I think this is a trope in multiple areas trying to pose personal accountability as a solution where one actually needs systematic solutions. You see it with the climate crisis (make sure to buy only 100% organic recycled meat), or student loans (make sure to choose a major that has a 20 year postivive ROI), and medical expenses (make sure to price out and choose the most cost performant cancer chemo cocktail).

Really we need working institutions and controls those institutions can impose because the markets for industrial processes, or educational funding, or heathcare are vastly complex products with large capital, time, knowledge commitments needed to adequately check misperformance. The investments needed far exceed most time or money resources that make sense for any one person can put into single transaction. That's why collective institutions are needed to focus on developing the specialized information and policy needed to manage the poorly performing systems.

The idea that we ought to throw our trust in with bureaucrats is kind of ridiculous, particularly in the age of Trump.

But even if this were Scandinavia, incentives would still matter.

If I have a broken arm I’m not going to price comparison shop amongst hospitals.

Anecdote: I attempted to comparison shop for an mri to diagnosis a potential rotator cuff injury. While I could get the actual scan fees I couldn’t get the fully burdened cost and during the visit it’s entirely opaque what things will be new line items on the bill.

https://www.politifact.com/truth-o-meter/statements/2013/oct...

Unfortunately the article doesn't make it easy to figure this out.

This gets mentioned in every healthcare thread. With transparent pricing we'll soon know which hospital costs 3x of the other, so we (or beforehand or family) can decide which one to go to for treatment.

Don't let perfect be the enemy of the good. People can make their own decisions. There is no ethical position for keeping pricing information secret. Just because one can imagine a rare scenario where it wouldn't be useful is hardly a reason to continue hiding it.

Also, I'm not against price transparency, but I'm highly skeptical that it will improve anything. The reasons should be quite apparent but price setters will settle on or near the highest prices since everyone in the system is incentivized to do so. It also doesn't solve the problem that many people pay a $N copay noatter what the price is due to insurance. And the third issue is the in and out of network problem.

When you consider all these, along with the lack of choice for pretty much everyone, it isn't going to change anything.

This argument is too dumb to qualify as sophistry.

They said it didn't matter though because insurance covered it. But they were wrong.

Forgive my perhaps being out of touch, but isn't the primary complaint that healthcare can be _ruinously expensive_ and unaccountable?

The real issue is when people don't have coverage or when their insurance denies it. The latter is hopefully mitigated by Obamacare's "no pre-existing condition" exclusion. The former happening is pretty obvious: people can't afford it and their employers don't provide it (single-payer would help with this). Alternatively, some people just need _a lot_ of health care, and 10% of a million dollars is still a lot of fucking money.

But if you need the health care, what are you supposed to do? That's what we mean when we say "people don't care about prices". The prices aren't going to change that much because of this legislation. The real issues are 1) not everyone is paying into the insurance pool 2) there's a needless layer of gamesmanship between insurance and providers and 3) providers and insurance are working on a profit motive.

To fix healthcare: 1) Put everyone in the pool via taxation (aka single-payer), 2) Move healthcare to public or non-profit with lots of oversight to prevent fraud.

Of course when the insurance doesn't cover the procedure and see the 400U$S bill people flip out.

Well if that’s the case...it’s because the $400 bill isn’t the real cost for the service and insurance actually pays $0 of the bilked $400.

What happens is the patient pays $20 copay gets billed ~20% of the $400, or $80...then everyone but the patient is happy, Dr. gets his $100 for the visit and gets a $300 tax deduction, the insurance gets its premiums from the patient and gets their 80% waived by the provider effectively shifting 100% of the cost to the patient while still being able to account for the 80/20 split on the books.

The best thing for the doctor is to get paid (and pay taxes on) $400. The $300 deduction is of no value to them because they never recognized the $300 as income. The deduction is basically "Hey, sorry you couldn't collect your billed amount. You don't need to pay taxes on money you didn't earn".

Sorry if you fully understand this already. The lack of understanding of basic taxes is a pet peeve of mine. People make statements like "Johnny was looking for one more tax deduction, so he donated to my charity". Johnny probably cares about the charity or at least looking good in the community, because he'd have a larger net worth if he just sucked it up and paid taxes rather than donating it.

No...the best thing is for the doctor to not upset the insurance company and get dropped from their network and lose all their patients.

Remember the famous line if you like your insurance/doctor you can keep your insurance/doctor. Turns out the president has no control over whether insurance will outright drop doctors from their networks.

As to your point on accounting, it simply depends on the doctors/hospitals accounting practices. It’s possible there is no deduction as you say (no big deal to the doctor, they got paid their fee anyway) or they can use an actual method of accounting and carry the loss forward.

