to ascertain the quality of the equipment used? The competency of the operator? The competecy of the person do the reading of the results that will guide your doctor/specialist?
Our family has four people in it. We've spent plenty of time and money on medical care in the past 18 years. Almost everything we've done medically, we could have made use of price transparency, if we had it.
Yes, there are scenarios where the most important thing is to get emergency care as soon as possible. These are the exception--the rare exception--not the rule.
> Emergency room visits happen quite often enough.
Many ER visits often happen because people can't afford insurance and preventative care. If this alleviates some of that by permitting more competition due to price transparency, then it will become even more rare.
> when a person is sick or injured, they usually are not able to comparison shop.
Strongly disagree.
According to NPR today, something like 75% of in-patient and 90% of out-patient events are shoppable.
Think something like having strep throat, or having a possible broken arm. Nothing stops you from looking at a few places before treatment.
Sure some cases are you got shot or had a heart attack and had to get rushed to the ER. Of your total medical visits in your life, what % of your total visits were like this?
> According to NPR today, something like 75% of in-patient and 90% of out-patient events are shoppable.
What are these numbers based on? I recently needed to have some blood tests done (cholesterol and A1C) and blood tests aren't covered by my NYS marketplace purchased health plan. So, I called multiple labs in my area and I couldn't get a single one of them to give me a number. They couldn't even give me a ballpark. I couldn't even get anybody at any of my local hospitals or doctor's offices to give me a base cost of an appointment with an allergist to look at a rash.
This is the point of transparent pricing. It's impossible to do so right now, even with insurance. If they can even give a ball park number for a particular procedure or test (average, or min-max range, or SOME number) it would help with shopping around.
I think you misunderstand shoppable. This just means that if anyone WOULD give you the prices you would be able to choose. Contrast with emergencies or procedures where there is only one specialist in the area etc.
The point of those numbers is exactly the same as what you describe. They are saying the majority of medical issues are things you could call around for beforehand, just the same as you tried and failed to do. The point of the executive order is to force places to actually give you a price when you ask.
...having a possible broken arm...Nothing stops you from looking at a few places before treatment
Except that you're laying on the ground writhing in pain, not the easiest time to pull out your phone and pull up pricewatch.com before you call 911 to find out which hospital has the best deal on x-rays today.
In the case of a broken shoulder (collarbone), the ER often does some X-rays, puts you in a sling, prescribes painkillers, and sends you home.
You find a specialist the next day. And if you require surgery, that's another day or two. There's no reason you couldn't do a cursory sanity-check on pricing in this case (if pricing info was easily accessible).
yep, sounds correct. Broke hand, went to the closest urgent care, they did xrays, confirmed it was broken, put it in a sling, and referred me to a specialist (by just giving me a note confirming that they referred me with the specialist's phone number) that they thought was good and was close to where I lived. However, they didn't have to pick that specific specialist. In fact, they even asked me if I had a preferred specialist and/or hospital. I called the specialist the same day, had the appointment a few days after.
Having had plenty of surgeries from fractured bones and torn ligaments you can certainly do this. There will be emergencies where you can't but I would think in the typical scenario you have the time and ability to price compare.
I've even broken bones on vacation and only had x-rays after I've arrived home. Does it hurt? Yes. Am I incapacitated? No.
I've only seen one person break his arm, and that was a fall from a tree, the bone was completely broken (his arm was bent at an unnatural angle), and he was in severe pain, the EMT's injected him with a painkiller almost immediately.
That's definitely going to the emergency room but there's a good chance it's a temporary cast and then surgery is scheduled the next day. That said, I'm not a physician and I'm only relying on my own experiences.
When I broke my arm, I immobilized it for a few days, then when the pain was still present after a week I went to urgent care. They took an X-ray and scheduled me to visit an orthopod a week later. He prescribed that I keep immobilizing it for a few months until it felt better, after charging me lots of money for an MRI.
When I broke two fingers a year later, I took my own x-rays at a dental clinic for which I did some maintenance work. Yep, they were broken. No, I didn't pay anyone to tell me to stop using them for a while.
Sure, lots of broken arms need a cast, but this idea that you can't shop if you're in pain is goofy.
Most people have some family members or friends who would do that. Where i live (admittedly not USA) it's very rare for a person to go to a doctor alone.
> Except that you're laying on the ground writhing in pain, not the easiest time to pull out your phone...
It's very doable. When I broke my arm in highschool, I was in mind bending agony for a few minutes. Then I put some ice on it and went to work the next day. Didn't get a cast on it until after work.
Once you start a complex procedure, many different things can happen, some very costly to respond to. So how does an organization price for that? Do you price in every emergency contingency? Do you shop for one regular heart bypass with or without emergency resuscitation in case of heart stoppage, or extra drugs needed to be pushed in for any of a number of different outcomes. Is there a fine for not adhering to the advertised price - does that create an incentive to avoid some measures independently of what would be good treatment?
Seems really convenient to claim that because of an edge-case that no price-transparency is possible. Americans seem to have a habit of claiming things are impossible/infeasible that plenty of other western nations have managed to implement successfully decades ago.
Edit: To clarify I am an American myself and this irritates me.
I don't claim it's impossible, but trying to point out that pricing and pretending that healthcare is like choosing one laundry detergent or another is simplistic. At the very least it pushes the complexity into trying to package a probabalistic fuzzy cloud of outcomes into a one price thing isn't an end all, and introduces all sorts of price gaming. At the very least, you increase the quoted price to cover some slice of probabilities - just like if you were a contractor quoting firm fixed price at a much higher cost.
Personally, I favor what many other nations of done and that's setting a set of fair prices through an expert panel - nations like Japan, Germany, and France do that IIRC.
You're talking about the non-shoppable expenses. Those would be handled the same way that they are now.
But most expenses are pretty predictable, like the colonoscopies that I have to get periodically (and which I do shop around for, altho it's damn difficult). Yeah, if there's a bowel perforation all bets are off, but that happens 1/1000 times.
This is the standard fallacy of "impossible to do it in 100% of every edge case means impossible to do it in 90% of common cases". Yes, in medical emergency it's impossible to put upfront price on everything. That doesn't mean one can't put known prices on thousands of more routine procedures and events - which still does not happen, or functionally does not happen - i.e. prices may exist, but they are not accessible, inquires about them are stonewalled, and every customer-facing employee is trained to say "you pay what we bill you or GTFO".
My wife and I agreed years ago that we would have a discussion before either of us makes a purchase of about $20 or more. (We haven't adhered to that perfectly, but it has been a great guideline.) Oddly, we failed to notice that we never have that discussion when it comes to health care, even though the vast majority of our interactions with the health care system are certainly not emergencies. We routinely go to a doctor, we don't ask what it will cost, we do whatever the doctor asks, and insurance covers only part of the bill. Health care is the only exception to our $20 rule. How odd...
We realized we've been bamboozled. Nearly every hospital and clinic uses the same trick: the doctors apparently don't know what anything costs, the office staff say they don't know what anything will cost us because it depends on the insurance, and the insurance company won't reveal the price until the office staff charges the insurance. All the indirection makes it difficult to determine even a ballpark figure. (It no longer surprises me when the hospital charges $4000 per night to merely sleep in a bed with nurses and doctors nearby.)
We decided we're no longer going to make an exception for health care (except in emergencies). We're going to require a price ahead of time so we can discuss it like we do everything else. We intend to annoy the office staff and insurance company until they comply and tell us what the prices will be. We think about it this way: heavy expenses can easily cause stress that reduce our quality of life, significantly offsetting whatever we might gain from medical procedures.
I'm glad the legislation seems to be working in our favor.
I once tried to figure out why two visits to the doctor, apparently exactly the same, by the same person, were billed different sum. The difference wasn't significant monetarily - it was about $20-30 or so - but I wanted to understand how much that visit is supposed to cost. It was an HMO, so there's no question of negotiation or anything - they are setting their own prices. Still, nobody could give me the answer. I called several time, and I spoke to five or so different people, and all I got is "yeah, you've been billed right, there's no mistake" (not what I asked!) and "well, that's how much it costs" and indeterminate mumble. Nobody ever could explain me where these prices come from, where I could see them upfront, and how I am supposed to know which visit will cost me how much. It's basically "you come, and we bill you later whatever we want and you hope it's not too much".
Interestingly enough, in dental medicine everybody seems to be completely able to give the full price upfront, and explain all out-of-pocket costs before I even start talking to the doctor. I wonder what's so different there that can't be replicated elsewhere.
It's an insightful contrast to draw. There are a number of differences between dentistry and other health professions, but I think the most relevant differences are the size of the typical firm together with the total cost for any particular patient. Many dental clinics are just one or two dentists, who have no business relationship with any other clinic. (There are "fast-food" chains like Aspen Dental, but they are a relatively low portion of the overall industry.) Also, although some patients might get low-five-figures worth of dental work in a particular year, that much is fairly uncommon. That same sum could be one day in a hospital, which is usually owned by a firm with thousands of employees. Lots of formerly self-employed physicians have been forced to join big firms to retain admitting privileges etc.
Dental insurance firms would probably like to engage in all the price-fixing and patient confusion that other health insurance firms enjoy, but they can't possibly employ enough people to arrange their dastardly schemes with tens of thousands of different dentists. Instead, they have to publish (to dentists, not to the public) lists of reimbursement limits by procedure code. Dentists decide whether they'll accept any particular insurance plan largely based on reimbursement, and many of them are willing to discuss those decisions with their patients. At the same time, most dental patients don't have insurance at all [EDIT: and many are fine with that, since they can afford the care they need].
Single physicians in family practice would be in largely the same position as the typical general dentist, but the work they do is a relatively smaller portion of the overall industry. After all the real screwing from medical costs takes place via hospital visits and high-tech imaging. Even a smaller hospital will start getting calls from insurance executives after they generate a few expensive cardiac procedures in any particular quarter.
Don't take this as a defense of dental insurance. It's fine if you get it from an employer, but after working in a dental clinic I don't think anyone should get it privately. If you need a lot of dental work they don't pay for much of it (this is also true of many employer-provided plans). If you don't need a lot of work you end up paying them more than you'd pay the dentist. Most people who need lots of dental work but can't afford it should get loans for that work, from e.g. Care Credit or one of its competitors. Yes, that sucks, but it sucks less than private dental insurance.
I've actually tried this. The doctors and office staff will always claim they don't know how much any of their services cost. They will stubbornly stonewall you if you escalate. I've gotten into an actual shouting match with a doctor over this and ended up getting banned from his clinic. Go ahead and threaten to go to another doctor: They don't care because they know every other practice will stonewall you about anything cost-related as well.
No clinic will even let you sign up as a new patient anymore unless you sign their form that essentially says "You agree to pay any amount that we decide you owe. If we make a mistake, tough luck. If you can't afford it, tough luck."
I wouldn't recommend shouting. :-) Also, we don't expect an exact price, just as we don't expect an exact price from a building contractor. We expect rough estimates so we can tell the difference between a $500 procedure and a $5000 procedure.
That's a good point. Not knowing how much something is going to cost could cause an enormous amount of stress to a patient - which could impact their outcome. I wonder if there have ever been any studies done about outcomes where the patients are fully informed about cost, vs being in the dark.
They're not lying though, at least if you're talking about a hospital. It's not an accident either, there's a strong norm in medicine about ignoring costs. Doctors aren't supposed to take cost into consideration when making medical decisions, to the point where they have no idea what anything costs and they fight to keep it that way.
That's the key, isn't it? Doctors tend to believe their services improve quality of life regardless of expenses. They need to be more aware of the long term reduction of quality of life caused by expenses.
The doctors won't know how much the insurance company will reimburse until they receive the reimbursement(except Medicare). They are essentially working in the dark as well. The transparency has to start at the insurance level.
I'd take an estimate without insurance reimbursements over nothing at all. At least I'd know what I was on the hook for if my insurance didn't cover it.
It is a bit ridiculous that there isn't ever even an attempt at informing a patient of their potential liability beforehand even in nonemergency situations.
I’ll repeat the same comment I always make in these threads:
This is the way the French system (mostly) works for outpatient care. So anyone who suggests it can’t/won’t work is ignoring that it does work.
Refresher: Government has a reasonable and customary price list. You pay the doctor out of pocket at time of service and you get reimbursed at some percentage of R&C (IIRC 80%)
> but more importantly, when a person is sick or injured, they usually are not able to comparison shop
You don't need to comparison shop reactively. You can look up some prices preemptively, and choose a preferred hospital that you know to go to when you need it. Obviously not ideal, but it does allow for something.
Also, just having the ability to comparison shop tends to hold down prices, because firms know that you could go elsewhere if they're gouging you and that information tends to escape. It's like how when the wage-fixing cartel among Silicon Valley employers was discovered, everybody at Google got an immediate ~50% pay bump. You didn't need to actively interview at Facebook, because they knew you could and would rather that you not get that idea in your head.
Heck, even post facto, if you're in an emergency and you end up stuck at a hospital that charges $50K for a procedure, and then while recovering you find a nearby hospital that does it for $10K, you're not necessarily without options. It's not hard to go to the provider who actually gave you service and say "You know, they charge 20% what you do... what's the odds I can cause $40K's worth of stink in the local news if you don't cut my price down now?"
(You may want to consult with a lawyer friend a bit before making quite such a naked statement; that may constitute blackmail in your jurisdiction. But there will still be "ways" of phrasing things in your jurisdiction. Talking to a lawyer may not be all bad anyhow, whatever it is you have to say will sound more credible with some lawyer's letterhead on top. Hospitals hear a lot of amateur lawyers expound their novel legal theories every day.)
I'm not going to deny the relationship in that situation is still lopsided in the direction of the first hospital, but the situation is not necessarily 100% in their favor.
A mild correction: it was an effective 10% bump. Google used to have an individual and company multiplier to the bonus which could top out to 25%. The company had repeatedly hit the 25% company multiplier and had strong feedback that the employees preferred predictability in pay. So, they gave a 35% pay raise and phased out the company multiplier.
It also happened in October 2010, which I think was before the wage fixing was discovered (I know the dates because it was after I signed and before I started. Any time I tried to negotiate on salary they countered on stock because they knew salary was going to multiply by a third)
That is not an apples to apples comparison. A gentleman's agreement not to poach engineers with valuable skills is very different from companies charging people with services who are not able to say "no".
There is a massive information asymmetry between health care providers and consumers. Doctors take decades of training. Hell, medical billing by itself is a degree. Consumers will never be prepared to properly assess costs. Even if they could, it doesn't matter when you are hurt and can't refuse.
It's more like food sales at a hockey game. Anyone in the arena that wants to eat or drink has to buy what is being sold. As such, prices are hugely inflated, even though the nearby gas station is much cheaper.
Choosing what you think is generally the cheaper hospital is not a solution. The things they charge you for is varied and you never have a choice as to what they will be. The doctors usually charge you separately, and you can't predict which doctors are on call at any time.
But even more fundamentally, the issue is information asymmetry. Consumers don't have anywhere close to adequate information to make intelligent choices about health care costs. 99% of consumers have no applicable medical training.
The fact that this data has to be published means any one person with medical knowledge and their techie friend can now build a "what's the cheapest hospital near me?" website, which is something we couldn't do yesterday.
This is an enormous problem, and the way you eat an elephant is one bite at a time.
AFAIK you don’t get to choose where you go in case of an ambulance, but if you are taking yourself to urgent or emergency care you can shop around. Heck, I had four torn ligaments this year and at least checked yelp reviews before going to urgent care.
"Ah, yes, I've self-diagnosed myself as having a heart attack. Now, which local hospital had the lowest charge for that? Oh, but what if it needs a bypass operation? That other hospital was cheaper for that..."
The actual thought process during an emergency tends to be more along the lines of "oh fuck it hurts make it stop".
Looking up the prices literally doesn't mean anything. This entire exercise is pointless because it is impossible to tell whether or not you will be charged the in-network fees or price gouged by out of network doctors.
You do some price shopping around and find a hospital that's cheap. It says the hospital is in network, and you go. While you're receiving treatment the hospital has another doctor treat you who happens to be out of network and now all of your shopping is rendered useless as you get slapped with a huge bill.
This is one of many reasons why shopping for healthcare treatment is ultimately useless. What do you do if you go to the hospital and get slapped with treatment that you need, but couldn't shop for until you arrive? What if it's especially critical treatment?
You simply cannot shop around for most medical issues like you can other things because information asymmetry is too high. And putting off a medical issue to do this shopping is frankly horrifying because you have zero clue if the issue you have is critical or not!
If you're experiencing the symptoms of a stroke for example this is an entirely time critical medical emergency. Any second spent not getting treatment reduces your chances of a fuller recovery.
We can’t pretend that this will solve everything, but I also struggle to see how it could hurt consumers. It seems like a common sense proposal with potential to help consumers.
Enforcing upfront price transparency in markets with few suppliers and significant geographic restrictions can result in higher prices through "collusion". This isn't theoretical, it has already happened.
>...but more importantly, when a person is sick or injured, they usually are not able to comparison shop. Emergencies make it impossible, but even a relatively common illness makes comparison shopping unrealistic.
I disagree. Almost all out-patient medical procedures are pre-planned and it would be possible to comparison shop if there was actual pricing info. Even in terms of hospitals, an estimate is that about 1/2 of the patients are admitted through the ER. Obviously there are emergencies and you aren't going to be doing price comparisons if you are in an ambulance after a car crash, but that isn't the majority of medical care.
> There's lots of regulation on health services (obviously, as there should be, because safety is important), but more importantly, when a person is sick or injured, they usually are not able to comparison shop.
this is absurd. there's plenty of spending that isn't in any hurry, and doesn't need to be. a couple of things off the top of my head; opthalmalogical checkups, having funny moles inspected/removed, annual exams of all varieties, vaccinations... the list is enormous.
> but even a relatively common illness makes comparison shopping unrealistic
take your GP's rates for the services you expect to need over the near year or two into consideration in advance when choosing them.
> Has anyone else had a doctor or nurse filed the wrong paperwork for a blood test...
maybe if you could check the price ahead of time, you could've checked that they wrote down the correct test?
This is the argument I have posed toward most closed systems, heck, even open.
For instance, our tax system.
The only real way you would ever have a true legit overhaul would be to burn the entire thing down. Now, while I'm not even remotely suggesting that, it seems the only feasible way to start from scratch.
I just don't see any incremental adjustments working that would not be thwarted in someway.
Now that I've typed this out and read it, a big part of the problem has got to be lobbyist. Get that out of our politics 100% and we might be able to see some progress.
The government (federal/state) and our legislators (senate and house of representative) don't always work for us or in our favor. Our political system is not strong enough to overcome the strong lobby/interest of few. We can however design our economy around solving these problems. Make it profitable to solve health-care problems. We would willingly pay a 'prime' membership if such an organization/corporation exist. And if we have more subscribers, then we will have more payer into the system.
Requiring explicit written consent to receive each service (after mandatory price disclosure) would also be welcome. I broke my ankle a few years ago, and half the bills sent to me I didn't recognize what they were for. In one particularly egregious example, some doctor literally spent less than 30 seconds near my ER bed, did not even look at the injury or the charts, and billed my insurance $700. And I've never seen him after that, received no prescriptions, no recommendations, and no treatment of any kind.
