[soitgoes511]

I hope this succeeds. My daughter was born with many medical issues and understanding the billing was always near impossible. Nothing could be gleaned from the bills which would arrive 6 months to a year later (sometimes 2 years) from the insurance company. In what world can I not know the price of something before hand? If I go to a restaurant and see hamburgers cost 6000$, I wouldn't buy one. But with medical it is always a surprise.

[mightybyte]

I'm also really hopeful for this. A couple years ago I had a potentially serious injury and the local urgent care clinic said I needed a trauma center. The message got lost in translation and I ended up at a Northwell Health hospital that did not have a trauma center. First they ignored the documents that I gave them and let me get past their triage so they could bill be and then told me that I needed a trauma center. After signing a refusal of care form and paying something like $200 to get out after getting zero care, I went to the nearest hospital with a trauma center where I was very quickly received by a full trauma team, got a CT scan, and determined that my condition was not serious.

I got a bill from the trauma center hospital for something like $500. Based on what I've been conditioned to expect from the U.S. health care system that seemed pretty reasonable. Then I got a bill from Northwell Health where I recieved no care for more than $800! Around that same time the NY Times came out with a piece about Northwell overcharging (https://www.nytimes.com/2021/03/30/upshot/covid-test-fees-le...). It took me months of badgering both my insurance company and Northwell to stop sending me payment delinquency notices.

Now, more than a year and a half later, they started sending me bills for that $800 again! So I'm very excited to see this kind of open source approach at this problem.

[tryptophan]

This is why you don't go to urgent care clinics. Half the time they don't even have doctors there, just NPs with online degrees.

[OrvalWintermute]

It sounds like you inprocessed at Northwell Health, went through billing, saw a Nurse/PA/NP, got vitals taken, met with an ER Doc, and received a confirmatory diagnosis, and the ER doc spent the time to read your documentation.

For a hospital, your care is not merely the interventional aspect of medicine, but also the vitals, diagnosis, charting, and time spent on reading your documentation by a medical professional with > 20,000 hours experience & training.

[amluto]

If I take my car to a shop, the shop contemplates my car, and concludes that they can’t help me on that visit (because they’re the wrong shop, they have the wrong part, etc), the usually charge me $0. Maybe $15.

I have never in my life experienced an ER doing anything competent that remotely resembles reading documentation as part of triage. Why on Earth should they get paid more than a tiny nominal fee for the use of the waiting room and a bit of time spent by the triage staff?

[secabeen]

My understanding is that this is because the car repair market is heavily regulated, estimates are required for all repairs, and payment is based on a standard number of hours for each job, not actual time taken. The cost of estimates is already wrapped into the cost of the completed repairs, and estimates are required before work is done, so few places charge for declined estimates.

https://www.bar.ca.gov/pdf/writeitright.pdf

[dboreham]

I think it's because car repair shops can't get away with being a total dick.

[dsfyu404ed]

Exactly.

"Terell's cousin is handy and while he's not the greatest he can probably get 'r done for more time and frustration but a lot less overall expense" is the nuclear option that caps how big a bag of dicks a shop can be.

Barrier to entry is low and they don't have an AMA cartel lobbying the government to protect them which helps a lot too.

[dsfyu404ed]

>If I take my car to a shop, the shop contemplates my car, and concludes that they can’t help me on that visit (because they’re the wrong shop, they have the wrong part, etc), the usually charge me $0. Maybe $15.

Because you're a regular.

If you're not a regular customer of theirs expect a diagnosis fee that's about equivalent to half an hour of labor.

[dghlsakjg]

Yeah, but you are still informed of, and sign agreement to the diagnostic fee.

They also won't charge you a diagnostic fee if they know ahead of time that it is a service they won't provide like in the example. If I somehow end up at the tire shop for an AC service, they don't send me a bill 6 months later for an arbitrary amount just because they had to tell me that I need to go to the shop down the road for my issue.

I don't live in the states anymore, but I genuinely don't understand how any of this is legal. If I started sending out invoices to every client months later for services that they didn't know they were getting, with arbitrary prices, sometimes with egregious errors on them, I would expect a knock on the door from the authorities.