Yep, it's been 7 years since I took an accounting class (and it shows). Thanks for adding that.

As you point out, a cash basis taxpayer pays taxes on actual income received. Money you may have hoped to receive but didn't isn't income, so there is no tax and no deduction related to it.

If the doctor filed taxes using the accrual accounting method it would be different.

It can be waived (not treated as income at all as you say) or it can be treated as income (taxes paid) and the loss carried forward for future deduction.

You are assuming that Johnny isn't the one that doesn't understand tax deductions.

If the marginal tax rate for the Dr. is 50% (like it probably is in CA) then a $300 deduction is $150 in tax savings.

With accrual, you report income when you bill for it, not when you receive it. Suppose you treat a patient on December 31 and bill the insurance $400 on same day. You report the $400 as income and pay taxes for the entire $400 in that year.

The next year, insurance only pays $100, so now you have a $300 loss to report in the new year. But you only have this loss because you've already reported the $300 as income.

If the doctor uses cash accounting, there would not be a $400 income entry on December. There wouldn't be any income to report until they are actually paid, and then the income is the actual amount they are paid, $100.

If you have a widget that cost $50 to make/market/sell and you sell it for $100, then have a "sale" or "friends and family" discount to $60, you don't get to write $40 off your taxes. If you sold it for $40 you could write the $10 loss off of your taxes.

> Dr. gets his $100 for the visit and gets a $300 tax deduction

I think that is the phrase all of us have been jumping on. What you wrote there is simply not true. There is no scenario, regardless of whether the doctor uses cash or accrual accounting, where they get $100 for the visit and a $300 tax deduction.

There are three possible situations here:

1. Doctor uses cash accounting. The $400 invoice is not a taxable transaction. Doctor gets paid $100, reports it as income in the year it is paid, and that's that. There is no $300 deduction.

2. Doctor uses accrual accounting and is paid the same year. They report $400 of income along with a $300 loss in that year. Net income is $100, and doctor pays taxes on the $100 income. Their tax for this transaction is exactly the same as if they had used cash accounting.

3. Doctor uses accrual accounting and is paid in a subsequent year. They report $400 of income in the first year and pay taxes on the entire $400. Then, in the year they get paid, they report a $300 loss, because they were only paid $100 out of the $400 they previously declared as income. The only reason this $300 loss exists is that they already reported the entire $400 as income in the previous year and paid taxes on it. They aren't getting $100 income and a $300 deduction, they got $400 income in one year and a $300 deduction in a subsequent year.

As you mentioned in another comment, there may be reasons why a doctor would want to do this. Perhaps they just started their practice and are in a lower income bracket this year but expect to be in a higher bracket next year. In that situation the accrual method may help balance their income across those two years: they can pay taxes on the accrued (billed) income in the year that their tax rate is lower, and then take the loss in the next year at a higher tax bracket.

There may be other reasons to do this as well, but none of them change the fact that accrual accounting would mean they reported $400 in income along with the $300 loss, whichever years those happen to be.

It's not $100 in income combined with a $300 deduction, whichever way you account for it.

There is certainly a difference between a list price and a negotiated rate, but there isn't some sort of secret "we'll tell the patient in writing we're paying $400, but actually we'll pay you nothing" rate.

The real fraud is the fact that insurance companies have been buying up health care practices/hospital systems and dropping all other providers from their networks and forcing the patients to go to the insurance owned providers (often times unbeknownst to the patients). Although there have been a couple successful large class actions by both doctors (who got dropped) and patients as well, but this hasn’t changed anything in practice just provided a little hush money.

I'm fairly certain this loophole doesn't exist.

Perhaps the latter is part of what leads to the former, and perhaps full disclosure will change things, but generally there has been no point in even trying to shop around based on price, since there are no good options and very little information about prices.

Is there a difference between going to the CareNow clinic near my house or the Code3ER near my house? I have no idea. Should I go to a hospital instead? Is that cheaper or more expensive? I have no idea. Once I get there, are things going to cost me more or less depending on which arbitrary doctor I end up with? I have no idea. If they order further tests or a consult with someone else or some medicine I've never heard of, do I have the ability there to ask questions about price? No, I've tried. Doctors genuinely seem to have no idea whatsoever what things cost, by and large.

So at that scale, not the big picture but the individual scale, prices don't matter because if they did, I'd just stay home and hope I live through whatever ails me. Which is often what I do, in fact.

I hope forcing publication of prices makes a difference. I'm suspicious that companies will find a way to do so that protects their profits, but hey, I'm hopeful.