Dude was in his late 40s from the looks of it. Definitely too old for a student loan to be an issue. Probably just got used to charging people arbitrary amounts without their consent.
There's an unsettling aspect to this story that is being glossed right over: This is, what should have been, a simple bit of congressional legislation that could/should have been drafted in the House or Senate and sent to the president for signing. Yet it had to be drafted as an executive order. Why is the legislative branch so willing to give up the power of the pen to the president? What the hell is going on? This feels like a huge breakdown in the responsibilities of the federal government.
Excuse me for being a little cynical... But I find the timing a little convenient that only after 2016 are people concerned about Executive Orders and presidential overreach.
I'm sure this comment will be followed up with someone saying "nah I've been concerned" and that may be true, but let's look at the common mode here.
It's like the people arguing for bigger government are many of the same people arguing against government when it's someone they don't like in power and can't see past their own noses on this.
Oh good, a whataboutism. Not enough of those, lately.
I'm not everyone, and it is something that's of deep concern to me, as it should be to you. So feel free to shelve your cynicism and join me in asking our representatives to do better.
A whataboutism would be if the topics weren't directly related. How is this that?
Let me help you out. A "whataboutism" would be if I made a post saying "Well, Trump did this one good thing, but Obama passed Credit Card Reforms!" See how those are non-sequitur?
Well, why was it drafted? For the good of consumers? Or as part of a re-election campaign, a promise to "do something" in the face of the hard reality that the GOP has pretty much nothing to show on the health care front, either in terms of legislation, or a plan more ambitious than "Kill Obamacare".
The healthcare cost problem is one of the top issues (maybe THE top issue) for voters in 2020, and Democrats have real, substantial proposals. What's the Trump response? I'm guessing it's this.
Outside of funding for the ministry of war, Mitch McConnell will not allow a vote or (when possible) even debate on anything the democratic sides of Congress support, and any bill of this nature would have been supported by both parties.
My sister suddenly needed a few surgeries and seems to now owe an effectively infinite amount of money.
I work for a startup without funding. Health care costs was one of the reasons I decided to move to Mexico. Some of the medicine is still kind of expensive to me, but for those ones it's still literally 10X less than across the border.
To say the healthcare system in the US is broken is an understatement, but this is a step in the right direction. Especially, if we cannot get a single payer system passed through Congress in the near term. Who knows, if the policy is actually done right, it might lower costs.
I don't understand how anyone (of course, besides Big Healthcare/Big Insurance, who is scalping the common man and lining their pockets with cash with these practices)
could not see this as a good thing
Mark my words: later this year Trump will allow re-importation of drugs, and Big Pharma won't be able to charge 5-10x for the same thing in the US. The only reason why previous administrations haven't done this is good old fashioned corruption.
I think there needs to be the concept of $5 generics. Have the common stuff readily available to anyone in any part of the US for $5 or less per month. And if the private industry in any one region doesn't meet this challenge, the government should offer it.
Lets put it this way. Being in kidney failure/dialysis. I take around 12 medications a day and I think only 1 is non-generic. I think lots of health needs could be met by affordable access to the basic stuff.
I'm kind of shocked that no healthcare providers have offered price guarantees as a selling point - I know I'd be incentivized by them.
My guess as to why is that hospitals are just as confused about how insurance pays for things as the general public is. They could never accurately estimate what a patient would pay out of pocket.
The problem with healthcare service is that it's not some off-the-shelf product - you don't know what level of work you need going in, and the need for more services may be uncovered later. Giving a price guarantee on something that changes based on the service being done isn't as feasible, especially when coverage changes depending on diagnosis codes.
I always look to things like Lasik surgery or plastic surgery where there is a ton of competition and real price transparency. Sure, those are elective surgeries, but so are most medical procedures people get done. We might not be able to solve it for every medical procedure, but it seems like there is a lot of low hanging fruit.
Hell, in Canada, there are private MRI facilities for people who don't want to wait for the public system. Here is one in Vancouver and look, all the prices are listed.[1] Why the hell can't we have that here?
Speaking of which, I had an MRI done that a bay area hospital charged $18K for. Insurance discounted it down to $8K, but apparently I could get done in Canada for $1400 out the door.
Ideally, we need to move to a system that prevents individuals from being liable for predatory pricing. There should be a law that prevents medical providers from charging their victims directly. They should be forced to only deal with the insurance companies and make it illegal to hold victims accountable.
It calls for the Department of Health and Human Services to issue a rule within two months that could require hospitals to publicize information on their negotiated rates with insurers for common procedures.
and
Lawsuits could be likely, meaning any action could be delayed until after the presidential election.
a great idea, but it sounds like the EO may not actually change anything for a long, long time, if ever.
It was somewhat limited. The ACA required hospitals to provide their charge-masters for their services online in “machine readable” format. These charge-master prices have limited relation to the prices faced by insurance companies or people seeking medical care.
The ACA had a "chargemaster" rule that required hospitals to post a list of standard charges for treatments, but this doesn't include charges for office visits or elective procedures.
More importantly though, these standard fees do not include any negotiated rates between insurance providers and hospitals, making it effectively impossible to comparison shop. A hospital's chargemaster price for procedure X might be $10,000, but might be only $2,000 for a particular insurance provider due to negotiation.
That's the difference between the ACA rule and this EO; the EO forces hospitals to post the real prices for each insurance provider.
That being said, does Trump have that power? Executive Orders are very powerful because the executive branch is huge. But this is an EO compelling private companies to do a certain thing. That seems beyond the reach of EOs.
I'd be happily wrong here, as I said I do strongly support this. Can anyone explain why I am wrong?
The legislative branch has ceded most regulatory authority to the executive branch. Telling companies what to do is a major part of that.
If the Department of Health and Human Services was given this authority, and the President is in charge of that department, then how would an executive order be inappropriate?
The EO requires health officials to propose a regulation that achieves the proposed price transparency. In that sense, it's an EO compelling the government to create a new regulation, not a law.
If this ever translates into reality then it is great, and I really dislike Trump both politically, and as a person. Willing to give credit where it is due, even though I strongly suspect that it is a political stunt that will get lost in committee. Would be delighted to be proved wrong however.
Not too long ago I led a team that built data products using a massive dataset comprised of more than 6B medical claims. This included Medicare, Medicaid, and private insurance. Two thoughts:
1) Trump is either bluffing or he doesn't have anyone around him that actually knows how medical billing works. If he were serious, the executive order would mandate that HHS publish the information based on the data that's already included in every claim (i.e. invoice) submitted to CMS for payment.
From a policy standpoint there are already rules in the federal register that allow HHS to publicly disclose cost information at the hospital-level. I'm no lawyer but it seems to me that a well-crafted executive order could stand up in court. Even if it were struck down, putting forth such an executive order would be a shrewd political move because it would cast its opponents in a bad light. These would presumably be insurance companies, the medical billing industry, and for-profit healthcare providers.
From a technical standpoint: there are already data pipelines in place for this sort of thing. The CMS Open Data initiative already reports hospital-level aggregates. It's not that hard to comment out a few 'GROUP BY' statements in order to get a POC up and running quickly.
2) Even if the current executive order comes to pass, people will continue to receive surprise bills and experience sticker shock. That's because the total (billed) cost is a function of:
- professional services (procedures rendered by doctors/therapists, etc)
For any given hospital stay or office visit the quantity and types of items in each category can (and does) vary. The current executive order mostly addresses the latter.
Furthermore, two patients seeing the exact same doctor for the exact same thing but using different insurance companies will get vastly different bills. That's because different insurance companies require healthcare providers to bundle/group (and sometimes break out/itemize) services in their own way.
Because out-of-pocket costs are, in turn, a % of the total negotiated rate patients necessarily end up with the short stick in terms of cost transparency.
Given the current medical billing system, there's simply no way for patients to know exactly what they're going to pay ahead of time because the charges won't be finalized until the insurance company decides what they will/won't cover.
No executive order will change that. Transparency will require Congress to muster up the will to write laws that put the patient first, not last.
Price transparency in healthcare sounds great after the first few seconds of thought about the matter, ever - after all with price matching TVs and Google Home at BestBuy, Amazon and the like work so well!
It's not just fancy electronics - it works for healthcary stuff too:
Look at how cheap plastic surgery is! Free market at its best!
However, past the above sarcasm and after a few more minutes of deep reflection, it starts to unravel that price transparency just does not work if there is no free market.
Yes, price transparency works well in a free market
No, healthcare is no free market. Definitely not the U.S. market.
Healthcare in the U.S. is a pseudo socialized care where private healthcare dollars subsidize social care programs.
Employees on employer sponsored health plans, which are only federally regulated and rarely have the additional protections that the states they reside in afford them are nickle, dimed and squeezed for the very last dollar that can be extracted from them.
Employees are beholden to the employer choosing good plans for them, keeping those good plans around at affordable prices and continuing to be in business and able to employ these employees. TOO MANY ifs and buts if you ask me but I digress.
As long as we have something like the EMTALA or similar where services have to be rendered regardless of ability to pay, the deficit in payment recieved will have to be covered somehow!
Here are two scenarios with Price transparency:
Base Scenario:
-------------
Provider: I charge $100 cash to see a patient
Insurance company (InCo) 1: We will pay you $170 if you agree to work with us. You cannot tell our insured that you will accept $100 cash or we will blacklist you.
Provider: ok
Insurance company (InCo) 2: We will pay you $120 if you agree to work with us. You cannot tell our insured that you will accept $100 cash or we will blacklist you.
Provider: ok
Medicare: We will pay you $70 if you agree to work with us.
Patient 1 (w/ InCo1): Doctor, I want to see you. How much do you charge
Provider: I cannot tell you. Depends. Speak with my biller
Patient 1 calls biller and they estimate $180
Patient 2 (w/ InCo2) has the same conversation and gets a $150 estimate
Patient 1 and 2 are friends and they compare notes.
Patient 1 complains to InCo1 that he paid too much money for the same visit that costs his friend, Patient 2, much less. Plus there's this website that shows the Provider accepts on the average, less than $120!
InCo 1 calls Provider: Hey! We heard you charged less for someone else! Trump has this website that says you accept on the average, less than $120! You better charge us less too or we will not renew our contract!
Medicare patient: Doctor, I would like to see you
Cash patient: Doctor, I would like to see you
Scenario 1:
----------
Provider: InCo1, Fair enough. I guess I will absorb the cost of your paperwork, cumbersome claims process, 90+ days of payment delays and reduce my reimbursement amounts because I don't have student loans, rent, staff bills to pay. Medicare patient, I will see you even if I lose money because I'm in this business because I love it. Cash patient, I will honor my $100 rate but I will appreciate if you could tip me $20 because I just lost a few hundred
InCo1: No, you have to accept $100 now because you're a push over
InCo2: Yeah, what they said. It's not fair you charge us more!
Cash patient: Do you want this money or not?
Scenario 2:
----------
Provider: InCo1, InCo2, not interested. There are few of me compared to the number of insureds you have and I will not absorb the cost of your paperwork, cumbersome claims process, 90+ days of payment delays. Infact, to renew our contract, my reimbursement amount is now $300 because dealing with you is too much of a hassle. Medicare patient, I will not see you because I am losing money on you. Go see someone else in a better position than I. Cash patient, I will honor my $100 rate because I don't have to deal with all the nonsense but only if you keep your mouth absolutely shut. If this $100 ever makes it to a Yelp review, our relationship is over. I almost considered charging you $200 instead because you don't have an insurance company bargaining for you but I have a weak spot for the unrepresented. President Trump, I charge everyone $300!
InCo1: Yeah, he charges $300. That's literally what it says in our paperwork. Here, see it!
InCo2: Yeah, he charges $300. That's literally what it says in our paperwork. Here, see it!
Cash patient: I have no clue what Provider charges. I am on a payment plan and paid $150 or $100. Maybe. I don't know, please keep me out of this I just want to get better OK?
Medicare patient: I have some cash but not enough to pay per visit. Maybe I should also go into business with InCo1 or
InCo2 as supplements
Which is more likely you think?
As long as we have something like the EMTLA or similar where services have to be rendered regardless of ability to pay, the solution to sane pricing is to have King Kong fight with Godzilla and keep each other in check.
We just have to ensure we can control both King Kong fight and Godzilla - and so far - they both have been very selfish and barely controllable.
We must begin with killing employer sponsored health plans and put individual citizens in direct control of their care instead of whatever the distracted HR team puts together or the even more distracted brokerage company that the distracted HR team contracted after googling for "employee health benefits examples"
Individual citizens are not even in the game. They have no bargaining power.
Time to change that. Let them regain control of which network they want to work with regardless of where they happen to work or not even work at all.
The employer might be looking for the cheapest network but the employee might be looking for a network with good coverage or covers certain doctors of their choosing etc
The idea of requiring list prices of drugs to be displayed in commercials seems like it might be very effective.
Imagine if you were able to do some quick mental math on your couch:
"Okay so ask my doctor about Poopathome for my rectal bashfulness... Well let's see first. It says $890/month average dose. My insurance covers 80% so that would cost me something like $180 a month. Yeah sorry Pfizer you'll have to do better."
> "Okay so ask my doctor about Poopathome for my rectal bashfulness... Well let's see first. It says $890/month average dose. My insurance covers 80% so that would cost me something like $180 a month. Yeah sorry Pfizer you'll have to do better."
..."but (hehe) maybe I'll check GoodRx too. Hmmm...they have discount coupons that bring it down to anywhere from $20/month to $100/month, depending on the pharmacy. Hmmm...it's $40/month at the pharmacy I have all my other prescriptions, but $20/month at the Safeway that is a bit out of the way for me. Ooh...look at this! It's also $40/month with GoodRx at my pharmacy for pills with twice the dosage I'd need. If I get that and cut the pills in half, it's effectively $20/month at my pharmacy! Maybe I'll talk to my doctor about it after all!"
It's ridiculous currently, and some of it makes no sense whatsoever. Here's a recent illustration of the absurdity which I experienced last month. (For those in Europe reading this--I swear I'm not making this up! This is really how we do prescription drugs over here).
There's a drug I take twice a day, 150 mg each dose. I had a monthly prescription for 30 x 300 mg, with directions to take half a pill in the morning and half a pill in the evening. That costs $9 cash at Walmart.
The cash price at Walmart for 30 x 150 mg is also $9.
The 300 mg pills were back ordered last time I needed a refill, and Walmart said they could change it to 60 x 150 mg. I said to go ahead.
Turns out they actually changed it to a 3 month supply, 180 x 150 mg...and the price was $400. WTF? I pointed out that this was rather absurd, and they redid it as 60 x 150 mg for one month...that was $300. Huh?
According to GoodRx the cash price at Walmart should be $24 for 60 x 150 mg (which still doesn't make much sense, because it is the exact same freaking pill used for 30 x 150 mg, which is $9. Filling a bottle with 60 pills instead of 30 pills should not add $6 to the cost!). They agreed to redo it yet again, as 60 x 150 mg, for the $24 cash price listed by GoodRx. (And I do mean "redo it". They could not just sell me the 60 x 150 mg bottle that they had just filled for $24. Nope. They had to count out another 60 x 150 mg into a new bottle and sell me that for $24. Presumably the first 60 x 150 mg bottle, the $300 one, got treated as a prescription that was never picked up).
When it is time to renew that, I'll be moving it to Safeway. 60 x 150 mg there is $13.99 with a GoodRx coupon.
Even if the pharmacy doesn't accept GoodRx coupons (some don't) - you can ask if the pharmacy has any discounts for uninsured persons.... if they do, it's often even cheaper than the coupon would have been.
I don't know, getting people to prioritize their wallet over their health seems like a bad solution. Maybe we should actually work on reducing the high prices instead of scaring people away from seeking medical care due to those high prices.
Right. The real solution is to be more like the rest of the modern world. Let drug prices be negotiated in bulk by your government, so that you can focus on being healthy.
I just don't believe the U.S. is capable of such significant change. So maybe one thing at a time.
Awareness of pricing will be the single biggest contributer towards reducing price. If I'm only aware of the price after services rendered how am I supposed to discriminate among my options?
Does this really increase awareness of pricing if the price displayed is only the worst possible situation in which the person has no insurance? Most people don't care what their insurance company is charged, they only care about the amount they personally are charged.
I also have a hard time believing that the reason prices haven't gone down is due to some overall lack of awareness of the problem.
Who knows, we might end up with that result that some studies found when restaurants starting posting calorie counts, there were people suddenly consuming more!
I think the fear here is that if prices are published its going to provide leverage to smaller outfits to get better pricing and that is a good thing.
the best benefit is to give Americans a true idea of what stuff is costing because so many are too separated from the cost of their health care to understand the magnitude of the problem
Damn straight. Sane countries don't put up with this shit. I don't watch normal TV so when I do see these ads they never fail to remind me what an oligarchic dystopia my country has become.
Can someone explain why advertisements for prescription medication should be banned? Perhaps I'm missing something but I don't see anything egregiously wrong with it.
The purpose of advertisement is to increase sales for a given product. Consumers are not qualified to decide what prescription drugs they need and can easily be tricked. Doctors are the only people qualified to make those decisions. And the advertisements are not targeted at doctors.
If an advertisement convinces someone to take a drug that they don't need, the best case outcome is that a company is enriched at someone's monetary expense. The worst case is that there are adverse side effects, impacting the user's health for no reason. So in this case, a company is profiting by poisoning someone and eroding the stability of society.
It's not many steps removed from selling radium water.
>. Consumers are not qualified to decide what prescription drugs they need and can easily be tricked.
>It's not many steps removed from selling radium water.
Except you've glossed over the critical extra step: you still need a prescription from your doctor, who presumably considers whether the drug a patient is requesting is appropriate.
Also consider your doctor is not aware of all of your problems and all available drugs, nor is the average patient aware of what conditions are treatable. For example, medications like chantix for smoking cessation may be brought up by patients without doctors necessarily aware of smoking habits.
I don't like ads, but I'm not convinced that ads for drugs are too much more evil than others.
> who presumably considers whether the drug a patient is requesting is appropriate.
Sure.. presumably, but let's not forget about drug reps. You know, those salesmen from the prescription companies (who run the ads) who "advertise" to doctors with fancy vacations and other perks. I've heard plenty of stories where a doctor prescribed something he/she knowingly wasn't supposed to (or there was a better alternative available), but had an "in" with the drug representatives allowing for perks they just weren't willing to give up.
You're being advertised a product that can cause irreparable harm to your health, even though you're not remotely equipped to understand how the product works, or if it even works at all.
How much worse can it get while most of the population still honestly believes it's great, though?
Getting China out of the hole it's in would be much harder than reversing the course on US politics, but only if US citizens stop fooling themselves into thinking they're in "the best country in the world".
Jamal Khashoggi. I guess moderators thought I was suggesting he was involved in the murder itself, rather than obstructing an appropriate diplomatic response. Sort of proves my point that nobody cares.
