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'Paying Till It Hurts': Why American Health Care Is So Pricey
August 11, 2013 12:55 AM   Subscribe

NPR's Fresh Air interviews Elizabeth Rosenthal about her year spent investigating the high cost of health care.
"Every part of the system needs to rethink the way it's working. Or maybe what I'm really saying is we need a system instead of 20, 40 components, each one having its own financial model, and each one making a profit."

Rosenthal has also been investigating why costs for the same procedure can vary so much within the U.S. — by thousands of dollars, in some cases — depending on where it's being performed. Before becoming a journalist, Rosenthal trained as a doctor and worked in the emergency room of New York Hospital, now part of New York-Presbyterian Hospital.

Transcript.
Article 1: The $2.7 Trillion Medical Bill.
Article 2: American Way of Birth, Costliest in the World (Previously)
Article 3: In Need of a New Hip, but Priced Out of the U.S.

Her follow-up article covers the trend of medical tourism from the US to Europe and other regions to save money on medical treatment.

All article links are NYT.
posted by arcticseal (105 comments total) 83 users marked this as a favorite

 
I think the argument that "healthcare costs in the US are not subject to free market forces" is the best new-to-me idea I've heard from that article and the (yes, I admit it) comments, in terms of being able to argue this with my "free healthcare is socialist communism!" acquaintances. (Perhaps it's been bandied about before, but this is the first I've heard it clearly stated like that) It's tough to argue with that when there is only the illusion of consumer choice -- the insurance you can't afford vs the insurance you get through work, the doctor out of network versus in network, the hospital that accepts your insurance or the one that doesn't, the specialist the want or the specialist your insurance will cover.
posted by olinerd at 1:43 AM on August 11, 2013 [2 favorites]


Based on my brief encounter with it, it's seriously fucked and if the UK model is (wooOoOo!) socialism then you'd be better off red.
posted by GallonOfAlan at 1:56 AM on August 11, 2013 [8 favorites]


The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees. (emphasis mine)

The fundamental problem here is that there is a widespread misconception that profit = effectiveness. Even the quote "each one having its own financial model, and each one making a profit." reveals this bias.

The effectiveness of healthcare should be measured against its ostensible goal - I'd suggest the Declaration of Geneva (the modern rendition of the Hippocratic Oath). In a profit-driven model, the health of the patient is not the uttermost consideration. Tests are expensive because they can be; even when there's a cheaper option:

While several cheaper and less invasive tests to screen for colon cancer are recommended as equally effective by the federal government’s expert panel on preventive care — and are commonly used in other countries — colonoscopy has become the go-to procedure in the United States. “We’ve defaulted to by far the most expensive option, without much if any data to support it,” said Dr. H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice.
posted by dubold at 2:10 AM on August 11, 2013 [13 favorites]


Another doctor named David Belk has been saying this for years. In essence, all the actual health care costs have declined because technology itself and improving techniques almost always decreases real costs.

There is a two tiered public-private system in the U.K. which results in public health care slowly eroding as the upper middle class invariably votes to screw the poor. In France, there is a flat government payout for each medical procedure, but many providers may charge an additional amount beyond this. So their middle class cannot much reduce the services available to the poor without elevate their own prices.
posted by jeffburdges at 2:18 AM on August 11, 2013 [6 favorites]


What struck me about this is even when it comes to a comparison between commercial hospitals in Belgium and the US, as in the case of the two people who went for a hip transplant, the American hospital is so much more expensive. Even on its own terms it's beated, let alone when you realise that for people under "socialised healthcare" a hip operation would be effectively free...

Of course the reason for why even when compared to another "free market" system the US system is so crap is because all the relevant parties -- excluding the patients of course -- profit from it. That's why you get not a single bill with a single price for your operation, but you get billed for everything that's done to you separately, even (especially) when it doesn't make sense. It's think of a number pricing:
This is one of those stories where there’s a business school whiteboard version, and then there is reality. The whiteboard version goes like this: they disaggregated all the service elements formerly bundled into the airline ticket, and priced them. As a result, through the wonder of revealed-preference, we know that people value some of them enough to pay for them separately. You then repeat the words “Southwest Airlines” several times, and ponies!

The cynical version starts off like this: ok sunshine, you expect me to believe a single write operation on their OLTP system costs £6? Seriously. If FR’s IT was that dreadful, they wouldn’t be able to run an airline.

You can’t choose to fly FR and be handled by some other company, so once passengers pick them, there is no competitive pressure on the fees. By transferring things from the headline fare into non-fare fees, part of the business has been removed from the domain of competition and moved into the domain of monopoly.
So low cost airlines like Fecking Ryanair like to competite on the airfare price, but then nickel and dime you to death with all sorts of fee: pay by credit card, six quid, have luggage on board, another twenty quid, etc. Had they kept these costs than a) their actual fare would be bigger and b) they couldn't built a profit margin into their handling costs. Basically the airline has transformed a cost into a profit centre by decoupling these costs from the total price.

