I feel like the societal pain and the regulatory response cycle in healthcare in the US is out of control. We have an itch, and we've been scratching it aggressively since the Kennedy Administration. We've scratched so deep we're not scratching, we're digging deep to the bone.
Everything that's good about the free market is gone from this system. Prices are not dictated by supply and demand: to the contrary, the suppliers (doctors) and consumers (patients) are the ones farthest from the negotiation of price.
Everything that's good about a regulated market is gone from this system. The system is so complex that the only people knowledgeable enough to write regulations are the ones whose profits need to be reigned in the most. The fox is guarding the henhouse.
The system is fucked. More regulation will make the system more fucked. Less regulation will make the system more fucked. We're fucked.
That’s pretty ridiculous given that it essentially concludes there is no way to create a viable healthcare system, when most other first world countries are not having these problems.
The issue is that the US system insists on clinging to the idea of a “free market solution”, without any of the crucial ingredients for making a free market solution work. The information regarding who pays what for what services is as opaque as any industry out there. People receiving the health care are different from the people paying for the healthcare, and the how the costs trickle between parties is unapparent until after services are rendered, and even then it’s fairly inscrutable. How is a free market supposed to work when people can’t actually shop around and compare prices? On the other hand, you have massive consolidation and monopoly creation occurring in both the hospital administration field, as well as for insurers and PBMs. Barrier of entry is also sky high, so in reality there is little to no competition going on, which is crucial for any free market solution.
The reality is that people need to accept that the functional “free market solutions” simply don’t exist for certain industries, chief among them healthcare.
I'm sorry but this is incorrect. The opposite is the case. Post-ACA, insurance companies deliberately pruned their provider networks to be so narrow so as to restrict access to care, in direct hopes that patients would go outside the network out of frustration. I can tell you personally as someone applying to be in network, I have been frequently denied as "they have too many people in their network already of my specialty" (exact quote).
[0] https://www.modernhealthcare.com/article/20181204/NEWS/18120... [1] https://www.nytimes.com/2016/10/18/upshot/savings-yes-but-na... [2] https://www.npr.org/2017/11/26/566634747/aca-s-narrow-networ... [3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547685/ [4] https://www.firstquotehealth.com/health-insurance-news/narro...
> You are extremely lucky that people dont think too deeply about the root cause of the outrageous costs of healthcare in U.S. and get quickly distracted, blaming insurance companies and the govt. about their crippling medical debt - because when they do actually run the numbers, look at the statistics, the invoices, the claims, they realize the root cause are the providers themselves. It's very likely though, that some here in the HN crowd will come to this realization because they do think deeper. There is 0 reason for an insurance company to charge more than absolutely necessary. The cheaper the premiums are, more volume they have.
I'd like to split this into three topics: Insurers, Physicians, and Hospitals. For insurers, profits are capped at 20% of premiums by the ACA. The only way they can increase profits is to increase premiums or increase subscribers. That's it. Insurance companies do not make up anything on volume. Occasionally, an insurance carrier will make too much money and be forced to refund premiums.
[0] https://www.healthinsurance.org/obamacare/billions-in-aca-re...
Physicians cost at most 20% of total health expenditures from CMS data, even though this number is at the high end and does not include individual practice overhead. However, the really outrageous bills that get people up in arms are frequently hospital bills (where people love to complain about overpriced tylenol).
[1] https://www.cms.gov/research-statistics-data-and-systems/sta...
> Here are my thoughts: Nothing stops a provider from telling a patient "Hey, I will cost you $10000 at most. Do you want me to treat you?". If a provider thinks that this question distracts them from providing the best of care, nothing stops them from joining a insurer's network and continue to do the good work. Do you, personally, think this is a fair expectation? No one is asking a provider to quote down to the last two decimal places what a visit might cost. The expectation is to know, atleast, what the maximum financial liability could be: $2000? $10000? $50000? Crickets. Indifference at best. Instead - here's what providers are doing: They explicitly try and stay OON to extract the maximal possible revenue from patients who were in a desperate situation with 0 leverage.
We don't like staying or going out of network, because it is hell to get paid. However, there are national private equity staffing groups that deliberately will go OON to force better rates across a state; since these are PE backed, they can stomach the pain it takes to get payment from angry patients. This is not a physician decision; the staffing group makes this decision. I personally think it should be illegal for non physicians to own physician groups like it is with legal practices, but currently, it is legal.