The obligatory reminder like in similar threads before - in most other first world countries it's not done because it's forbidden; mass media advertisements of prescription medicine is a practice specific to USA and a couple other places.
Exactly. In Canada you an only advertise either that a drug to treat a certain condition exists, or that a drug with a certain name exists, but not both in the same ad. Why advertise drugs to customers, they're not medical professionals - that's why we have GPs.
Why advertise drugs to customers, they're not medical professionals - that's why we have GPs.
Frankly (and maybe it's different in Canada), but I feel like people will have better health outcomes if they are aware of the options and consult, work with, and even challenge if need be, their GP.
GPs (or Primary Care Physicians, PCPs in the U.S.) share some goals with their patients, but many goals are not shared:
* Spending less money / good drug success / less side effects vs. using only tests/drugs they GP is comfortable with
* Avoiding lawsuits vs. candid discussion
* Taking time to research medical hypotheses vs. needing to get to the next patient
Come to think of it, if one is willing to invest the time, have an inquisitive mind, and demand a partnership relationship with most service providers, perhaps that person will generally have better outcomes in many areas (home repairs, dental, car service, etc.).
The only thing drug companies are incentivized to do is make money and you’re giving them a side channel to an uninformed audience, then they go and whack the trained professionals over the head with this data and risk they don’t understand because TV told them.
Does Tylenol in Canada have a small amount of codeine in it? It did when I lived there in the 90's.
Does that make a difference when it comes to advertising? If I recall correctly it was like 2 or maybe 5 mg of codeine which is a very small amount. Any dose over that needed a prescription so I wouldn't be surprised if Tylenol was considered just an OTC drug but knowing there is codeine in it made me unsure.
Yes, Tylenol 3 with codeine was available until 2018 in Canada without a prescription, oddly. But that 'loophole' would eventually be exploited by those needing their 'fix' ... so it's now prescription only.
As far as I know the rule for ads is 'non prescription', beyond that it's hard.
I don't recall seeing an ad for a prescription drug in Canada in the last decade, though they might exist in some form.
We get American TV and those ads seem quite ridiculous, what with the senior citizens dancing away, and the narrator iterating through a huge list of symptoms, then listing off 30 or 40 side effects as fast as he can, as if people are remotely capable of understanding.
My family works in the drug industry, I should say one thing that people don't want to hear: a lot of doctors are lazy. Just because they're doctors, does not mean that they keep up in any way with current issues, trends. The level of power they have, and the relative lack of ongoing certification is ridiculous. Once they get their ticket, it's a golden ride for the rest of their lives if they want.
Many people complain about the 'free lunch' doctor's visits by the sales reps, but I don't see it as such a bad thing. It's intense and important information, I have no problem with Doctors getting a 'free ham sandwich' to entice them to go through the data on the latest trials.
Obviously, there are shenanigans there, misrepresentation, competitive issues, pricing etc. etc. - but frankly a 'highly moral sales/communication force' actually I think does add value - they get doctors to pay attention to the specific issues. Obviously, there are probably better alternatives ... but again, Doctor's guilds are very powerful and archaic, nobody can tell them what to do.
Thanks, that's interesting. I left Toronto in 2001 to come back to the US for work.
I remember being shocked when I first moved there that you could get even a small amount of codeine over the counter. That would never fly in the US for precisely the reason you gave for them finally pulling it from the market - people here would buy the crap out of it to get "high" even though at those small doses you'd have to eat a LOT of them to feel a real effect. I can't imagine the stomach problems people would have taking that much of an analgesic.
Wait, so the ad goes "We have this wonderful new drug Blablagmuglub, but we can't tell you what it's for - you'd have to ask your doctor, maybe it treats exactly the condition you have!"? How that makes any sense? Or it goes "there's a drug that cures your acute bonitis, but we can't tell you how it is called"? How that's an ad for anything? That sounds like a way to ban drug advertisement completely, so why not just come out and say it upfront that drug manufacturers are not allowed to publicly speak about any prescription drugs they manufacture?
It's not that strange for new medications. Here's a personal example.
Lots of people suffer from hyperhidrosis, which is excessive sweating, generally on the palms, feet, or armpits, where sweat glands are clustered.
There have never been great treatments. There are all sorts of them, but many of them just don't work, or have horrific side effects.
Among these is a drug called glycopyrronium bromide, which is an anticholinergic. Taken orally, it absolutely cures hyperhidrosis dead in its tracks. It also has a tendency to dry up every part of your body that should naturally be lubricated in some way.
Imagine your mouth, tongue and throat so dry you can barely form the movements necessary to speak. Imagine your eyes so dry you can barely blink. Imagine your nose dry and cracking and frequently bleeding.
Lots of people would have talked to their physicians about this in the past, and lots of people would have tried options available to solve the problem, including surgical options. But all of those options were either terrible, or did little to alleviate the fundamental problem.
And then in 2018 there was a new treatment developed, qbrexza, essentially the same drug, but delivered as a topical cloth treatment. It turns out this drug is not readily absorbed into the surrounding bloodstream, and in any event doesn't cross the blood-brain barrier at all. It turns out that topical treatment works quite well for the primary purpose, with significantly reduced side effects.
But imagine you've already talked to your doctor about this problem, years ago, tried several remedies, and none of them worked. Imagine you had already given up on seeking treatment.
Then you see an advertisement on TV for your particular affliction. It sounds like a new, and promising avenue of treatment. And so you decide to go back to your doctor, and ask about this new treatment, which never existed before. And you never would have done that, probably ever, if you hadn't seen the advertisement.
How many drug advertisements do you see for old drugs? Not that many. There are some, for very common ailments like hypertension. But primarily drug advertisements are focused on new drugs.
It's not that odd to advertise a new treatment. There are still doctors that need to evaluate patients and prescribe the medication. If doctors are prescribing useless medication to patients, that seems like the primary problem to me, not the advertisements.
> And so you decide to go back to your doctor, and ask about this new treatment, which never existed before. And you never would have done that, probably ever, if you hadn't seen the advertisement.
This should be your doctor's job when you go for annual checkups. If you don't go for annual checkups, you shouldn't be surprised that your health choices are falling out of date.
>This should be your doctor's job when you go for annual checkups.
How would you know to ask the doctor about it during your annual check-up, if you aren't aware of the existence of the drug? As others have mentioned already, doctors do not tend to track every single new medication for every possible little condition that their patients could have. And even if they physically could do that (not sure if it is actually possible), do you think they would, just like every web developer would keep track of every new little framework/tool that gets released and could potentially serve their needs better?
> How would you know to ask the doctor about it during your annual check-up, if you aren't aware of the existence of the drug?
I don't rely on business users asking me about technical solutions to their problems based on advertisements they've seen, and I'm not in a field with as much required specialized prerequisite and continuing education and mandated licensing as medicine.
Now, certainly there are patients that meaningfully contribute by, e.g., actually doing deep dives in the scientific literature related to their diagnosis and related treatments, and bringing questions and references derived from that research to their doctor, which really does cover things at a level that the average practitioner might not be aware of for a particular conditjo . But the kind of ads in popular media are of marginal if any value to them.
> As others have mentioned already, doctors do not tend to track every single new medication for every possible little condition that their patients could have.
They are bombarded with even more aggressive marketing than the public is for any of the ones that are spending money on public ads, so even if there is a real issue here, public-facing drug ads are not directed at solving it.
Your doctor knows all the medications you take as well as what conditions you suffer from, when you describe that you still suffer from side effects they will update you on the latest medications.
As far as "they do not track" , they are supposed to. That's a failing on the doctor's part but putting the patients in charge based on paid TV advertisements for what is actually an extremely narrow portion of available drugs is not the solution.
Maybe there's a gap for some kind of doctor-patient communication application? The idea is a new drug like this comes out and a doctor can go into their system and send some notification to their patients
Agreed, I think it's crazy. I don't know what's more surreal, the fact that those ads are 50% recitations of side effects (which they have to say, but surely it makes them think twice about advertising), or the inevitable "ask your doctor if <blank> is right for you". What?!? I would hope that if it was, my doctor would already know about it and have prescribed it for me. If not- new freaking doctor time.
Until I saw an tv ad for Paxil, I didn’t know social anxiety disorder was a thing... visited their website, took their ‘survey’ and talked to my Dr. Started taking it and it was very helpful. Then after a few years, I didn’t need it anymore.
Yeah, see, here your GP would refer you to a psychiatric provider (probably a nurse) or you’d see it a pamphlet in the waiting room when you came to talk about how you feel because you saw your doctor more than once every 2 years because you weren’t terrified by how much it cost/if you would lose your job taking time off work.
At the time, my healthcare was fully paid for with small copays. Went to Dr as needed. The issue is, that until I saw the Paxil add talking about social anxiety. I thought I was just very shy, so why would I talk to my dr about that?
It worked for you but consider the vast population who are not as privileged to have easy access to health care. Do the ads help them? Will their lives be improved by more ads, or by removing barriers that make it harder to get medical assistance (physical & mental)?
Even though this is one step in the direction of 'free markets' ... they need to go further.
With healthcare, we fall into an entirely different domain of economics, especially because the leverage of those who have 'life saving' services over those who don't is basically existential.
A better solution would be: 'one price for everyone'.
The entire gambit of 'negotiated prices' is a fallacy in the end, it's just a matter of groups having collective power over another, it's not really economically efficient.
Either A) all Americans form a 'super powerful buying conglomerate' which is 10x more powerful than any healthcare provider, thereby forcing 'amazingly low prices' (which basically socialized medicine) - or B) we let the 'aggregate market demand' determine price, which is basically 'one price for all'.
America should probably follow one of the European examples where they have a public/private mix. I respect that some people just want full control and want to pay for that, it's fine, but there needs to be a socialized component more efficient than Medicare.
I'm not sure if Canada or UK are the best examples for America. Germany, Netherlands or Switzerland might be better.
Expecting the general public to comparison shop for their healthcare needs is unrealistic. Healthcare is a human right in the rest of the developed world, it's time for the US to catch up.
The Obamacare push is the most powerful and organized push that we will likely ever get. It failed to reach that mark. Not sure what could possibly do it now.
> The Obamacare push is the most powerful and organized push that we will likely ever get.
No, it's not too even the most powerful and organized push we have gotten, so far, but, even assuming it was:
> It failed to reach that mark.
Yeah, but it moved the starting point quite a lot. Just like the adoption of Medicare and Medicaid before it moved the starting point that it started from. Just like the adoption of Veterans health care before that...
This may make pricing more transparent but it isn't going to help anyone unless action comes from regulation or something. Martha may check which local hospital has the best pricing for an anticipated upcoming medical need but in the moment the ambulance will take her to the closest and she'll be charged bankruptcy levels for care because the system itself is broken.
It'll help further see how broken the system is, but this does nothing to actually change it. It'll be held up by lawsuits for a while then either dropped when politically viable or used to prop up a 2020 plank without anything to actually stand on.
If Trump wanted to do something positive he'd bring back the individual mandate and try to reverse the loss of insurance and cost spikes since he signed the 2017 tax bill and other legislation aimed at destabilizing the Us healthcare system. He won't, because the GOP won't, because their goal isn't to help Americans, just the wealthy and corporations like the for profit groups running the detention centers at the border for $750/kid per day sans soap and toothbrushes.
The headline “Trump Signs Executive Order Compelling Disclosure of Prices in Health Care” is a lie [0] and unsupported by the body of the article. Trump did not sign an executive order compelling disclosure of prices in healthcare (nor is that even possible, that's not how EOs work), and the body of the article does not support the claim that he did. He signed an executive order directing various government agencies to propose regulations consistent with existing law which would do that (which seems unlikely to be possible; to be both possible and necessary that would require a federal law to exist permitting the executive to require such disclosure without itself mandating it; if such a law did exist, you'd expect the EO to have cited it, which it didn't presumably because it doesn't) and also directs agencies to do some other, more likely to be possible, things (e.g., write reports identifying who the agencies think we should blame for the absence of price transparency.)
It's perhaps worth noting that this EO explicitly described itself as a follow-up of the report produced by the Administration as an outcome of the last EO Trump issued on this issue.
[0] propaganda rather than clickbait, I suspect—its a lie to shape opinion of the large number of people who will only see the headline rather than one to get people to click through to read the article.
Exactly this. Forcing companies to show pricing is not something a EO can do. It could direct Medicare to indicate the prices it is willing to pay for example, but not to require corporations to do the same. That would require actual legislation.
We saw what happened to airlines when they allowed 'comparison shopping' and internet search engines did that for us. Ugh. I'd much rather not have the same thing happen with hospitals. For that matter, i'd much rather remove it back for airlines too, as would every middle class passenger (someone who isn't bothered by extra $30 in ticket price, but can't yet afford a private jet).
I already see people thrown out of ER room handcuffed because someone with a loyalty card of a higher priority level called in :)
If you guarantee me 32'' pitch on all flights, 50lb of check in luggage, ability to change and return any ticket, any time, and good food and wine on every flight in economy, i sign to pay 2x.
After all, we have more or less this in premium economy when you have it on the flight (unfortunately it's on just a few, and business is, too drying up), and it's MORE than 2x more expensive.
What airlines have become is just an insult to the human dignity. No industry should operate that way. If you are concerned with what comparison shopping, price optimized on the Internet, and free competition done to the taxi drivers, turning them into precarious, powerless and poor Uberists, why aren't you concerned with the 'demand side' of the same problem? Much less healthcare. I'd absolutely hate to get any treatment in a system which is 'optimized' in the similar manner.
This will do exactly jack squat to control prices, but it MIGHT make enough people that are not paying attention to start thinking about what's going on with healthcare in this country and why it's so expensive.
Every time I go to the doctor in the US I wonder WHY they are doing what they are doing, WHY they want to see me two weeks from now even if I have a chronic condition that's perfectly managed already and hasn't changed in years...
I never met so many unethical individuals like since I moved to the US and started going to the doctor.
Can you share some?
I have been beaten by the surprise billing so many times that I now dedicate some of my personal time to researching the root cause and taking action, one of which is sharing my thoughts with other people in a vain hope that things will get better and improve.
I wrote a response to this article here: https://news.ycombinator.com/item?id=20281150
Would love any input!
Absurd list prices were used to screw Medicaid and Medicate. Because they often paid at 85% of list price. When commercial payers had negotiated as much as 90% discounts. But that doesn't work anymore, I think.
This kind of effort is what is required in order to allow for comparison shopping to occur. Maybe this even enables consumers to shop better for their insurance plans depending on their common needs. That would likely allow folks with certain recurring conditions to shop for the best insurance plan for them (thus also raising the risk level for that insurer and changing prices?) but that's a bit more like how a market is supposed to work.
I can't speak specifically to whether the order just increases legal ambiguity or whether it will be enforced, but I'm happy to see any initiative toward price transparency in medicine that will allow the public to start making better decisions.
> But the order doesn’t say if hospitals would have to disclose the average of all rates they get from insurers or the specific rate they get from an individual’s insurer. That detail matters: The average rates would have a milder effect on local markets as insurers and hospitals still wouldn’t get clarity on rivals’ specific secret rates.
PRECISELY. If everybody understands the negotiated rate, then any size organization can argue for that rate. This would make it easier for smaller-scale companies to get the same rates as larger plans and also reduce some of the incentives for large insurer / care company mergers that seem to be really rent-seeking given the industry comment on this order.
> we should also add that paying cash means you get the Medicare price.
Medicare doesn't pay enough. What if the doctor doesn't accept medicare?
Of course, reimbursement rates are hardly our only problem. We also use more expensive treatment options for the same conditions, give doctors (and thus patients) a level of flexibility unheard of elsewhere that allows to spend money on unnecessary medicine just to make a patient happy and have ridiculous administrative overhead costs.
Medicare's reimbursement rates could just as well be published by Gosplan. If you squint hard enough, they are almost an application of the Labor Theory of Value: There is an intrinsic value of everything determined by how much labor went into producing it. That, of course, leads to all sorts of fun stuff like seniors in Florida loading up on cosmetic surgery and ED medication on the backs of the younger generations.
The “price” is really just the unit cost. Companies seem to have no problem computing unit costs (and thus margins!), no gosplan-like apparatus is required for this beyond supply-chain management and accounting. The U.S. situation is complicated considerably by all the different parties involved which I guess is why this idea might work less well there.
Correspondingly I suppose the “true value” would be the value provided to the recipient of the procedure and society as a whole, and as you observe is much more subjective and probably best not even measured in dollars. I think “quality of life adjusted years” is a thing. The major problem is when the you and the state disagree on the value of a procedure and whether it justifies the costs...
Another way to look at it, “socialised medicine” is just health insurance collected by the state with full vertical integration; your insurer also runs the hospitals and provides the care. The upside is you’re covered, the downside is you don’t get to choose a plan.
You tell the working parents that they can deliver the baby in the shared room for no additional cost or upgrade to the private suite for $100k.
> We overtrain docs and we’ve built hospitals that focus on private rooms instead of wards. Both of those hugely increase the labor cost and will take a long time to undo.
If I was a patient at a hospital, I would not be able to control this:
> We overtrain docs
That part is outside my control.
... but, I, as a patient at a hospital, would be able to control this:
> we’ve built hospitals that focus on private rooms instead of wards
Infact, some of hopitals in the U.S. do have ward deliveries - I believe Kaiser Permanente have shared rooms?
However, that is the rub - people are not explicitly requesting private rooms - hospitals just have them so they can charge as much as they can.
If you walk into a hospital, you cant ask to have a ward delivery. They take you to a private room by default - no questions asked. That's all they have.
Then the bill comes and the game begins - if the insurance company does not pay, the hospital will then come after you. They will put you on a payment plan.
If you can't make payments, they will sell you to collections. Some hospitals might settle for an upfront cash payment but then it cannot go through your insurance and you are out of money AND you did not meet your family deductible either.
If there was a choice to new parents between ward deliveries for $50k and private rooms for $150k, I know which one I would take.
I don't have that choice because my employer might not be offering care though Kaiser Permanente and the hospitals in network might only have private rooms.
So change employers because I prefer ward deliveries?
Thank you for pointing out where I can end up confusing a reader. I write occasionally. Example: https://www.quora.com/Do-all-citizens-have-a-right-to-afford...
Not every new parent can afford the expense of birth. So the hospitals try and squeeze out as much as they can from every party to try and even it out.
As a high income earner, I'm specially vulnerable to this practice.
No judge or newspaper or activist has particular empathy that I got charged $200k for a delivery or $6k for an 2 mile ambulance ride.
I can afford to pay it so why am I being so picky about it?
It's such a regular occurrence that it does not make news anymore.
Much higher amounts make the news now:
https://www.theguardian.com/us-news/2018/jan/16/why-does-it-...
https://www.cbc.ca/news/canada/saskatoon/jennifer-huculak-ki...
I will quote:
> The insured person pays the insurance premium for the basic plan up to 8% of their personal income. If a premium is higher than this, the government gives the insured person a cash subsidy to pay for any additional premium.