[shigawire]

If the human body was as easy to fix as a car you might have a point.

[mightybyte]

They had a full report from the urgent care clinic including x-ray and blood test results. They added precisely zero value. It was a completely inexcusable failure of triage, solely to extract money. I paid the $200 or so on-site, and even that is not defensible IMO.

[karmelapple]

I was visiting Singapore, and I had to take a family member to a hospital. We went to the emergency room by recommendation of the private hospital’s front desk.

The front desk also had a menu of pricing options there for us to see - a rough cost of the entirety of the visit’s potential costs was glanceable right as you walked in the door. It was amazing, excellent, and I’ve never seen anything like it anywhere in the USA or Germany.

[duffpkg]

I hope your daughter is doing well now. I wrote Hacking Healthcare for O'Reilly, yada, yada. If you still have these bills and would consent to sharing them with me they may make a good example to share publicly (redacting any private info) to help explain what happened, what's there and why.

You can email me at [e-mail] .

[soitgoes511]

Thank you for asking. She is 24 hour ventilator dependent (spina bifida, chiari malformation, etc.. etc..). She just celebrated her 5th birthday last month. My wife and I hope she will be able to breath on her own someday too. As for bills, I would be shocked if I could not find any as we have piles of them. We have relocated to France, but had no outstanding balances before leaving. I have noted your email and will check our files for bills this weekend. I have absolutely no problem sharing them. Anything to bring light to the insanity and opaqueness of the US medical system.

[three_seagrass]

>In what world can I not know the price of something before hand?

In a world where you're not the primary payer.

The complexity of healthcare prices is an artifact of decades of negotiations between providers and insurers, with the added headaches of linked diagnosis and procedural dimensions.

IME the pricing is so overtly complex that transparency into it isn't going to make much of a difference, it's just going to create more questions. If you want simplicity, switch to single payer.

[dig1]

Probably because the US healthcare system has been so corrupt for many years that, sadly, people are taking it as the default/normal state. Going outside the US and seeing how other countries handle it is an eye-opening experience.

[missedthecue]

In my country, it's corrupt and cheap!

[midoridensha]

In other corrupt countries, even the corrupt people recognize the value to society of having a decently-working healthcare system.

[tyingq]

Agreed, it's a huge mess. Often, you are also not always told when something is even a billable item at all. You can find examples of itemized bills including things like band-aids at crazy inflated prices.

[yamtaddle]

I've received bills from entities halfway across the country with no fucking clue what role they actually played in care. It's completely fucked. No other industry gets away with billing this messed-up and sloppy. And I'm 100% sure some of the errors are "accidentally on purpose".

[SkyPuncher]

Caveat: I get that humans are a lot more complex than cars.

Medicine is one of the most well-documented, well-studied fields in human history. Every single thing a doctor does and charges for is stored and coded in an electronic system.

It blows my mind that my mechanic can give me an accurate estimate and they are legally bound to honor that estimate. However, my doctor can't even tell me how much my routine medications will cost.

[baby]

Hell I can't even understand what my dentist and orthodontist are billing me for, it just looks like they're making up all sorts of charges.

[comprev]

The key difference is you don't need the burger but most likely do the hospital thing. This is where the exploitation lies.

[soitgoes511]

Very true. The optional part comes in with the itemization of items in the hospital room like baby diapers or a tylenol. I would definitely bring my own if I knew the hospital would bill me (or my insurance), 800$ for a tylenol. I live in France now, so it is a different story (doctor shortage currently)..

[xboxnolifes]

If that was truly the only exception, then it wouldn't be the case that I am only told the price of routine, non-life-threatening visits after visiting. Things like yearly doctor checkups, dental cleanings/checkups, vision checkups, specific x-rays/MRIs, etc.

[SkyPuncher]

Yes and no.

