I tried paying the cash price. They inadvertently billed my insurance anyway. Turns out, I actually saved like 33% using the insurance price ($180 vs $120 for an xray + analysis).

They said the only way to get a copy of the x-ray was to pay $5 for a CD. None of the computers I still use have a CD reader.

The whole system is such a clusterfuck. I understand the aversion to giving a governmental bureaucracy more control (esp over something as important as healthcare); however, it's hard to imagine a worse way to pay for care than what we have now.

This is about the 6th time this has happened. It's always 15+ e-mails back and forth, then threatening lawyers, then they back off.

I'm wondering if it would be faster if I just take it directly to a small claims court. I am insured and it is preventative care, so I believe I'm entitled to pay nothing. Advice welcome.

I know healthcare billing in the US is f-ed up but Stanford is particularly bad.

I can get the price of my fast food burger to the penny - but good luck getting a quote on something that will cost 50,000.

I did medical billing for a bit and in my space 70% of the issue was stupid politics

I'm due for an ICD battery replacement later this year or early next year and trying to figure out where to get it done.

We should crowdsource a guide to navigating healthcare in Northern California, it’s utterly fucked up.

Even getting a primary care physician is impossible, nobody is taking patients and the websites of any place (sutter, ucsf etc) don’t reflect any accurate info about who could actually become a primary care provider for you.

The best healthcare situation I experienced was via Cedar Sinai while we lived in Los Angeles.

I got a physical in Oct 2020, but the coronavirus spiked and it took me until April 2021 to go in and do the labs. One Medical screwed up the billing, coding them as diagnostic instead of preventative (or however that works).

I got nasty letters from both LabCorp and One threatening to send me to collections and ding my credit and all that. I'd text One and they'd be like "oh, just ignore those. We'll fix it." Months go by. "Just ignore them. We'll get to it."

It's such a massive what the fuck.

I'm not 50 years old yet, so I had to pay for it myself. A magical experience, since it's the first time I ever saw a medical bill in my life.

It was two pages long. Everything from taking blood to the medication and doctor was listed there, but the price at the end was only 200€. I thought it was a joke and expected a lot more.

How or why do you think an echo is preventative care? While insurance plans are free to define any additional menu of services as preventative - an echo is not included in the minimum set required by the federal government - which are procedures based off of US preventative services task force guidelines - there are no published guidelines that include an echo.

I wish you luck on your billing problem but I think you’re going to hit a wall on your own definition of “preventative”.

https://www.healthcare.gov/preventive-care-adults/

> It's fully preventative in my case.

Fully preventative is not a term of art either for delivery or billing - but there is a difference in categorization between screening tests given to the entire population (ie colon, mammo) and screening given to those with personal risk factors or family history (LD chest CT, echo for congenital HD), and then further on surveillance for personal history of a pre-disposing condition (ie surveillance echo for prior potential fatal arrhythmia).

This is where it starts to get complicated - but the need for an echo every 2 years is not normal. I can't really divine your specific history from the information given - and it isn't necessary - but a history of cardiac arrest alone is not an indication for serial echocardiography. There are numerous specific circumstances where it is recommended, and then there are the cases where it is not consensus recommended but there is controversy. I assume because your insurance company is willing to touch it at all it falls in the former - but we are way off the ranch here in terms of the scope of routine preventative care/health maintenance.

As to whether it should be this way, probably not. If a surveillance echo is clearly indicated to prevent costly sequelae (unfortunately answering this question isn't nearly cut and dry as most think), then it makes sense that an insurance or public health agency would want to do this. Curious if you know if your indication for serial echocardiography falls under the European guidelines? Maybe move there /s. Is Stanford your only reasonable place to obtain an echo?

The simple answer to this is that “preventative” in the case of billed medical services has a specific and clearly defined meaning - it does not even mean all services that ever would be considered preventative. This definition will be found in your insurance paperwork and corresponds at least to the site I posted - so a further philosophical discussion is irrelevant.

To your actual question - No, the echo is usually pallative. However, right off the bat I'll say this is an overly reductionist and not terribly useful schema for classifying the delivery of medical care. While it might be good as a way for the general public to think about prevention, it’s way too oversimplistic to be useful beyond that.