So too do American hospitals, but on a much grander scale. Each department gets to set their own prices and bills directly to the insurer, so there isn't anybody in the hospital who has an incentive to lower costs. The insurer meanwhile can push its costs on to its customers, so has no real incentive either. It can get a discount so it's even in its favour that costs are so high that few people could ever save up for e.g. a hip operation. (You could possibly do that if it's 13,000 dollars, 130,000, not so much)
posted by MartinWisse at 2:51 AM on August 11, 2013 [23 favorites]


What always gets me about US health care is the endless lying. Providers inflate the costs of procedures to force insurers to increase their reimbursement. Hospitals increase their billed rates for the same reason, and also to show greater losses from unpaid bills for uninsured people using the ER for primary health care, goosing municipalities to pay them more. Who even knows what gets said between providers and insurers about what procedures are performed. I cannot imagine what "new employee orientation" for a medical billing clerk is like.

I had a vasectomy this year. The provider gave me a general anesthetic without telling me, I ended up with $5k not covered by my insurance company... And then never received a bill, the doctor apparently accepting my copay plus the $200 reimbursed by the insurer as payment in full. I am certain that there are layers and layers of lies underneath this behavior... the provider did an artificially expensive and unneccessary procedure on me, and financially got what they needed, or they would be dunning me, but they are showing a huge loss somewhere, and the insurer accounts for the difference between billed and reimbursed when they update their "usual and customary" costs tables in the future.

I'm party to the deception too, because I am sure as hell not calling the doctor to ask why they haven't sent me a bill for $5k. And while I'm annoyed about being knocked out, I'm pretty sure I signed a consent that covers it, so I'm not going to complain about that.

So -- case closed.. I paid my copay, got the procedure, and a flurry of lies whirled around for a while, contributing to the statistics of how expensive and inefficient the US health care system is.
posted by bgribble at 4:27 AM on August 11, 2013 [46 favorites]


When you live in a country with socialized medicine, you realize that it is a better system for the majority of people in that country.

For those who don't want socialized medicine and can afford it, they can pay to go to other places for the doctors and procedures they want (and might not get in their home country.)

The problem with capitalism in medicine is that companies try to maximize the profit margins, which is why the US has the highest costs in the world.
posted by gen at 5:35 AM on August 11, 2013 [4 favorites]


I have experienced firsthand how some US doctors put their profits above their patients' well-being. I had atrial fibrillation, requiring defibrillation in a hospital. The cardiologist I began seeing afterward kept saying it was bound to get worse, and I should expect to get a pacemaker. I hated the idea, and went to another doctor. He was the same. Then I went online, and found there is a procedure called catheter ablation with a better than 80% cure rate. I asked the 2nd doctor about it, and he said "I've heard of it." He also said the guy who would know more was the 1st doctor. 1st doctor calls me up and says "There's this new procedure called catheter ablation." It isn't new; it's been done routinely for more than 10 years. He recommended a guy who did the procedure, whom he had studied with. There is no way 1st doctor did not know about the procedure all the time he was setting me up for a pacemaker.

I had the ablation done, and have been completely free of fibrillation for several years. I also don't have to take Coumadin any more, which was another cute little benefit (for the doctors) of my not being cured. 1st doctor clearly wanted to make me into a cash cow with a pacemaker and drugs requiring ongoing care.

Don't trust them, even if they come highly recommended, as 1st doctor did. Do your own research. The only person you can be sure of caring about your welfare is you.
posted by Kirth Gerson at 5:57 AM on August 11, 2013 [46 favorites]


What always gets me about US health care is the endless lying.

According to a friend who was until recently a surgeon working for the Cleveland Clinic, the only patients who actually cough up the full asking prices are wealthy ones flying in from other countries and paying cash because the Clinic can deal with whatever the problem is better than anyone close to home, and high profits from those wealthy customers help to defray losses on poorer ones. On its face that's a plausible explanation at the Cleveland Clinic, which is world-famous and has fantastic track records for treating certain problems, but it becomes less satisfying when I consider that the high sticker prices are not confined to top-tier hospitals.

To me it seems there are a lot of parallels between US health care and US higher education. Either service is hard to do without. In both cases, the costs have long been rising much faster than inflation, sticker prices have little relationship to what most customers pay, and actual costs are increasingly slanted towards administration and services that are tangential to the primary mission.
posted by jon1270 at 6:06 AM on August 11, 2013 [4 favorites]


She doesn't seem to explain why the hip replacement part is so much cheaper in Belgium... at least in text. But she claims that the reason it is so expensive in the US is "lack of competition." so, medical parts in europe are sold in a glorious free market?
posted by ennui.bz at 6:41 AM on August 11, 2013


Let's boil it all down, shall we? What the hell kind of market transaction does not make its cost known to the consumer before the good/service is provided?

