[ChuckMcM]

I really salute these guys for doing this. It's freakin' awesome. This I've added to my next letter to my representatives in Congress:

"Dr. Smith said federal Medicare regulation would not allow for their online price menu. They have avoided government regulation and control in that area by choosing not to accept Medicaid or Medicare payments."

I've suggested that one non-controversial way in which Healthcare could be "reformed" would be to make it easier for hospitals to be transparent about their prices. Any sort of regulation that prevents hospitals from disclosing their prices is bad for the citizenry, please fix that part of the regulations.

[showerst]

Copying my comment below. The government not only allows healthcare providers to reveal their prices, it encourages it. The graf about the government is a political statement, not a policy fact, and does not belong in a news story.

-----

Medicare/caid prices are standardized and public. They also release data on what specific hospitals bill for the most common procedures.

http://www.cms.gov/Research-Statistics-Data-and-Systems/Stat...

Dealing with Medicare/caid involves lots of additional overhead and billing oversight, but that graf is a political cheap shot, not anything related to transparency.

-----

Hijacking my top comment with a more info edit -

If you don't know, Pricing Data in the US for health care is super insane, partially because both insurers and regulators need billing to fall into a semi-standardized set of 'billing codes' that don't really map well to actual care.

There are regulations about only billing the government for 'procedures' and not 'overhead', and medical procedures often don't map well to billing codes because they're new or slightly different. So basically after a procedure or hospital stay, the care givers make up a basic list of the things they did and the drugs given, etc, and it's passed on to a billing department, who maps to a set of codes that might differ depending on who's paying (gov't vs insurer 1 vs insurer 2). This is by definition lossy.

It's an oversimplification, but one hospital might say "Well we've got a superstar brain surgeon here whose time is 3x as expensive as normal, but can only bill for 'BRAIN SURGEON - 1 HOUR', so we'll crank the prices up on the scalpel and the tylenol to compensate", where another picks totally different things to compensate the prices on because they have a different cost structure.

Big insurers expect to be negotiated with separately for competitive advantage reasons, and sometimes use different billing codes anyway, so even if you had the closely guarded master price list of the hospital, it wouldn't necessarily do you any good.

For the uninsured, the occasional price-insensitive person rolls in (aka the "Saudi Prince wants his own wing for cancer treatment" situation), so they jack the uninsured prices WAY up only expecting a few percent back from 98% of patients. This further breaks the pricing data, and causes major problems for less-saavy people who are used to seeing a bill and being expected to pay it, as opposed to negotiate.

Bottom line: It's complicated, and politically fraught. If you're interested, Oreilly's "Hacking Healthcare" is a great intro to how billing and the new CMS Meaninful use stuff works.

[lettergram]

I worked in a billing office for 5 years, there are literally thousands of codes for EACH insurance company, again EACH insurance company.

The reason the cost of healthcare is so high is because medicare pays roughly 15% of a bill, others are somewhere between 20-50% of a bill depending. That is to say if the doctor charges you $40,000 you pay your 10% co-pay of $4,000 and the insurance then only pays maybe another $8,000.

Also, just so everyone knows, it's pretty easy to negotiate down your bill. The reason healthcare is so expensive is so many people don't pay it. If you are willing to pay say 40% of your bill it's already 25% better than medicare.

[badclient]

Also, just so everyone knows, it's pretty easy to negotiate down your bill. The reason healthcare is so expensive is so many people don't pay it. If you are willing to pay say 40% of your bill it's already 25% better than medicare.

This. My Dad is a surgeon and the stories I hear are incredible. Once he operated on a child whose insurance was out of network. So the insurance company writes the parents a check to give to my father. Instead, the parents decide to cash it and never pay for the surgery. So, the parents literally make a few thousand bucks from having their child operated instead of paying that.

[sanderjd]

This is the part I'm always curious about in these discussions: how do people get away with not paying? Is it a debt that is often discharged in bankruptcy or is there some other mechanism by which the debt is erased?