As I mentioned in a sibling comment, we can always provide a charge master rate, but it's usually extraordinarily high (because we have to charge a single rate to all payers) and people want to know what their insurance will pay. Can't easily just query the BCBS API as much as I wish I could.
> It was no longer the individual physicians choice The bulk of the individual physicians NEVER chose to be in network in the first place. Not when they were independent. Not now. The American people are hurting from the thousands of dollars in medical debt foisted on them without them even being told what they are getting into. Thousands of dollars in surprise bills from tens of providers in addition to the tens of thousands of dollars from the hospital after spraining an ankle, dislocating an elbow, getting a cut. I am not talking about blood gushing out of an open wound. I am not talking about a head cracked open. Nickle, dimed and harassed by collection agencies that add on fees and interest rates multiples of prime if you can't settle in full. I understand the medical education system in the U.S. is expensive and long but I, as your customer, should have the ability to know, UP FRONT, how much seeing you, might get me into debt so I can make a decision whether I should work with you or not. NOT after the fact. Do you, personally, think this is a fair expectation?
I think this is a fair expectation; why not make it so insurance companies actually stop hiding this information?
> Not a SINGLE doctor in the WHOLE of California has ever come forward to answer this question of mine, which at this point is more than 3 years old: https://www.quora.com/How-do-I-find-a-general-physician-in-S.... All this question asked (details can be found in comments for those logged in) was: Is there any general physician in San Diego that will provide an estimate (NOT a guarantee) of a visit planned weeks in advance with their staff. I have found tens of doctors in Mexico who were more than happy to provide a quote down to the last two decimal places and they went beyond what was expected of them. Yet, 0 responses so far from the WHOLE of California sans one extremely disingenuous, snarky Anonymous remark that stood up a strawman argument that I somehow wanted the estimate for free (which I did not and was more than happy to pay for) Every regulation is a response to societal pain. This pain has been cutting in too deep for far too long.
I'd suggest you seek out a concierge or direct primary care practice. It's not absurd to just pay for people's time. If I were in primary care, I'd probably just set an hourly rate for people to purchase medical advice consultation and bypass insurance entirely.
Of all specialties, I'm the most sympathetic to billing issues because our billing is very predictable: an imaging examination is an encapsulated episode of care. However, the problem is that a lot of hospitals own imaging equipment and use it to cross-subsidize their other departments.
Most billing is predictable. Doctors in India, Mexico (two countries I have first hand experience in) quote down to the single digit, a price. Some surgeons guarantee it - as in 0% variance. You pay what you sign up for. I am talking triple bypass surgery. Sounds pretty complicated.
I don't have medical training but is triple bypass surgery way less complicated than an office visit for a flu symptom?
I don't believe doctors in India or Mexico receive special price estimation training that doctors in the U.S. is banned from attending. My body is still the same irregardless of whether I'm in India or Mexico or the U.S., so why all this baloney?
Now I don't fly down to India or Mexico to treat my flu symptoms but when I was in India, a physician visit was a flat USD $1, no matter what the issue was unless you needed hospitalization. I am talking walk in prices as in "go right now to see a doctor because I'm running a fever".
The $1 was the unsubsidized, full retail price paid by those who could afford to pay, like myself. There was no health insurance fad in India when I was there. There was 0 need and demand for it. The doctors would often take way less for the poor or completely waive it and these doctors would still be making bank.
Yet a visit here is an involved appointment process with multiple day waits and you still don't know what you owe as the copay is just the starting price.
It has become ridiculous.
> I personally think it should be illegal for non physicians to own physician groups like it is with legal practices
Hmm, I thought that applied and the board of directors all need to have a current medical license?
> I think this is a fair expectation; why not make it so insurance companies actually stop hiding this information?
First, I really appreciate the time and dedication you have shown here. YOU REALLY care about your profession and I love you for it.
Thank you.
It will be a pleasure to speak with you in person or over the phone or however we can connect. I am looking forward to it. I am my handle at gmail. Please, reach out.
I am sure, if everyone in your professional felt like you do, we would not be having this conversation right now.