It should be illegal to provide medical care in non-emergencies without giving the patient a not-to-exceed estimate and a meaningful opportunity to choose cheaper alternatives, object to proposed charges, and seek cheaper treatment elsewhere. That estimate should include insurance benefits.

I can't for the life of me figure out why we don't do this.
posted by valkyryn at 6:49 AM on August 11, 2013 [17 favorites]


Let's boil it all down, shall we? What the hell kind of market transaction does not make its cost known to the consumer before the good/service is provided?

If the cost is determined by a cartel, then "shopping around" doesn't make sense. There are five manufacturers of hip replacement parts in the US but it's in all of their best interest to keep the 1000% mark-up on a part which costs $350 to make.

even when it is completely factually obvious that medical products and services is an example of market failure, everyone is still trying to "liberalize" the market, when every other medical industry in the world is much more strongly regulated.

that's what being in the grips of an ideology looks like.
posted by ennui.bz at 6:55 AM on August 11, 2013 [16 favorites]


The only person you can be sure of caring about your welfare is you.

This is actually the root of the problem. If the incentives are such that your doctor is not looking out for you but trying to rake in money for themselves and/or their employer then that's a pretty strong indicator that the system is broken.
posted by delicious-luncheon at 7:00 AM on August 11, 2013 [16 favorites]


The thing that consistently boggles my mind is blood tests. A simple blood panel gets invoiced to my insurance company at $300. The insurance company pays like $7.50 on it, and that is not an exaggeration. Of course, the doctor or lab billed separately for drawing the blood. Since the lab accepts the $7.50 as payment in full, I have to assume that are making money at the price. So why the hell are they trying to charge $300? When people in FL try to sell water for $5 a gallon after a hurricane they get arrested. But in health care they'd question why is the water priced so low.
posted by COD at 7:12 AM on August 11, 2013 [16 favorites]


that's what being in the grips of an ideology looks like.

"America" is pretty much an ideology. From kindergarten on, rah-rah manifest destiny bullshit is drummed into little minds. PATRIOTISM!1eleventyone!

Which makes it nigh impossible to effect positive change. You don't change that which is perfect!

America is in one hell of a bind.
posted by five fresh fish at 7:43 AM on August 11, 2013 [8 favorites]


valkyryn: "I can't for the life of me figure out why we don't do this."

David Goldhill wrote about this for The Atlantic a couple of years back after his father died in the ICU:

For that matter, try discussing prices with hospitals and other providers. Eight years ago, my wife needed an MRI, but we did not have health insurance. I called up several area hospitals, clinics, and doctors’ offices—all within about a one-mile radius—to find the best price. I was surprised to discover that prices quoted, for an identical service, varied widely, and that the lowest price was $1,200. But what was truly astonishing was that several providers refused to quote any price. Only if I came in and actually ordered the MRI could we discuss price.

Several years later, when we were preparing for the birth of our second child, I requested the total cost of the delivery and related procedures from our hospital. The answer: the hospital discussed price only with uninsured patients. What about my co-pay? They would discuss my potential co-pay only if I were applying for financial assistance.

Keeping prices opaque is one way medical institutions seek to avoid competition and thereby keep prices up. And they get away with it in part because so few consumers pay directly for their own care—insurers, Medicare, and Medicaid are basically the whole game. But without transparency on prices—and the related data on measurable outcomes—efforts to give the consumer more control over health care have failed, and always will.

posted by jquinby at 7:45 AM on August 11, 2013 [9 favorites]


The cause for them not wishing to discus price may simply be that since medical costs have been totally split apart, with the actual billing divorced from the billers - they just may not have known, and couldn't be arsed to figure it out.
posted by wotsac at 7:56 AM on August 11, 2013 [2 favorites]


There's nothing inherently wrong with how healthcare itself is delivered in America, though there are many many ways to increase the quality of healthcare delivery and health outcomes. We have the "best healthcare in the world" after all, and that's probably true sometimes.

There is something inherently wrong with how we pay for healthcare in America. The current system of healthcare reimbursement is a positive feedback loop that guarantees rising healthcare costs.

For-profit doctors/hospitals must continually increase what they charge for procedures (and/or the number of procedures they bill) in order to ensure that they are reimbursed sufficiently to overcome their costs. (As bgribble mentioned, even non-profit hospitals are not immune for many reasons, e.g.: their costs increasingly include the uninsured who use the emergency department as their only point of access to healthcare.) Accordingly, similarly for-profit insurance companies must continually increase what they charge their customers in order to ensure their continued profitability. The insurers' costs are of course passed on to their customers who then pay more and more over time. As mentioned above, this all occurs absent free-market pressure if for no other reason than nobody chooses to get sick or have an accident, and furthermore because the cost of procedures is completely hidden from the consumer until after services have been rendered, which is really what the articles are getting at.