That said, they also have to deal with liability (especially in an ER) so they have to treat any POSSIBLE thing that you might have before you leave since people often arrive with zero medical history and they have to rule out side effect things that may not be an issue. Further, the fact that their physicians often deal with advanced specialities and/or emergency medicine means you're paying for a specialty for something that could be simple. I try to stay out of ERs unless I'm worried about my life and instead use urgent care / clinic visits when my GP is not available. Their billing seems to be much more consistent, anyway, and there's less risk a physician won't be covered by your insurance just happening to stop by.

Just out of curiosity you wouldn't happen to be a twenty-something in relatively good health would you? :)

Wait until op has a baby delivered and sees crap like:

* BP/READ $349

* OR/FOO $2090

* OR/BAR $1000

* OR/BAZ $2090

Not real codes, but they might as well be with the current system...

I also bring up single-payer in a related way because the need to find in-network providers within reasonable distance often is such a limiting factor that price shopping isn't possible.

With single-payer, one could actually choose between all of the providers... in addition to other benefits.

There are websites like ZocDoc which are like yelp for doctors, but they can only do so much because of the lack of price transparency, and lack of ability of consumers to choose doctors out of network.

There could be many more, if not for various policies that impede this.

If price transparency and quality comparison were made easily accessible, and one could actually choose options regardless of considerations like "in-network," then it would be entirely conceivable that the majority of medical procedures would involve price shopping.

And such shopping around based on price and quality would improve things even for those who do not price shop. Feeling the pressure of market discipline would force providers to compete on quality and price.

There are sites that try to be like yelp for healthcare, but you ultimately don't have any price transparency, not every doctor is listed, and you have to navigate a maze of insurance categories. In a saner world, we would have better transparency in healthcare than pizza delivery.

The other half of this has to be aggressive antitrust enforcement in the healthcare sector.

Meanwhile, my total annual premium cost is still > 20k.

I absolutely do care about prices (which doesn't matter right now, nobody will tell you what they are), and so does everyone I know, most of whom are on these same plans. The only people I know who aren't are unionized. But I have no way of finding out what they are beforehand. I don't even think this mandate will help. Yeah, sure, now the hospital posts the price - but what about the other dozen providers that involve themselves in a single procedure?

For example, my wife underwent a routine procedure a few months ago. I am still receiving bills from different providers. So far I'm at 7. Never mind trying to even audit them to see if they really did anything!

At the same time, do we really want health care to be under intense price pressures? I'm not so sure. I imagine the medical bureaucracy will continue to expand unimpeded while actual quality of care will go down. That's what I already see happening as a result of cost-cutting.

That said, there are definite things that increase the cost disproportionately, and the way the government subsidizes insurance through an employer makes a major disconnect between patients and providers. If the subsidy were eliminated and insurance untied to employer you would have a huge step in the direction of unleashing market forces.

Untying insurance from employment is a great idea, but it won't solve this. With HDHPs being so common the 'disconnect' between providers and patients is already not a real thing. Neither will single payer fix the underlying problem, although at least individuals will be better off.

At any rate, entrusting laymen to understand when they should and should not seek emergency medical attention means that people will die through entirely preventable causes in an attempt to ration their health care spending. Your cure sounds worse than the disease.

There are no effective market forces you can 'unleash' in the case of health care. It wouldn't matter if you removed all government regulation and subsidies tomorrow. Even in a world where it all somehow works out, do you want medical providers in a race to the bottom? In the absence of meaningful quality of care information (impossible), consumers are incredibly sensitive to one thing: price. What you will end up with is cheap(ish) providers providing incredibly substandard care by cutting corners and killing people.

Long way to go for HDHP to take over the market. But its definitely the way to go. It will however attack mostly the primary care market, not the hospitals which are 40% of the national health spending.

> At any rate, entrusting laymen to understand when they should and should not seek emergency medical attention means that people will die through entirely preventable causes in an attempt to ration their health care spending. Your cure sounds worse than the disease.

Not my "cure" thats the economic reality. Unfettered access to healthcare will give you skyrocketing costs. You cant complain about both at the same time, they are a trade-off. I do think that cost is the single most important thing to attack, and the policies to do so are very easy to enact. They are just very unpopular, because the democratic party wants to increase the state, not make healthcare cheaper, and because republicas have their head up their ass on this topic for reasons I dont understand.

> Not my "cure" thats the economic reality. Unfettered access to healthcare will give you skyrocketing costs. You cant complain about both at the same time, they are a trade-off.

Yes, if the problem is skyrocketing demand. But it isn't. Yes, if we waved a magic wand and provided unlimited free access to medical care, demand would rise somewhat. But demand is not the reason for the current high prices, and it's not the reason costs are outpacing inflation. Medical care in the US is much more expensive than in comparable countries, but demand is not appreciably different.