So, it's a basic insurance that doesn't cover everything. Also quoting:
> "Health insurance covers the costs of medical treatment and hospitalization of the insured. However, the insured person 'pays part of the cost of treatment' and 'For hospitalisation, one pays a contribution to room and service costs'."
As you can see, there's no 'free' but subsidizied basic healthcare treatments, but then you should pay everything.
When I originally read it, it seemed like the former, but given everyone’s responses it must be the latter.
Neither would violate the constitution. It's not that long a document and written reasonably clearly. If you disagree please cite the section.
I would gladly pay more to be seen sooner by a more qualified doctor. If I have to fly to another place to do that, I would.
Other counties pay less and have plenty of doctors per capita plus waste far less on middle men.
If anything I ended up having issues at the few parts that _arent_ price controlled (eyecare in France is a pain, though I think mostly because supply of optometrists are limited)
I'm not arguing for price controls on everything in general. I'm pointing out that _in this context_ price controls are a proven strategy and work and mean that people don't _die due to not affording their insulin_.
Price control generates scarcity. Because bureaus can't have all the information about the market, it's impossible. The moment a bureau determinate a price you're generating an impact on the different areas without having the possibility to address it. The gov. is not the market, the gov can't be an omnipotent entity that knows everything, that's why they screw everything.
I lived in Canada for three years, and growing up in a fairly conservative area in the US, I was prepared for the worst - six-month wait times for life-saving procedures, etc. What I saw was more like Star Trek - people who needed medical care went to a clinic or hospital and got it, and they didn't have to worry about being bankrupted in the process.
After I moved back to the US, I got to see what it was like for most people - delaying or never getting critical procedures done, people with teeth rotting in their heads because they can't afford to go to the dentist, almost everyone 1 unexpected medical bill away from permanent financial ruin. Our system is objectively bad, and we deserve to feel bad for sticking with it.
You can cite all the market theory you want, but the US is a perfect empirical example of why those theories are wrong.
* Except for the tiny minority of the ultra-wealthy who can afford to pay any price for health care.
What a diversity of thinkers!
You can't just claim something which is demonstrably functional somewhere doesn't in fact work because your half baked theory trumps actual reality. This is why this sort of comment is downvoted.
What actual reality? Because there's price controls doesn't mean it works. It generates scarcity, always.
Go to SF, put all rentals to 100 dollars and see the effects of the price controls. They will be the same there and in China.
I am not surprised people who deny the fact of economic science is downvoting this.
Some of the middle men would have to get bent.
I imagine that dollar-for-dollar a non-profit with the right incentives and oversight could out do the VC-backed leeches driving up prescription med prices.
These amounts are small enough where the U.S. government could pretty easily cover the expenditures. So by your logic, why do we need Silicon Valley venture capital? Why not just have the government pay for the R&D and make the results freely available to everyone?
Either the government is good at allocating capital for high-tech R&D or its not. Whether you're talking about medical tech or computer tech doesn't make a difference.
This sounds like a bit of an oversimplification.
In theory, theory always beats practice. In practice, however...
Case in point: nearly every other developed country.
A single payer system would eliminate those points and drive costs to their equilibrium point.
The fallacy is assuming large insurer / care companies are interested in paying more to providers or keeping a lot for themselves.
Insurers work on margins, floats and risk pools.
More the better.
They would rather have more insured to have a larger float, a more diverse risk pool and lesser margins but more volume.
Also, why would a large insurer be OK with a smaller-scale company getting the same rate?
No market I know of works that way - a larger negotiating body always gets an advantage over a smaller negotiating body.
Which is WHY smaller companies want to become larger companies.
Otherwise it would not make sense - it's way easier and cheaper to run a smaller company than a larger company for example.
You and I can't start NewCo and demand the State of Alaska give us tax credits.
Alaska will bend over backwards for Amazon.
That's how it works.
I wrote a response to this article here: https://news.ycombinator.com/item?id=20281150
Would love any input!
Works in Japan where prices are super low and the system is very good (far more private doctors per capita than in USA).
I'm not convinced that the government can get a better rate - especially when you look at other sectors where government contracting has become a lucrative business like IT, military or space where the private sector does things much cheaper than what the government does.
>> Japan where prices are super low ... far more private doctors per capita than in US
I think the real reason in Japan might be that costs are low because there is more competition due to more private doctors. The cost of becoming a doctor are lower (lower education costs, lower malpractice insurances costs etc) and that incentivizes more people to become doctors and they are able to charge a lower fee as a result.
https://www.statista.com/statistics/268826/health-expenditur...
https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
The US is an outlier, because the US system is broken.
IMO the US healthcare market either needs to be properly regulated, or it should be converted to single-payer (a system which many other countries use with great success) - other developed countries are spending significantly less per capita for better outcomes while still allowing private healthcare for those who want it and can afford it.
It doesn't matter what seems plausible to you, what matters are the hard facts of how much is spent for what outcome, and as you'll see from those graphs, the evidence is overwhelming that the US spends a lot (both per capita and as % of GDP), and gets less in return.
I thought it obvious, but the first hypothesis from the OP:
I'm not convinced that the government can get a better rate
From the data:
Single payer system countries have far lower costs for similar if not better outcomes.
The other hypothesis:
I think the real reason in Japan might be that costs are low because there is more competition due to more private doctors
From the data:
Japan has dramatically lower costs than the US, while having a radically different system far more similar to 'Medicare for all'. The far more private doctors comment was I think addressing irrational concerns that private healthcare would somehow disappear under medicare for all (instead of just being a lot cheaper). Japan is the proof that doesn't have to be the case.
What are better outcomes ? How are those measured ?
US is still the leader in healthtech, health quality, and health service timing.
Canadians are literally pouncing on new doctors like freshmen on beer, because existing doctors no longer take patients. The UK NHS has waiting times that are measured in months.
The only thing we struggle with is cost. So again, what are better outcomes ?
https://slatestarcodex.com/2017/02/09/considerations-on-cost...
We need some price setting regulation to protect consumers from getting fleeced. When the hospital knows that I'm going to say yes, why not price every surgery at $100k?
We've tried letting the insurance companies regulate the price, but they've proven themselves incapable either because there are so many secrets making the market not fair or because they don't have an incentive. It is time to try something else. The government is our mechanism for regulation. Let's use it.
Emergency medical care isn't.
But most other things are.
It should be possible to shop around for imaging and testing services. The regular "family doctor" is something families can (or at least should) be able to choose at will.
Heck people shop dentists all the time. They shop physical therapists, and even mental health providers.
If all the local X-Ray providers near me publish their prices online the fact is prices will drop, and that will likely carry over to what price is paid during emergency services as well. It will be hard to charge someone 5k for an X-Ray in the same imaging center that has a price of $120 listed on their website!
So if you want to make people price shop, it has to be coming out of their pockets for it to work. Dentists, PT, etc that you listed have much higher rates of cash/self pay.
The reason this matters is that we don't see the same problems in other inelastic markets - for example, automotive gasoline is highly inelastic (estimated to be at -0.02 - https://www.eia.gov/todayinenergy/detail.php?id=19191), but we don't have the same pricing pathology with it that we do with healthcare (emergency healthcare estimated to be at -0.04 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5600717/). Therefore, we can't conclude that the problems are specifically due to inelasticity.
Next time when a bone in broken in your body, go comparison shopping because it's a free market and you should get the best deal while your bones hang freely.
Health care is a special case not comparable with any other market.
Or already know the price of how much it costs to get a bone set at different local providers and make your pick ahead of time.
Why assume people aren't going to shop around until something happens? "Hey ambulance driver, my preferred clinic is such and such take me there please."
Most medical situations are non-emergency.
Unless of course you aren't conscious enough to direct the ambulance driver at all.
Imagine a world where prices are openly advertised, and as a result they start to drop.
Take laser eye surgery as an example. Prices are insanely competitive! They have been going down for years, and equipment manufacturers have been hard at work making more reliable and cheaper to operate equipment that has less side effects!
We have a free market for literally curing blindness and it works really well.
Now take more urgent but not life threatening cases. Last couple times I broke something, it was of the "well that sucks and it is kind of swollen but whatever" type, and I got to choose where to get an X-Ray at.
That is a perfect case where open pricing would drive the market price down and save me money.
As another example, physical therapy prices are often advertised on the open market. So are therapeutic massage prices. Both are price competitive markets.
Sure life threatening emergencies will still be subject to price gouging, but if the entire medical system is running more efficiently then even emergency services may see a reduction in costs in places. Maybe not for the trauma center, but for the hospital stay outside the ICU, why not?
I wouldn't have done said yes to that if I had known the price.
It is also illegal to change advertised prices, not to mention a great way to lose business!
I definitely would, why wouldn't you? Broken bones are urgent but usually not life threatening - in that situation I'd definitely take a few minutes to decide how exactly to handle the situation - call an ambulance, or have a friend drive me to the hospital? ER, urgent care, or GP? Lots of options with different trade-offs, even if cost wasn't one of them!
Urgent, life and death situations are obviously a special case but are also a pretty small percentage of medical care at least IME. My wife has had quite a bit of medical care over the last few years including having 3 kids and several unrelated, important but not immediately life or death surgeries. In every case we evaluated several options before picking a Dr and a hospital. We looked at price, recs from friends, distance from home, reviews, etc just like picking a restaurant or a new car. Even in the few urgent life/death ER visits we've had we still picked where to go, we just picked ahead of time - when we get a new insurance plan we usually glance through it to make sure we know what are the closest ERs and urgent cares that are covered, and if there are multiple options we'll pick a default. Again I don't know why someone wouldn't do that, even if our healthcare were free we'd still compare on other metrics.
Why would cost not play a role in that decision?
In your anecdotal situation let's say you fell and broke your arm and are now sitting in the back of the ambulance when they ask that question. North or South hospital?
With your one good arm are will you load up a cost comparison of services between the hospitals, checking what the procedure might be if the break is impacted, if muscle tissue is torn or needs to be repaired surgically, what followups or cast removal costs, and building a spreadsheet of possible scenarios based on the underlying medical statistics combined with the risk factors of your incident? Ar you comparing that against hospital ratings for those departments and doctors and their success rates combined with education or training in line with best practices or regulations? Then are you compiling this data to make a decision based on which hospital is the most viable economically vs the standard of care for your suspected injury and reaching a decision?
Are you going to do this for every viable healthcare situation in advance so you're aware of updated costs at South or the new star surgeon hired at North hospital?
There's certainly a market for that analysis but I don't think it's analogous to real life. Most people are going to call 911, get in the ambulance if needed, and go to the closest hospital with capacity. The price, quality, and other checks need to happen at a higher level while still be transparent and open. Medicare has tools to solve this just like how the FDA us meant to resolve food safety questions and other governing bodies are there to regulate and enforce standards. Unfortunately it's not as simple libertarian as "North or South?"
So, no, of course no one is going to fire up the equivalent of GasBuddy when they're in an ambulance. You no doubt already know this, so why make such a ludicrous argument?
The only substantially cheaper across the board hospitals are those people go to die in because they are profoundly incompetent and understaffed.
Hi "Mason General Hospital" in Washington State.
...And tend to get sued out of business for malpractice.
In a free market, I can open a hospital across the street from your hospital and charge whatever I want for similar (or completely different) services. Presumably, our hospitals would also have a brand reputation: I know lots of folks who say "I'll never go to X HMO again, it's so much better at Y public hospital" and would gladly drive an extra mile or two with their broken arm kid if it means they're fairly certain they'll save a few grand (or more).
A similar example is that I'm halfway down a 200 mile highway, and I need gasoline. There could be one gas station, there could be five, but the fact that I'm allowed to open a gas station next to the sole one that exists means it's a free market. If the government says "there shall be one [or two, or ten]" gas stations here, or that "all gas stations here shall charge this rate", then it's less of a free market.
You may be trying to describe the concept of perfect competition[1]. If so, I'd agree with you that health care can almost never achieve perfect competition because perfect information becomes harder to obtain as situations become more expedient or dire.
[1] https://en.wikipedia.org/wiki/Perfect_competition
The government needs to regulate markets like this.
Consider the example of food, in general. Demand for food is wildly inelastic - without it provided regularly, for your entire life, you _will_ die. If elasticity were the only consideration in pricing, we should expect food to be break-the-bank expensive, but it clearly isn't. What else is different between the healthcare and food markets?
(To be clear, I'm not defending the current state of our healthcare system. It's broken in a lot of ways, and is way more expensive than it needs to be. I'm just arguing against the idea that the cause of its dysfunction is inelasticity of demand.)
[1] https://www.forbes.com/sites/zackfriedman/2019/01/11/live-pa...
Because welfare (and subsidy) programs exist so people aren't desperate for food, just like people who are covered under medicaid are not desperate to pay for health services.
There is really no mystery here.
The government is EXTREMELY good at negotiating prices. In other words, there are already examples of it working really well, so it's pretty clear it can work well here too with enough care.
Japan is known for really high-quality care that is insanely cheap and has more doctors per capita than in the USA. So the worry that overall service and competition would decline is unfounded.
So let's take really good working examples and try them here. The USA can do so much better, it's not even funny.
https://www.bloomberg.com/opinion/articles/2017-09-19/want-a...
We're paying our doctors sometimes double what they make in other countries and receiving inferior health outcomes. It's easy to vilify the AMA but our doctors also have an unusually high amount of risk and obligation when it comes to malpractice, which wouldn't go away if everyone magically was on Medicare For All tomorrow.
To reduce health care costs, someone needs to get squeezed... but who? Reducing doctor salaries will lead to a shortage of doctors unless there's some additional action on easing the education burden they presently have to take on.
[1] http://nbakki.hatenablog.com/entry/Annual_Salary_by_Occupati... (2014) [2] https://www.businessinsider.com/how-much-salary-does-a-docto... (2014)
https://washingtonmonthly.com/magazine/julyaugust-2013/speci... https://mises.org/library/how-government-helped-create-comin... https://www.washingtonexaminer.com/thanks-to-doctors-there-a...
in mexico, they only make geos. So prices reflect that.
in the US, you are only allowed to supply healthcare if you buy into $500,000 of loans and give up 6 years of your life. The AMA and government have mandated it to be so.
That's the price of a ferrari. US Medical salaries reflect that medical ferrari
Oh wait...
I can think of two. First, so they can spend the money on other things they want (military, social security, education, etc.). Second, is so they can get re-elected by those same citizens.
==There is no way to tell if the price we are paying is at all good value for money compared to what it could cost.
We could look at the dozens of other developed countries who work like this, should give us some clues.
Respectfully, is there any reason to think that the US government would actually do this, based on past behavior? Government spending is famously wasteful, both parties spend like it's going out of style when it aligns with their interests, government debt continues to explode, and spending continues to grow year-over-year effectively unchecked. I may just be overly cynical here, but I don't think that responsible spending is the primary election issue for hardly anyone today.
Insurance companies are not subject to FOIA requests like the government. People tie Medicare to the Government, why would this be different?
==A single negotiator will likely only make pricing more opaque==
Not sure it's possible to be more opaque than today. All of the other country's who do it this way have far more transparent pricing than the US, so I'm not sure I buy this reasoning.
American politicians are not elected by voters or citizens, they're elected by contributors. This unhinging is either a root or partial cause to many problems.
Because larger purchasers have more leverage to negotiate better discounts/bulk rates. When your choice is, "take the offer or you don't get any payment", you take the offer.
Here are three good ones: the UK, Japan and Canada. All different systems, all providing medical care for much less cost than we do in the US.
Additionally, your reasoning is flawed at best. The government can legislate that providers can only charge $x for y service, which private actors cannot. 300 million+ people is a very large market to leave just because you are slipping on profits. There are many other levers a single payer who is the government can pull as well.
"While available data are limited to select services and drugs, we find that higher prices – more so than utilization – explain the United States’ high health spending relative to other high-income countries." [1]
Perhaps the US is closer to those other countries than you claim.
1. https://www.healthsystemtracker.org/chart-collection/how-do-...
https://www.theguardian.com/world/2018/dec/27/japan-shrinkin...
The difference over there is that kids are born into families that are at least middle-class, while here in the US a huge number of children are born in poverty and raised by single parents. I don't think having a higher birthrate is going to turn out well in the long run when that's the case, compared to a country where children have a much better upbringing.
In Japan, they have to worry about the younger generations supporting the elderly.
In the US, we have to worry about the productive generations (the ones of working age) supporting both the elderly AND all the children and families in poverty and not having that bite us in the ass when those kids become adults (e.g., committing crimes, something that Japan doesn't have much trouble with).
I would prefer to trust actual stats compared to your powers of observation. In this case 1.4 births per female in Japan vs 1.8 in the US. +0.7% annual population for the US vs -0.2% for Japan.
The point is that the Japanese system isn't inherently flawed its dealing with the consequences of there being fewer working age people supporting a greater number of older individuals. This has nothing to do with your opinion on the relative social mores of the 2 countries.
Now, whether or not health care should operate under free market principles is a different discussion entirely. But the established powers seem to consistently fall back on the free market argument, but continue to keep pricing as opaque and complicated as possible.
It's some bastard child of socialized medicine where the poor and old are covered mixed with gov mandated private insurance coming from a few very large insurance companies capable of operating within the regulatory environment.
Which is basically one step removed from full blown single-payer public health insurance (as we have here in Canada) and about a hundred steps removed from "free market" health care.
I hope the US gov decides on single payer soon as I see no path towards going back to an actual market. Which would be better than the current system which features much of the worst of both worlds.
https://www.cbc.ca/news/canada/newfoundland-labrador/samanth...
https://www.cbc.ca/news/canada/nova-scotia/mother-iwk-halifx...
and for a description of typical hospital visit https://www.cbc.ca/news/opinion/health-care-1.5170948
note, CBC is basically a more liberal Canadian CNN
If you can’t provide a better alternative then it’s still an improvement.
The much larger UK NHS system where even hospitals are publicly run would be even harder to pull off in America. So single payer insurance is basically the lowest hurdle. Plus the simpler the better.
At some point the right in the US has to concede on healthcare because it’s already been gutted and killed by a thousand cuts. And I say that as a libertarian leaning person. You can’t honestly believe they can solve this problem by writing a thousand more small reform bills.
Plus if you give the mob public healthcare they will be much more tolerant of pro-economy policies and take a strong argument away from the people who want to gut even more industries so they function just as poorly as the pseudo healthcare market in the name of “fairness” and “equity” (mediocrity for all!). Lesser of evils.
Not true. Like literally every sector of a mixed economy, there is government interference. And sure, there is a lot more in the healthcare industry than most. But it does operate as a highly regulated market system wherein private enterprises compete and consumers make decisions.
And certainly it is not strictly "free market", but then again nothing is.
The existing system is nothing like a free market and anyone trying to justify keeping things the way they are with that reasoning is either being intentionally dishonest or is completely naive about the situation.
Indeed. And generally there is an enormous difference between "pro business" and "pro free market". In many cases they are the opposite. For example the information asymmetry you point out. Another is lack of enforcement of anti-trust.
Heaven help consumers and employees who live in the wrong one.
Additionally, patents and the onerous burden of the FDA need to be reduced to encourage competition.
Absolutely not.
