[candiddevmike]

Everyone assumed there would be malicious compliance here but it's definitely eye opening just how malicious they made it. Speaks volumes for the perceived risk releasing this data, IMO. Still waiting to hear about someone using this data to negotiate down a hospital bill, seems like it's just insurance companies that can weaponize this data for better rates.

[ethbr0]

> but it's definitely eye opening just how malicious they made it

As someone familiar with insurer, provider, and facility IT systems, I'd offer an alternate explanation -- the data is bad because healthcare IT is understaffed (and often incompetent).

These are businesses that have squeezed most costs out, and IT is definitely a cost.

Imagine banking... if there were much less competitive pressure and an inability to offer services across state lines without substantial additional effort.

They received a mandate.

They tried to respond in the way that required the least amount of effort.

From someone in the industry, it's entirely plausible this is the best they can do.

Which usually means it takes CMS threatening to drop them for them to launch a multi-year project to finally fix the issue (somewhat).

[walnutclosefarm]

I'm pretty sure the truth is a mix of malicious compliance and inability, but I'd weight it heavily in favor of malicious compliance, especially for the insurance data. Insurers know their costs, and when and why they pay specific charges.

(My qualifications to make this statement: 15 years in healthcare IT, including UHG/Optum, and 8 years as CTO of a large clinical organization that included primary through tertiary care, research, and an insurance operation.)

[jcrawfordor]

I'm not so confident from my experience in healthcare IT, admittedly shorter than yours. One of the issues seems very telling, the fact that one of the listed rates from the insurer matched the portion paid to the radiologist but not the total. Problems with matching up different line items are really ubiquitous in healthcare systems because, despite the standardization that theoretically exists, there's huge variation in how different accounting and analytics systems represent line items. It seems extremely plausible to me that all the numbers in these MRFs are real numbers, but aren't the numbers they're supposed to be. Probably the reports were generated by people using BI tools that didn't have the expertise in the underlying data to understand what values they should actually be reporting on, so it ends up being a hodgepodge of different dollar amounts that are often not the actual reimbursement amount but instead a subtotal or breakdown line items used for analytics.

Sure, insurance companies ultimately know what they paid, but consider that these MRFs are almost certainly not being prepared by the people responsible for that knowledge. They were probably tasked to one or two data analysts who quickly banged them out in whatever BI/reporting tool they use and did nothing to verify correctness. It's not like they had an accountant audit these if they weren't absolutely required to (they weren't). Most healthcare analytics tools are complete junk drawers of data from numerous systems and getting these MRFs right was probably never a priority for anyone. Just a total "I have no idea if these are right but they sure are numbers" exercise.

I mean, how many times have you seen some Tableau report that's all screwed up because some of the MRNs aren't actually MRNs (even though someone named the model field community_mrn) but file numbers from the scheduling system, and now you've got duplicate patients? BI systems just breed that kind of problem unless you are extremely careful about managing them, and since they're "not systems of record" (these are scare quotes) few people are.

[phkahler]

>> Problems with matching up different line items are really ubiquitous in healthcare systems because, despite the standardization that theoretically exists, there's huge variation in how different accounting and analytics systems represent line items.

Maybe the problem IS the line items. You know the labor cost of tracking the fact a person was given Tylenol is way more than the cost of the pill? Just give people the incidentals and stop billing for them. Half your overhead might vanish.

BTW, yes every medication need to go on their chart. But it does not need to go through the entire finance system and to insurance.

[ethbr0]

It's a good point and ties in to the broader issue of opaqueness of reporting, especially now that we've empowered self-serve report generation. We can democratize data systems... but documenting them is a whole different level of effort.

> Sure, insurance companies ultimately know what they paid

It came to mind reading the above that a more accurate/useful perspective might be "The insurance companies' system knows what they are paid," but those system may comprise multiple software systems, none of which have data in compatible formats.