[tracker1]

Well, you can hire a collection agency (who usually gets X% of the collected amount with an $X as a minimum acceptable ammount, usually around 50%).

You, or an agency on your behalf can then have the unpaid amount due as a collection account appear on their credit report, and after that (7 years of no activity) it is supposed to come off. Some unscrupulous collection companies will modify the last account change date to keep it on, but that can be challenged.

You can also take the person to court and have a declaratory judgement, which will stick around on said credit report until paid.

There are also specific laws regarding where the involved parties are as local state laws apply too. It gets a little complicated.

I have two bills on my credit report with agencies that refused to negotiate... and I had an auto loan that was charged off (they repossessed my truck after they broke the payment arrangements that were made when I lost my job, and I refused to pay), after 8 years the collection company had changed the dates several times, I pointed out to the credit reporting agencies that the amount was the charged off amount for over 8 years, and had it successfully removed.

YMMV.

[badclient]

It is a combination. First, healthcare debt isn't weighted as heavily on credit reports. Second, healthcare is one of the few businesses where it is illegal to deny services before payment. You can't walk into a walmart, grab a candy bar and just walk out. With emergency healthcare, you can do just that and sadly, too many people take advantage of it.

[refurb]

To give you an idea of how big of a problem not paying is, I'll relate a story I heard from a small business owner in California:

In an effort to provide his blue collar workers with a decent benefits package, he setup a health insurance plan. After 6 months or so, his HR person came back and said "none of the employees have used the insurance at all!" This was weird since these workers had families and obviously children get sick on a regular basis.

He spoke to his employees and asked why they weren't using their insurance. The answer? Instead of having to pay a $20 co-pay to see a doctor, they could just go to the hospital and say they were uninsured. If they did that, they didn't pay a dime for their healthcare.

[njharman]

Debt is not a crime in the U.S.A. Just don't pay it. Eventually collectors write it off as tax loss.

[commandar]

Yeah, I work at a ~400 bed not-for-profit hospital. One of the culture shocks when I started working here was learning that we have an entire department whose sole job is figuring out what billing codes to send insurance companies so that the hospital gets paid for its services.

From everything I've seen, it's a very difficult job, and any mistake -- or not even a mistake per se, just coding something in a way that disagrees with the particular quirks of a given insurance company -- can have a drastic impact on whether and how much we actually get paid for a particular line item on a bill.

[Bamafan]

The reason the cost of healthcare is so high is because medicare pays roughly 15% of a bill, others are somewhere between 20-50% of a bill depending. That is to say if the doctor charges you $40,000 you pay your 10% co-pay of $4,000 and the insurance then only pays maybe another $8,000.

Another reason is the supply of doctors is artificially restricted by the AMA.

[riahi]

The supply of doctors is not restricted by the AMA. The supply of doctors is determined by the number of residency spots available to new graduates; that number is entirely determined by the Centers for Medicare and Medicaid (CMS). Thanks to the Balance Budget Act of 1997, Graduate Medical Education (GME) was dramatically slowed due to decreases in Medicare funding of residency positions. [1]

As long as we require physicians to be US trained and to have completed a US residency, the bottleneck will be GME funding. To fix that, the AMA or any other concerned citizen can lobby Congress for an increase.

[1]: http://jama.jamanetwork.com/article.aspx?articleid=182532

[justincpollard]

If there's a shortage of doctors we could increase the supply or examine whether we need fully trained doctors for certain more basic services in the first place. There are plenty of beneficial/ necessary medical procedures that don't require an MD's expertise.

[bradleyjg]

Why should Medicare pay for every residency in the country?

If hospitals can afford to give their executives seven figure compensation packages, they can afford to fund a few residents.

[Bamafan]

I wasn't referring to residency spots at accredited medical schools.

I was referring to medical school accreditation itself.

