As a country, the US hasn't decided whether healthcare is a fundamental right or privilege. As a result, we constantly make political decisions that straddle the line without ever really going one way.

The biggest culprit is the "fee-for-service" model of reimbursement, where healthcare providers (physicians) are reimbursed based on the quantity of care rather than patient outcomes. Each procedure has a code (CPT) that is used to bill insurance. Billing for each of these codes is completely arbitrary and up to provider/payer negotiations. The fee-for-service model is a clear example of a perverse incentive.

Who reimburses the fee-for-service model? Either the government (Medicare/Medicaid isn't even entirely government-run, as many states rely on a for-profit Medicare Administrative Contractor) or private health insurance companies. The perverse incentives can now be seen from both the provider's side and the payer's side: hospitals and physicians negotiate to get the best reimbursement rates that they can. And of course, because these insurance companies want to make money, they make it "difficult" for providers to get paid for each procedure and will find any reasonable way to deny the claim from going through. Because of this, providers artificially raise the amount charged to the payers as high as they think they can get away with in the hopes that insurance will pay up.

Meanwhile, patients suffer greatly as there's no transparency.

I've seen evidence (firsthand) that value based care can work, but it's hard to get provider networks on board when they are the ones who aren't getting paid when readmission rates are too high.

Charge a hospital based on patient outcomes? How would that work?

Granted there would be major devils in the details especially if it causes "underwater" patients.

I had worked as an engineer and was closely aligned to the fraud division for one of the larger insurers some time ago.

Before anyone objects with "but what about emergencies!" note that emergency care is a single-digit percentage of total health expenditures.

[1] If you're going to try to say that what is "unforeseen" is relative it's not that relative, you can get an independent committee of doctors and provide a percentage based on their experience how much often that event is expected in that situation

Software development is inherently nonrepetitive and therefore unpredictable.

Healthcare is much closer to auto repair than software development.

Sure, on a car that's running that you can't turn off, with parts you can't replace, a maintenance history you can't see, and an ECU that actively misrepresents what's going on.

That is a dangerously naive view of software. Even apps that look like simple CRUD end up riddled with specialized business logic. Apps which truly are a few screens of simple CRUD end up as spreadsheets or Microsoft Access. We've gotten pretty good at not reinventing wheels.

Say what you will about the challenge of it, doctoring is fundamentally procedural and repetitive. Patients don't really show up with whole new undiscovered diseases anymore.

O'boy. What doctor do you go to?

  Rolled ankle
    100% [of patients get charged]: Office visit: $50
    58%: X-rays: $55 - $95
    22%: boot/cast: $240
    3%: surgery: ??
    <1%: other: ??

""" When you are estimating tasks that are done over and over, you can look to your historical execution time for insights. We average chopping X logs per hour.

If I hand you a Rubik's Cube and ask you to tell me how long it will take you to solve it...what is your answer going to be? If you've done it before you might have an idea. Maybe you just kept plugging away until you finally solved it? Maybe you've watched one of those videos about how to solve a Rubik's Cube, have practiced it and are confident that you could do it in 3 minutes flat? Maybe you have no idea?

Complexity and experience will dictate your answers, but then those estimates still only reflect your perception of the task...not everyone else on your team.

At best those numbers are a guess.

Every step in a software project is solving problems. You don't know how long it will take to solve the problem. You don't know how many new problems you might run into along the way. Can the new problems be solved by you or do they need to be solved by other people? """

[1]: https://www.brightball.com/articles/reality-driven-developme...

>Vox's database shows that patients are especially vulnerable to these surprise bills when out-of-network doctors work at in-network hospitals.

“It does happen quite a lot in the emergency room,” says Christopher Garmon, an assistant professor at the University of Missouri Kansas City.

Garmon published a study last year that found as many as one in five emergency room visits led to a surprise bill from an out-of-network provider involved in the care.

https://www.vox.com/2018/5/23/17353284/emergency-room-doctor...

Insurance is through her work, so I had to coax her through logging in to her account so that I could try to find an in-network ER list.

After spending ~30 minutes grumbling at the website over the complete lack of anything resembling clarity, I had a list of 3 hospitals that appeared to be in-network (and a sinking feeling that this could easily cost thousands of dollars). Set off around 2am. Arrived at first. 5+hour wait. Went to the next, no wait. They didn't manage to do much aside from giving a few tests that came up negative, administered fluids, gave her a steroid shot, and did a blood panel.

