[arnonejoe]

We created a similar product in 2014 and closed 18 months later (openhospital.com). Our team landed an interview with YC for the S2014 batch. I will say number of doctors were very interested in this, especially the concierge docs. We ran in to a number of issues but the gist was that medicine needs to be sold as a product. Anything surgical is typically billed against a dozen or more CPT codes for a single procedure and often involves more than one provider.

Finding consumers is going to be difficult. You guys are also going up against an entrenched multi billion dollar health care industry. We found that the providers were all required by their contracts with the health insurance companies to ask for an insurance card. If a patient had disclosed that they have health insurance, the provider was not allowed to offer a cash price (which is often cheaper).

Since you are building a marketplace I would strongly recommend reading The Coldstart Problem by Andrew Chen. I wish this book were available back when we launched our marketplace.

Good luck. I hope it works out.

[blastbking]

Thank you for the support! I think it is a challenging product to build for sure. We're focusing with simpler procedures that involve a few CPT codes and a single provider to make the problem easier but definitely want to figure out a way to make those complex procedures shoppable.

I didn't know that they weren't allowed to offer cash rates to insured patients! Definitely a bummer from the patient's perspective (why pay for insurance if it will just cost you more...).

Have heard a lot about the book, will check it out!

[arnonejoe]

If you are using CPT codes they are licensed by the AMA. I remember calling them to see if we could use them on our site and at the time I think they wanted a $15 fee per practice to use them. It was too cost prohibitive for us to use them. We ended up coming up with our own CPT code equivalents to get around this. One of the surgeons on our team pulled together a few hundred new codes and wrote new titles for them. We came up with a rosetta stone that we would use to set up providers. If you end up doing the same, it would be nice to publish a set of open source CPT codes for small start ups. I’ve included the link to the AMA CPT licensing page below. Good luck! I really hope you make it.

https://help.practicefusion.com/s/article/CPT-License-FAQ#:~....

[blastbking]

That's a great idea / suggestion! Due to the licensing rule we avoid showing CPT codes to patients and write our own descriptions. I think we might open source that as I hate that AMA tries to charge so much for this - they don't do any work and just make healthcare more expensive for everyone.

[arnonejoe]

That would be awesome if you could do this. We had planned to create an open source site and seed it with our codes but we didn’t want to take focus off of our product. It would almost need to be done as a wikipedia style site that could be maintained by the community.

[NTDF9]

> Anything surgical is typically billed against a dozen or more CPT codes for a single procedure and often involves more than one provider.

This is the real startup gap. There are thousands of CPT codes. When a medical provider is trying to give an estimate, it should be easy for Medical providers to have packaged, template CPT codes for template procedures. Then, they should be able to add/remove CPT codes from the package (like drag and drop), and the prices should change automatically.

The template packages could even be put on a social marketplace for doctors so that the information is shared.

[reureu]

That was what Nuna (nuna.com) was originally trying to do ~10 years ago (put together bundled payments for value-based care models). I think they've since pivoted to more general healthcare data tools.

One of the difficulties is that in many systems medical billing is done by coding specialists based off the provider's note. They may recommend CPT codes, but that may not be what's actually billed. In addition, most providers are too swamped to do things like put together an estimate or drag and drop CPT codes. Hell, many providers will literally count the clicks they have to make in an EHR and will LOUDLY let you know if your proposal will increase their number of clicks by even one.

I don't mean to be a downer on this, and I do think there are solutions... but I think 90% of the problems in healthcare aren't technological ones but are navigating large, entrenched systems that have very little incentive to change.

[jmye]

> I don't mean to be a downer on this, and I do think there are solutions... but I think 90% of the problems in healthcare aren't technological ones but are navigating large, entrenched systems that have very little incentive to change.

Having led provider operations and data systems in various settings for the last decade, this is absolutely true. I find a lot of the 'healthcare is ripe for disruption' comments miss that most of the work isn't going to be fixed by some neat javascript or whatever.

To your note on CPT codes, I'd also bet that, if a given provider is seeing ACA or MA patients, their billing systems and payer interactions will also be more complicated, in terms of coding (diagnosis and procedure), in order to satisfy risk adjustment needs. It's effectively impossible to incent a provider to use two entirely different systems, depending on who the patient is.

[cddotdotslash]

> to ask for an insurance card

Are patients required to disclose this? Or can I simply decline to provide insurance?

[codegeek]

You can decline but then you have to deal with people on the desk who may not even know what to do without insurance. They may have to call their boss to figure out if there is even a cash price possible. You will get crazy looks and stares. DOn't let someone tell you otherwise. I have done this dance for 10+ years with 3 kids now.

[gymbeaux]

Do you not have insurance or do you just prefer to pay the cash price where possible? It’s interesting that you might be voluntarily uninsured despite having 3 kids. The system is such that your kids’ health is a bargaining chip to employers. I know people who have stayed at jobs just for the health insurance, and then there are the H1-B folk who are effectively indentured (“yeah we’re paying you $20k below market rate but we are sponsoring you so… try to be a little more grateful”)

[codegeek]

I do have insurance because that's the game. I don't like it though. Btw my Insurance Premium is $24k/Year and $5k/Year for deductible. So I am almost $30K out of pocket BEFORE insurance pays a dime. If thats not a scam, what is.

[ceejayoz]

Why is that a scam?

My house has never burned down, but I pay homeowners insurance every year. My dad has never had a car accident, but pays every year. Both have deductibles awaiting us if we need them.

It’s insurance, not a prepaid debit card.

[zaroth]

There’s nothing wrong with the concept of an insurance premium or even a deductible.