An aside, palliative has a specific and different meaning within medicine: roughly, treating symptoms without a goal of cure. Reducing a broken arm or removing an inflamed appendix is not palliative care in that sense.

But even if we widen the scope of palliative to be treatment an echo would be neither. An echo is diagnostic - it doesn’t prevent nor treat heart failure or disease. Often when an echo is ordered it leads to some form of treatment for some found disease, in which case if we’re going to stick to the simple classification would be “palliative” - we’re using it to guide treatment, we can’t prevent something that we already see.

> If he had violent symptoms it would clearly be palliative

It's just not that simple. Echos are sometimes used to further evaluate or manage asymptomatic disease, for instance A-fib or a concerning murmur. We're using the echo to rule out suspected coexisting conditions, that's not prevention, and it's not treatment either at that point. Also, echos usually have some symptomatic indication - and they don't have to be violent, whatever that means.

> it can only be preventative

Can you actually think of a disease that an echo would be used to prevent?

But again, in practice we don’t think of delivery of medical care in such grossly general terms - it’s doesn’t simplify in a useful way.

Yes, checking the extent of mitral valve prolapse (which I have, doesn't warrant valve surgery yet but it's expected I may need valve repair in 10-30 years if it gets worse), ejection fraction, early detection of dilated cardiomyopathy (which I'm known to be genetically predisposed to), etc.

Ejection fraction is not a disease, but let's call it heart failure. An echo evaluating for heart failure is a good example where we can use it as a diagnostic tool to prevent further progression - but again through other interventions - and if we're evaluating for abnormal ejection fraction we haven't prevented it.

Another example might be evaluating for a shunt to prevent stroke. However we don't routinely screen everyone for this.

Echo for inherited cardiomyopathies is a good example of primary or secondary prevention.

There are definitions within medicine that matter for defining appropriate use criteria, but all this preventive vs palliative is arguing loose semantics - the people you’re up against have already put in place the policy to avoid most of that.

CD is honestly the easiest way for them to send the images to you, because you can give them to any doctor and they can load them within minutes. For the hospital to send them directly to another hospital would literally take weeks (at a minimum) of back and forth between two overworked and incompetent IT teams.

Last time I had imaging done, my doctor gave me a list of nearby imaging services, and the one I selected was able to electronically send files back to my doctor.

Heck I've witnessed my old dentist send x-rays over to my new dentist, it took like 5 minutes. Then again it seems like dentists are better at technology all around.

The point is to send it to any arbitrary doctor they've never spoken to before, which requires offline media.

If you've ever gotten a cd with your medical imaging on it, it will come with the software required to read it.

Cool dudes. Have you considered letting me download the x-rays I just paid for from that portal?

This is the reason that non-emergency healthcare is so expensive - the purchaser does not know the price of something at the point of purchase.

This results in the price being significantly higher than what the market can bear.

When consumers are informed and can force suppliers to compete with each other, prices go down to exactly what the market can bear.

Emergency healthcare is a different beast, but will probably also decrease if non-emergency healthcare prices was left up to the market to set.

This is only solvable for the cases where what needs to be done is completely known and certain in advance. Which for very complex human biological systems would not be the majority of cases, unless providers decide to only deal with health issues that fit that criteria and send everybody else to someone else.

I think the problem of not being able to accurately predict the required care is an intrinsic part of health care. Some of it actually is taken care of in some way, for example, if you go to ER they will only fix any immediate urgent issues and then send you home. Or, they send you home after n days in the hospital no matter what (example links: https://www.ombudsman.org.uk/sites/default/files/page/A%20re... or https://pubmed.ncbi.nlm.nih.gov/12568426/).

> When consumers are informed and can force suppliers to compete with each other,

Uhm... how do you imagine this would happen? Genetical engineering so all humans become standardized clones with identical completely predictable issues? I think you severely underestimate the inherent unpredictability. Simple stuff like teeth cleaning can be a price known in advance, or coming in only to renew a prescription for a known health problem, but many, most?, of the "real" issues are not.

OR, what would happen if you enforce this is that the MDs would be forced to press the cases into the pattern. They may think they should order an additional test or imaging procedure after actually looking at the patient, but since it's not in the pre-approved plan it would not get paid, so they don't, only things that were known before any doctor looked at the person get treated and only using the predicted methods.