[mbreese]

Medical schools are free to set their own limits on the number of students they admit. But they aren't going to admit more students than they predict can find a residency spot. It would look bad to have a high percentage of your students not be able to find a residency.

The real reason why there are fewer doctors is that it simply doesn't make any economic sense to be a doctor anymore. You need too much school, at too high a price, and you push off any real earning potential 6-9 years away from your peers. If you specialize, you can add an extra 2-4 years on top of that. And you really don't make enough over the long run to justify the lost opportunity costs.

So yes, there is a shortage of doctors, but that isn't going to change anytime soon.

[toomuchtodo]

So we replace doctors with software. Will it be perfect? Not at first. But eventually...

[newbie12]

The same self-interested political forces that keep the number of doctors low are also fighting against automation.

[lifeisstillgood]

Oh that's just utter nonsense.

Automation (especially in diagnosis) is welcomed and supported by the medical profession.

Some vague idea of walking up to a kiosk and the computer telling you your condition and dispensing pills is opposed by everyone apart from the CEOs of kiosk makers

[bradleyjg]

> The reason the cost of healthcare is so high is because medicare pays roughly 15% of a bill, others are somewhere between 20-50% of a bill depending. That is to say if the doctor charges you $40,000 you pay your 10% co-pay of $4,000 and the insurance then only pays maybe another $8,000.

That help may explain extremly high nominal prices, but it doesn't explain the fact that the median price paid is also really high (The $12,000 in your example). Nor do cross subsides explain the high costs.

Both bottom up analysis looking at the amounts paid by various insurance companies for procedures and top down analysis of overall per capita health care spending reveal a system that is far, far more expensive than any other health care system in the world.

[dragonwriter]

> Both bottom up analysis looking at the amounts paid by various insurance companies for procedures and top down analysis of overall per capita health care spending reveal a system that is far, far more expensive than any other health care system in the world.

Its not so much a system as dozens of different systems with completely different premises and extraordinary complex interactions which have to deal with each other.

Which is why it is so expensive.

[Splendor]

This is incorrect. Procedure codes are standardized across the industry (CPT codes, HCFA codes, etc.). Don't confuse figuring out the correct code to bill for a procedure with determining some proprietary code for each insurance company; that is simply false.

[fizzbar]

Re: negotiating your bill: It blows my mind that in America you would approach paying for healthcare the same way you would purchase an expensive car. I don't consider my health to be a luxury good... But in the USA it is priced as such?!

[sseveran]

The vast amount of technology available is turning healthcare into a luxury good. There are newer and better technologies for treating many things available. How much is that worth?

[fizzbar]

The technology should enable better outcomes. But the "good" in question here is your personal health -- its "worth" is infinite.

[pdx]

Pricing transparency, for whatever reason, does not exist as a rule in the medical industry. The "charge masters", are a joke that the hospitals themselves admit are useless as indicators of actual prices paid unless you're out of pocket, and then you get to pay them. Even then, the charge masters, as useless as they are, are still kept well hidden from all but the most inquisitive.

I hope you're right about the government not hindering medical pricing transparency. Now we need to get them to mandate it.

[rogerbinns]

Even getting lab work done is ridiculous. There isn't any discretion, risk, variability or uncertainty involved. A cholesterol test is a cholesterol test. I needed a bunch of tests a while back and pay for them myself. The labs don't put their prices online - you have to call. And then you have to talk to multiple departments because they just aren't setup to tell you pricing and require fragments of information from other departments. Astonishingly I did eventually find somewhere that posted prices, and they turned out to be a quarter of what would have been charged from the regular lab.

I wrote more about it here https://plus.google.com/110166527124367568225/posts/eiThZXx7...

[sbercus10]

If this topic is at all interesting to you, you should read Steven Brill's dissertation in TIME titled "Better Pill" from a few months ago. Since TIME has a paywall, here is a link to the PDF of the article:

http://livingwithmcl.com/BitterPill.pdf

[tylee78]

yes. that's an amazing piece of research. this article really opened my eyes. after studying that article it's much clearer how healthcare can and should be reformed.