Like all positive feedback loops, the only way to stop the vicious cycle is for an outside influence to step in and effect a change. The only thing that can do that in the American healthcare system is the not-for-profit government. (Certainly, the business parties have shown that they won't change on their own.) What is needed is some system that regulates the reimbursement rates for procedures -- a strong arm on the market that holds down or defines prices across the board. I'd prefer a single-payer "Medicare for all" type thing, but I'd settle for 1,000 different private payers so long as there was powerful regulation on the prices. Something must control the profit motive, as anathema as that is to American ears.

We'll see how the Affordable Care Act changes things, but I fear it will only postpone the inevitable by slowing down the rising costs. The inevitable being that the vicious cycle will grind to a slow halt as people's bank accounts are drained to the point where we have masses of sick people declaring bankruptcy. I really hope I'm wrong about that and something else steps in first.
posted by cyclopticgaze at 8:02 AM on August 11, 2013 [4 favorites]


If the cost is determined by a cartel, then "shopping around" doesn't make sense. There are five manufacturers of hip replacement parts in the US but it's in all of their best interest to keep the 1000% mark-up on a part which costs $350 to make.


actually what's really remarkable is that its the same five manufacturers in Belgium, but because of how the governments control prices the players can't act like an oligopoly. Yet remarkably they are still happy to sell replacement joints. Its a miracle!!!
posted by JPD at 8:02 AM on August 11, 2013 [17 favorites]


"You would think that if five different companies were making candy bars, that would drive the price of candy bars lower. But if five different companies are making joints and trying to sell them at $10,000 a piece, it's really in no one's interest to say, 'Hey, guess what guys? I'm going to sell mine for $1,000 because that's what it really costs me to make it.' Because then everyone loses money; the whole industry kind of implodes."

This misses a major point, which is that this is collusion: they've all agreed not to price their joint at, say, $5000, or $8000, or whatever. If the part costs $1000, then any price above $1001 means a profit, and thus the statement that "then everyone loses money; the whole industry kind of implodes" is accepting the industry's excuses for what is actually an illegal price-fixing scheme.
posted by goatdog at 8:09 AM on August 11, 2013 [10 favorites]


She doesn't seem to explain why the hip replacement part is so much cheaper in Belgium... at least in text. But she claims that the reason it is so expensive in the US is "lack of competition." so, medical parts in europe are sold in a glorious free market?

Transcript:
So there are many, many differences. The first one is that the joint implant itself is priced by the country. Well, different countries do it differently. Some have a national negotiation, where they'll say we're going to purchase Stryker joints for all of our hospitals. So they have tremendous bargaining power, and they get a much better rate.

Others, like Belgium and France, set an allowed rate that can be charged for that particular joint in that country. So if you look in Belgium or in France, there are lists of all the joints, and this is what you can pay for them, and you can mark them up but only by $180 for the patient.

So it's - pricing is very, very regulated. Another big difference is that hospital day charges are three or four times as much in the U.S. as in most other countries. So even though routinely for most procedures in other countries, patients stay in the hospital longer, their hospital bills are much less.

Then again, they tend to see things as a package. I think one of the most striking things is, in the U.S. hospital bill for a joint replacement, you see things like operating room fees, $13,000; recovery room fees, $6,000; facility fees, you know, X thousands of dollars. If you look at a European bill, those things don't exist.

posted by jon1270 at 8:11 AM on August 11, 2013 [2 favorites]


If I remember my economics, when you have a market sector where prices grow at a multiple of the inflation rate over an extended period of time you have a shortage (real or contrived) of supply and/or competition. In our case it seems to be both...
posted by jim in austin at 8:12 AM on August 11, 2013


actually what's really remarkable is that its the same five manufacturers in Belgium, but because of how the governments control prices the players can't act like an oligopoly. Yet remarkably they are still happy to sell replacement joints.

Yeah, fancy that! The reasoning is definitely Flemish or something.

No, I am not a Walloon.
posted by Wolof at 8:16 AM on August 11, 2013 [1 favorite]


The thing that consistently boggles my mind is blood tests. A simple blood panel gets invoiced to my insurance company at $300. The insurance company pays like $7.50 on it, and that is not an exaggeration. Of course, the doctor or lab billed separately for drawing the blood. Since the lab accepts the $7.50 as payment in full, I have to assume that are making money at the price. So why the hell are they trying to charge $300?