As long as people keep looking at this through a "market" lens, or through a "just make it single payer" lens, the problem will never be solved. The fundamental problem isn't that demand is too high. The problem is cost disease, the root of which consists of dozens of different factors. This is a decent article, albeit one that barely scratches the surface.

https://slatestarcodex.com/2017/02/09/considerations-on-cost...

Look at those graphs! It's mindblowing! Medical costs have increased ten times more than inflation, while doctor and nurse salaries were flat (actually worse, since now their salary goes to paying off educational debt) over the same time period. If there's a demand problem, why aren't salaries of medical professionals rising faster than inflation?

Lastly, I think most people would disagree that cutting costs is the most important thing. Going bankrupt is better than dying of pneumonia because you were worried about wasting money on a doctor visit.

There is definitely a sort of impasse on both ideological positions. The forces that be for some reason have not agreed to test out their ideas: a public option and deregulation simultaneously. But neither policy is popular in neither party.

I disagree with your diagnosis, but I'm willing to do a policy that satisfies both your ideas and mine. Support a public option that will not have the issues you mention, and let me have my unlicensed, foreign, cash-pay, non-subsidized doctors, non-FDA meds and malpractice waivers.

The other part that someone like Sanders is pushing is tuition-free colleges. If doctors aren't burdened with half a million in student debt, maybe we can get cheaper care.

You combine both programs and you get a real win.

I already posted a link showing doctor and nurse compensation have been flat in the same time period that medical costs increased 10x faster than inflation. While free university might be a good idea for other reasons, this isn’t it.

You don't have the benefit of government negotiation today and you cant seriously say that the government runs without overhead.

Except that quality information gets provided quite satisfactorily in plenty of industries, even ones that might appear otherwise quite opaque. Sure, sometimes it is done in distorted and counterintuitive ways (many marketing practices, including many kinds of advertising, are ultimately reputational games that are designed to signal quality), but meaningful info is far from "absent"!

It should be possible to reopen those negotiations and reach a fair conclusion, but there's going to be a lot of fighting on a case-by-case basis (with a lot of cases). I believe it would ultimately work out better for everybody, but the "ultimate" would be years -- if not decades -- away.

Welcome to vested interests.

> It should be possible to reopen those negotiations and reach a fair conclusion

As much as Uber can negotiate with taxis. The solution here is to cut all the bs out and dereg. Import free doctors from all the world for cheap, by allowing them to practice medicine and to apply to a Doctor visa. US can triple its doctoral staff in 5 years with no educational cost by simply doing less things.

That's exactly how things were in the 1930s. Healthcare was unaffordable to the degree of public outcry, which is why universal healthcare legislation was introduced repeatedly and stifled by the AMA every time. In fact, early health insurance programs were designed to bypass pay-as-you-go medical fees because they weren't meeting the needs of the hospital or patients. It wasn't a tenable system.

It seems we're regressing.

The problem is not that the AMA was able to attack socialized healthcare, but that the AMA was able to dictate who would be able to practice medicine, what their education should be, how much they should charge and how they would organize.

Any american could go abroad to a country like say, Argentina, get free medical education and come back and treat patients without half a million dollars debt. But its illegal.

Although, we certainly do spend irrational amounts on healthcare, partly because consumers don't bear consequences for going with the pricey procedures.

There's also numerous layers of regulatory capture, artificial scarcity, and rent-seeking in order to protect various industry-wide or regional cartels. The combination of that with consumers who have no reason to care about price is a potent recipe for price gouging.

The AMA is one of those. Hospital associations, medical device associations, phamaceutical associations, electronic medical record companies, and so on all take their cut.

I think public investment in educating medical providers is too small (it shouldn't be profitable to wrap a provider in like 5 people...), but doctors that aren't total fuck-ups are doing great by the time they are 45. We are likely in a supply constrained situation right now, prices would be nicer if there was excess supply.

There's plenty of people on Obamacare who are getting heavily subsidized low deductible policies, and paying very little.

The government is the largest employer, and most government employees do not care about prices.

Throw in those who are unionized or at cushy stable jobs with low deductible plans, which is innumerable millions more.

I'm thinking at least 75% of the country has little reason to care about prices, and even if they did the system is so byzantine that there isn't much they could do if they did. This is all an interlocking and self-reinforcing problem, which rewards the various layers of the healthcare industry with windfall gains irrespective of their own quality.

I think everyone here recognizes the insane inefficiencies of US healthcare. Maybe single payer could help streamline things. Or what if this price disclosure requirement could be wrapped into a more comprehensive system that allows all parties choice and visibility and interoperability?

I know it doesn’t work great for everyone though and I’ve seen some discussion that it doesn’t bring down costs because of the lack of transparency in pricing preventing comparison shopping (which is also my experience).