In the US healthcare system because of the lack of price transparency it seems to be impossible to know which hospital or doctor overcharges, and so a free market cannot arise. It is not even possible for a competitor to advertise better prices, because there is no practical way to check that their prices are indeed better.

> a free market cannot arise

A free market is not the best model I think, because even if you had perfect price transparency, people don't have nearly enough knowledge to evaluate the suggestions of doctors. Sure, they will select one the like more, but base don superficial information, not based on actual medical knowledge. For some truly "free market" you really want easily comparable and quite equal things to shop for. Medicine is too individual. Yes I know the desired model is you go in with your list of symptoms, get a few tests based on it, then an algorithm, right now in an MDs head, selects the appropriate treatment - time for the next patient in the overcrowded waiting area. It seems to me, and I had personal experiences with this model's limitations too, that there is a lot of dissatisfaction with this model not least with burned out medical professionals. But it sure is something the business-minds like, you can optimize processes and manage the heck out of such a system beautifully.

I - German (but I lived in the US for a decade and also had a bit of regular contact with various health providers, such as Stanford hospital or a Berkeley orthodontist for minor - and predictable, as you say - stuff like straightening teeth and hypo-sensitization) - am certainly not against a free-market component. I grew up in the GDR and we had a small bit of it even there! As a child my parents and grand parents actually did shop around for some specialists for some very reasonable amount of money, for my eyes for example (it worked out great, I stopped needing glasses as a late teenager, I ran around with one side of the glasses covered for a few years very early in childhood, for example, to strengthen one eye).

I think a little bit of that helps to reward those who care a bit more about their health and go about looking for solutions to problems more diligently and intelligently than others who just go with the flow. But I think this works best in small doses, not with the entire system set up this way.

But caring about pricing is entirely different than caring about the right solutions

Sure, the GP might want to order tests, but the cost of the test will be known in advance, the cost of the consultation was already known by the patient.

The patient can tdecide which radiologist they want, using price as a criteria if they want to.

The existing method is basically "you can only know what the cost is after you owe it to us", which is, frankly, insane. It allows the sellers to set a price that the ma let cannot bear, which results in secondary markets that provide insurance and skim even more off the top.

Yes what kind of procedure is needed often is known in advance. The details often only emerge after it's been started though. Just because it's routine does not at all mean it's all predictably-in-advance the same throughout, except for really basic stuff, which in turn is unlikely to be the big cost driver.

I dunno that I'd call a broken leg "really basic stuff".

This is what I responded to and what I quoted in my original post:

> "Here is the cash price. We won't know your HDHP insurance price until after we bill them, which could be good for you or could be bad."

So, yeah, the supplier currently knows in advance what it costs to fix a broken leg. There is no reason for the price of more mundane medical care to be opaque at all.

No, the solution to most social ills in America is to simply not be poor. If you are poor, stop it. Then you don't have to worry about any of this. Consider abortion, a procedure now outlawed in many US states. If you're not poor, you can just pay to travel to another state or country, have the procedure, do some sight-seeing, and come home. The law has no de facto effect on you. Same with every aspect of healthcare. So, just don't be poor and you'll be fine. (Even better if you are connected to the wealthy and powerful in your city & state. It is very nice indeed to be a VIP in an American hospital, court, or anywhere else.)

American healthcare works well if you have money and better than anywhere else in the world if you have money and a chronic condition. If you get in an accident, however, particularly while away from your posh neighbourhood, you’re getting the same overworked, hyper-indebted surgeon as the homeless man. (If you’re a billionaire or head of state, that’s different, but that’s different everywhere.)

Spoken like a salesman!

It's mostly false. Last time I did a deep dive on this, the US had a genuine but small edge in treatment for diabetes and breast cancer, but that was it -- and the edge was nowhere near proportional to price.

What documentation/studies did you find in your deep dive?

You’re looking at gross statistics. On average, American healthcare is average. If you zoom into the top 10%, it outperforms other countries’ top 10% (in general; of course there are exceptions). This goes from virtually instant imaging with concierge medicine to the Cleveland Clinic’s global medical evacuation jets and helicopters.