Just to expand on this, from the perspective of the health care provider, there is all kinds of pressure to look for ways to charge patients, even over nickel and dime stuff, because we really don't know who is going to pay, or how much they're going to pay. There are armies of people on the insurance side, so we counter-attack. Doctors have very little control over their revenue stream and simply being a good doctor with a busy practice isn't enough in the current model to ensure financial security. The business managers who would run my practice seemed to really believe that the continued existence of the practice depended on collecting not only every bill for consultation, but charging for every bandage, every vital sign checked (no shit!). There was also daily pressure to squeeze in one or two more patients, always, as though we'd be laying off people if we didn't make those extra two visits per day. Obviously, you can see how this all leads to overcharging and short changing patients, with very little time left for you know, actual medicine. The thing I could never explain to my financial managers was that although the difference between 25 patients a day and 27 patients a day may not seem like much to them, to me, it means never having dinner with my family. So I left.

In my dingey little community health practice now, we do ten times as much medicine for a third the cost. There is no doubt in my mind I won't ever go back to dealing with private insurance. I just hope the time comes when more doctors realize what they've given up to allow this dysfunctional system to continue to exist.
posted by Slarty Bartfast at 8:18 AM on August 11, 2013 [52 favorites]


Here is a depressing slide illustrating the Cumulative Increases in Health Insurance Premiums, Workers’ Contributions to Premiums, Inflation, and Workers’ Earnings, 1999-2012, as produced by a program area at my place of work.

The team that produces this report has changed their internal process somewhat, so I am no longer responsible for proofreading it, for which I am extremely grateful because doing so causes me to be simultaneously depressed and enraged.
posted by rtha at 8:24 AM on August 11, 2013 [3 favorites]


This seems painfully obvious to me, and I just don't get why politicians can't just come and out and say "Look, we need to socialize the health care system." (Insert your own approved euphemism for the "s" word.)

My guess is the answer is, you know, business, profit, dolla dolla billz y'all. Which is of course the real priority in America, not anyone's health.
posted by nowhere man at 8:39 AM on August 11, 2013 [4 favorites]


I went to the ER last month for severe head pain. The ER doctor shone a flashlight in each ear, up my nose, and proclaimed me someone unfamiliar with intense sinus pressure due to an infection, which I self-deprecatingly translate into "you're a wuss"). Twenty minutes and a Naproxen later, I leave with a prescription for antibiotics, and a bill for $1200. My insurance has a deductible of $5,000 on ER visits, so it was cheaper to call and ask the hospital to charge me as uninsured, as thye have a built in 35% discount for that situation.

Last week I apparently had a TIA. I didn't go to the ER, fearing another $1200 bill for a frivolous visit. It faded, and I just hoped it either wasn't a stroke, and/or I'd wake up in order to get to a non-ER doctor for a check up. (Which I have a battery of tests scheduled now)

Last night my three year old vomited 10 times in the span of two hours after taking some OTC medicine. Poison control said the dose was fine, but that she should go to the ER for monitoring. I sat in the parking lot of the hospital for 30 minutes, debating back and forth about the decision to go in. She threw up one more time, so I whisked her in.

Two hours later and some anti-Naseau medicine, we're looking at another $1200. I don't regret it fundamentally, but my wife spent some time crying as this is going to really hurt us financially.

And yet more recalcitrance to visit the hospital.


But there's nothing wrong with healthcare, now that we've all got the Affordable Care Act.
posted by Debaser626 at 8:42 AM on August 11, 2013 [38 favorites]


The third-party billing system is a scammer's paradise. Story:

I get a robo-voicemail from a 800 number, which tells me I have outstanding medical bills and I can go to this site to pay. No mention of amount, no medical provider ... no additional information. I hadn't received a paper bill from anyone. Sounds pretty phishy, right?

So I go to the site. The first thing the billing site wants is your phone number. However there's nothing telling me about the operator of the site -- no name, no address. Googling the company name left in the voicemail didn't reveal anything. So I don't enter my phone number.

I call them back. Their rep won't tell me anything unless I identify myself. The most I can get out of them is that they're a company in Indiana -- Diagnostic something or other. They won't tell me if they do billing for the clinic where I get tested. They won't even tell me if they do business in my region. HIPAA and all that. So I refuse to give them information and hang up.

I call the clinic where I got some bloodwork done a couple months ago. Yes, they say, that's the company that does billing for us. Go ahead and pay it. I know you paid in full, but there are sometimes additional charges.

So I go back to the website, fill in my info, and look at the invoice. $7.00. My test is mentioned, so I assume they're legit. I pay.

It took a lot of time and energy to distinguish this legit bill from a phishing attack, and I'm a healthy individual with *one* bill. I can't imagine how much fraud goes undetected.
posted by RobotVoodooPower at 8:48 AM on August 11, 2013 [21 favorites]


There is also the problem of inflexible demand. When you have consumers willing to spend themselves into penury or bankruptcy to save the life or restore the health of themselves or loved ones, there is practically no downward pressure on pricing. Normal market mechanisms simply don't function...
posted by jim in austin at 8:51 AM on August 11, 2013 [9 favorites]


I'm trying to figure out why neither her nor NPR seems to want to disclose that she went to Harvard Medical School and finished her residency in Emergency Medicine at New York Hospital. I would have at least thrown in an MD in there somewhere rather than making vague comments about medical training that give the impression she dropped out. It's fairly germane to the conversation. But I can't come up with a plausible reason.
posted by hobo gitano de queretaro at 8:54 AM on August 11, 2013 [5 favorites]


If you look at a European bill, those things don't exist.