Her blood panel had one abnormal result that the doctor was willing to admit her for observation over (and had admitted people in the pass for less), but the doctor also noted that the parameter can vary a lot person to person; some people would be fine at that level. I had a sinking feeling in my stomach and decided it would be better to take her home to keep an eye on her than risk financial ruin. I think we were there 2-3 hours.

When the bill came months later, it was $2600 because the doctor was out of network.

For all technological advancements in US, the healthcare system is quite backwards. It’s not a new problem. Tons of countries do it well “Canada, Australia, Sweden ...”

The US political and healthcare system refused to accept other models since there is sooooo much money to be made at the expense of “some-other” people dying and going bankrupt.

House insurance, car insurance, all other forms of insurance are transparent, US healthcare is the most “mafia-like money extortion” system.

Right, as soon as the patient is admitted, it's a cardiothoracic surgery issue, or an oncology issue, or a high-risk obstetrics issue, or a critical care issue, or a neurosurgery issue, or a nephrology issue, or a general surgery issue, or an in-patient psych issue, or an ENT issue, or an opthalmology issue, or a geriatrics issue, etc.

Too expensive to fix healthcare issue. You’ll probably die or make it worse if you don’t fix it. “How much is your life worth to you?”

You can get a ton more random money by holding people’s lives over them. That is in summary the US healthcare system. Full of middlemen squeezing every penny they can out of you because they can.

Whoever campaigns for a transparent healthcare system, I’m voting for them.

Our broken healthcare system kills more people than all terrorist attacks and natural disasters combined because people can’t afford to pay the bill mafia.

That’s just a very sad state of affairs.

How does that contrast with "care provided by emergency departments?"

That is true, but emergency care disproportionately results in bankruptcies compared to other forms of care.

Moderate sarcasm.

But really that’s a deeper issue with insurance causing most of that. If you don’t have insurance, most hospitals will severely discount the costs that you are originally charged if you just work with them. It shows those prices are bullshit to begin with.

My locality has a ballot initiative up this year that would put a % cap on what hospitals can charge over their costs, and boy oh boy are the industry mouthpieces out in force to oppose it! They are having a field day with patients’ wallets, they know it, and they don’t want it to end.

Edit: since we only just warned you about this, I've banned your account until we get some indication that you intend to follow the rules from now on. You're welcome to email [email protected] if that's the case.

It might take a day. It may take a decade. It may take you the customer to change your entire approach.

This is not feasible. You can not disregard hidden defects and the cost of fixing them unless you do not really want reliabilty. If you do not want it, then don't complain.

In IT this requested lack of reliability is accepted. In healthcare and auto repair it is barred by law.

EDIT: i hate autocorrection.

This idea that medicine is different than other fields is crazy.

It costs $75 to pull the car into the garage, the lift fee is $105, it's $21 to open the hood, $64 to unplug the wires from the old plugs, $64 to plug the wires into the new plugs, then there's $18 to close the hood (gravity assist discount), and another $75 to put the car back in the parking lot.

Don't worry, changing your plugs is only $16.

You would be asking what goes into that hourly rate.

Turns out it cost $30 for flurodie and $60 for xrays. Fluoride is only covered in kids, and xrays every 2 years. I call up dentist office and you know what they tell me? They don't provide treatment based on insurance coverage.

Right...they provide treatment based on how much money they can rip you off on. Fluoride for adults is new. We have fluoride in the water and in the toothpaste.. I don't recall having it in the past and my Google search tells me where's a debate on whether it's even beneficial. I only see that it benefits the dentist's pockets.

The parent post expanded on that point by trying to list all the other charges for a common car service in the style that would be similar to what one would see if they were admitted to the hospital for an procedure. He then reiterated the point that the cost estimate only included the cost of parts (the 4 spark plugs).

I just expanded on that by listing the other labor related charges for the procedure that still wouldn't be included in the estimate.

In terms of car repair, you just have to know about the hourly rate of the shop and the number of hours they state a particular repair will take. In a hospital setting, you have no idea how many people will interact with you and what their charges will be (which appear to be unrelated to how much time they actually spent with your case).

Because every single one I've been to also includes labor cost in the estimate.