> A functioning free market requires the open and honest sharing of price information for consumers to make informed choices.
A free market does not require any of this. In a free market the producer can do whatever they want, in a free market the consumer is free to choose different options if given producer does not adhere to their personal standards thus driving other providers to either change their behavior or just losing business. A free market does not require a government ruling them to adhere to some business practices. That is regulation and not a free market.
In theory, no, but in practice market failure is usually due to information asymmetry and consolidation. The real world is, unfortunately, not full of that economists call "perfect competitors".
> in a free market the consumer is free to choose different options if given producer does not adhere to their personal standards
This requires information symmetry -- per Wikipedia, a free market is "a system in which the prices for goods and services are determined by the open market". How can the this work if pricing information isn't available to one side of the market?
> A free market does not require a government ruling them to adhere to some business practices
Free markets in practice require legal guardrails around things such as information symmetry and anticompetitive behavior, in order to protect against market failure. Again, per Wikipedia: "[free markets] require a framework that allows new market entrants".
This regulation is not for its own sake, but _to keep a market free (i.e., open to competition) by protecting it from the grasp of one extremely powerful entity going forward_.
This executive order is also useful for uninsured patients because you now have a basis for arguing for a lower bill. And the courts would be sympathetic because everyone knows list prices are random numbers!
We have insurance. But we knew the procedure wasn't covered by insurance. So we would get the list price. We asked about the cash price. But they said we couldn't get the cash price because we have insurance.
They said that you cannot get the cash price if you have insurance because the hospital requires procedures always go through insurance if you have it. But we could lie and claim we don't have insurance. On the day of the procedure, they said, oh, if we bill it like this, your insurance would cover it! Sounded good to us.
They were wrong. So we ended up with the list price.
Your only choice is to change your employer or decline your employer provided insurance if you wanted to join an network that's receptive of your tests.
Just because InsCo1 treats a lab test as experimental does not mean InsCo2 treats the same lab test as experimental.
In your last sentence though, you seem to assume publicly listing prices would lead to a lower bill
I wrote a response to this article here: https://news.ycombinator.com/item?id=20281150
Would love any input!
That's not public information. Even if that was available, that's useless.
Realistic price does not matter at all unless we are talking millions of dollars. Being in network or not does.
Let me explain why:
Have you been to court on this matter? I am interested in what your experience was.
Here is mine: the judge was tired from the previous case and really did not care what I nor the ambulance provider thought.
To her we were just sqabbling over prices: The ambulance provider wanted way more ($6k vs $600) than I thought was reasonable and I felt I had been taken advantage of when I was most vulnerable and it was not a honest way to make a living and we should not encourage it.
The judge had no interest in how I felt: it was all a matter of how to get us out both quickly and have the next hearing.
The ambulance provider said their 2 mile trip to the ER was worth $6k because blah blah blah.
Then I presented.
I had printouts that showed that ambulance providers that were in network with my plan typically charged $550 for the same exact service with the same level of staff in the ambulance.
I was hopeful that showing this and that there was no in network ambulance providers within a reasonable distance where I was injured would help me.
Nope.
I also said it was pretty unethical for the ambulance provider to have a business plan where they would be out of network by design with all insurance companies as way to extract as much as they could from people in distress.
I was with Anthem Blue Cross - they are a pretty big company, no small fish.
This ambulance provider clearly puts it on their website and all paperwork that they explicitly don't work with insurance companies because they don't get paid a fair price.
The judge asked me if I had signed the paperwork that said I would bear all expenses before I got into the ambulance.
I said yes.
Then she asked how much money I made and what payment plan I would be able to afford.
Maybe if the ambulance charged me a million dollars, then I could try with the "bill is not fair or reasonable" story, but I had the feeling the ambulance could have charged me $10k and I would have had to pay it because I'm a highly compensated individual in the top 1% income bracket in the country so I deserve to pay more.
I now always carry blankets and bags in my car so I can cover myself if I am bleeding and get into a taxi or Uber/Lyft/etc, without getting blood on the seat, to the nearest hospital if I can.
In the end I didn’t pay a penny. I have good insurance so if they declined payment that must be for a good reason. So I researched that angle. It turned out that the test the doctor ordered was FDA approved, but not as a cancer screen, which is what the doctor ordered it for. I threatened to sue the doctor for malpractice, and she worked with the manufacturer of the test and the lab and made the bill go away. The manufacturer was pushing the test as a cancer screen, but the doctor should have checked if it was FDA approved as a cancer screen.
Healthcare and health insurance should almost be separate but should not be tied to a workplace. Disconnecting health insurance from work benefits in favor of payment will help the private market and public market pricing, whichever or a combination of both that it eventually goes.
Healthcare that is consumer focused and disconnected from employer provided:
- will have to be price transparent
- will make starting a business easier
- will make the US more business competitive as companies in other countries don't have to provide it
- will allow people to change jobs more easily
- will make ageism less of an issue
- will get companies out of your private health
- will allow bigger grouping by insurance companies across the nation not at the job level (right now small/medium/family/individual private insurance is seen as more risky because private insurance groups by employer and smaller is more risky)
Health insurance is personal and shouldn't be known by your employer, and re-signing up every year and anytime you get a new job is tedious, it needs to be like all other insurance (auto, home, life mostly) that it is a personal consumer choice and private.
Unbinding and de-coupling healthcare from the job is pro-business and pro-consumer health and will lead to true market price transparency.
I wrote a response to this article here: https://news.ycombinator.com/item?id=20281150
Specifically echoed your sentiments at the bottom of the long post, if you want to skip it.
What can we do to change it?
Would love any input!
Essentially, free market relies on certain assumptions under which the supply/demand 'invisible hand' works properly and the benefits of free market are realized - the key economics 101 assumptions are (1) large amount of both suppliers and buyers; (2) small barriers of entry and exit; and (3) full and truthful information about market conditions. The further we get from these assumptions, the less free (and usually worse for the people) the market becomes, and often we need gov't intervention to ensure that these assumptions stay true and the market behavior stays close to theoretical free market instead of degenerating into an exploitative uncompetitive monopolistic market with hidden information - as the USA medical market is doing, and seems to need such intervention.
Whatever the system, the goal should be cost effective betterment of public health.
Agreed. I feel like people just like using the "socialism will solve everything" argument while not acknowledging that right or wrong - healthcare in the USA is anything but free market.
Since much of the above is not true in real life, a patient centered market for Healthcare does not work well.
You can go from healthy to cancer to treatment to more cancer (wash rinse repeat until you or the cancer is dead) without a single decision made under any meaningful time pressure.
In the UK, where I'm originally from, I've never met anyone who wishes they had a role in evaluating healthcare pricing. In the US, I personally don't either.
All transparency will do is put a number in front of my single choice.
Furthermore, if other competing providers see room to compete on price because of transparency you might actually get more providers.
I wrote a response to this article here: https://news.ycombinator.com/item?id=20281150
Would love any input!
What's your argument against it?
I wrote a response to this article here: https://news.ycombinator.com/item?id=20281150
Would love any input!
Overwhelming even
I dont think the constitution envisioned how big of an organization the executive branch is, all with independent sweeping rule making autonomy. Only industry enthusiasts know the specifics of one agency’s depth of rules. Someone elected by the people for totally unrelated reasons has no way of knowing everything these agencies are influencing
I feel like your response is copy pasted for any use of an EO
I don't think anybody wins in this event
The Constitution outlines specific responsibilities of the President in Article Two. [1] Those responsibilities:
* Command the armed forces
* Have a Cabinet (have the heads of subbranches as direct reports)
* Conduct foreign diplomacy
* Give State-of-the-Union addresses
* Not be bad at carrying out the will of the law; "faithfully execute" whatever the law tells them to do
* Get impeached if Congress says so
There are some things that the President is enabled to do at a whim, but they are not as broad as you'd think:
* Issue pardons
* Appoint judges, diplomats, etc. with Congress's approval
* Call special sessions of Congress
I agree that, in order to be aware of the full nature of the law, the President needs to be surrounded with legal professionals who can advise them on how to not violate the law. But, in Article Two, it's clearly spelled out that the President should have a Cabinet in order to delegate day-to-day responsibilities further.
Finally, as a reminder, the President wasn't supposed to be chosen by the people, but by the Electoral College. [2] The Presidency should not be a popularity contest.
[0] https://en.wikipedia.org/wiki/Corporatism#Fascist_corporatis...
[1] https://en.wikipedia.org/wiki/Article_Two_of_the_United_Stat...
[2] https://en.wikipedia.org/wiki/United_States_Electoral_Colleg...
The president is, literally, the chief executive officer of the US government. He holds an office under the United States, and that office is executive in nature, and it is not subordinate to any other office.
In the time when the Constitution was framed, and in many times since, there is the meme of "checks and balances". [0] The overall idea is that no one branch of the Federal powers may be unilaterally or universally unabridged in its ability to act; other branches have powers which may check, veto, review, or otherwise neutralize certain actions.
So, why is the President sometimes called "chief"? Because, as Article Two also states, they are the "Commander in Chief" of the armed forces. When it comes to military decisions, yes, there is no office above the President's; however, note that the President's military powers are neither unilateral nor unlimited. Crucially, the President isn't able to declare war or allocate funds for military use without Congress' approval.
Hope this was informative. The USA's Constitution is a fascinating document worth reading, even for those not from the USA.
[0] https://en.wikipedia.org/wiki/Separation_of_powers#Checks_an...
Correct. Well, I mean, popular among the states, but not the people individually. I'm stunned how this is a difficult concept for people. I'd bet the people arguing for popular vote would change their mind in a hot second if LA and NYC went red.
The whole union's representative model is bent over backwards to keep consensus with the south eastern US for reasons that have little relevance this century, but are impossible to change.
The electoral college is from when there were 800,000 free white males in all the original states (US 1790 census), and the union still felt like it needed Georgia and South Carolina to agree to be a part of this contract for strategic reasons. I wonder how many of them were literate land owners!
Is that relevant today? Is ANY of that relevant today? Many other countries looked at the electoral college over the last 250 years and saw how it was a strategic compromise masqueraded as a feature. They decided not to do it and stick with popularity contests.
DO other countries not use it because they are not a collection of geographically / culturally / and relatively-recently separate states that have united so there is little reason to adopt a system that fairly treats unique states in relation to a larger unified federal body?
The people vote in thier states, the states vote for the president. Without it, all 48 other states get railroaded by the 2 with the highest population. We have a representative democracy because that's not fair.
You may even think you want NYC and LA to pick the president every year, but you don't.
For reference [0] I think you're going to have a bad time if you tell the people outside of NYC and LA that their voice, concerns, representation is totally irrelevant. We don't have a perfect system, but we have one that's been working for 240-some years.
[0] https://kingsjester.files.wordpress.com/2018/04/election-201...
What does that mean?
Just because we haven't had a military coup then our system is good enough and the should not be questioned?
I'm really curious what you and other people mean by that
You know people laugh at ours right? People laugh at our religion of checks and balances, since they don't accomplish that in the most optimal way. I'm not promoting any alternative, only pointing out that accepting its flaws is missing in the collective conscious in the US. Practically all attempts at democracy over the last 200 years contain patches seen as improvements over what the US created and mostly stuck with.
Youre going to have to be more specific.
> if you tell the people outside of NYC and LA that their voice, concerns, representation is totally irrelevant.
Nobody is saying anyones representation is irrelevant. But how is it fair that the vote of someone living in Wyoming weighs 3.5x that of someone in New York or California?
I don’t buy this argument. If it was majority rules, like Brexit, you would complain about that when it didn’t go “your” way.
The system is always broken according to someone.
You're viewing things from the point of view of the states instead of the people. Either - The states get railroaded because each person gets an equal vote, OR - The people get railroaded because each state gets an equal vote.
There are plenty of countries with proportionally representative/popular-vote (or at the very least, mixed-member PR) models that are culturally and geographically diverse. Germany is the best example that comes to mind.
> The people vote in thier states, the states vote for the president. Without it, all 48 other states get railroaded by the 2 with the highest population. We have a representative democracy because that's not fair.
The alternative was shown in 2016. Trump lost the popular vote by millions, but won in three smaller states by ultra-thin margins. So instead of California, Texas, Florida, and NY dominating Presidential elections, we have Iowa, Pennsylvania, and Michigan dominating them. Considering that small states are already dangerously overrepresented in the Senate, it seems reasonable to have the one truly national official elected by true popular vote.
> We have a representative democracy because that's not fair.
This is wrong on two fronts. First, we have a representative democracy because southern states essentially held the Constitutional Convention hostage. Second, the truly "representative" part of government is already sufficiently exhibited in Congress. If you want empty space to have power, you already have that in the Senate (and the House, in which small states are also over-represented).
Analogies compare dissimilar things with common attributes.
There are many many many common attributes between modern corporations and the modern executive branch.
What would be best if this was a way to collect medical cost trends for a couple of years to pave the way for price regulation.
Why pay $20k+ per year in premiums when I can just save and invest that and pay low prices when needed?
$25k/year over ten years is $250,000, and compounded at 6% is $319,000.
So yeah, I'd easily be able to self insure for anything.
Negotiated prices paid by insurance actually are pretty good, but could be even better with the price transparency that will come about with Trump's executive order.
High deductibles are one way that consumers can be made to care, but obviously that has its own problems. Single-payer would not fix the problem by itself, either... although using monopsony power could certainly help, if executed competently.
Merging a single-payer approach with a high deductible approach could work, and the deductibles could actually be paid via a government-filled HSA account that one could rollover into a retirement or college savings account, if unspent.
I think this is a trope in multiple areas trying to pose personal accountability as a solution where one actually needs systematic solutions. You see it with the climate crisis (make sure to buy only 100% organic recycled meat), or student loans (make sure to choose a major that has a 20 year postivive ROI), and medical expenses (make sure to price out and choose the most cost performant cancer chemo cocktail).
Really we need working institutions and controls those institutions can impose because the markets for industrial processes, or educational funding, or heathcare are vastly complex products with large capital, time, knowledge commitments needed to adequately check misperformance. The investments needed far exceed most time or money resources that make sense for any one person can put into single transaction. That's why collective institutions are needed to focus on developing the specialized information and policy needed to manage the poorly performing systems.
The idea that we ought to throw our trust in with bureaucrats is kind of ridiculous, particularly in the age of Trump.
But even if this were Scandinavia, incentives would still matter.
If I have a broken arm I’m not going to price comparison shop amongst hospitals.
Anecdote: I attempted to comparison shop for an mri to diagnosis a potential rotator cuff injury. While I could get the actual scan fees I couldn’t get the fully burdened cost and during the visit it’s entirely opaque what things will be new line items on the bill.
https://www.politifact.com/truth-o-meter/statements/2013/oct...
Unfortunately the article doesn't make it easy to figure this out.
This gets mentioned in every healthcare thread. With transparent pricing we'll soon know which hospital costs 3x of the other, so we (or beforehand or family) can decide which one to go to for treatment.
Don't let perfect be the enemy of the good. People can make their own decisions. There is no ethical position for keeping pricing information secret. Just because one can imagine a rare scenario where it wouldn't be useful is hardly a reason to continue hiding it.
Also, I'm not against price transparency, but I'm highly skeptical that it will improve anything. The reasons should be quite apparent but price setters will settle on or near the highest prices since everyone in the system is incentivized to do so. It also doesn't solve the problem that many people pay a $N copay noatter what the price is due to insurance. And the third issue is the in and out of network problem.
When you consider all these, along with the lack of choice for pretty much everyone, it isn't going to change anything.
This argument is too dumb to qualify as sophistry.
They said it didn't matter though because insurance covered it. But they were wrong.
Forgive my perhaps being out of touch, but isn't the primary complaint that healthcare can be _ruinously expensive_ and unaccountable?
The real issue is when people don't have coverage or when their insurance denies it. The latter is hopefully mitigated by Obamacare's "no pre-existing condition" exclusion. The former happening is pretty obvious: people can't afford it and their employers don't provide it (single-payer would help with this). Alternatively, some people just need _a lot_ of health care, and 10% of a million dollars is still a lot of fucking money.
But if you need the health care, what are you supposed to do? That's what we mean when we say "people don't care about prices". The prices aren't going to change that much because of this legislation. The real issues are 1) not everyone is paying into the insurance pool 2) there's a needless layer of gamesmanship between insurance and providers and 3) providers and insurance are working on a profit motive.
To fix healthcare: 1) Put everyone in the pool via taxation (aka single-payer), 2) Move healthcare to public or non-profit with lots of oversight to prevent fraud.
Of course when the insurance doesn't cover the procedure and see the 400U$S bill people flip out.
Well if that’s the case...it’s because the $400 bill isn’t the real cost for the service and insurance actually pays $0 of the bilked $400.
What happens is the patient pays $20 copay gets billed ~20% of the $400, or $80...then everyone but the patient is happy, Dr. gets his $100 for the visit and gets a $300 tax deduction, the insurance gets its premiums from the patient and gets their 80% waived by the provider effectively shifting 100% of the cost to the patient while still being able to account for the 80/20 split on the books.
The best thing for the doctor is to get paid (and pay taxes on) $400. The $300 deduction is of no value to them because they never recognized the $300 as income. The deduction is basically "Hey, sorry you couldn't collect your billed amount. You don't need to pay taxes on money you didn't earn".
Sorry if you fully understand this already. The lack of understanding of basic taxes is a pet peeve of mine. People make statements like "Johnny was looking for one more tax deduction, so he donated to my charity". Johnny probably cares about the charity or at least looking good in the community, because he'd have a larger net worth if he just sucked it up and paid taxes rather than donating it.
No...the best thing is for the doctor to not upset the insurance company and get dropped from their network and lose all their patients.
Remember the famous line if you like your insurance/doctor you can keep your insurance/doctor. Turns out the president has no control over whether insurance will outright drop doctors from their networks.
As to your point on accounting, it simply depends on the doctors/hospitals accounting practices. It’s possible there is no deduction as you say (no big deal to the doctor, they got paid their fee anyway) or they can use an actual method of accounting and carry the loss forward.
Yep, it's been 7 years since I took an accounting class (and it shows). Thanks for adding that.
As you point out, a cash basis taxpayer pays taxes on actual income received. Money you may have hoped to receive but didn't isn't income, so there is no tax and no deduction related to it.
If the doctor filed taxes using the accrual accounting method it would be different.
It can be waived (not treated as income at all as you say) or it can be treated as income (taxes paid) and the loss carried forward for future deduction.
You are assuming that Johnny isn't the one that doesn't understand tax deductions.
If the marginal tax rate for the Dr. is 50% (like it probably is in CA) then a $300 deduction is $150 in tax savings.
With accrual, you report income when you bill for it, not when you receive it. Suppose you treat a patient on December 31 and bill the insurance $400 on same day. You report the $400 as income and pay taxes for the entire $400 in that year.
The next year, insurance only pays $100, so now you have a $300 loss to report in the new year. But you only have this loss because you've already reported the $300 as income.
If the doctor uses cash accounting, there would not be a $400 income entry on December. There wouldn't be any income to report until they are actually paid, and then the income is the actual amount they are paid, $100.