The problem is the sheer magnitude of the cost. It’s an extraordinary sum of money to be paying out of pocket as an annual family expense for a non-discretionary basic living expense.

And more or less every single family in the US is doing the same? It’s totally untenable.

[vxNsr]

Yikes! That’s horrifically bad insurance, I’m paying $10k in premiums for a $2k deductible. And I was paying (until my company cheaped out on insurance) $15k/yr on a combined in/out $1k deductible and combined in/out $3k OOP. Which might seem worse but we were using fantastic OON providers that normally would barely be covered but instead were essentially the same as in network.

[i_like_pie1]

thank you for sharing. good learnings +1 strong recommend to that book

curious what you do now?

[arnonejoe]

The Cold Start Problem? I have listened to it on Audible 3 times. It’s on par with Zero to One in terms of an important startup book (imho). Chen goes in to strategies for building the hard side and easy side of a new marketplace. Product strategies for building networks (ex. come for the tool, stay for the network). He gives examples of how to get to a minimum viable network and discusses why Slack spread so fast. I could go on and on. It’s a pretty good on Audible.

[codegeek]

"If a patient had disclosed that they have health insurance, the provider was not allowed to offer a cash price (which is often cheaper)"

Sums up the problem with our Health Industry in America. The middle-man Health Insurance mafia is too powerful to let anything else happen.

[avgDev]

To be fair is not like providers are hurting either. Nobody wants better pricing.

"Physicians in the United States are among the best paid in the world (Bodenheimer, 2005). The average U.S. specialist physician earns $230,000 annually—78 percent above the average in other countries, as shown in Table 2. Primary care physicians earn less (they earn $161,000 on average), but the same percentage more than their peers in other countries." - sauce https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4511963/

[hn_throwaway_99]

I think this comparison misses the impact of Baumol's cost disease in the US. I mean, your link says a primary care physician earns $161k in the US. That's after going into a ton of debt with 4 years of medical school, and then making slave wages and horrendous hours as a resident for 4-5 years.

Meanwhile, it's pretty easy for a software engineer in the US to make that much not long after graduating college (I don't want to over reference something like FAANG salaries, which relatively few engineers make, but still, it's totally reasonable for a software dev to make that much somewhere between 0-10 years after graduation). That's after going into much less debt, and software jobs are way, way, way easier than medical jobs - honestly I think anyone who says otherwise is just full of shit (I'm a software eng for what it's worth).

So most people who can go on to be doctors have at least a similar level of intelligence/work ethic etc. as software devs (or lots of other careers in business, etc.) There is no way doctors are ever going to get paid significantly less than similarly credentialed professionals in the US.

[Calavar]

Insurance based reimbursement is not financially lucrative for physicians. That's why plastic surgeons, who take almost entirely out of pocket payments, are the highest paid physicians.

As for why US salaries are so high, it's because the training it so much longer and more expensive than it is in other countries. The most common training scheme for general practitioners internationally is 6 years of medical school + 1 year of internship. In the US, it is 4 years of undergrad + 4 years of medical school + 3 years of residency. Add on the ridiculous pricing for higher education in the US (public medical schools charge about 50k/year, and since medical school is a type of graduate degree, med students do not qualify for subsidized Stafford loans) and it would be financially untenable to be a physician in the US if salaries were the same as they are in Europe.

[haldujai]

Not sure how accurate those numbers are. "Physician" is not a singular job even within a single specialty and varies significantly based on practice pattern so averaging the numbers like that doesn't make a lot of sense.

For similar job descriptions most equivalent physicians would have higher compensation in Canada than the US, contrary to what that dated study says.

Definitely agree the majority of physicians aren't hurting in either country although I think the US/Canadian compensation is fair given the years sacrificed/intensity/work hours/stress (disclosure: I'm a physician). Some specialties like primary care and pediatrics remain very underpaid.

[FireBeyond]

That number is higher now. $351,000 for physicians across the board, $382,000+ for specialists.

Source: https://www.whitecoatinvestor.com/how-much-do-doctors-make/ (actually a MedScape survey, but that requires a login, so I found this which summarizes the survey).

[lotsofpulp]

The provider entered an agreement to give the health insurer the lowest publicly available price, which is usually how all insurance companies operate.

How would it work if the insurance company’s vendors charged the insurance company more than they charged random people off the street?

[TheJoeMan]

I can tell you haven’t ever received a self-pay bill, waited a month, and unrequested a cheaper bill shows up and mysteriously Dr. Popped-in-for-5-minutes got dropped from billing. Sure it’s the “cheapest rate” but they’re billing for every tiny thing.

[lotsofpulp]

No, I have seen that. I have even called and asked why I was charged $15 for a towel to wipe the ultrasound gel off my wife's belly, when it was just paper towel, and if I knew it was going to cost me $15 I would have done it myself. And I was told to ignore it.

But that seems irrelevant to my point. If you worked at an insurance company (not just health), and were tasked with contracting vendors (such as doctors or mechanics or construction), would you not want to stipulate that your vendor is giving you the lowest price publicly available from that vendor to avoid paying more than necessary, which would then allow you to offer your customers lower insurance premiums and compete with other insurance companies?

[amluto]

Health insurance companies have weird incentives. For one thing, they are not permitted to charge more in premiums than what they pay out times a small multiplier. So health care being expensive is good for insurers.

[lotsofpulp]

This is tempered by the fact that they have to compete with each other on pricing of premiums.

And if they had such amazing power to unilaterally increase healthcare costs, there would not be many people complaining about healthcare not being covered.

[shellfishgene]

I don't understand how this works. So if you have insurance the procedure is 120$, which you pay as the patient because it's not covered, but if you paid cash it's 100$? Where does the 20$ go, and why does the insurance want this?