If I need antibiotics, my employer provided insurance covers the full cost and I pay a fixed $10 or so fee to the pharmacy.

You live a few hundred km south of me I bet, and in every way except this our world is very similar.. but you guys have far deeper problems then just transparency. Your entire view of healthcare is wrong.

One day I'll figure it out but at 24 years old it's not a huge deal to me.

-I went to urgent care for some swelling on my neck that escalated quickly. 45 minutes later I was getting a MRI. This was on a Friday. They called and said it was cancer.

-Monday I was seen by a ear nose throat doctor. Yes, cancer indeed.

-Tuesday I saw a oncologist.

-At this point I decided to move to Portland since my sister lives up here. So the oncologist referred me to another ENT doctor in Portland.

-About a week later I saw a dentist and radiologist on the same day. Everyone agreed that due to the bad shape my teeth are/were in and the location of the cancer my teeth need to come out.

-A few days later another oncologist

-All my teeth removed (this has been rough)

-Tomorrow a "simulation" and PET scan to see if the cancer has spread

-Tuesday is something called a swallowing test

-Wednesday is a check up with the oral surgeon

-Friday is some intake thing for the feeding tube and a meeting with the nutritionist.

-Next Monday feeding tube installed.

-Next Tuesday another check-up with the G.I doctor.

-Next Wednesday radiation and chemo start.

So yeah.. I have no clue how much this shit is costing and I don't really care since I have Medicare. I just wish everyone had the same luxury.

For example, I got a quote this summer for an outpatient MRI that was 20% the cost of a hospital MRI, faster, and would accomplish the same thing. Now I tell everyone I know about this. If enough people do this, the hospital will not be as free to increase the cost and might even lower it (or at least start providing quotes!)

This price-shopping process is slowed by all the shenanigans that keep prices and services provided confusing, and demand to improve this is hampered by insistence that patients are never in a state of mind to shop for the best healthcare provider. It’s simply untrue—and there are workarounds in the worst cases like healthcare POAs and family members donating time.

Calling around and shopping is what people do on practically every other service or good they buy now.

In terms of how they would be set, Medicare already spends a ton of time created a system of DRG codes for every condition along with a set payment (adjusted by COL and other things).

Of course Medicare rates are sometimes less than the cost to provide the care. But I see us just getting to the point that the govt will just say “tough shit”.

You dont call around for quotes of $100+ services?

Why?

Free services mean a few people will overuse and abuse.

It is perfectly sustainable if you have a population that isn't ideologically opposed to taxes. You can fix that with education.

> and bad capitalism.

Good capitalism or bad capitalism, who cares? This sounds like a pointless ideological concern, again.

> Free services mean a few people will overuse and abuse.

It seems spiteful to me to deny universal healthcare to the majority because a minority might abuse it.

The most efficient provider should get his or her business. That way we can treat more people for strep and increase human welfare.

There's obviously some variation here, and for that an hourly rate makes sense.

Health care should be more like car repair: go in for a quote, then pay when you decide on a provider. Obviously emergencies are different, but things like strep or broken bones are pretty common, so they should have a set price.

That's an assertion, not an argument supported by observations. In the European countries the government sets prices for procedures, and it works well, life expectancy there isn't lower than it is in the US.

Americans pay out the nose for drug prescriptions, which fund the vast majority of research and development budgets, which then benefit all people, worldwide.

And all of those countries make more revenue selling to the US than they do any other country by a long shot.

What you haven't answered is whether the research can be supported without the American market subsidizing of that research.

It is in fact, expensive to develop new drugs and something has to pay for that development.

If the world wants and needs better drugs, there are other ways to fund research. If we give a damn, we can find such solutions.

Citation needed.

Given that the US has this system and US healthcare is multiples more expensive with worse or similar outcomes in essentially every field, I suggest we can put that theory to rest now.

(definitely not defending the US system)

The US does not have this system.

No one thinks that no end user cost (what people usually mean when they say free) <> no money spent.

My point: Let's stop comparing healthcare to road construction/maintenance. It's human lives. It works differently.

Also, speed limits can be comparable to turnpike's, the interstates are rarely "blocked" unless you mean congested, which is a different issue and one that more road at that location would actually make worse. Construction costs are comparable to turnpike construction and maintenance costs and are slow because, unlike a turnpike it's most visible and most delaying in areas like cities where you can't move cars to a shoulder, something that isn't an issue for turnpikes..

