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Medicare/caid prices are standardized and public. They also release data on what specific hospitals bill for the most common procedures.

http://www.cms.gov/Research-Statistics-Data-and-Systems/Stat...

Dealing with Medicare/caid involves lots of additional overhead and billing oversight, but that graf is a political cheap shot, not anything related to transparency.

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Hijacking my top comment with a more info edit -

If you don't know, Pricing Data in the US for health care is super insane, partially because both insurers and regulators need billing to fall into a semi-standardized set of 'billing codes' that don't really map well to actual care.

There are regulations about only billing the government for 'procedures' and not 'overhead', and medical procedures often don't map well to billing codes because they're new or slightly different. So basically after a procedure or hospital stay, the care givers make up a basic list of the things they did and the drugs given, etc, and it's passed on to a billing department, who maps to a set of codes that might differ depending on who's paying (gov't vs insurer 1 vs insurer 2). This is by definition lossy.

It's an oversimplification, but one hospital might say "Well we've got a superstar brain surgeon here whose time is 3x as expensive as normal, but can only bill for 'BRAIN SURGEON - 1 HOUR', so we'll crank the prices up on the scalpel and the tylenol to compensate", where another picks totally different things to compensate the prices on because they have a different cost structure.

Big insurers expect to be negotiated with separately for competitive advantage reasons, and sometimes use different billing codes anyway, so even if you had the closely guarded master price list of the hospital, it wouldn't necessarily do you any good.

For the uninsured, the occasional price-insensitive person rolls in (aka the "Saudi Prince wants his own wing for cancer treatment" situation), so they jack the uninsured prices WAY up only expecting a few percent back from 98% of patients. This further breaks the pricing data, and causes major problems for less-saavy people who are used to seeing a bill and being expected to pay it, as opposed to negotiate.

Bottom line: It's complicated, and politically fraught. If you're interested, Oreilly's "Hacking Healthcare" is a great intro to how billing and the new CMS Meaninful use stuff works.

The reason the cost of healthcare is so high is because medicare pays roughly 15% of a bill, others are somewhere between 20-50% of a bill depending. That is to say if the doctor charges you $40,000 you pay your 10% co-pay of $4,000 and the insurance then only pays maybe another $8,000.

Also, just so everyone knows, it's pretty easy to negotiate down your bill. The reason healthcare is so expensive is so many people don't pay it. If you are willing to pay say 40% of your bill it's already 25% better than medicare.

This. My Dad is a surgeon and the stories I hear are incredible. Once he operated on a child whose insurance was out of network. So the insurance company writes the parents a check to give to my father. Instead, the parents decide to cash it and never pay for the surgery. So, the parents literally make a few thousand bucks from having their child operated instead of paying that.

You, or an agency on your behalf can then have the unpaid amount due as a collection account appear on their credit report, and after that (7 years of no activity) it is supposed to come off. Some unscrupulous collection companies will modify the last account change date to keep it on, but that can be challenged.

You can also take the person to court and have a declaratory judgement, which will stick around on said credit report until paid.

There are also specific laws regarding where the involved parties are as local state laws apply too. It gets a little complicated.

I have two bills on my credit report with agencies that refused to negotiate... and I had an auto loan that was charged off (they repossessed my truck after they broke the payment arrangements that were made when I lost my job, and I refused to pay), after 8 years the collection company had changed the dates several times, I pointed out to the credit reporting agencies that the amount was the charged off amount for over 8 years, and had it successfully removed.

YMMV.

In an effort to provide his blue collar workers with a decent benefits package, he setup a health insurance plan. After 6 months or so, his HR person came back and said "none of the employees have used the insurance at all!" This was weird since these workers had families and obviously children get sick on a regular basis.

He spoke to his employees and asked why they weren't using their insurance. The answer? Instead of having to pay a $20 co-pay to see a doctor, they could just go to the hospital and say they were uninsured. If they did that, they didn't pay a dime for their healthcare.

I'm amazed at the ways the U.S. healthcare system is so much worse than most of the rest of the world's.

I guess there are humungous lobbying efforts and entrenched interests to make it stay the way it is.

The caveat being, it also has some of the most advanced medical technology and procedures too, but the day-to-day healthcare is surely the worst.

How it works here in Uruguay:

There are three levels of care

1) Universal (public) healthcare, you just show at the door and you're admitted. The quality is poor (although doctors are mostly good), and some hospital conditions are close to appalling, but it's 100% free (paid by taxpayers blablah), even up to cancer or AIDS treatment (yes, thousands of dollars). Time to treatment is also very bad for surgeries and other conditions.