If you have a widget that cost $50 to make/market/sell and you sell it for $100, then have a "sale" or "friends and family" discount to $60, you don't get to write $40 off your taxes. If you sold it for $40 you could write the $10 loss off of your taxes.
> Dr. gets his $100 for the visit and gets a $300 tax deduction
I think that is the phrase all of us have been jumping on. What you wrote there is simply not true. There is no scenario, regardless of whether the doctor uses cash or accrual accounting, where they get $100 for the visit and a $300 tax deduction.
There are three possible situations here:
1. Doctor uses cash accounting. The $400 invoice is not a taxable transaction. Doctor gets paid $100, reports it as income in the year it is paid, and that's that. There is no $300 deduction.
2. Doctor uses accrual accounting and is paid the same year. They report $400 of income along with a $300 loss in that year. Net income is $100, and doctor pays taxes on the $100 income. Their tax for this transaction is exactly the same as if they had used cash accounting.
3. Doctor uses accrual accounting and is paid in a subsequent year. They report $400 of income in the first year and pay taxes on the entire $400. Then, in the year they get paid, they report a $300 loss, because they were only paid $100 out of the $400 they previously declared as income. The only reason this $300 loss exists is that they already reported the entire $400 as income in the previous year and paid taxes on it. They aren't getting $100 income and a $300 deduction, they got $400 income in one year and a $300 deduction in a subsequent year.
As you mentioned in another comment, there may be reasons why a doctor would want to do this. Perhaps they just started their practice and are in a lower income bracket this year but expect to be in a higher bracket next year. In that situation the accrual method may help balance their income across those two years: they can pay taxes on the accrued (billed) income in the year that their tax rate is lower, and then take the loss in the next year at a higher tax bracket.
There may be other reasons to do this as well, but none of them change the fact that accrual accounting would mean they reported $400 in income along with the $300 loss, whichever years those happen to be.
It's not $100 in income combined with a $300 deduction, whichever way you account for it.
There is certainly a difference between a list price and a negotiated rate, but there isn't some sort of secret "we'll tell the patient in writing we're paying $400, but actually we'll pay you nothing" rate.
The real fraud is the fact that insurance companies have been buying up health care practices/hospital systems and dropping all other providers from their networks and forcing the patients to go to the insurance owned providers (often times unbeknownst to the patients). Although there have been a couple successful large class actions by both doctors (who got dropped) and patients as well, but this hasn’t changed anything in practice just provided a little hush money.
I'm fairly certain this loophole doesn't exist.
Perhaps the latter is part of what leads to the former, and perhaps full disclosure will change things, but generally there has been no point in even trying to shop around based on price, since there are no good options and very little information about prices.
Is there a difference between going to the CareNow clinic near my house or the Code3ER near my house? I have no idea. Should I go to a hospital instead? Is that cheaper or more expensive? I have no idea. Once I get there, are things going to cost me more or less depending on which arbitrary doctor I end up with? I have no idea. If they order further tests or a consult with someone else or some medicine I've never heard of, do I have the ability there to ask questions about price? No, I've tried. Doctors genuinely seem to have no idea whatsoever what things cost, by and large.
So at that scale, not the big picture but the individual scale, prices don't matter because if they did, I'd just stay home and hope I live through whatever ails me. Which is often what I do, in fact.
I hope forcing publication of prices makes a difference. I'm suspicious that companies will find a way to do so that protects their profits, but hey, I'm hopeful.
That said, they also have to deal with liability (especially in an ER) so they have to treat any POSSIBLE thing that you might have before you leave since people often arrive with zero medical history and they have to rule out side effect things that may not be an issue. Further, the fact that their physicians often deal with advanced specialities and/or emergency medicine means you're paying for a specialty for something that could be simple. I try to stay out of ERs unless I'm worried about my life and instead use urgent care / clinic visits when my GP is not available. Their billing seems to be much more consistent, anyway, and there's less risk a physician won't be covered by your insurance just happening to stop by.
Just out of curiosity you wouldn't happen to be a twenty-something in relatively good health would you? :)
Wait until op has a baby delivered and sees crap like:
* BP/READ $349
* OR/FOO $2090
* OR/BAR $1000
* OR/BAZ $2090
Not real codes, but they might as well be with the current system...
I also bring up single-payer in a related way because the need to find in-network providers within reasonable distance often is such a limiting factor that price shopping isn't possible.
With single-payer, one could actually choose between all of the providers... in addition to other benefits.
There are websites like ZocDoc which are like yelp for doctors, but they can only do so much because of the lack of price transparency, and lack of ability of consumers to choose doctors out of network.
There could be many more, if not for various policies that impede this.
If price transparency and quality comparison were made easily accessible, and one could actually choose options regardless of considerations like "in-network," then it would be entirely conceivable that the majority of medical procedures would involve price shopping.
And such shopping around based on price and quality would improve things even for those who do not price shop. Feeling the pressure of market discipline would force providers to compete on quality and price.
There are sites that try to be like yelp for healthcare, but you ultimately don't have any price transparency, not every doctor is listed, and you have to navigate a maze of insurance categories. In a saner world, we would have better transparency in healthcare than pizza delivery.
The other half of this has to be aggressive antitrust enforcement in the healthcare sector.
Meanwhile, my total annual premium cost is still > 20k.
I absolutely do care about prices (which doesn't matter right now, nobody will tell you what they are), and so does everyone I know, most of whom are on these same plans. The only people I know who aren't are unionized. But I have no way of finding out what they are beforehand. I don't even think this mandate will help. Yeah, sure, now the hospital posts the price - but what about the other dozen providers that involve themselves in a single procedure?
For example, my wife underwent a routine procedure a few months ago. I am still receiving bills from different providers. So far I'm at 7. Never mind trying to even audit them to see if they really did anything!
At the same time, do we really want health care to be under intense price pressures? I'm not so sure. I imagine the medical bureaucracy will continue to expand unimpeded while actual quality of care will go down. That's what I already see happening as a result of cost-cutting.
That said, there are definite things that increase the cost disproportionately, and the way the government subsidizes insurance through an employer makes a major disconnect between patients and providers. If the subsidy were eliminated and insurance untied to employer you would have a huge step in the direction of unleashing market forces.
Untying insurance from employment is a great idea, but it won't solve this. With HDHPs being so common the 'disconnect' between providers and patients is already not a real thing. Neither will single payer fix the underlying problem, although at least individuals will be better off.
At any rate, entrusting laymen to understand when they should and should not seek emergency medical attention means that people will die through entirely preventable causes in an attempt to ration their health care spending. Your cure sounds worse than the disease.
There are no effective market forces you can 'unleash' in the case of health care. It wouldn't matter if you removed all government regulation and subsidies tomorrow. Even in a world where it all somehow works out, do you want medical providers in a race to the bottom? In the absence of meaningful quality of care information (impossible), consumers are incredibly sensitive to one thing: price. What you will end up with is cheap(ish) providers providing incredibly substandard care by cutting corners and killing people.
Long way to go for HDHP to take over the market. But its definitely the way to go. It will however attack mostly the primary care market, not the hospitals which are 40% of the national health spending.
> At any rate, entrusting laymen to understand when they should and should not seek emergency medical attention means that people will die through entirely preventable causes in an attempt to ration their health care spending. Your cure sounds worse than the disease.
Not my "cure" thats the economic reality. Unfettered access to healthcare will give you skyrocketing costs. You cant complain about both at the same time, they are a trade-off. I do think that cost is the single most important thing to attack, and the policies to do so are very easy to enact. They are just very unpopular, because the democratic party wants to increase the state, not make healthcare cheaper, and because republicas have their head up their ass on this topic for reasons I dont understand.
> Not my "cure" thats the economic reality. Unfettered access to healthcare will give you skyrocketing costs. You cant complain about both at the same time, they are a trade-off.
Yes, if the problem is skyrocketing demand. But it isn't. Yes, if we waved a magic wand and provided unlimited free access to medical care, demand would rise somewhat. But demand is not the reason for the current high prices, and it's not the reason costs are outpacing inflation. Medical care in the US is much more expensive than in comparable countries, but demand is not appreciably different.
As long as people keep looking at this through a "market" lens, or through a "just make it single payer" lens, the problem will never be solved. The fundamental problem isn't that demand is too high. The problem is cost disease, the root of which consists of dozens of different factors. This is a decent article, albeit one that barely scratches the surface.
https://slatestarcodex.com/2017/02/09/considerations-on-cost...
Look at those graphs! It's mindblowing! Medical costs have increased ten times more than inflation, while doctor and nurse salaries were flat (actually worse, since now their salary goes to paying off educational debt) over the same time period. If there's a demand problem, why aren't salaries of medical professionals rising faster than inflation?
Lastly, I think most people would disagree that cutting costs is the most important thing. Going bankrupt is better than dying of pneumonia because you were worried about wasting money on a doctor visit.
There is definitely a sort of impasse on both ideological positions. The forces that be for some reason have not agreed to test out their ideas: a public option and deregulation simultaneously. But neither policy is popular in neither party.
I disagree with your diagnosis, but I'm willing to do a policy that satisfies both your ideas and mine. Support a public option that will not have the issues you mention, and let me have my unlicensed, foreign, cash-pay, non-subsidized doctors, non-FDA meds and malpractice waivers.
The other part that someone like Sanders is pushing is tuition-free colleges. If doctors aren't burdened with half a million in student debt, maybe we can get cheaper care.
You combine both programs and you get a real win.
I already posted a link showing doctor and nurse compensation have been flat in the same time period that medical costs increased 10x faster than inflation. While free university might be a good idea for other reasons, this isn’t it.
You don't have the benefit of government negotiation today and you cant seriously say that the government runs without overhead.
Except that quality information gets provided quite satisfactorily in plenty of industries, even ones that might appear otherwise quite opaque. Sure, sometimes it is done in distorted and counterintuitive ways (many marketing practices, including many kinds of advertising, are ultimately reputational games that are designed to signal quality), but meaningful info is far from "absent"!
It should be possible to reopen those negotiations and reach a fair conclusion, but there's going to be a lot of fighting on a case-by-case basis (with a lot of cases). I believe it would ultimately work out better for everybody, but the "ultimate" would be years -- if not decades -- away.
Welcome to vested interests.
> It should be possible to reopen those negotiations and reach a fair conclusion
As much as Uber can negotiate with taxis. The solution here is to cut all the bs out and dereg. Import free doctors from all the world for cheap, by allowing them to practice medicine and to apply to a Doctor visa. US can triple its doctoral staff in 5 years with no educational cost by simply doing less things.
That's exactly how things were in the 1930s. Healthcare was unaffordable to the degree of public outcry, which is why universal healthcare legislation was introduced repeatedly and stifled by the AMA every time. In fact, early health insurance programs were designed to bypass pay-as-you-go medical fees because they weren't meeting the needs of the hospital or patients. It wasn't a tenable system.
It seems we're regressing.
The problem is not that the AMA was able to attack socialized healthcare, but that the AMA was able to dictate who would be able to practice medicine, what their education should be, how much they should charge and how they would organize.
Any american could go abroad to a country like say, Argentina, get free medical education and come back and treat patients without half a million dollars debt. But its illegal.
Although, we certainly do spend irrational amounts on healthcare, partly because consumers don't bear consequences for going with the pricey procedures.
There's also numerous layers of regulatory capture, artificial scarcity, and rent-seeking in order to protect various industry-wide or regional cartels. The combination of that with consumers who have no reason to care about price is a potent recipe for price gouging.
The AMA is one of those. Hospital associations, medical device associations, phamaceutical associations, electronic medical record companies, and so on all take their cut.
I think public investment in educating medical providers is too small (it shouldn't be profitable to wrap a provider in like 5 people...), but doctors that aren't total fuck-ups are doing great by the time they are 45. We are likely in a supply constrained situation right now, prices would be nicer if there was excess supply.
There's plenty of people on Obamacare who are getting heavily subsidized low deductible policies, and paying very little.
The government is the largest employer, and most government employees do not care about prices.
Throw in those who are unionized or at cushy stable jobs with low deductible plans, which is innumerable millions more.
I'm thinking at least 75% of the country has little reason to care about prices, and even if they did the system is so byzantine that there isn't much they could do if they did. This is all an interlocking and self-reinforcing problem, which rewards the various layers of the healthcare industry with windfall gains irrespective of their own quality.
I think everyone here recognizes the insane inefficiencies of US healthcare. Maybe single payer could help streamline things. Or what if this price disclosure requirement could be wrapped into a more comprehensive system that allows all parties choice and visibility and interoperability?
I know it doesn’t work great for everyone though and I’ve seen some discussion that it doesn’t bring down costs because of the lack of transparency in pricing preventing comparison shopping (which is also my experience).
Can’t wait to hear their arguments how open pricing would only confuse consumers and cause complete destruction of the US healthcare system.
They have private providers, employer-provided private insurance, and somehow manage to come in at around half the cost of the US system, for universal coverage and some of the best outcomes in the world.
If we used fixed prices, as Japan does, this sort of regulated transparency would be unnecessary.
This might help a little bit, but there is no silver bullet.
Putting that burden on the individual is akin to a reverse lottery, where an unlucky few pay are forced to pay obscene bills in order to survive.
Putting that burden on society is "socialism" and is at odds with market economics.
You could drop the cost of care just de-regulating. But Milton Friedman failed, who would succeed today on that path?
That's a huge oversimplification and isn't true in many cases, for example when a single drug company owns the patent on a life saving drug. The laws of supply and demand are not in favor of those who require that drug to live.
Patents are a form of regulation. De-regulating would include voiding those patents. The government created that monopoly and all its attendant problems; there is absolutely no reason why it can't remove it just as easily.
A silver bullet would consist of introducing a single-payer system and winding down the HMOs.
We can start with the medical facilities, who will literally lose nothing by having transparency in their pricing. Now you can compare hospital prices; great!
Next we can expose the insurance companies policies per code, and we can apply them to each hospital. I could imagine tools where you select your plan, then select what you'll need.
Yes, I know there are well over 10k codes, and this can get complicated. But that doesn't mean we should just give up.
It's a start. Right now I have no idea what a hospital bill will be. If I know that I can figure out what will be left over after insurance (or even, what the cost will be when insurance company routinely denies a claim because they can.)
All progress is incremental. And pooh-poohing a small step forward is IMO what's holding us back.
Many (most?) hospitals will give you semi-accurate estimates if you hassle them long enough these days; I recently spent a month and a half and a dozen phone calls getting an accurate estimate from UCSF on a predictable medical procedure (cost: $3,300 OOP on a $10,000 negotiated rate).
To treat the problem, you have to go straight to the root.
And that problem is: The cost of free is too damn high.
Most people in the US don't pay for their medical care or their medical insurance. It's "free", at least in terms of money out of pocket.
We need to remove the corporate tax deduction for healthcare insurance from the tax law. This in turn will solve most other problems as market forces are brought back into the picture.
Once people start selecting and paying for their own policy, they will be more price conscious on their claims, as most people already are on their auto insurance.
Once people are more price conscious, medical facilities will begin to complete again on price and insurance companies will focus on individual plans.
It all has to start with the consumer though, and currently the consumer doesn't care what the price is. They don't pay for the medical care and they don't the insurance premiums.
The government should be giving this away for free.
The government has no money. So you're saying the tax payers should be paying $2000/mo/recipient.
In this scenario you've made nothing cheaper. You've only externalized the costs on to us. You could argue this is for my/public good, but you didn't ask me, you didn't get a representative vote from me. In your scenario you've just decided how to spend my money. I hope you understand you've only just made the problem worse because nothing has preventing it from being $4000/mo now that they know the gov will buy an unlimited supply.
edit: To be clear since posts below don't seem to get it... You're missing a step. You've done nothing to solve the $2000/mo problem, just shifted the costs to everyone. This is the issue with healthcare, the off the cuff solutions don't actually fix the root problems.
The government is able to achieve economies of scale that the private sector can't. I think you know damn well "the government should be giving this away for free" is just a simplified way to describe the economics.
> You could argue this is for my/public good, but you didn't ask me, you didn't get a representative vote from me. In your scenario you've just decided how to spend my money.
Right, you got yours, so you're rationalizing away your part of the cost burden.
You're participating in a society. The consent is implied. If you don't like the terms of the contract, feel free to stop enjoying all the fruits of civilization.
No. I earned mine. And now here you want to come along and have it spent on something we all agree is a scam at $2000/mo/user.
I reject the premise that any money spent on the social good is money well spent by default. I argue that money spent wisely the goal, GP had no plan for wisely, just spend to spend. That is why ACA failed, it did nothing to adjust costs, just signed everyone up into a broken system.
At the same time most people here are just saying "it's been invented, patent expired and should be free now!" which is another way to say "I want remove incentives for new drug research by making it very high risk and low reward". So I disagree with that too. I wonder how many people understand why the USA is the center of pharmaceutical research and in general healthcare research?
Feel free to attack me for just not caring about people selfishly, surely I'm a greedy monster. That seems ineffective to me, but what do I know!?
I think you are technically correct that Truvada is a life saving drug but I feel you are being dishonest. If you exclude occupations where you could be exposed to HIV, most of the US users of Truvada could choose to change their behaviors and reduce their chance of contracting HIV to <1%.
There is also the general trend that US companies pay large amounts of money to develop drugs, charge US customers enough to cover R&D costs and then sell the drugs at cost internationally. Does that suck for us? Yes, but it helps the rest of the world significantly.
For type 2 diabetics, behavior changes should be a part of the treatment plan. That said, if you currently have diabetics and you don't get insulin you will die thus it does qualify as life saving medicine.
>Why don’t men stop having sex with each other and then they won’t be at risk for HIV?
While it is not pleasant, people are not going to die just because they have to stay abstinent. You don't even have to be abstinent, you can find a group of 10 or even 50 guys, make sure everyone is HIV negative and then you can do what ever you want, as often as you want, with no need for drugs.
Calling it a "life saving drug" is correct in many cases (NGO worker in parts of Africa) using the term "life saving drug" to advocate for people to be able to cheaply have unprotected sex with strangers is dishonest rhetoric.
And we can stop working on making cars safer - all we have to do is tell everyone to follow the rules of the road and almost all collisions will be prevented!
A lot of money has been spent reducing tobacco use which has paid for itself in better health outcomes.
In the case of Truvada, we already did the hard part (inventing it). Now it’s just a chemical that can be infinitely duplicated a low cost. It would be a huge wasted opportunity, a moral crime really, not to give it away for free to everyone that can benefit from it.
And the same is true for the flu vaccine, the birth control pill, the seat belt, etc. These are miraculous technological advances. If you support the use of these advances, but not Truvada, I would take a hard look at what factors might be playing into that.
OK, you seem to have some misunderstandings about HIV. Through an accident of history, HIV in the US spread through the gay population first. That is not the case for HIV generally, and any thought that not having sex with other men is going to protect you is totally wrong.
https://www.cdc.gov/hiv/group/msm/index.html
The second risk factor is using intravenous drugs. Stay away from these two things and you are very safe.