By whom? Traffic is just an argument for mass transit

>roads not really good

That’s an argument for more government not less. They’re fine where I live.

>speed limit low

It’s reasonable in cities and towns

>construction expensive and slow

Also high quality

You already have a beurocracy in “your” health care system. It’s just a private one and not a public one. The difference is cost involved in administrative overhead deciding who gets care and for what.

A nation needs a good health care system and a good road system to afford productive workers.

Both systems when implemented poorly cause human death and disability.

Huh? I don't see any argument at all. The fact is that it is, right now, blocked.

> That’s an argument for more government not less. They’re fine where I live.

Yeah, sure - I live in the Czech Republic, a place where we have more government and the worst roads you will ever see in a first world country.

It's definitely not an argument for "more government" - actually it's not an argument for either because you've provided zero arguments. Why it'd be better than it is now?

> Also high quality

The highways are definitely not high quality, it's just good enough. Visit Germany sometimes. Construction time has almost no relevance to quality, btw (if we don't talk about extremes).

> It’s reasonable in cities and towns

We are talking about interstates.

> You already have a beurocracy in “your” health care system. It’s just a private one and not a public one.

Yeah, I know. Again, what's your point? You stated facts that are well known by everyone interested in this topic. There are very clear advantages to a free market and there are very clear disadvantages of a public solution (and of course the contrary).

Have you ever thought about the fact that only people in the USA actually want a public system? Maybe a private system could work well if implemented correctly (see Switzerland, a country with one of the best healthcare in the world - that is private) - government is not a universal and definitely not always the best solution.

> The difference is cost involved in administrative overhead deciding who gets care and for what.

Is that the only difference, really? How much experience exactly do you have with public systems? Are you sure you have a complete picture? I have lived in several ones over my whole life. I prefer the US system.

BTW is there really a difference? You know the same thing needs to happen in a public system as not everyone is eligible for everything? How does it compare to waiting for 4 months until a doctor is available (in non-urgent cases)? How does it compare to generally substantially lower quality of care (not medical, but care - as in quality of food in hospitals, whether they treat you respectfully, whether you need to sleep on a hallway because all rooms are packed with 5+ people...)?

Do you know that only the most basic (we call it "medically necessary") treatments are paid and everything else needs to be paid out of pocket in full as there is no possibility to insure yourself for upper level of care (actually it's illegal)?

> Both systems when implemented poorly cause human death and disability.

Exactly. So let's stop with "hurr durr we need full government intervention" and let's focus on what's wrong, why it happened and how to fix it ASAP - and you're not going to fix anything ASAP if your way is to rebuild the whole thing and nationalize/bankrupt (or both, as is common with governments doing business) huge companies.

The USA system needs change, however I'm pretty sure that such dramatic change would leave the country in ruins (or more likely in a lot of dead bodies) simply because it's extremely hard to run such system even if you've been doing it and continuously improving it and gaining experience for the last 70 years and your country is 20x smaller - and there is no country in the world where a public system would have substantially better results than the US one.

Transparency won’t fix healthcare in the US, but it is a starting point. Hell, it’s fundamental to simple free market economics. It’s silly to say we have a free market healthcare system when there is virtually no cost information about goods and services until after purchase.

It seems that a major driver of insurance and medical costs is that doctors are allowed to charge different pricing for the same service. In this case, paying a monthly fee for insurance ended up costing me more.

This stuff is all bad, but it's useful to remember that primary care is actually a small fraction of the overall price of health care. Where we're really spending the money is on long-term and end-of-life care.

Agreed. When I visit my PCP, I normally meet with a NP. I’ve been quite happy with the quality of care received.

> Where we're really spending the money is on long-term and end-of-life care.

With the boomers entering the end-of-life phase of their lives it will be interesting to see if we will be able to change culturally and realize the huge sums of money spent with little benefit to the economy. I’m struggling with this myself currently as my parents are aging (quickly). They don’t have unlimited savings to spend on health care. While I have ample resources, I’m not convinced shelling out $1MM is worth it for them to live with a marginal quality of life for just a couple of years. Just writing that makes me feel like a terrible person but I try to think rationally and without emotions.

Edit to add: I’m genuinely curious about your thoughts on this, @tptacek. I’ve always respected and appreciated your opinion here on HN.

The free market works pretty dam well for those.