Ergo, even though the insurance company "knows" operationally (it can generate a number on request), it might be unable to generate a list of all numbers (effectively: every path through the system).

But that's why mandates work in insurance: if CMS pushes hard enough, eventually the insurers will develop the functionality.

[thewebcount]

> Insurers know their costs, and when and why they pay specific charges.

I certainly don’t have your credentials, but my experience in being an insured person doesn’t match this. I’m willing to believe you, but having filled out forms for UHC to get reimbursed for an out-of-network doctor, it sure feels like they kind of make it up based on how they feel that day. I’ve submitted what appear to me to be identical forms for reimbursement (like the super bill the doctor gives me has the same codes, duration, etc.), and the reimbursement differs for no reason I can discern (had long blown past my deductible, etc.). It feels like sometimes you get lucky and the person evaluating your form gives you a break, and sometimes you’re unlucky and they don’t.

On the other hand, malicious compliance does seem par for the course for these assholes. So what you say makes sense.

[medellin]

If this is the best they can do maybe capital markets don’t work best for insurance companies and they should be taken over.

Dealing with them right now feels like dealing with the government might as well just have the government run it

[lazide]

Don’t take it too much at face value.

This is the best they can do when all their incentives align so that being as opaque and disingenuous as possible about costs (and understaffing and often screwing it up helps with that!) helps them.

[ethbr0]

Not going to argue. In their defense, I'd say insurers are more innovative (especially on the operations side and post-ACA) than the federal government.

IMHO, best of both worlds would be the federal government taking over and centralizing the most core services (rates, interchange, data systems, etc) and allowing private insurance companies to build offerings on top of that (customer service, servicing, product mix, etc).

[rqtwteye]

"insurers are more innovative (especially on the operations side and post-ACA) than the federal government."

They are certainly very creative in making the system as expensive as possible. See Medicare Advantage.

"IMHO, best of both worlds would be the federal government taking over and centralizing the most core services (rates, interchange, data systems, etc) and allowing private insurance companies to build offerings on top of that (customer service, servicing, product mix, etc)."

This would be best. There is so much unnecessary bureaucracy at providers and insurers because the insurers have different setups. The medicare setup would be a good foundation .

[wolverine876]

> I'd say insurers are more innovative

In what way?

> especially on the operations side

If the US had national, universal health insurance, the operations would be much simpler.

[joe_the_user]

They received a mandate. They tried to respond in the way that required the least amount of effort. From someone in the industry, it's entirely plausible this is the best they can do.

Assuming this is true for the sake of argument, saying that this sort of thing isn't malicious compliance is a sad kind apologistics for bad behavior that seems to regularly appear on HN.

[m463]

I agree.

How can these kinds of companies optimize their charge codes to get the max for the procedures, optimize their taxes to pay the minimum possible, and then do a poor job on these existential crisis kinds of things? I think they know what they're doing in all cases.

[ethbr0]

I've known at least a few insurers who have automated running test claims through their systems, because it's the quickest way to find out what will actually happen.

It's not rocket science! But it is decades of code on top of decades of code. There's a reason they still pay COBOL programmers...

[phkahler]

>> These are businesses that have squeezed most costs out, and IT is definitely a cost.

What's the cost of an X-ray? Did you know they used to do a FREE X-ray at the shoe store back in the day to check fit? Yeah, don't tell me they squeezed out most of the cost.

[nsvd]

They squeezed out most of the cost and gave the profits to healthcare administrators. Why did you think those savings would be delivered to the consumer (you)?

American healthcare not a free market.

[Vvector]

cost =/= price

[pwinnski]

They don't seem to have any trouble sending out bills, though.

[JPws_Prntr_Fngr]

> seems like it's just insurance companies that can weaponize this data for better rates.

That’s because their negotiating power is mainly due to the size of their buying power, not special knowledge or skills. Health “insurance” is basically the lamest, most economically perverted form of collective bargaining ever.

[maxwell]

And why federal governments make the best health insurance carriers.

