I got an abdominal ultrassound, because some of my bloodwork was off and the doctor wanted to confirmed my liver was ok. Very routine. So I agreed. 15 minutes from the time I got to the reception desk to the time I was out of the door.

Hospital billed $6000 (already negotiated down with insurance). Insurance paid around $4000. They wanted me to pony up 2k. Told no. Went to collections, negotiated to just under 1000. According to the line items, doctor took ~$100.

I have no clue why this was so high. My wife did pelvic ultras-sounds at another hospital (so not exactly the same procedure), but was billed $300.

The only reason I can think of is the 'name' of the hospital. It's in the Bay Area and shares the name of a well known university.

Had I known, I would never have gone there. That incident caused me to ditch my plan and go with Kaiser. It's been ok so far. No ultra-sounds, but I got a sleep apnea exam and a cpap for about 150 - and that was disclosed upfront.

Ultrasound is a quick and relatively simple procedure. They could get a few in the ER and a few technicians on staff. Then doctors are encouraged to say bloodwork is off let's do an ultrasound and there you have it - $4k / 25 minutes. Bill the insurance and keep raking in the money.

Normally I'd say that's far fetched but after having relatives advised to get unnecessary surgery I wouldn't be surprised.

I'm not sure what you mean by the doctors being encouraged but unless the doctor ordering the U/S is getting a cut then there is no direct incentive. But I don't know how your system works so I might be wrong.

In some emergency departments, the physicians participate in profit sharing. I know of a few EDs where they add up all the revenue, subtract all the costs, and divide the rest into each doctor's paycheck based on how much that doctor billed each month.

Do you not understand that doctors have levels of management above them? Their incentive could be "Boss wants me to encourage them for X reasons"

This is basically the reason I have Kaiser and have stuck with them for over a decade. The quality of service is shaky sometimes, and there is doctor turnover, and sometimes I have to travel relatively far to see a specialist - but if a KP physician refers me for something, I get scheduled to see someone, then I get it done, and I pay a reasonable copay that I know about immediately. I've never had to haggle with insurance or been surprised with fees later, even for relatively complex surgeries.

I left Kaiser. As far as I can tell, they don't have any doctors. I've been told that if I yell at them repeatedly, they could get me one, but I don't have time for those shenanigans. I went there for a GI issue. They poked my belly and said, "It's a virus". Had I not figured out the issue on my own, it could have become life threatening. Several coworkers know people that have been misdiagnosed and lost loved ones because of Kaiser. It seems to me that Kaiser is an entry level place for new doctors to get some experience. The offices are tiny and everything is rushed.

Yet, I've heard on HN so many people love that place. I can't fathom how that is the case. Even military clinics are decades ahead of Kaiser.

The only positive thing I have seen about Kaiser is that they are an amazing drug company. Each campus has 2 to 4 pharmacies. That must be a very lucrative business.

Goddamn, are you me? I have the exact same story. Minor blood test anomaly, liver ultrasound, 30 minutes, surprise $6,000 bill. Pretty sure it's the same hospital too.

The only thing that would make it weirder is if the initial bloodwork happened to have been also ordered and checked by a doctor from your company's 'health center'.

My wife is scheduled for ultrasound #4 because of pregnancy irregularities. The fact that it's covered by universal healthcare gives me peace of mind in a few ways: I don't have to worry about affording it, I can just worry about keeping my family healthy. I don't have to doubt if the medical experts have my family's interests at heart or if it's just a cash grab.

First pregnancy we had a scare about genetic issues. Instead of wondering where the money would come from, I was able to take time off work and be there for my wife between the phone call and the battery of tests done 45 mins away. Another hour long ultrasound and a sit down with a geneticist in the afternoon. No bills, invoices, anything.

There's simply no reason for capitalism in healthcare to directly involved the patient. At least I believe that to be true.

  There's simply no room for capitalism in healthcare

Yet the very technologies you specifically required in both cases (ultrasound and genetic screening) are direct results of capitalism in healthcare.

Medical Ultrasound was pioneered by a UK university in conjunction with the NHS. Are you giving "capitalism" broad credit for everything in modern society or is there some more specific claim you're making here?

Medical is in bed with the government

https://www.opensecrets.org/lobby/top.php?indexType=s

Heck, if you want to know why something in the US sucks, just look at that list.

Massive government corruption from legal bribery.

This is amazing. The list reads like a "who's who" of the most insufferable sectors of American life. I was surprised not to see auto manufacturers and agriculture in the top twenty, but medicine and telecom have definitely got them beat.

What makes auto bad?

The same kind of regulatory capture dynamics occurring with telecom and medicine. In the case of auto, preventing startup competition by mandating the old and needless system of dealer middlemen.

Not just ER. We went to urgent care with a bean stuck up my sons nose. The doctor spent about 30 seconds getting it out. We were in and out in 10 minutes or so. The bill was $2000.

Should have planted that bean. Maybe it would have grown an entire stalk of $2,000 beans.

In all seriousness, that they are able to charge that much with no upfront warning is pretty insulting. But then again they know they have you hostage, its not like you are going to change your mind and tell the doctor to just leave it in there.

> But then again they know they have you hostage, its not like you are going to change your mind and tell the doctor to just leave it in there.

I hear people make this argument about patients who are bleeding out, and that's one thing. You're not going to suffer any extra harm from leaving a bean in your nose for a week. The nose just dumps out into the back of your throat. Why wouldn't you shop around in that case?

How would you shop around?