[1] If the technician later determines that it will take additional work and will cost more to fix your car than the original estimate, someone from the shop must contact you, describe the additional work and cost, and get your permission to proceed. -- https://www.bar.ca.gov/Consumer/Auto_Repair_Guide.html

You walk back past the reception desk, ask what the bill was, and they either say "that'll be $40 which you can claim back by taking the receipt around the corner to Medicare", or they'll say "Oh nothing to pay, it's all bulk billed".

You walk out having either spent nothing, or spent a few bucks which you get back after a five minute walk up the road.

That was my recent experience.

You don't go to a restaurant and get the pricing after you eat. Heck when you go to a buffet you don't get billed based on how many plates you get.

Edit: and wouldn't this lead to lawsuits against medical practitioners for extortion if it can be proved that they make a habit of doing this to patients?

This works terribly for most advanced economies, Britain and Canada in particular.

https://www.ctvnews.ca/health/health-care-wait-times-hit-20-...

The official government figures, where about half of patients get care within 24 hours, and about 90% within 48, are much more in line with my experience.

When you look at the stats aggregated by OECD, Canada is indeed among the worst public health services in the developed world, but it still provides better care to the median earner than the US health system, at half the aggregated cost per capita.

I'm sorely disappointed in your arguments so far. Your stats support your point and are legitimate but mine are not. Typical liberal nonsense.

The stats you provide are collected by an institute looking to further their ideology. They come from a far smaller data pool,and their collection method seems rather suspect. For example, they're asking the actual practitioner rather than anyone involved in scheduling.

Proof?

> The governments stats basically have to be kept. Running the system requires all of the necessary data to already be collected for other purposes, and their stats are drawn from that.

You trust a government entity to accurately report data that's not in it's best interest? When has that ever happened?

Can you explain what your criteria would be for a trustworthy source?

That's essentially the definition of a think tank. This one was founded by a libertarian and considered by many to be libertarian. Certainly cause to question their stats, and I didn't like what I saw.

>You trust a government entity to accurately report data that's not in it's best interest? When has that ever happened?

This is probably enough for you to question their stats, but you've done nothing to show they are wrong.

Combine that with multiple agencies such as Health Canada and OECD which have measured wait times an order of magnitude lower than you cited, I am not sure what else to say.

I challenge you to find a second source that is both consistent with your article, and breaks down the waiting times by type of treatment, including treatments that do not need follow ups with specialists.

Why not?

Most people are in serious pain and have their mobility severely compromised while they wait - I know from personal experience.

https://www.vancouverobserver.com/politics/charitable-fraser...

As to the invalidity:

The fact that I have never waited for more than a couple of days for treatment in over 25 years, and neither had anyone I know (with 2 exceptions, both of which were for elective surgery like breast reduction surgery) does imply that, at best, their median measurement is measuring a specific niche, rather than general treatment.

Combine that with the fact that multiple agencies have measures wait times as being an order of magnitude lower than your source, and yes, I do think your numbers are invalid.

Nobody's stupid enough to believe that one doesn't imply the other.

> The Fraser institute, which published this study, has a right wing bias and is funded by the Koch Brothers. It seeks to displace the public system in Canada with private healthcare modelled after the US. While they claim independence and give their research away freely, one should be aware of their interests.

You requested "proof". Given that the only quantifiable claims which could possibly be proven is that they are funded by the Koch brothers, and would like to replace the public system with a private one, I assumed you were asking for proof of that.

Now, if you were not asking for proof of that, can you quote the section of the above you did want proof of?

Can you point me to where I say that? You've just killed any potential discussion by arguing in bad faith. Why should I listen to anything you have to say on the subject now that I know your intentions are hostile and that you're not open to debate?

Well, part of the problem is that the state now assumes that consumers are not qualified to take care of themselves, and that the only people who are qualified are state-approved high-demand professionals. Oddly enough, opioid overdoses were not higher when you could just buy the stuff over the counter; but people have forgotten that people used to be responsible for their own well-being, and are convinced that they should not be trusted to defer to experts when they see fit.

Also, the US has seen a recent huge rise in opioid overdoses ...

Also do yourself a favour and never assume that your US libertarian bubble definition is the de facto standard around the globe. Europe has a long and dark history of the kind of (neo-)feudalism that you're peddling, it's not hard to spot.