Brokers, medical billing staff, and other middlemen serve no purpose other than increasing cost (in order for an inefficient, openly colluding private cabal to invest premiums, deny claims, and collect profit) because everybody needs access to medical treatment.

[xupybd]

I live with free healthcare. The last three trips to the emergency department have been over eight hour waits. My father's cancer treatment was not covered so the last year of his life cost him everything.

On the other side my child's healthcare is amazing and all free. We get instant access to great services.

[christophilus]

I live with private healthcare. The last few trips to the ER have been 8 hour waits, too. This is an under capacity thing. I live in a place that has boomed, and the mismanaged hospital hasn’t remotely kept up. They fired a bunch of folks during COVID, then shocked pikachu found themselves understaffed.

The point is, the entire thing is broken nearly everywhere you look. I don’t know what a better alternative is, but we sure need one.

[softsound]

It's not the same... But what about emergency clinics or walk-in clinics? My brother had a chainsaw accident and they were able to treat him in a few minutes. I kinda hope we get more clinics like this over ER options, I used to go to the ER for a lot of issues until I found these clinics available, now whatever country I'm in America or in Europe I look for them over ER options when available. Good for fevers, fixing injuries, most of the more minor things... I'm not sure about the 8 hour wait but if you already exhausted other options I understand.

[cmh89]

I don't know where OP is from, but long-waits frequently are because of triaging higher severity rates.

If you have a chainsaw accident and its serious, you arent going to wait 8 hours

[chrisweekly]

My visit to the Mass General ER in 2012 involved waiting 25 hours for a ready room.

[sbaiddn]

I live in the US. Every trip to the ER has had <5 min. waits. They're so fast, last time my kid had a fever I went there because the after hours pediatrician was a ten minute drive (10>5).

So you millage may vary.

[softsound]

ER visits really vary. In Austin, Texas you may be able to get in a few minutes to a few hours. Just really depends, when my mom when to the ER last year for extremely high blood pressure she had to wait half a day before she could she see anyone and they thought she might have a stroke. She was fine in the end, but if there was a real emergency I can't imagine what we'd do. I remember we went to the ER at like 4pm but it took until like 2am before she was able to get in and they decided to have her stay the day. I stayed up all night waiting for her to get help it was very stressful. Also what a joy of getting that bill literally a year later, you'd think they would have due dates of when they have to send these out!

[brewdad]

You either live in a miracle land where no one ever gets sick yet ER capacity remains high just in case or your child was on the verge of death. The last time I visited an ER with my child it took 10 minutes just to check in. Then a 2 hour wait to be seen.

[sbaiddn]

I should add this is for my local ER. Although I've never had a long wait in the US (my wife has), my local ER is literally half empty every time I go there, and the triage area 100% empty.

[yamtaddle]

Last time I went to the ER with my dad it was about a 3-hour wait, and he really needed to get in. Saw a few people who looked like they definitely ought to get help, given the runaround and told it'd be hours and hours of waiting, until they left to try to find another ER with a shorter wait (in one case, the patient was delirious, sweating, and being guided around by a couple friends—I hope she got help somewhere), I assume because they looked like they couldn't pay and were probably uninsured (there was definitely a pattern to who got this treatment), so the staff were doing everything they could to discourage them. Some people who were there when we arrived, were still waiting when we got out, so they'd been there at least 4 hours.

US, and he's insured, and it's supposedly a pretty-good hospital.

I've been to the same ER within months of that, and it was empty and I was back in a room (well, cubby) within 15 minutes, with something just barely severe enough to merit an ER visit. Quick. Fucking expensive (think it was almost $3k by the time they were done sending bills, for 5 stitches and an x-ray—and that's with insurance), but quick.

It was mostly just timing and luck.

> My father's cancer treatment was not covered so the last year of his life cost him everything.