Is that what you had to pay out of pocket? With or without insurance?

Unfortunately we thought that urgent care clinic was in-network, but it wasn't. Insurance covered a little bit, but we were left with the majority of the bill. We complained about the high cost and asked for a discount to no avail.

That's an easy one.

- (1) With an admirable humanitarian intention, the government forces hospitals to treat patients whose life is immediately in danger, and figure out later whether they'll be able to pay. If 1/10 people have the means to pay for the treatment they receive, then you're paying for your treatment, plus the expensive life-saving treatment of nine other destitute people who couldn't pay.

- (2) It's a monopoly. If your choice is letting your daughter possibly lose a finger, or taking her to the hospital, you'll take her to the hospital. Because you don't really have a satisfactory alternative.

- (3) It's opaque. You have no idea what treatment she'll need or how much it'll cost going in. They're loth to make promises about this up-front ahead of a diagnosis.

- (4) Because they can. Why would they ever charge $400 when they could charge $4000? The only surprise here is that it's not $40,000 or $400,000 or $40,000,000.

In Japan or Korea, that would've been $50-$100 tops without insurance.

And almost all hospitals are walk-in without appointments, and many big ones have night coverage.

ER? sure, it's there. But only if you have rebar sticking out of your torso.

Part of it is because consumers are completely detached from the price aspect of medical care. Getting an estimate, shopping around? Forget it. It’s a black box.

And, frankly, part of it is because hospitals can’t refuse care to anyone and if they can’t pay, someone else has to.

"And, frankly, part of it is because hospitals can’t refuse care to anyone and if they can’t pay, someone else has to. "

I think that's a cheap excuse they have to rip off everybody else. I would like to see the actual numbers of people who aren't paying and what losses they incur.

It's substantial but doesn't come anywhere near explaining prices. The PDF here has some numbers:

https://www.aha.org/data-insights/2018-01-03-uncompensated-h...

Somewhere in the ballpark of $40 billion dollars a year vs total revenues in the ballpark of $3 trillion. Various aspects of Obamacare had the effect of leveling them off.

There is likely additional underpayment due to Medicaid and Medicare (to the extent those programs are underfunded and operate by mandating care, they are a hidden tax).

That's what mandatory insurance is for. Everyone pays what they can, and gets what they need. Doesn't work perfectly, but allows me to go to a hospital anytime without being broke after.

There's benefit for everybody, which is risk reduction. You actually blame poor people for going to the ER in case of emergency.

It's crazy because the initial idea was, insurers would be more educated buyers and thus better able to negotiate with medical providers. As it turns out, with no skin in the game, they hardly seem to care to negotiate prices at all!

They do negotiate - the prices they’re charged are vastly less than what you would be as an individual.

As far as I can tell the problem is really the big HMOs seem to be essentially managing another companies money, rather than their own, and they essentially get a cut of money going in and out of them.

And the worst thing is that there’s no way to predict the cost. Even if you go to an ER that’s in network (good luck with that in an emergency), you might be assigned an out of network doctor and be charged out of network prices

We've had 2 children in the last 4 years and this concept was foreign to me. Our 2nd child we were billed for an out of network anesthesiologist at an in network hospital. Several thousand dollars in total, I called the insurance after reading online a bit about it. Eventually they said they would "resubmit" the claim for reconsideration. A few weeks later we got an EOB showing we didn't have to pay any of it. The whole experience we shocking to me, I can't imagine dealing with this sort of thing on a regular basis.

Even worse is receiving bills from various providers up to a year later. How are these people still in business?

Anesthesiology is a particularly pathological case, so to speak. You don't choose your anesthesiologist; it's the medical equivalent of a (very important and highly-paid) back-office function. So you've chosen an in-network hospital and an in-network surgeon? Surprise! You may also discover, months later, that your chart was read, while you were sleeping, by an out-of-network physician on call. Surprise!

The American system is literally (literally literally) unsustainable.

How could they go out of business? Any time they need money they can just go through patient records and charge for anything they feel like with very little statute of limitations. Its a license to print money at the expense of those that can least afford it.

Yep...I got an email last week for something for my daughter's birth...which 2 years ago. It was charged to an insurance I no longer have. I met deductible that year so everything was covered and it says I'm paying $0. They could lie about the some missing cost and I wouldn't know where to begin disputing it. If I don't successfully dispute it, it goes to collections and hurts my credit. Is my time worth disputing a $500 bill (it I had to pay it?).

It's a lose lose situation.

Regulatory capture.

Worse - you can get a bill in the mail later for some out of network doctor who looked at a chart without ever interacting with you, in addition to the hospitals charge.

Yup, or a bill from an out of network doctor that consulted while you were under or generally unaware [0]

[0] https://www.nytimes.com/2014/09/21/us/drive-by-doctoring-sur...

My favorite is that the hospital will use the external consultation to charge more for the visit.

Recruitment fee for the out of network you didn’t ask for!

Urgent care or walk-in clinics will likely cost much less. If it's a simple wound, a CVS clinic will work too.

Some urgent care clinics post wait time online so you can find out how to see a doctor the fastest way.

> Some urgent care clinics post wait time online so you can find out how to see a doctor the fastest way.

These are often misleading, though - the clinics that market this way essentially perform triage with docs instead of nurses, so you're technically seen by a doc quickly. Time-to-discharge would be a far more useful data point.

They're also often marketing like this because they're standalone clinics that are out-of-network for major insurers in the area. https://khn.org/news/surprise-that-urgent-care-center-may-se...