It’s also not so much historical factors as the fact that anal sex is a little more than 30x more likely to spread HIV than vaginal sex.
It also cheaper to put people on prep than to pay for their HIV treatment. Who is paying for all the HIV treatment to opiate addicts? Medicaid is which is the government.
Considering that the alternative is simply not having unprotected sex, it is hard to convince people that they should subsidize this in rich countries. This is by design, or else we won't have drugs at all
What about being born to a parent with HIV? Or not making a one-time mistake? Or being raped by someone who has HIV? The issue with HIV (unlike with other health issues that could stem from lifestyle habits, e.g., obesity or diabetes, to a certain degree) is that one slip is enough to get your life depending on that drug for the rest of your days.
Even if I disagree with the whole "make people pay for their mistakes, to amortize the costs for the rest of the society", I at least understand the logical train of thought occurring there. But there is no real lifestyle change for someone who got HIV that will cure them, and it doesn't even necessitate to have a certain "wrong" lifestyle to get HIV.
I believe its use is for pre-exposure? Anyway its not about passing judgements about lifestyles, but since there is a much cheaper alternative, people won't be persuaded to subsidize the expensive stuff.
It’s also not a rich vs poor country thing at all. It’s generic in almost all other parts of the world outside the US.
in rich countries it s subsidized by generous healthcare contributions
The Preventive Services Task Force also just put new obligations on insurers in the past two weeks - through an A rating on PrEPs - to provide people with private insurance the drugs at no cost (a mechanism the ACA put into place).
https://www.hhs.gov/about/news/2019/05/09/trump-administrati...
Maybe those free doses are being distributed to clinics for people who are not capable of initially paying for or even filling out forms for reimbursement.
I don’t believe this press release is actually announcing any change in the situation on the ground for people who need Truvada - I’m saying that as a person who’s on Truvada, and who’s helped other people get it. If there’s any change, it’s not mentioned in that press release.
I think it’s just like all the press releases where Trump claims credit for some growing business’s hiring plans. It’s a cheap way companies can curry favor from the administration. Kind of slimy but of no great consequence.
Has anyone else had a doctor or nurse filed the wrong paperwork for a blood test, and then you get stuck footing the bill for an obscenely expensive test you didn't need or want? It's happened to me several times. And you have to pay whatever price the test facility sets, period.
The system is broken and until the insurance industry's grip is broken, we are not going to get relief.
You argument seems to be that since this doesn't work in all situations, it is useless. I strongly disagree.
On my current commute to work, I drive by at least 2 major hospitals and know that a 3rd is not far out of the way. If I was willing to drive up to 2 hours, I could choose from at least 7 major hospitals. For emergencies I don't have time to shop. If it is something important but planned (fixing a torn ACL) it would be nice to be able to look up the price at the 7 different hospitals. If one is 1/3 the price of the others, I know which one I am picking. Current rules make it impossible to price shop for fixing an ACL this would make it at least possible.
What if you shop before the emergency?
Most of us either choose the lowest cost option on the public market that suits our needs for emergency care or take our employers options, of which there are one or two. Even if you had previously made a choice, which again is not something most people can or want to do, when an emergency happens, it’s an emergency! You will have to be taken somewhere.
There are many times when an ER is full, you are outside of your home area, maybe just traffic, that would push you to another hospital in an emergency. Your argument is not only poorly made, I find it hysterically obtuse. Most people don’t want to get to or even have to choose their damned emergency care. To assert otherwise is disingenuous
That's called buying health insurance.
And for most major health care issues, the primary concern of the patient isn't price, but rather outcomes - quality of care. Do we choose the cheapest doctor, or the doctor with the best reputation?
My wife, who is a dancer, tore her ACL last year. Not getting it fixed, and fixed right, was the difference between being able to continue dancing, and having to give up the thing she loves the most. So when decisions like "Use transplant tissue, or cadaver tissue?" came up, there was zero thought given to "Which one costs the most?" It was all "Which one is most likely to get her back on her feet and allow her to continue dancing?"
Most people in the US have never had a way of knowing who the 'cheapest' doctor is until after the bill comes.
The real financial decision isn't on price comparison, but rather whether or not to get the treatment at all. I made a cost-based decision on treatment a while back. I was being treated for an eye problem where I was at risk of permanent blindness in my right eye. Treatment involved monthly injections of a quite inexpensive drug (about $27 iirc), that was inexpensive because it was developed for other, more common conditions and had been around for a long time. My doctor wanted to try a new, specialized drug, hoping for better results. It cost $8000 a dose. With 90% coverage, I would have been paying $800/mo out of pocket. I decided to stick with the cheap drug that seemed to be working.
But that's the sort of cost difference that matters, not the "This doctor is 5% cheaper!" dream of idealized free markets.
Many people, perhaps not you, but many, would like price to be able to be one of those variables, as it is with nearly everything else in our society.
This is exacerbated by the fact that our insurance hides most of the cost variation from us anyway, and health care networks turn potentially cheaper care into probably much more expensive care. Writing this all off as "privilege" is a gross, lazy oversimplification.
Our family has four people in it. We've spent plenty of time and money on medical care in the past 18 years. Almost everything we've done medically, we could have made use of price transparency, if we had it.
Yes, there are scenarios where the most important thing is to get emergency care as soon as possible. These are the exception--the rare exception--not the rule.
Stop. It's not rare, 6% is not rare [1]. 10 states have 10% and above, up to 26%. Emergency room visits happen quite often enough.
[1]: https://www.kff.org/other/state-indicator/emergency-room-vis...
adjective
(of an event, situation, or condition) not occurring very often.
I'd say 6% fits that definition. You're also ignoring the fact that, for various reasons, people show up in an ER when they really didn't need to.
This helps in the vast majority of cases and you're being needlessly argumentative.
In fact, to use that stat per 1000 people is not very useful.
Number of people per 1000 visiting a hospital for an emergency would be more helpful.
I suspect it would be much less than even 1%.
Many ER visits often happen because people can't afford insurance and preventative care. If this alleviates some of that by permitting more competition due to price transparency, then it will become even more rare.
Strongly disagree.
According to NPR today, something like 75% of in-patient and 90% of out-patient events are shoppable.
Think something like having strep throat, or having a possible broken arm. Nothing stops you from looking at a few places before treatment.
Sure some cases are you got shot or had a heart attack and had to get rushed to the ER. Of your total medical visits in your life, what % of your total visits were like this?
What are these numbers based on? I recently needed to have some blood tests done (cholesterol and A1C) and blood tests aren't covered by my NYS marketplace purchased health plan. So, I called multiple labs in my area and I couldn't get a single one of them to give me a number. They couldn't even give me a ballpark. I couldn't even get anybody at any of my local hospitals or doctor's offices to give me a base cost of an appointment with an allergist to look at a rash.
Except that you're laying on the ground writhing in pain, not the easiest time to pull out your phone and pull up pricewatch.com before you call 911 to find out which hospital has the best deal on x-rays today.
You find a specialist the next day. And if you require surgery, that's another day or two. There's no reason you couldn't do a cursory sanity-check on pricing in this case (if pricing info was easily accessible).
I've even broken bones on vacation and only had x-rays after I've arrived home. Does it hurt? Yes. Am I incapacitated? No.
When I broke two fingers a year later, I took my own x-rays at a dental clinic for which I did some maintenance work. Yep, they were broken. No, I didn't pay anyone to tell me to stop using them for a while.
Sure, lots of broken arms need a cast, but this idea that you can't shop if you're in pain is goofy.
It's very doable. When I broke my arm in highschool, I was in mind bending agony for a few minutes. Then I put some ice on it and went to work the next day. Didn't get a cast on it until after work.
Next time you're in a car accident, I really want you to stop and "comparison shop"
Edit: To clarify I am an American myself and this irritates me.
Personally, I favor what many other nations of done and that's setting a set of fair prices through an expert panel - nations like Japan, Germany, and France do that IIRC.
But most expenses are pretty predictable, like the colonoscopies that I have to get periodically (and which I do shop around for, altho it's damn difficult). Yeah, if there's a bowel perforation all bets are off, but that happens 1/1000 times.
We realized we've been bamboozled. Nearly every hospital and clinic uses the same trick: the doctors apparently don't know what anything costs, the office staff say they don't know what anything will cost us because it depends on the insurance, and the insurance company won't reveal the price until the office staff charges the insurance. All the indirection makes it difficult to determine even a ballpark figure. (It no longer surprises me when the hospital charges $4000 per night to merely sleep in a bed with nurses and doctors nearby.)
We decided we're no longer going to make an exception for health care (except in emergencies). We're going to require a price ahead of time so we can discuss it like we do everything else. We intend to annoy the office staff and insurance company until they comply and tell us what the prices will be. We think about it this way: heavy expenses can easily cause stress that reduce our quality of life, significantly offsetting whatever we might gain from medical procedures.
I'm glad the legislation seems to be working in our favor.
Interestingly enough, in dental medicine everybody seems to be completely able to give the full price upfront, and explain all out-of-pocket costs before I even start talking to the doctor. I wonder what's so different there that can't be replicated elsewhere.
Dental insurance firms would probably like to engage in all the price-fixing and patient confusion that other health insurance firms enjoy, but they can't possibly employ enough people to arrange their dastardly schemes with tens of thousands of different dentists. Instead, they have to publish (to dentists, not to the public) lists of reimbursement limits by procedure code. Dentists decide whether they'll accept any particular insurance plan largely based on reimbursement, and many of them are willing to discuss those decisions with their patients. At the same time, most dental patients don't have insurance at all [EDIT: and many are fine with that, since they can afford the care they need].
Single physicians in family practice would be in largely the same position as the typical general dentist, but the work they do is a relatively smaller portion of the overall industry. After all the real screwing from medical costs takes place via hospital visits and high-tech imaging. Even a smaller hospital will start getting calls from insurance executives after they generate a few expensive cardiac procedures in any particular quarter.
Don't take this as a defense of dental insurance. It's fine if you get it from an employer, but after working in a dental clinic I don't think anyone should get it privately. If you need a lot of dental work they don't pay for much of it (this is also true of many employer-provided plans). If you don't need a lot of work you end up paying them more than you'd pay the dentist. Most people who need lots of dental work but can't afford it should get loans for that work, from e.g. Care Credit or one of its competitors. Yes, that sucks, but it sucks less than private dental insurance.
No clinic will even let you sign up as a new patient anymore unless you sign their form that essentially says "You agree to pay any amount that we decide you owe. If we make a mistake, tough luck. If you can't afford it, tough luck."
Things are changing... very slowly.
It is a bit ridiculous that there isn't ever even an attempt at informing a patient of their potential liability beforehand even in nonemergency situations.
This is the way the French system (mostly) works for outpatient care. So anyone who suggests it can’t/won’t work is ignoring that it does work.
Refresher: Government has a reasonable and customary price list. You pay the doctor out of pocket at time of service and you get reimbursed at some percentage of R&C (IIRC 80%)
You don't need to comparison shop reactively. You can look up some prices preemptively, and choose a preferred hospital that you know to go to when you need it. Obviously not ideal, but it does allow for something.
(You may want to consult with a lawyer friend a bit before making quite such a naked statement; that may constitute blackmail in your jurisdiction. But there will still be "ways" of phrasing things in your jurisdiction. Talking to a lawyer may not be all bad anyhow, whatever it is you have to say will sound more credible with some lawyer's letterhead on top. Hospitals hear a lot of amateur lawyers expound their novel legal theories every day.)
I'm not going to deny the relationship in that situation is still lopsided in the direction of the first hospital, but the situation is not necessarily 100% in their favor.
It also happened in October 2010, which I think was before the wage fixing was discovered (I know the dates because it was after I signed and before I started. Any time I tried to negotiate on salary they countered on stock because they knew salary was going to multiply by a third)
There is a massive information asymmetry between health care providers and consumers. Doctors take decades of training. Hell, medical billing by itself is a degree. Consumers will never be prepared to properly assess costs. Even if they could, it doesn't matter when you are hurt and can't refuse.
It's more like food sales at a hockey game. Anyone in the arena that wants to eat or drink has to buy what is being sold. As such, prices are hugely inflated, even though the nearby gas station is much cheaper.
But even more fundamentally, the issue is information asymmetry. Consumers don't have anywhere close to adequate information to make intelligent choices about health care costs. 99% of consumers have no applicable medical training.
This is an enormous problem, and the way you eat an elephant is one bite at a time.
“Transparent” pricing is meaningless without a functioning market, which healthcare can’t be for anything but the most discretionary procedures.
The actual thought process during an emergency tends to be more along the lines of "oh fuck it hurts make it stop".
You do some price shopping around and find a hospital that's cheap. It says the hospital is in network, and you go. While you're receiving treatment the hospital has another doctor treat you who happens to be out of network and now all of your shopping is rendered useless as you get slapped with a huge bill.
This is one of many reasons why shopping for healthcare treatment is ultimately useless. What do you do if you go to the hospital and get slapped with treatment that you need, but couldn't shop for until you arrive? What if it's especially critical treatment?
You simply cannot shop around for most medical issues like you can other things because information asymmetry is too high. And putting off a medical issue to do this shopping is frankly horrifying because you have zero clue if the issue you have is critical or not!
If you're experiencing the symptoms of a stroke for example this is an entirely time critical medical emergency. Any second spent not getting treatment reduces your chances of a fuller recovery.
https://onlinelibrary.wiley.com/doi/full/10.1111/1467-6451.0...
I disagree. Almost all out-patient medical procedures are pre-planned and it would be possible to comparison shop if there was actual pricing info. Even in terms of hospitals, an estimate is that about 1/2 of the patients are admitted through the ER. Obviously there are emergencies and you aren't going to be doing price comparisons if you are in an ambulance after a car crash, but that isn't the majority of medical care.
https://www.nytimes.com/2013/05/21/business/half-of-hospital...
>...The system is broken and until the insurance industry's grip is broken,
I don't think there is a simple magic bullet that will solve all of the problems with health care in this country.
If we have to completely solve the problem and overhaul the system in one giant step then we'll never get anywhere.
The insurance companies and hospitals know it, and that's partly why they fight so hard against small changes like this.
this is absurd. there's plenty of spending that isn't in any hurry, and doesn't need to be. a couple of things off the top of my head; opthalmalogical checkups, having funny moles inspected/removed, annual exams of all varieties, vaccinations... the list is enormous.
> but even a relatively common illness makes comparison shopping unrealistic
take your GP's rates for the services you expect to need over the near year or two into consideration in advance when choosing them.
> Has anyone else had a doctor or nurse filed the wrong paperwork for a blood test...
maybe if you could check the price ahead of time, you could've checked that they wrote down the correct test?
maybe you could. I couldn't. My knowledge of the difference between various unpronounceable enzymes is not adequate.
Even if I had an app that could tell me the exact costs, how would I know what the Doctor actually intended?
For instance, our tax system.
The only real way you would ever have a true legit overhaul would be to burn the entire thing down. Now, while I'm not even remotely suggesting that, it seems the only feasible way to start from scratch.
I just don't see any incremental adjustments working that would not be thwarted in someway.
Now that I've typed this out and read it, a big part of the problem has got to be lobbyist. Get that out of our politics 100% and we might be able to see some progress.
I'm sure this comment will be followed up with someone saying "nah I've been concerned" and that may be true, but let's look at the common mode here.
It's like the people arguing for bigger government are many of the same people arguing against government when it's someone they don't like in power and can't see past their own noses on this.
I'm not everyone, and it is something that's of deep concern to me, as it should be to you. So feel free to shelve your cynicism and join me in asking our representatives to do better.
Let me help you out. A "whataboutism" would be if I made a post saying "Well, Trump did this one good thing, but Obama passed Credit Card Reforms!" See how those are non-sequitur?
The healthcare cost problem is one of the top issues (maybe THE top issue) for voters in 2020, and Democrats have real, substantial proposals. What's the Trump response? I'm guessing it's this.
I work for a startup without funding. Health care costs was one of the reasons I decided to move to Mexico. Some of the medicine is still kind of expensive to me, but for those ones it's still literally 10X less than across the border.
Lets put it this way. Being in kidney failure/dialysis. I take around 12 medications a day and I think only 1 is non-generic. I think lots of health needs could be met by affordable access to the basic stuff.
If so, how does their omission not fit the legal definition of fraud?
My guess as to why is that hospitals are just as confused about how insurance pays for things as the general public is. They could never accurately estimate what a patient would pay out of pocket.
The problem with healthcare service is that it's not some off-the-shelf product - you don't know what level of work you need going in, and the need for more services may be uncovered later. Giving a price guarantee on something that changes based on the service being done isn't as feasible, especially when coverage changes depending on diagnosis codes.
It would make sense if there was enough competition pressure. Lack of price guarantees pretty much proves lack of real competition / price finding.
I always look to things like Lasik surgery or plastic surgery where there is a ton of competition and real price transparency. Sure, those are elective surgeries, but so are most medical procedures people get done. We might not be able to solve it for every medical procedure, but it seems like there is a lot of low hanging fruit.
Hell, in Canada, there are private MRI facilities for people who don't want to wait for the public system. Here is one in Vancouver and look, all the prices are listed.[1] Why the hell can't we have that here?
Speaking of which, I had an MRI done that a bay area hospital charged $18K for. Insurance discounted it down to $8K, but apparently I could get done in Canada for $1400 out the door.
[1]https://www.canmagnetic.com/contact-us/
and
Lawsuits could be likely, meaning any action could be delayed until after the presidential election.
a great idea, but it sounds like the EO may not actually change anything for a long, long time, if ever.
https://pbghpa.org/blog/aca-price-transparency-results-in-st...
More importantly though, these standard fees do not include any negotiated rates between insurance providers and hospitals, making it effectively impossible to comparison shop. A hospital's chargemaster price for procedure X might be $10,000, but might be only $2,000 for a particular insurance provider due to negotiation.
That's the difference between the ACA rule and this EO; the EO forces hospitals to post the real prices for each insurance provider.
That being said, does Trump have that power? Executive Orders are very powerful because the executive branch is huge. But this is an EO compelling private companies to do a certain thing. That seems beyond the reach of EOs.
I'd be happily wrong here, as I said I do strongly support this. Can anyone explain why I am wrong?
If the Department of Health and Human Services was given this authority, and the President is in charge of that department, then how would an executive order be inappropriate?
Worst-case it's not, and congress will probably take up a similar initiative so as not to appear ineffective.
It would be nice if it worked that way, actually.
Kudos to Trump on this one.
1) Trump is either bluffing or he doesn't have anyone around him that actually knows how medical billing works. If he were serious, the executive order would mandate that HHS publish the information based on the data that's already included in every claim (i.e. invoice) submitted to CMS for payment.
From a policy standpoint there are already rules in the federal register that allow HHS to publicly disclose cost information at the hospital-level. I'm no lawyer but it seems to me that a well-crafted executive order could stand up in court. Even if it were struck down, putting forth such an executive order would be a shrewd political move because it would cast its opponents in a bad light. These would presumably be insurance companies, the medical billing industry, and for-profit healthcare providers.