Sucks that it happens to anyone, but the final year(s) of healthcare finding a way to soak up every cent, before the end, is basically the norm here in the US. Everyone's retirement savings is just money the healthcare industry's lettings us hold temporarily.

[xupybd]

I have never heard of anyone in my city getting in within 3 hours. That would be amazing.

[lostlogin]

I have both, and the wait at the paid clinic is long, as is the wait at the free clinic.

It’s not whether the cost is socialised or not that decides how long the wait will be.

It also doesn’t help that the private system is incentivised to undermine the ‘free’ system at every turn.

[TedDoesntTalk]

> It’s not whether the cost is socialised or not that decides how long the wait will be

If care is free, aren’t you more likely to go than if you had to pay even a minimal cost?

[lostlogin]

It more complicated than that unfortunately.

New Zealand has an accident compensation system which pays for accidents (though there may be a small surcharge) but not most medical events. They split the hair finer that is sane. Swallow a foreign body? Medical problem. Swallow a foreign body as say ‘it feels scratched’? Accident. Insect bite? Medical. Mosquito bite? Accident (it’s a distant memory from when I billed these things but I’m fairly confident I’m right).

It’s all to do with cause and effect, and each must be identified.

The accident compensation scheme covers a portion of wages too. Medical problems cost, not US style but not free.

[relaxing]

Yeah man I love spending my time in the hospital.

[thewebcount]

Are you? I kind of try to avoid going to doctors and particularly hospitals and ER/EDs as much as possible. Between people with contagious illnesses, and huge amounts of wasted time, I have very little incentive to use as much healthcare as possible.

[lelanthran]

> It also doesn’t help that the private system is incentivised to undermine the ‘free’ system at every turn.

By competing on ... what? Can't be price (because "free" wins). The only other option is competing on quality.

Your statement doesn't sound correct.

[lostlogin]

Staff, including very senior staff often work in both systems. They then hire staff from the public system into the private one. This runs down the public system. There are accusations that they don't work fast or efficiently in the public system, leading to inefficiency. Senior staff with roles or even ownership of private facilities arrange contracts for outsourcing of work to private facilities. I have worked in both systems and currently work in the private setting.

[Timon3]

Competition isn't the only way for a private system to have influence on a non-private system. You understand that, right?

[fellowniusmonk]

I think another component to the equation in wait times is also doctors per capita and GDP per capita.

It's hard to compare apples to oranges but with high doctors per capita, low wait times for speciality services, long lived citizens and a far lower percentage of GDP spent on health, I wonder if there are any serious holes to poke in Italy's system when compared to the U.S. or if they simply just beat us on every metric.

https://www.oecd-ilibrary.org//sites/242e3c8c-en/1/3/2/index...

[xupybd]

Interestingly we do better on doctors per 1000 than the US.

https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?location...

[ecommerceguy]

I just had kidney stones, while extremely painful not very high on the er totem pole. Got in, got a bed, IV all within 10 minutes of walking in. There's at least 30 hospitals in my metro and hundreds of urgent cares.

$1500 on my HSA plan, which btw right now is returning 4.6% in a money market. How awesome is that?

Great deal. Worst pain ever.

[rqtwteye]

Last time I was the ER in the US, I waited four hours with a pretty serious fever. Talked to a doctor for maybe 5 minutes and got sent home. Cost me only $500.

[sdenton4]

If only there were some automated system you could talk to to decide whether it's worth going to the ER in the first place...

[xupybd]

We have a free health line. It operates 24/7. You talk to an operator who puts you in a queue to talk to a triage nurse. They tell you if you need to go to the ER.

[brewdad]

My urgent care facility, the only option between 5pm and 9am or on weekends, pretty much sends everyone to the ER as a precaution. If it’s serious enough, they’ll call ahead and get you into the triage system before you arrive.

[pessimizer]

Insuring massive populations isn't really insurance because of large numbers (there's no risk involved.) It's just an economic rent. It's a poker game where most of the players are cooperating.