I had an emergency this year within a very tiny insurance gap between employers and now all of my savings and retirement are gone.

I'm really not sure who it works out better for versus universal healthcare, but I can't imagine it's a whole lot.

My probably naive understanding was that COBRA can be activated retroactively if you get in an accident during the coverage gap.

My prescriptions seemed kind of high so I checked with GoodRx and they were cheaper! Cheaper without insurance than with, like how does that even make sense?

Right now I'm trying to negotiate on my last and only unpaid bill, the hospital won't negotiate with 1st parties so I've been trying to go through a newer company called Goodbill or something. I can't vouch for them yet as it's still in process, but just trying to get this all out of the way so I can just move on. Honestly, this whole thing has been so terrible that I'm just like, nope you're not even going in the worry pile. I'll go through the motions, pay it as best I can, and move on. I'll save the worry for the next totally normal work meeting coming up :)

I'm just very fortunate that I don't have a family to support or a mortgage to pay, even though I've been very close to breaking my lease and moving in with my parents until I can get back on my feet. I mean, I make good money too, I never thought I'd be in this situation.

I will absolutely go through the insurance options with a fine toothed comb when I interview again. Mama mía, aye yay yay

Talk to an FCRA lawyer. There are certain notices that if you send them and they are ignored can let you remove the lines from your credit report should they mark them as defaulted on. They will likely also help if the hospital chooses to sue.

This did not stop my insurance company from cashing my premium payments for over three months, even though they silently canceled my policy (no email, mail, or phone call). I only learned I had no coverage when I actually tried to have a dental appointment. Refunds of these premium payments took another another 3 months to be returned!

Not technically true when I used it last. I did have to pay for it.

"Employers may require individuals to pay for COBRA continuation coverage. Premiums cannot exceed the full cost of coverage, plus a 2 percent administration charge." But yes, the American Rescue Plan act allocated funds to make COBRA free. I wouldn't doubt that I was using cobra wrong at the time either prior to the passage of the act. Small pdf warning: https://www.google.com/url?sa=t&source=web&rct=j&url=https:/...

From now on I'm making sure I have good insurance, which requires a crazy amount of due diligence, but not something I'll take for granted anymore. It's one of reasons I'm currently trying to move to another country. Quality of healthcare is important, but how much does it matter if you're in massive debt, lost nearly everything, and don't have a retirement anymore?

Which isn’t saying much. Even for wealthy people in the US, chronic conditions get you labeled anywhere from annoying to chronic drug seeker to mentally ill. Many doctors simply don’t believe that conditions that thousands to millions of people have are real, and no amount of money will change their minds. You do however get targeted for all kinds of scams!

So they will do all kinds of useless tests and treatments because that is what they earn money on.

You will never really know if this treatment is good for you or good for the hospital.

Citation needed.

Medicaid is actually very good coverage.

If you happen to have a kid with a rare disease, that matters.

As the saying goes, "it's the best insurance money can't buy".

Those people deserve it. I mean, some people chose to be born to wealthy parents; if you were too lazy to do that why should I have to reward your laziness by paying to look after you? Really, some people can be so selfish!

> It is very nice indeed to be a VIP in an American hospital

My gf had a life threatening illness and went to Stanford hospital. They gave her the special blanket just for Stanford Faculty so she'd get the VIP treatment. Which in practice meant nothing. Thankfully she survived; now I wonder if I should be glad or not that VIPs get the same shitty health care there as everybody else.

BTW there is a carrot and a stick going on. Yes, the hospital admin wants to make VIP patients happy for donations, but they also want to avoid making the patient unhappy because they have resources to sue, and win. All of this is highly motivational.

When you are a doctor, you're part of the club. Skipping the line and getting a consult in 30 seconds? Well, that is 15 seconds too long. Got a laceration on your child, and want a 3 layer closure by the head of Plastics? No issue there. Want to convene a board on your rare medical issue? Well, there is a doctors only Facebook group for that, with about 500 docs ready to chime in on their breaks.

It goes way behind this too. Indepth knowledge and advice about who the actual locally best doctors and surgeons are, across specialties (not the popularity contest or bought magazine ones either). Early tracks on new promising studies. Handouts of non-scrip medical supplies like event swag. Pharma-reps wanting to market their novel products and spread the info on them. The amount of free stuff is off the charts.