From a technical standpoint: there are already data pipelines in place for this sort of thing. The CMS Open Data initiative already reports hospital-level aggregates. It's not that hard to comment out a few 'GROUP BY' statements in order to get a POC up and running quickly.
2) Even if the current executive order comes to pass, people will continue to receive surprise bills and experience sticker shock. That's because the total (billed) cost is a function of:
- professional services (procedures rendered by doctors/therapists, etc)
- facility fees (hospital bed, in-house labs, etc)
For any given hospital stay or office visit the quantity and types of items in each category can (and does) vary. The current executive order mostly addresses the latter.
Furthermore, two patients seeing the exact same doctor for the exact same thing but using different insurance companies will get vastly different bills. That's because different insurance companies require healthcare providers to bundle/group (and sometimes break out/itemize) services in their own way.
Because out-of-pocket costs are, in turn, a % of the total negotiated rate patients necessarily end up with the short stick in terms of cost transparency.
Given the current medical billing system, there's simply no way for patients to know exactly what they're going to pay ahead of time because the charges won't be finalized until the insurance company decides what they will/won't cover.
No executive order will change that. Transparency will require Congress to muster up the will to write laws that put the patient first, not last.
It's not just fancy electronics - it works for healthcary stuff too:
Look at how cheap plastic surgery is! Free market at its best!
However, past the above sarcasm and after a few more minutes of deep reflection, it starts to unravel that price transparency just does not work if there is no free market.
And guess what: healthcare in the U.S. is no free market: https://www.quora.com/Is-free-market-healthcare-actually-pos...
Yes, price transparency works well in a free market
No, healthcare is no free market. Definitely not the U.S. market.
Healthcare in the U.S. is a pseudo socialized care where private healthcare dollars subsidize social care programs.
Employees on employer sponsored health plans, which are only federally regulated and rarely have the additional protections that the states they reside in afford them are nickle, dimed and squeezed for the very last dollar that can be extracted from them.
Employees are beholden to the employer choosing good plans for them, keeping those good plans around at affordable prices and continuing to be in business and able to employ these employees. TOO MANY ifs and buts if you ask me but I digress.
As long as we have something like the EMTALA or similar where services have to be rendered regardless of ability to pay, the deficit in payment recieved will have to be covered somehow!
Here are two scenarios with Price transparency:
Base Scenario:
-------------
Provider: I charge $100 cash to see a patient
Insurance company (InCo) 1: We will pay you $170 if you agree to work with us. You cannot tell our insured that you will accept $100 cash or we will blacklist you.
Provider: ok
Insurance company (InCo) 2: We will pay you $120 if you agree to work with us. You cannot tell our insured that you will accept $100 cash or we will blacklist you. Provider: ok
Medicare: We will pay you $70 if you agree to work with us. Patient 1 (w/ InCo1): Doctor, I want to see you. How much do you charge
Provider: I cannot tell you. Depends. Speak with my biller
Patient 1 calls biller and they estimate $180
Patient 2 (w/ InCo2) has the same conversation and gets a $150 estimate
Patient 1 and 2 are friends and they compare notes.
Patient 1 complains to InCo1 that he paid too much money for the same visit that costs his friend, Patient 2, much less. Plus there's this website that shows the Provider accepts on the average, less than $120!
InCo 1 calls Provider: Hey! We heard you charged less for someone else! Trump has this website that says you accept on the average, less than $120! You better charge us less too or we will not renew our contract!
Medicare patient: Doctor, I would like to see you Cash patient: Doctor, I would like to see you
Scenario 1: ----------
Provider: InCo1, Fair enough. I guess I will absorb the cost of your paperwork, cumbersome claims process, 90+ days of payment delays and reduce my reimbursement amounts because I don't have student loans, rent, staff bills to pay. Medicare patient, I will see you even if I lose money because I'm in this business because I love it. Cash patient, I will honor my $100 rate but I will appreciate if you could tip me $20 because I just lost a few hundred
InCo1: No, you have to accept $100 now because you're a push over
InCo2: Yeah, what they said. It's not fair you charge us more! Cash patient: Do you want this money or not?
Scenario 2: ----------
Provider: InCo1, InCo2, not interested. There are few of me compared to the number of insureds you have and I will not absorb the cost of your paperwork, cumbersome claims process, 90+ days of payment delays. Infact, to renew our contract, my reimbursement amount is now $300 because dealing with you is too much of a hassle. Medicare patient, I will not see you because I am losing money on you. Go see someone else in a better position than I. Cash patient, I will honor my $100 rate because I don't have to deal with all the nonsense but only if you keep your mouth absolutely shut. If this $100 ever makes it to a Yelp review, our relationship is over. I almost considered charging you $200 instead because you don't have an insurance company bargaining for you but I have a weak spot for the unrepresented. President Trump, I charge everyone $300!
InCo1: Yeah, he charges $300. That's literally what it says in our paperwork. Here, see it!
InCo2: Yeah, he charges $300. That's literally what it says in our paperwork. Here, see it!
Cash patient: I have no clue what Provider charges. I am on a payment plan and paid $150 or $100. Maybe. I don't know, please keep me out of this I just want to get better OK?
Medicare patient: I have some cash but not enough to pay per visit. Maybe I should also go into business with InCo1 or InCo2 as supplements
Which is more likely you think?
As long as we have something like the EMTLA or similar where services have to be rendered regardless of ability to pay, the solution to sane pricing is to have King Kong fight with Godzilla and keep each other in check.
We just have to ensure we can control both King Kong fight and Godzilla - and so far - they both have been very selfish and barely controllable.
We must begin with killing employer sponsored health plans and put individual citizens in direct control of their care instead of whatever the distracted HR team puts together or the even more distracted brokerage company that the distracted HR team contracted after googling for "employee health benefits examples"
Individual citizens are not even in the game. They have no bargaining power.
Time to change that. Let them regain control of which network they want to work with regardless of where they happen to work or not even work at all.
The employer might be looking for the cheapest network but the employee might be looking for a network with good coverage or covers certain doctors of their choosing etc
Why complicate matters? Keep things simple.
Politics, employment and healthcare do not mix.
Healthcare is too important.
Keep them separate. Break the ties.
Imagine if you were able to do some quick mental math on your couch:
"Okay so ask my doctor about Poopathome for my rectal bashfulness... Well let's see first. It says $890/month average dose. My insurance covers 80% so that would cost me something like $180 a month. Yeah sorry Pfizer you'll have to do better."
..."but (hehe) maybe I'll check GoodRx too. Hmmm...they have discount coupons that bring it down to anywhere from $20/month to $100/month, depending on the pharmacy. Hmmm...it's $40/month at the pharmacy I have all my other prescriptions, but $20/month at the Safeway that is a bit out of the way for me. Ooh...look at this! It's also $40/month with GoodRx at my pharmacy for pills with twice the dosage I'd need. If I get that and cut the pills in half, it's effectively $20/month at my pharmacy! Maybe I'll talk to my doctor about it after all!"
It's ridiculous currently, and some of it makes no sense whatsoever. Here's a recent illustration of the absurdity which I experienced last month. (For those in Europe reading this--I swear I'm not making this up! This is really how we do prescription drugs over here).
There's a drug I take twice a day, 150 mg each dose. I had a monthly prescription for 30 x 300 mg, with directions to take half a pill in the morning and half a pill in the evening. That costs $9 cash at Walmart.
The cash price at Walmart for 30 x 150 mg is also $9.
The 300 mg pills were back ordered last time I needed a refill, and Walmart said they could change it to 60 x 150 mg. I said to go ahead.
Turns out they actually changed it to a 3 month supply, 180 x 150 mg...and the price was $400. WTF? I pointed out that this was rather absurd, and they redid it as 60 x 150 mg for one month...that was $300. Huh?
According to GoodRx the cash price at Walmart should be $24 for 60 x 150 mg (which still doesn't make much sense, because it is the exact same freaking pill used for 30 x 150 mg, which is $9. Filling a bottle with 60 pills instead of 30 pills should not add $6 to the cost!). They agreed to redo it yet again, as 60 x 150 mg, for the $24 cash price listed by GoodRx. (And I do mean "redo it". They could not just sell me the 60 x 150 mg bottle that they had just filled for $24. Nope. They had to count out another 60 x 150 mg into a new bottle and sell me that for $24. Presumably the first 60 x 150 mg bottle, the $300 one, got treated as a prescription that was never picked up).
When it is time to renew that, I'll be moving it to Safeway. 60 x 150 mg there is $13.99 with a GoodRx coupon.
I just don't believe the U.S. is capable of such significant change. So maybe one thing at a time.
I also have a hard time believing that the reason prices haven't gone down is due to some overall lack of awareness of the problem.
I think the fear here is that if prices are published its going to provide leverage to smaller outfits to get better pricing and that is a good thing.
the best benefit is to give Americans a true idea of what stuff is costing because so many are too separated from the cost of their health care to understand the magnitude of the problem
It's bizarre that prescription medication is advertised like that in the first place.
If an advertisement convinces someone to take a drug that they don't need, the best case outcome is that a company is enriched at someone's monetary expense. The worst case is that there are adverse side effects, impacting the user's health for no reason. So in this case, a company is profiting by poisoning someone and eroding the stability of society.
It's not many steps removed from selling radium water.
>It's not many steps removed from selling radium water.
Except you've glossed over the critical extra step: you still need a prescription from your doctor, who presumably considers whether the drug a patient is requesting is appropriate.
Also consider your doctor is not aware of all of your problems and all available drugs, nor is the average patient aware of what conditions are treatable. For example, medications like chantix for smoking cessation may be brought up by patients without doctors necessarily aware of smoking habits.
I don't like ads, but I'm not convinced that ads for drugs are too much more evil than others.
Sure.. presumably, but let's not forget about drug reps. You know, those salesmen from the prescription companies (who run the ads) who "advertise" to doctors with fancy vacations and other perks. I've heard plenty of stories where a doctor prescribed something he/she knowingly wasn't supposed to (or there was a better alternative available), but had an "in" with the drug representatives allowing for perks they just weren't willing to give up.
[1] https://www.ineteconomics.org/perspectives/blog/meet-the-eco...
Getting China out of the hole it's in would be much harder than reversing the course on US politics, but only if US citizens stop fooling themselves into thinking they're in "the best country in the world".
Frankly (and maybe it's different in Canada), but I feel like people will have better health outcomes if they are aware of the options and consult, work with, and even challenge if need be, their GP.
GPs (or Primary Care Physicians, PCPs in the U.S.) share some goals with their patients, but many goals are not shared:
* Spending less money / good drug success / less side effects vs. using only tests/drugs they GP is comfortable with * Avoiding lawsuits vs. candid discussion * Taking time to research medical hypotheses vs. needing to get to the next patient
Come to think of it, if one is willing to invest the time, have an inquisitive mind, and demand a partnership relationship with most service providers, perhaps that person will generally have better outcomes in many areas (home repairs, dental, car service, etc.).
[1] http://theconversation.com/drug-ads-leave-canadians-in-the-d...
But not Oxycontin.
Does that make a difference when it comes to advertising? If I recall correctly it was like 2 or maybe 5 mg of codeine which is a very small amount. Any dose over that needed a prescription so I wouldn't be surprised if Tylenol was considered just an OTC drug but knowing there is codeine in it made me unsure.
As far as I know the rule for ads is 'non prescription', beyond that it's hard.
I don't recall seeing an ad for a prescription drug in Canada in the last decade, though they might exist in some form.
We get American TV and those ads seem quite ridiculous, what with the senior citizens dancing away, and the narrator iterating through a huge list of symptoms, then listing off 30 or 40 side effects as fast as he can, as if people are remotely capable of understanding.
My family works in the drug industry, I should say one thing that people don't want to hear: a lot of doctors are lazy. Just because they're doctors, does not mean that they keep up in any way with current issues, trends. The level of power they have, and the relative lack of ongoing certification is ridiculous. Once they get their ticket, it's a golden ride for the rest of their lives if they want.
Many people complain about the 'free lunch' doctor's visits by the sales reps, but I don't see it as such a bad thing. It's intense and important information, I have no problem with Doctors getting a 'free ham sandwich' to entice them to go through the data on the latest trials.
Obviously, there are shenanigans there, misrepresentation, competitive issues, pricing etc. etc. - but frankly a 'highly moral sales/communication force' actually I think does add value - they get doctors to pay attention to the specific issues. Obviously, there are probably better alternatives ... but again, Doctor's guilds are very powerful and archaic, nobody can tell them what to do.
I remember being shocked when I first moved there that you could get even a small amount of codeine over the counter. That would never fly in the US for precisely the reason you gave for them finally pulling it from the market - people here would buy the crap out of it to get "high" even though at those small doses you'd have to eat a LOT of them to feel a real effect. I can't imagine the stomach problems people would have taking that much of an analgesic.
Lots of people suffer from hyperhidrosis, which is excessive sweating, generally on the palms, feet, or armpits, where sweat glands are clustered.
There have never been great treatments. There are all sorts of them, but many of them just don't work, or have horrific side effects.
Among these is a drug called glycopyrronium bromide, which is an anticholinergic. Taken orally, it absolutely cures hyperhidrosis dead in its tracks. It also has a tendency to dry up every part of your body that should naturally be lubricated in some way.
Imagine your mouth, tongue and throat so dry you can barely form the movements necessary to speak. Imagine your eyes so dry you can barely blink. Imagine your nose dry and cracking and frequently bleeding.
Lots of people would have talked to their physicians about this in the past, and lots of people would have tried options available to solve the problem, including surgical options. But all of those options were either terrible, or did little to alleviate the fundamental problem.
And then in 2018 there was a new treatment developed, qbrexza, essentially the same drug, but delivered as a topical cloth treatment. It turns out this drug is not readily absorbed into the surrounding bloodstream, and in any event doesn't cross the blood-brain barrier at all. It turns out that topical treatment works quite well for the primary purpose, with significantly reduced side effects.
But imagine you've already talked to your doctor about this problem, years ago, tried several remedies, and none of them worked. Imagine you had already given up on seeking treatment.
Then you see an advertisement on TV for your particular affliction. It sounds like a new, and promising avenue of treatment. And so you decide to go back to your doctor, and ask about this new treatment, which never existed before. And you never would have done that, probably ever, if you hadn't seen the advertisement.
How many drug advertisements do you see for old drugs? Not that many. There are some, for very common ailments like hypertension. But primarily drug advertisements are focused on new drugs.
It's not that odd to advertise a new treatment. There are still doctors that need to evaluate patients and prescribe the medication. If doctors are prescribing useless medication to patients, that seems like the primary problem to me, not the advertisements.
This should be your doctor's job when you go for annual checkups. If you don't go for annual checkups, you shouldn't be surprised that your health choices are falling out of date.
How would you know to ask the doctor about it during your annual check-up, if you aren't aware of the existence of the drug? As others have mentioned already, doctors do not tend to track every single new medication for every possible little condition that their patients could have. And even if they physically could do that (not sure if it is actually possible), do you think they would, just like every web developer would keep track of every new little framework/tool that gets released and could potentially serve their needs better?
I don't rely on business users asking me about technical solutions to their problems based on advertisements they've seen, and I'm not in a field with as much required specialized prerequisite and continuing education and mandated licensing as medicine.
Now, certainly there are patients that meaningfully contribute by, e.g., actually doing deep dives in the scientific literature related to their diagnosis and related treatments, and bringing questions and references derived from that research to their doctor, which really does cover things at a level that the average practitioner might not be aware of for a particular conditjo . But the kind of ads in popular media are of marginal if any value to them.
> As others have mentioned already, doctors do not tend to track every single new medication for every possible little condition that their patients could have.
They are bombarded with even more aggressive marketing than the public is for any of the ones that are spending money on public ads, so even if there is a real issue here, public-facing drug ads are not directed at solving it.
As far as "they do not track" , they are supposed to. That's a failing on the doctor's part but putting the patients in charge based on paid TV advertisements for what is actually an extremely narrow portion of available drugs is not the solution.
The Ad changed my life.
With healthcare, we fall into an entirely different domain of economics, especially because the leverage of those who have 'life saving' services over those who don't is basically existential.
A better solution would be: 'one price for everyone'.
The entire gambit of 'negotiated prices' is a fallacy in the end, it's just a matter of groups having collective power over another, it's not really economically efficient.
Either A) all Americans form a 'super powerful buying conglomerate' which is 10x more powerful than any healthcare provider, thereby forcing 'amazingly low prices' (which basically socialized medicine) - or B) we let the 'aggregate market demand' determine price, which is basically 'one price for all'.
America should probably follow one of the European examples where they have a public/private mix. I respect that some people just want full control and want to pay for that, it's fine, but there needs to be a socialized component more efficient than Medicare.
I'm not sure if Canada or UK are the best examples for America. Germany, Netherlands or Switzerland might be better.
No, it's not too even the most powerful and organized push we have gotten, so far, but, even assuming it was:
> It failed to reach that mark.
Yeah, but it moved the starting point quite a lot. Just like the adoption of Medicare and Medicaid before it moved the starting point that it started from. Just like the adoption of Veterans health care before that...
We’re not resetting to zero before each push.
It'll help further see how broken the system is, but this does nothing to actually change it. It'll be held up by lawsuits for a while then either dropped when politically viable or used to prop up a 2020 plank without anything to actually stand on.
If Trump wanted to do something positive he'd bring back the individual mandate and try to reverse the loss of insurance and cost spikes since he signed the 2017 tax bill and other legislation aimed at destabilizing the Us healthcare system. He won't, because the GOP won't, because their goal isn't to help Americans, just the wealthy and corporations like the for profit groups running the detention centers at the border for $750/kid per day sans soap and toothbrushes.
It's perhaps worth noting that this EO explicitly described itself as a follow-up of the report produced by the Administration as an outcome of the last EO Trump issued on this issue.
Actual EO text appears to be here: https://www.whitehouse.gov/presidential-actions/executive-or...
Though the official text will be whatever is published in th Federal Register, not what is on White House public info pages. When it is published, it should show up here: https://www.federalregister.gov/presidential-documents/execu...
[0] propaganda rather than clickbait, I suspect—its a lie to shape opinion of the large number of people who will only see the headline rather than one to get people to click through to read the article.
That said it's a good topic to wish for.
I already see people thrown out of ER room handcuffed because someone with a loyalty card of a higher priority level called in :)
After all, we have more or less this in premium economy when you have it on the flight (unfortunately it's on just a few, and business is, too drying up), and it's MORE than 2x more expensive.
What airlines have become is just an insult to the human dignity. No industry should operate that way. If you are concerned with what comparison shopping, price optimized on the Internet, and free competition done to the taxi drivers, turning them into precarious, powerless and poor Uberists, why aren't you concerned with the 'demand side' of the same problem? Much less healthcare. I'd absolutely hate to get any treatment in a system which is 'optimized' in the similar manner.
Every time I go to the doctor in the US I wonder WHY they are doing what they are doing, WHY they want to see me two weeks from now even if I have a chronic condition that's perfectly managed already and hasn't changed in years...
I never met so many unethical individuals like since I moved to the US and started going to the doctor.