2) Almost-universal healthcare in a co-op mode (Mutualism, "Mutualistas" and FONASA). Anybody who works or draws a pension has the right to one of those for himself and his children. Quality is decent, and there are some small costs associated (U$ 5 per doctor visit, and a few hundred dollars for major events). Medicine is provided by the hospital at an extreme discount (usually U$ 5 for any medicine, including the ones costing hundreds of dollars. Generics are mandatory whenever possible). The thing is, it's becoming a bit overcrowded and quality is going down, government is over-regulating IMO.

3) Private insurance, US-style. This one can replace 2) although 1) is still free to everybody (double coverage). That one gives access to the very best hospitals, doctors, etc... but it's the most expensive by far, and usually doesn't cover medicines outside of hospital stay.

Otherwise, please tell me which hospital is giving away free service to the uninsured.

When asked about billing they simply said "I don't have insurance". Many hospitals, including the DSH (disproportionate share hospitals) write these things off all the time. The hospital just doesn't bother following up. Are you going to spend $200 to chase down a $100 hospital bill?

I think I would. Do it few times at random and get the offenders to pay $1k+, and soon people will stop scamming hospitals. For what I can tell, similar system (random ticket checks + penalties 10x the ticket price) works quite well for public transit in many cities worldwide.

From everything I've seen, it's a very difficult job, and any mistake -- or not even a mistake per se, just coding something in a way that disagrees with the particular quirks of a given insurance company -- can have a drastic impact on whether and how much we actually get paid for a particular line item on a bill.

Another reason is the supply of doctors is artificially restricted by the AMA.

As long as we require physicians to be US trained and to have completed a US residency, the bottleneck will be GME funding. To fix that, the AMA or any other concerned citizen can lobby Congress for an increase.

[1]: http://jama.jamanetwork.com/article.aspx?articleid=182532

If hospitals can afford to give their executives seven figure compensation packages, they can afford to fund a few residents.

I was referring to medical school accreditation itself.

The real reason why there are fewer doctors is that it simply doesn't make any economic sense to be a doctor anymore. You need too much school, at too high a price, and you push off any real earning potential 6-9 years away from your peers. If you specialize, you can add an extra 2-4 years on top of that. And you really don't make enough over the long run to justify the lost opportunity costs.

So yes, there is a shortage of doctors, but that isn't going to change anytime soon.

I encourage you to run the numbers. You will find that $250k/year catches up very quickly to $100k/year even with a 10 year head start and $300,000 in extra debt.

Median compensation for all physicians is above $200,000/yr for every region of the country.[1] The highest averge earning speciality is not surgery but radiology at $315,000. [2]

Focusing on primary care doctors is a goalpost shift. Your original talking about the extensive opportunity costs for all doctors and specifically mentioned the additional time needed to specialize. Furthermore foreign born and educated doctors, who faced very different trade-offs, make up a disproportionate percentage of primary care physicians.[3] Finally, primary care is the area most suitable for less expensive medical professions, if only doctors quit engaging in anti-competitive lobbying.

In any event, medical school applications alone put lie to any sort of overall compensation-driven doctor shortage, which was your original complaint.

Maybe it's because I'm not a Christian, but I'm puzzled as to how a profession can be plagued simultaneously with God complexes and Martyr complexes.

[1] http://www.medscape.com/features/slideshow/compensation/2012... pg 5 [2] ibid pg 2 [3] http://www.nytimes.com/2010/08/12/health/12chen.html

Median compensation for all physicians. I encourage you to look at the actual distributions, based on age of the doctor and specialty. Early doctors make very little, and primary care doctors (GP, family practice, pediatrians), make the least. Oh, and while they are in training (residency, fellowhips), they wouldn't quality in the median compensation calculation, because even though they are MDs and treat patients, they are still considered students/trainees, and they make very little (~40K residency, ~60K fellowship, depending on area of the country). Those are the specialties that are in need - hence the reason to focus on those.

Really, I don't know why you're arguing this so much...

The cost of health care is a very complicated topic, and not one that is conducive to this type of forum.

My source: me, my wife, and a bunch of our friends. I almost became an MD, but left med school to get a PhD. I left for a variety of reasons, but once factor was the math didn't add up. My wife is an MD/PhD (pediatrics with a specialty). And we know many other doctors - all young, the category I was focusing on, and some make a lot, and others make very little.

Your data model is too simplistic to get a full grasp of the situation.

Automation (especially in diagnosis) is welcomed and supported by the medical profession.

Some vague idea of walking up to a kiosk and the computer telling you your condition and dispensing pills is opposed by everyone apart from the CEOs of kiosk makers

That help may explain extremly high nominal prices, but it doesn't explain the fact that the median price paid is also really high (The $12,000 in your example). Nor do cross subsides explain the high costs.