When my wife had our first child, the hospital sent the placenta out for sampling without our permission. This "in network" hospital then billed us for an "out of network" expense on a decision they made without our consent. Same hospital also double charged us for anesthesia because they choose to have a CRNA and anesthesiologist in the room at the same time.

Thankfully, my wife works in healthcare so we called their BS. We suspect that this hospital is doing this to essentially birth.

[diob]

We also need to start acknowledging most medical care is urgent and not a choice.

Happy to see some movement on at least price transparency though.

[adam_arthur]

Most medical care is not urgent. In fact, emergency care is a tiny fraction of all medical spending.

Thus the ability to "shop around" and thus subjectivity of medical care to price competition definitely exists in the majority of cases. If the system were setup to incentivize and support this. But due to lack of price transparency and skin in the game, there is no competitive pressure on pricing in practice.

https://www.politifact.com/factchecks/2013/oct/28/nick-gille...

[three_seagrass]

Your link doesn't support your claim about shopping around.

Most health insured patients can "shop around" in their network, which is a list of pre-negotiated priced providers that the insurance company has approved. Providers that are already vetted to be the lower cost for insurance, created through purchase power. And that's assuming it isn't an HMO, for which there is no shopping around.

There are not enough options for real market competition in healthcare.

[diob]

Just like how we can shop around for our internet here :)

It's wild to me how folks will continue to support the predatory healthcare industry here.

[adam_arthur]

Yes, increasing competition will lead to better results for society, in all markets.

Through competitive pressures which drive down cost and encourage increases in quality.

There is very little competitive pressure in healthcare from the consumer due to the issues already mentioned above

[diob]

You're not wrong that competition helps, but you're being naive if you think healthcare is a market, or that it would not eventually be captured like so much else in the USA.

In fact, I think you'll find most of healthcare has already been captured by private equity, resulting in worse outcomes for the both doctors and patients.

[adam_arthur]

My comment's point was that it's theoretically possible for healthcare to allow for shopping around, but in practice it's not. Due to lack of price transparency and lack of incentives for consumers to care (max out of pocket)

[diob]

I love how we go to theory instead of looking at other nations where healthcare works, like Australia. American exceptionalism at it's finest.

[adam_arthur]

America didn’t become great by copying Europe. Or Australia.

There are obvious flaws in the healthcare system that are apparent from first principles. No need to blindly copy others.

Removing incentives for people to use the system efficiently leads to poor outcomes in different ways

[johnthuss]

This is the entire purpose of this legislation. It requires hospitals to publish their prices for these specific “shoppable” services.

The problem with this legislation is that prices at one hospital are only useful in comparison to another hospital’s prices. Since the law doesn’t provide a facility for comparison, even the compliant hospital’s data is nearly useless. There needs to be a centralized database with compatible definitions for each procedure that allows consumers not just to see the prices, but to directly compare them.

[nickff]

Is most medical care urgent? I dislike asking for citations, but that is quite the claim!

Are you saying the majority of patient-practitioner encounters are emergency visits, or that the majority of spending is on emergency care, or something else?

[yamtaddle]

I'd expect the majority of people's encounters with big medical bills from hospitals before old age are either emergency, or childbirth related, so those are the two things you'll see young and middle-aged people complain about.

But the biggest bills are probably near end-of-life, and mostly not emergency care.

[mwerd]

Sure, that makes sense.

We should also acknowledge that it costs money to deliver and we live in a resource constrained world.

[EMIRELADERO]

That doesn't seem to have stopped most other countries from having free or near-free healthcare. You shouldn't even have to think about money when dealing with hospitals.

[gwright]

This language isn't very helpful. It is likely paid for from general tax revenue. That might be a better implementation but it certainly isn't "free". And if it isn't explicitly paid for via tax revenue it will end up being paid for via inflation if the government spending is out of line with its revenue.

[olddustytrail]

The language is fine because that's what the word "free" means. Do you complain that a cloud provider's free tier isn't really free because it's paid for by other customers?

It seems it's only with healthcare people forget the meaning of the word.

[EMIRELADERO]

By "free" I meant "free at the time of treatment". Of course nothing is free. Traffic lights aren't free. Road maintenance isn't free.