In seven years in the UK my wife and I never even saw a bill. In 35 years in Canada the only bill I ever saw was the anaesthesia for my appendectomy when I was 13 (which would have potentially killed me if I was American because there is no way in hell I would have seen a doctor until it had burst because my parents were not well off and pretty tight with money to put it mildly).

In America we were overbilled and haggling over a bloody checkup within a month of getting off the plane.
posted by srboisvert at 9:21 AM on August 11, 2013 [1 favorite]


That seems like a good list for healthcare costs:
  • Use too much.
  • Pay too much for what you use (have no ability to price ahead of time; all prices are crazy).
  • Set plenty of money on fire.
I'm trying to figure out why neither her nor NPR seems to want to disclose that she went to Harvard Medical School and finished her residency in Emergency Medicine at New York Hospital.

She isn't invoking her experience as a doctor, and it's been a pretty long time since she left medicine. "ROSENTHAL: Well, you know, I think I said I trained as a physician. I worked in an ER for a few years before converting to journalism, as it was, 20 years ago. "
posted by a robot made out of meat at 9:24 AM on August 11, 2013 [2 favorites]


For the laaaaaand of the meeeee
And the home of the knaves!
posted by lordaych at 9:39 AM on August 11, 2013 [4 favorites]


Each department gets to set their own prices and bills directly to the insurer, so there isn't anybody in the hospital who has an incentive to lower costs.

Not to defend the ludicrous US healthcare reimbursement system, but individual hospital departments aren't setting their own prices or billing separately. The hospital as a whole has a single finance department that sets prices, and a central billing office that will drop a single bill for the entire hospital stay. The profusion of bills for the same encounter comes from the fact that in many cases, physicians that work in hospitals are in independent practice, rather than working for the hospital, and bill for their own professional services separately from both the hospital itself and other physician practices working there.

This is still a pretty silly way of doing things, and is one driver of cost escalation, but I think a pretty minor one compared to the lack of a single national payor or rate-setting authority, or the preposterous push for consumer-driven price control in a "market" where consumers have zero visibility into costs until after they've already made purchasing decisions.
posted by strangely stunted trees at 9:48 AM on August 11, 2013 [1 favorite]


What's crazy to me is that virtually everyone has some sort of "I paid tons of money for something dumb and also the whole thing was a huge bureaucratic mess" story, so everyone knows the system is awful, yet somehow the only politically palatable way to ACA healthcare reform was one in which great pains were taken to not meaningfully change the system.

Don't get me wrong, I would rather have the ACA than nothing, but holy shit is it a half measure.
posted by ghharr at 10:06 AM on August 11, 2013 [11 favorites]


There's nothing inherently wrong with how healthcare itself is delivered in America...There is something inherently wrong with how we pay for healthcare in America.

You cannot separate the two, as Kirth Gerson's story above clearly demonstrates. The payment system has utterly corrupted the delivery system.
posted by Steely-eyed Missile Man at 10:15 AM on August 11, 2013 [3 favorites]


The thing that slays me is that if you do go to the hospital, there is literally no way to know when you're done paying the bills. I've told this story before, but last year, I took my son to the hospital for a severe croup attack -- a legitimate medical emergency, he was dying. This was our fourth visit to the hospital for croup, but the first since we'd changed insurance away from our cadillac plan (supplied through COBRA). I knew the bill would be high, and we were trying to budget for it, so I was watching our insurance claims website like a hawk.

The first bill came through about 10 days after the visit. $1700. OK. That's a lot of money, but our insurance knocked it down to about $400 through negotiated discounts. They didn't COVER any of it, since we have a $2500 deductible, but they did lower the bill substantially.

About 2 weeks after that, another charge came through, this one for about $1400. This was the hospital's charge (he was admitted), rather than the ED's charge. Once again, we got a substantial discount, but our portion of the bill ended up being about $850. At this point, I called the hospital to ask how many more charges were outstanding.

They didn't know. They had no idea, and no way to find out. "Well, see, the doctor who saw him in the ER has one billing group, so they'll bill you for his time. And the doctor who rounded on him in the Peds unit has another billing group. And the respiratory therapist, he has another billing group -- and the pediatric hospitalist who admitted him, she works for a different hospital entirely, and there may be two or three other charges associated with her. We really can't tell you, just keep paying them as they come in."