[bhawks]

Senior / elderly care can be enormously expensive. Especially towards end of life. I could agree with you if the population was all teen to 45 year olds but that is not realistic.

The same dynamics play out with pension schemes. Declining birth rates play havoc with proposals that rely on a large, young employed base who's work supports a small, retired set of pensioners.

My own perspective is that healthcare is extremely limited on the provider side. Professional organizations have been limiting the supply of doctors / doctor equivalents for decades. Not to minimize the work a family medicine or general practitioner puts in, but many important health services/early interventiona can be safely and reliably provided by a nurse practitioner or physicians assistant (what a horrible name) on a much larger and affordable scale then exists today.

[throwawaytemp29]

I always believed that nurse practitioners would be just about as good at primary care as a doctor. But fuck me my nurse practitioner is useless. Like tons of British Columbia residents I don’t have a family doctor, so thought this would work. But they are afraid to do anything. At least a doctor will be confidently wrong like chat gpt.

[dsfyu404ed]

Insuring populations that are too small/niche/finite or over which you have too much information and ability to price discriminate (i.e. charge them exactly the cost of insuring them) isn't insurance either.

It's a perverted cross between escrow and welfare in which the population basically pays their own way in the long run plus supports all the people who make their living by being "administrative overhead" along the way.

[lazide]

Don’t bet on it.

There is enough (potential) money and incentive here that almost any system will be perverted eventually.

NHS is not known for speedy treatment, for instance.

It’s about ongoing oversight and a willingness and ability to cut through bullshit to fix things. That’s in short supply here and everywhere else.

The stories (first hand from relatives who use it) of blatant profiteering and abuse of the system in Medicare is mind boggling.

[brewdad]

If you need anything more serious than your family doctor, expect a long wait in the US too. My colonoscopy is booking 6 months out for what should be a very routine procedure.

[ChrisMarshallNY]

> NHS is not known for speedy treatment, for instance.

From what I understand (I am not a UK citizen, but me mum's mum spoke Scouse. My mother, on the other hand, spoke The Queen's English), everyone loves to hate on the NHS, but no politician in their right mind will touch it. It's a "third rail."

[lazide]

Well, it’s the same here for the existing healthcare system in the US. Even basic reforms (obamacare) get met with insane opposition.

[ChrisMarshallNY]

The difference is who the opposition is from.

In the UK, it's from the voters.

In the US, it's from the Healthcare Industry.

[paulddraper]

If you think government doesn't have those things, you don't know much about how it works.

Most of Medicare is administered by middlemen and private companies.

[ecommerceguy]

The current administration has basically decided that this will not be enforced so most of the carriers have ditched phase 3 - searchable 500 popular procedures. Really is a shame, I was very much looking forward to utilizing this, especially for HSA and or ASO clients.

t. licensed broker / agency owner

[drstewart]

>That’s because their negotiating power is mainly due to the size of their buying power, not special knowledge or skills. Health “insurance” is basically the lamest, most economically perverted form of collective bargaining ever.

Now can you make a cogent argument for why more than one federal / national union should exist? Why does Europe allow multiple unions?

[JPws_Prntr_Fngr]

I don’t follow. What unions?

[IG_Semmelweiss]

For a customer advocate, the pervasiveness of the artificial low rates seems to be an interesting opening.

You should be able to go back to the hospital and say - based on the hospital public fee schedule , total FFS for CPT should be (very low number) . Therefore, my deductible payment is overstated, please reduce my bill dramatically.

A lawsuit would follow, which would make it very interesting. Chief argument:

The customer can clearly say its fraud - he/she looked at the public rate schedule and believed the charges would be based off the public rate schedule.

Ultimately, the disconnect between published rates and the EOB is going to come back to bite hospitals, once people shop around using the data.

[xmddmx]

I wonder, does the law have any whistleblower provisions? Seems like a programmer who had been coerced to fudge the data, and kept receipts, could be in a good position...