[gwright]

Many people really don't connect the dots between tax policies and health care insurance/payment policies. Saying that health care/insurance is "free" makes it difficult to have a coherent policy discussion.

I know the ship has sailed on this but it I continue to see people truly believe that they are not paying for health care and that sort of misguided understanding of economics shouldn't be encouraged as it makes it difficult to have coherent discussions about many different public policies.

    College education should be free...
    College loans should be free (even when they weren't when the loan was taken out)...
    Income should be free (UBI schemes)...

If you switch to "subsidized" from "free" the list expands exponentially.

[coredog64]

As is common in these discussions, I’ll reference the French system as I experienced it.

If you have to go to the hospital, that’s not billed to you.

If you see your GP, they charge you up front. There’s no copay as in the US system, the doctor just charges what they want. The doctor doesn’t keep any significant medicine on prem. If you need a vaccine, they write a script that you take to the pharmacy and return with. In either case, you submit your paperwork after the fact and get reimbursed. For office visits it’s 80% of the “reasonable and customary” changes. For medicine it’s usually 50-60%.

You can purchase additional insurance that covers more of these costs, but I didn’t see any value in it for my situation.

When I left, French insurance companies were setting up US style networks with doctors. If you saw an in-network provider, you were reimbursed more.

Only the truly indigent get “free” healthcare under the French system.

[ealexhudson]

The cost of the thing is effectively irrelevant if you both need it and don't get the bills for weeks/months. If patients are expected to self-ration, they need the info up front...

[maxerickson]

Government restricts the resources available for health care with the idea that it costs to much to have extra.

So my local hospital just does whatever and charges Medicare their CAH rates, doesn't matter a lot if they suck or could be cheaper, no one else can open a hospital (both by state law and because Medicare probably wouldn't agree to pay them).

[komali2]

I think it's unethical that this can happen to people, so I justify my actions in these cases as an ethical opposition to being strongarmed:

this happened to me when I was hospitalized for a heart palpitation that matched a side effect for medicine I was on as an emergency that, according to the medicine's documentation, warranted a 911 call. I turned out to be fine, yet my insurance company decided I owed a couple thousand bucks for the ordeal.

I was doubtful and so when I got the bill (3 months later and very unexpectedly), I simply started making calls to get someone to justify me why it was my responsibility to pay the bill and not the insurance company's. The hospital said the insurance company already paid some ungodly amount of money for my bill and the bill was... some made-up clown world insurance company term. Copay, or payable, or deductible, or co-insurance. How many new daft words do they have today? This was 2015.

Insurance company just didn't have clear answers. I read the policy, it was vague enough that I was arguing that the entire hospital visit should simply be 100% covered, I'm guessing the insurance company didn't have a way for their support staff to make the legal argument they'd have to make if I just straight up sued them for it. That's probably the only way to get a clear answer: sue, and get them to trot out a lawyer to say the justification to me.

I honestly was happy to pay what I truly owed, I just wanted to make sure I wasn't overpaying, that's all. But lo, I lost the paper bill, and asked the hospital to send it again in the mail. They did, 6 weeks later. The account number on it was different than what I wrote down. I asked them to check. They sent another one, 6 weeks later, correct account number, my name mispelled. This comedy continued until the bill was sent to collections, a year after the original bill. The collections agency couldn't provide proof of debt, and it was sold again, to a different one. This one also couldn't provide proof of debt. 3 years later I'd still get random calls from some new debt collector. The original hospital had shut down, and so nobody could provably connect the debt they had bought with my phone number on it, to the identity of the person that walked into the hospital. I mean, honestly at this point I'm not even sure if there was a genuine mistake in billing: there's literally no way to know now.

Regardless, I never paid the bill, and this remained my strategy for the miserable few remaining years I had to deal with the USA healthcare system: just make some phone calls and the bureaucracy will get so tangled up in itself it seems I could continually just slip through the cracks unscathed.

Before anyone asks, nope, the unpaid bills never showed up on my credit report.