[rthomas6]

You and the article seem to be saying totally contradictory things. Was the article just outright lying, or is there some nuance I'm missing?

[Amadou]

A couple of months ago, Time magazine (of all places) did a really good story about the lack of price transparency in healthcare and how that may well be the single largest contributor to the burgeoning healthcare costs in the US. I think it is behind a paywall, here is a starter though:

http://www.time.com/time/magazine/article/0,9171,2136867,00....

In a stunning example of competence and efficiency, the US government responded to that article by publishing a ton of medicare pricing information on a hospital by hospital basis. Here's one article discussing the data:

http://www.boston.com/lifestyle/health/blogs/white-coat-note...

FWIW, as a person who has been using catastrophic insurance (e.g. super high deductible) for over a decade I find this move to more price transparency long over due. I've had the experience where some practitioners simply refused to take cash up front, it was insurance or nothing while others would give a significant discount, like over 50% for cash up front. We've still got a long, long way to go, but it's a start.

[EvanAnderson]

Fellow high deductible plan-holder here. Have you run into the circumstance yet where a provider is under an exclusive contract w/ your insurer and, once the provider finds out who your insurer is, is obligated to refuse to allow you to pay cash? I've had this happen 3 times in the last year and it's driving me mad. The providers were unwilling to talk to me unless I divulged my insurer, and when I did they were then unable to give me cash pricing. Maddening.

[jen_h]

Or worse, some providers won't even provide care if you are a high deductible insured person paying cash.

On more than one occasion after having an appointment scheduled, and mentioning to the provider that we have a high deductible, doctors' office staff have changed their stories and claim that they didn't accept our insurance or that they weren't accepting new patients (after already putting family members "into the book" for an appointment, even; one provider used one excuse after another, despite prominently advertising in the local paper that they are looking for new patients and "accept all insurance"). Another office actually claimed that the doctor had gone to lunch and wouldn't be back for 3 hours...immediately after I told her our deductible amount--her mouth dropped open and she ran back into the back and came back with the lunch story. I don't understand it, because I offered to pay up front and the care was always for simple issues that never would have hit the deductible nor broken the bank anyway (a flu in one case, a basic checkup and blood tests in another). I assume it's illegal, too, otherwise the universal response wouldn't be a stammered excuse.

This kind of behavior does help to weed out bad doctors/doctor's offices (net good, I guess?), but in a situation where your issue isn't bad/acute enough for the emergency room and not forestallable enough to wait a month to get an appointment for a good doctor, it's really frustrating.

Luckily, there's a nice urgent care locally with prices on the walls, accepts real money and even gives a cash discount, and handles the basics...but for traditional/specialist doctor's visits, I no longer offer up any information about the fact that the deductible is high and we're paying for services ourselves before the appointment.

[Amadou]

I have not had that happen, but it is rare for me to see a new doctor. I would be super pissed though. I'd be writing to my state attorney general if it happened to me.

[jrmg]

Why do you want to pay cash? Wouldn't it be better to pay via your insurance company to 'use up' some of the deductible?

[LogicX]

That only works if you anticipate regular medical needs that will 'save' you money by tapping into insurance.

Otherwise if you never anticipate hitting your deductible for the year, it makes more sense to pay a discounted cash rate out of pocket, and maintain the insurance only for a catastrophe situation where you far exceed your annual deductible: preventing yourself being stuck with a $100k hospital bill.

[drakeandrews]

As far as I am aware, most deductibles are per-incident. If you have a $5k (figure pulled from arse) deductible and paid $1200 last month, $2300 last week and have a bill for $2000 today on three visits for three separate things (with three separate bills), you still owe $2000 because that bill is under the deductible.

[showerst]

I don't think the article was exactly _lying_ as putting a spin on the truth to make a political point.

What they did is totally cool, and more providers should post their pricing transparently. There are complicated, sensible reasons not in the current world, which I hope will change.