So not only do you not know the cost beforehand, you don't even know the cost after the fact! You never know when you're done! We've paid about $1700 on that hospital bill so far, and haven't gotten a new bill in seven months, so I think we're done. . . but I have no idea! And again, he was dying, it's not like we had a choice of whether to go to the hospital or not -- in a previous attack, I'd waited too long to go to the hospital, and he'd stopped breathing in the car. It really feels like you're just showing up and prostrating yourself before the altar of Almighty Medicine, begging for supplication.
posted by KathrynT at 10:22 AM on August 11, 2013 [55 favorites]


What's crazy to me is that virtually everyone has some sort of "I paid tons of money for something dumb and also the whole thing was a huge bureaucratic mess" story, so everyone knows the system is awful, yet somehow the only politically palatable way to ACA healthcare reform was one in which great pains were taken to not meaningfully change the system.

I don't think it was the average Joe who killed healthcare reform. I think it had to do more with the insurance companies with their armies of lobbyists and lawyers not intending to stand by and watch their business get legislatured away. The health insurance industry is a cancer on our country.
posted by bleep at 10:24 AM on August 11, 2013 [11 favorites]


actually what's really remarkable is that its the same five manufacturers in Belgium, but because of how the governments control prices the players can't act like an oligopoly. Yet remarkably they are still happy to sell replacement joints. Its a miracle!!!

which is why it's hilarious that the npr website says we need to open up the US market for medical devices to foreign competition and that would solve the problem.

but price controls, good god, what is this... Belgium has gone communist!
posted by ennui.bz at 10:30 AM on August 11, 2013 [1 favorite]


Slarty Bartfast: "In my dingey little community health practice now, we do ten times as much medicine for a third the cost. There is no doubt in my mind I won't ever go back to dealing with private insurance. I just hope the time comes when more doctors realize what they've given up to allow this dysfunctional system to continue to exist."

Bless you, man.
posted by notsnot at 10:52 AM on August 11, 2013 [15 favorites]


There was a really good article a few weeks back about who decided on medicare costs for procedures, which in turn determines how much private insurance will pay. It's all really disheartening.
posted by hopeless romantique at 11:05 AM on August 11, 2013 [2 favorites]


When my daughter was born I got to experience the "new $400-1500 medical bill" every few months roller coaster myself. The last $1,000 bill came after her first birthday. America sucks.
posted by lordaych at 11:20 AM on August 11, 2013 [1 favorite]


Lewis Thomas used to tell the story of how when he was in med school, the students were advised to marry rich because they could expect to make no money as doctors.
posted by IndigoJones at 11:21 AM on August 11, 2013 [1 favorite]


I work in healthcare myself and "vertical integration" is all the rage now. Doctors want to own hospitals and rehab facilities and make a dime on every bandaid used. I don't know if it's a good or bad thing, but doctors suck at business and let assholes handle it for them IME. The assholes tend to take the whole "I'm not here to make friends" approach to the extreme except the friends are meaningful patient engagements
posted by lordaych at 11:23 AM on August 11, 2013 [3 favorites]


This is why, every time you go home from a hospital room, you take everything with you that's not nailed down. After all, you (or your insurer) are already being gouged for it.
posted by gottabefunky at 11:24 AM on August 11, 2013 [1 favorite]


There is an alternative system in the west US: Kaiser. I've mentioned it before, though I was criticized for it. They own their own doctors offices, pharmacies, hospitals. There are never any bills. You pay the co-pay (for me $20) to see the doctor, to buy any medicine, and even to get an operation (actually I think the copay for this is higher, maybe $100?).

There is no little dance between the hospitals, doctors, and insurance companies to fill out the bills with sometimes ridiculously detailed expenses or to drive up costs. Doctors get paid a salary. There's no way to turn patients into cash cows.

Nowdays kids can get a pneumococcal vaccination that prevents a lot of meningitis and pneumonia cases. Kaiser paid for the study that lead to this vaccine, because it reduces costs. Can you imagine the normal medical system paying for a study that would result in less hospital care, and therefore less money? It turns the incentives on their head. Kaiser has been paying for a lot of studies like this, leading to better health and reduced costs.

That leads to the criticism I got the last time I mentioned this: the incentive is to provide less expensive care. You won't get a colonoscopy test, you'd get the fecal occult blood test. The colonoscopy will only happen if there are symptoms. What if you need heart surgery? Will they try to recommend something cheaper? Yes, you could get a doctor who cares more about costs than about their patients.

But these doctors are easy to identify and avoid (and the new questionnaire they now send to everyone after every visit has helped them weed some of these out). There are a lot of very good doctors in the system. The doctors like it because they don't have to play the insurance game and deal with all the forms. They get a salary, and they practice medicine.

Also, read back at some of the horror stories in some of the posts on this site. That's the alternative. Overpriced care, no care vs care where the incentive is to reduce costs.