Both bottom up analysis looking at the amounts paid by various insurance companies for procedures and top down analysis of overall per capita health care spending reveal a system that is far, far more expensive than any other health care system in the world.

Its not so much a system as dozens of different systems with completely different premises and extraordinary complex interactions which have to deal with each other.

Which is why it is so expensive.

I hope you're right about the government not hindering medical pricing transparency. Now we need to get them to mandate it.

I wrote more about it here https://plus.google.com/110166527124367568225/posts/eiThZXx7...

http://livingwithmcl.com/BitterPill.pdf

http://www.time.com/time/magazine/article/0,9171,2136867,00....

In a stunning example of competence and efficiency, the US government responded to that article by publishing a ton of medicare pricing information on a hospital by hospital basis. Here's one article discussing the data:

http://www.boston.com/lifestyle/health/blogs/white-coat-note...

FWIW, as a person who has been using catastrophic insurance (e.g. super high deductible) for over a decade I find this move to more price transparency long over due. I've had the experience where some practitioners simply refused to take cash up front, it was insurance or nothing while others would give a significant discount, like over 50% for cash up front. We've still got a long, long way to go, but it's a start.

On more than one occasion after having an appointment scheduled, and mentioning to the provider that we have a high deductible, doctors' office staff have changed their stories and claim that they didn't accept our insurance or that they weren't accepting new patients (after already putting family members "into the book" for an appointment, even; one provider used one excuse after another, despite prominently advertising in the local paper that they are looking for new patients and "accept all insurance"). Another office actually claimed that the doctor had gone to lunch and wouldn't be back for 3 hours...immediately after I told her our deductible amount--her mouth dropped open and she ran back into the back and came back with the lunch story. I don't understand it, because I offered to pay up front and the care was always for simple issues that never would have hit the deductible nor broken the bank anyway (a flu in one case, a basic checkup and blood tests in another). I assume it's illegal, too, otherwise the universal response wouldn't be a stammered excuse.

This kind of behavior does help to weed out bad doctors/doctor's offices (net good, I guess?), but in a situation where your issue isn't bad/acute enough for the emergency room and not forestallable enough to wait a month to get an appointment for a good doctor, it's really frustrating.

Luckily, there's a nice urgent care locally with prices on the walls, accepts real money and even gives a cash discount, and handles the basics...but for traditional/specialist doctor's visits, I no longer offer up any information about the fact that the deductible is high and we're paying for services ourselves before the appointment.

Otherwise if you never anticipate hitting your deductible for the year, it makes more sense to pay a discounted cash rate out of pocket, and maintain the insurance only for a catastrophe situation where you far exceed your annual deductible: preventing yourself being stuck with a $100k hospital bill.

What they did is totally cool, and more providers should post their pricing transparently. There are complicated, sensible reasons not in the current world, which I hope will change.

The government does not obviously stop them from providing pricing information about how much they charge for medicare/medicaid, hell the gov't releases that info themselves for the really big providers. It is, however, their business and I'm _sure_ they could point to some of the thousands of regulations and laws they operate under and say that it realistically prevents them from releasing pricing. It's like when people who haven't done so say they won't start a business because taxes are too high. Not false, but politically laden.

Saying that they don't take medicare/medicaid so that they provide a higher standard of care or be more successful or whatever is kind of like saying "Our private school doesn't accept kids who get reduced price lunches, so that it can operate efficiently and provide the best education."

It's not _lying_ so much as blatantly spinning it. This just feels like when you see a tech site re-run a breathless press release verbatim. It's not _false_, but it's not exactly fair to readers, either.

Medicare very likely does not allow for the prices featured on their online price menu. You could therefore say that it "won't allow for their online price menu" since without the underlying prices, there can be no menu.

I agree that as written, the statement is misleading and feels politically motivated. No way to know if the spin was applied by the doctor or the journalist.

Reason also did a story and short video on the Surgery Center of Oklahoma last year that I think is worth watching:

http://reason.com/reasontv/2012/11/15/the-obamacare-revolt-o...

The center was started by Dr. Keith Smith, who is very much a free-market guy. Even if you don't agree with a lot of his libertarian stuff, you have to admit that he's very well read and knowledgeable of economics, especially for a physician. He runs an active blog at: http://surgerycenterofoklahoma.tumblr.com/

It's almost as if somewhere in the middle between over-regulation and no regulation at all might be prudent...

Given that something as simple as allowing Medicare to negotiate with care providers and suppliers as any other insurer is massively controversial, I think you would be amazed just how controversial seemingly-straightforward reforms actually are. Particularly those things that would increase competition and thus threaten the status quo.