Now, for some reason, it seems to me that you detest insurance companies. IF I might estimate why - perhaps they make processing claims very hard. Sometimes they don't pay you what you expected. We can have that conversation, but do understand that there are no lack of providers that outright defraud these insurance companies and while you might be extremely ethical, you are having to shoulder the burden of those who have betrayed the trust.
To address the topic at hand - no insurance company has ever refused to give me the information you claim that they hide - they just need the CPT CODES and they will gladly run the numbers for me. They will even give me a list and contracted rate for CPT codes.
The issue here is that I need a provider to tell me what those CPT CODES are.
Neither I NOR the insurance company are in the medical diagnosis business and only the medical diagnosis providers get to generate those CPT CODES.
I have a 250MB spreadsheet full of CPT codes and their negotiated rates for my plan, but I have no clue how D6010 ($2050) is different from D6190 ($125) or when they apply (these are not medical CPT codes because I have them at a secure location but you get the idea).
Just to be clear: The insurance company at no point in time tried to hide this information from me.
This is extremely disingenuous.
The reason for the regulation was precisely because most physicians never bothered joining a provider network knowing that doing so would cap their income and the ability to hold the patient hostage.
Hey - it's ok to make money. But it's not OK to make it unethically.
You are extremely lucky that people dont think too deeply about the root cause of the outrageous costs of healthcare in U.S. and get quickly distracted, blaming insurance companies and the govt. about their crippling medical debt - because when they do actually run the numbers, look at the statistics, the invoices, the claims, they realize the root cause are the providers themselves.
It's very likely though, that some here in the HN crowd will come to this realization because they do think deeper.
There is 0 reason for an insurance company to charge more than absolutely necessary. The cheaper the premiums are, more volume they have.
Here are my thoughts:
Nothing stops a provider from telling a patient "Hey, I will cost you $10000 at most. Do you want me to treat you?".
The provider does not have to know what network the patient is in, what their deductible is. Whether the patient is employed or not.
All they have to know is that the maximum they have charged for stitching a cut, that this patient in front of them, has, is $10000 and that is what they inform them.
If a provider thinks that this question distracts them from providing the best of care, nothing stops them from joining an insurer's network and continue to do the good work.
Provider does not want to handle money at all? Fine - work at a hospital that has someone willing to do that. To have the numbers ready. Or even have an estimate printout in a new minutes.
Computers do that now.
Do you, personally, think this is a fair expectation?
No one is asking a provider to quote down to the last two decimal places what a visit might cost.
The expectation is to know, atleast, what the maximum financial liability could be:
$500? $2000? $10000? $50000?
Crickets. Indifference at best.
Instead - here's what providers have been doing: They explicitly try and stay OON to extract the maximal possible revenue from patients who were in a desperate situation with 0 leverage.
> It was no longer the individual physicians choice
The bulk of the individual physicians NEVER chose to be in network in the first place. Not when they were independent. Not now.
The American people are hurting from the thousands of dollars in medical debt foisted on them without them even being told what they are getting into.
Thousands of dollars in surprise bills from tens of different providers in addition to the tens of thousands of dollars from the hospital after spraining an ankle, dislocating an elbow, getting a cut.
I am not talking about blood gushing out of an open wound. I am not talking about a head cracked open.
Nickle, dimed and harassed by collection agencies that add on fees and interest rates multiples of prime if you can't settle in full.
I understand the medical education system in the U.S. is expensive and long but I, as your customer, should have the ability to know, UP FRONT, how much seeing you, might get me into debt so I can make a decision whether I should work with you or not. NOT after the fact.
Do you, personally, think this is a fair expectation?
Not a SINGLE doctor in the WHOLE of California has ever come forward to answer this question of mine, which at this point is more than 3 years old: https://www.quora.com/How-do-I-find-a-general-physician-in-S...
All this question asked (details can be found in comments for those logged in) was: Is there any general physician in San Diego that will provide an estimate (NOT a guarantee) of a visit planned weeks in advance with their staff.
I have found tens of doctors in Mexico who were more than happy to provide a quote down to the last two decimal places and they went beyond what was expected of them.
Yet, 0 responses so far from the WHOLE of California sans one extremely disingenuous, snarky Anonymous remark that stood up a strawman argument that I somehow wanted the estimate for free (which I did not and was more than happy to pay for)
Every regulation is a response to societal pain.
This pain has been cutting in too deep for far too long.