The government does not obviously stop them from providing pricing information about how much they charge for medicare/medicaid, hell the gov't releases that info themselves for the really big providers. It is, however, their business and I'm _sure_ they could point to some of the thousands of regulations and laws they operate under and say that it realistically prevents them from releasing pricing. It's like when people who haven't done so say they won't start a business because taxes are too high. Not false, but politically laden.

Saying that they don't take medicare/medicaid so that they provide a higher standard of care or be more successful or whatever is kind of like saying "Our private school doesn't accept kids who get reduced price lunches, so that it can operate efficiently and provide the best education."

It's not _lying_ so much as blatantly spinning it. This just feels like when you see a tech site re-run a breathless press release verbatim. It's not _false_, but it's not exactly fair to readers, either.

[pekk]

When you knowingly, intentionally mislead people, that is usually known as lying.

[tapp]

The article's statement is misleading, but arguably true if you parse it the right way.

Medicare very likely does not allow for the prices featured on their online price menu. You could therefore say that it "won't allow for their online price menu" since without the underlying prices, there can be no menu.

I agree that as written, the statement is misleading and feels politically motivated. No way to know if the spin was applied by the doctor or the journalist.

[Shivetya]

Part of the Affordable Care Act is a requirement for hospitals to bill cash payers no more than someone who has insurance must pay. So if insurance companies negotiate a rate for a procedure, stay, or the like, and you pay cash the hospital needs to charge you the same or less.

[me2i81]

Do you have a citation for that?

[jacalata]

not the OP, but here's an article: http://washington.cbslocal.com/2013/06/23/promise-of-price-c...

[desireco42]

If true this would be awesome. The problem currently for me is that with cash payments I would always be the one who has to pay most.

[beefman]

I can't square your statement that 'government encourages healthcare providers to reveal their prices' with the following paragraphs.

[clarkm]

If you're looking for some more information, you can see the pricing on their website here: http://www.surgerycenterok.com/pricing/

Reason also did a story and short video on the Surgery Center of Oklahoma last year that I think is worth watching:

http://reason.com/reasontv/2012/11/15/the-obamacare-revolt-o...

The center was started by Dr. Keith Smith, who is very much a free-market guy. Even if you don't agree with a lot of his libertarian stuff, you have to admit that he's very well read and knowledgeable of economics, especially for a physician. He runs an active blog at: http://surgerycenterofoklahoma.tumblr.com/

[tempestn]

The great thing is, health care has been such a study in what can go wrong with free-market capitalism that it's nice to see a counter-example.

[mattmcknight]

Free-market capitalism? It's highly regulated, subject to inconsistent taxation, and over 50% of care is bought by the government...

[wavefunction]

Wow, I wonder why that is? It's almost as if tempestn is referring to a time before the situation we currently find ourselves in that brought about the high level of regulation, inconsistent taxation, and 50% of care being provided via government purchasing.

It's almost as if somewhere in the middle between over-regulation and no regulation at all might be prudent...

[sneak]

Are you suggesting that it was worse at some point in the past?

[roc]

There's a very large amount of medicaid/medicare practice (and 'obamacare' practice) that was written by insurance and hospital lobbyists with a financial incentive to perpetuate the status quo, if not outright extend regulatory capture and stymie any actual market competition.

Given that something as simple as allowing Medicare to negotiate with care providers and suppliers as any other insurer is massively controversial, I think you would be amazed just how controversial seemingly-straightforward reforms actually are. Particularly those things that would increase competition and thus threaten the status quo.

[bobwyman]

It is not correct to say that Medicare "would not allow" online pricing. Medicare doesn't care what hospitals charge. Medicare ignores hospital charges. It only pays what Medicare calculates is a fair price based on what hospitals report as their actual costs. It would be more reasonable to say that Medicare will ignore any posted prices whether or not they are posted online.

[joewallin]

Publication of all pricing ought to be required.