I've seen exponentially more over the top professional courtesy "Good Old Docs" club from my Dr. wife and the associated professional network, than I have in any other profession by far.

In healthcare not being poor is sufficient. You actually have to be quite well off in order to not worry about cost.

https://www.aflac.com/individuals/products/cancer-insurance....

> The out-of-pocket expenses displayed are estimated at 40% of the total medical cost, assuming that average major medical plans cover approximately 60% of the expense. Your major medical coverage may be more or less, and if an individual or family incurs expenses for non-covered benefits, these out-of-pocket expenses may increase potential unexpected costs. You will also need to pay for any limits or exclusions on your benefits which may include the number of refills for certain drugs, visits to certain specialists, or days covered for certain benefits.

I'm trying to find a case study but nothing turns up. A story - someone got a major injury, cancer, or other life-threatening hard/impossible-to-cure condition, and how exactly the events had unfolded financially. I.e. how many tens of millions the treatments were worth, how much insurance had covered, and how much was still left to pay and why. So maybe I could see what my insurance covers and see if I need another insurance to fill some obvious gaps.

All that my naive search attempts produce are mentions about people without coverage or with insufficient cheap coverage, which is a problem but a different one from what I'm trying to research. Oh, yes, and lots of mentions of out-of-network ambulance drives' crazy costs - I get this one.

Americans desocialized because of equal rights.

No, the solution is to be either poor or well off. The lower middle class are the people that have the most to worry about in the US healthcare system.

Also this reminds me of one of the more evil things I have ever seen in healthcare. Practice Fusion gave doctors a "free EMR" because it was being paid by opiate pharmecuitcal companies to create an electronic EMR workflow that intentionally increased unecessary opiate prescribing. Absolute evil in my opinion.

https://www.justice.gov/usao-vt/pr/electronic-health-records...

If you are a hospital, and you are shopping for an EMR to maximize revenue, is that a feature or is it a bug?

Evil, yes, stupid, no.

It's absolutely stupidity.

Because I have seen many people, and they do the tasks asked of them. They are “stupid” on tasks not prioritized, but their employers are perfectly happy with that.

If you know anything at all about doctors, you know that they have way too much institutional inertia to change from writing one word on a prescription pad to writing a totally different word on a prescription pad, especially if the second word is almost twice as long, and especially especially if it’s just to do something silly like save a patient money. I have an attending who, whenever we are dealing with anything other than a life-or-death matter, just dismisses it with “Nobody ever died from X”, and I can totally hear him saying “Nobody ever died from paying extra for an adrenaline injector”. So Adrenaclick continues to languish in obscurity.

https://slatestarcodex.com/2016/08/29/reverse-voxsplaining-d...

I generally have a pretty high opinion of physicians, but they are incredibly overworked, and typically just lazy enough for this quote to be more true than we probably think it should, especially with e.g. 20 years of history writing a specific word for a specific diagnosis.

I'm not sure this is that common, unless you have an adversarial relationship with your doctor. It's actually the opposite: in most states the Dr. must write DAW-dispense as written or 'name brand only' to get the expensive brand. Otherwise, the pharmacist can and will substitute a generic if available.

I've always found docs to be very willing to work with you on budget issues. If there's a similar med that is available in generic where their original recommendation isn't, they're happy to switch.

BTW, Hopefully the last word is just a typo.

Which basically summarizes as "EDs that accept payments from Medicaid are required to at minimum stabilize all patients, regardless of their ability to pay or several named statuses."

The idea wasn't to get people to shop around, at least in my opinion, but rather to not use healthcare altogether unless absolutely necessary, because they feel the cost of the services more when they pay for the directly.

That’s rather disturbing, and from a purely pragmatic point of view, you might consider raising a fuss with your employer…

https://www.cms.gov/nosurprises/consumers/new-protections-fo...

And the medical providers (not the insurance company) will always have discounts on their procedures...just have to ask for them. Makes one wonder how steep the mark-ups are.

Funny, I always thought it was just squeezing every last penny out of customers without letting them feel like they didn’t have health insurance for big ones

It's not going to happen, so the most likely scenario is innovation will be coming from fringe services.