There's no perfect system, but one of these choices is getting out of control and becoming unaffordable.
posted by eye of newt at 11:25 AM on August 11, 2013 [14 favorites]


I worked for a while in the medical field. A group of Beverly Hills plastic surgeons had this idea to buy a decaying hospital, make it really posh, and soak the celebs for mucho dollars. They tried, but the whole project was a fiasco, and it eventually failed. So yeah, doctors aren't the best businesspersons.
posted by Windopaene at 11:27 AM on August 11, 2013 [1 favorite]


She doesn't seem to explain why the hip replacement part is so much cheaper in Belgium... at least in text. But she claims that the reason it is so expensive in the US is "lack of competition." so, medical parts in europe are sold in a glorious free market?

Medical care in the US is by no means a free market. There are entire bureaucracies in between you and the healthcare provider. The patient can only choose HCPs that are "in network" and doctors will only choose networks that pay well enough to keep the lights on. If all the doctor is getting is the $10 copay, that doesn't leave very much room to pay the rent, insurance, receptionist and various other staff. Much less a quarter million in med school loans.

Then there is the squeezing the balloon thing. Countries with socialized medicine squeeze the prices of things down, so the US is stuck footing the bill for a lot of the worldwide research. You can't sell something at the marginal cost and still have enough revenue to pay the R&D people. (That's not to blame one side or the other, just pointing out something that happens.)

The entire US medical system is full of perverse incentives. That doctors and nurses want to make money at their profession is the least of them.
posted by gjc at 11:30 AM on August 11, 2013


WRT research -- a lot of research is done at publicly-funded universities and their associated hospitals. Private companies often pick up the "final step" that makes it profitable. It's yet another "socialize the costs, privatize the profits" model.
posted by KathrynT at 11:33 AM on August 11, 2013 [1 favorite]


Kaiser is a good model. They practice evidence based medicine for fuck's sake. Imagine that. It's such a rarity in the US it's framed as this odd new science-y approach to medicine. The people I work for see Kaiser as the enemy. Just as an example, a for profit practice very likely will prescribe expensive new anticoagulant drugs for no good fucking reason, while kaiser relies on evidence and research rather than catered lunches from busty pharmaceutical reps to make a decision.
posted by lordaych at 11:33 AM on August 11, 2013 [13 favorites]


valkyryn: "It should be illegal to provide medical care in non-emergencies without giving the patient a not-to-exceed estimate and a meaningful opportunity to choose cheaper alternatives, object to proposed charges, and seek cheaper treatment elsewhere."

I deal daily with discussing with patients the benefit of a test or procedure versus the risk of a positive or negative result and the associated costs deriving. And I also just finished dealing a crazy set of ED bills for a trivial procedure. So while I agree with you in principle, in reality in a multi-payer, multi-point healthcare delivery system like the US, it simply isn't feasible to deliver this sort of a contract to a single individual (especially at the start of treatment). So many of the cost inputs are unknown, occult or exhibit variable and dynamic latency and interdependency that creating final cost envelopes for them is an exercise in fuzzy logic with extremely wide ranges. And then the nature of the thing being delivered comes into play. Is it a product, or a service, or both? What is considered a single episode? When does downstream payment coverage for that cease? Who pays what for the adverse drug or procedure reactions? What happens in the 20-30% of cases (in general medicine) when the diagnosis is incorrect or incomplete? What if you're treating a downstream product of a primary process, such as paraneoplasia, but the primary neoplasia remains unidentified? Who pays for what? You're going to have neurologists, psychiatrists and endocrinologists arguing over the bill even before the oncologist arrives (and sets up the patient for the internist, the surgeon and the rad-onc, etc).

The only way you can give any kind of reasonable envelope of costs is within a much more tightly integrated, limited-payer, limited point-of-delivery system with much more constrained "choice" over delivery mode. And even then, you're dealing much more with population averages and symptom clusters, adjusted for age, SES and location. You're foregrounding "rationing" through your medical system as a technique for optimizing delivery. You're now more accurate, you've got your costs more under control and got more predictability, but you've just transformed into "socialized medicine" (or Kaiser, or the VA).
posted by meehawl at 11:35 AM on August 11, 2013 [6 favorites]


The hip article was what stood out for me as my Dad had just had his knee replaced on the NHS. For this he paid a grand total of NOTHING. He received excellent care and is now recuperating at home and driving my Mum crazy.
Of course, it didn't really cost him nothing as he's been a taxpayer his whole life, but he didn't have to sit in a car park and worry about whether having it seen to would cost him more than he could afford.
My heart goes out to everyone who faces this dilemma. It's a choice I hope I never have to make myself.
posted by arcticseal at 11:36 AM on August 11, 2013 [4 favorites]


There is an alternative system in the west US: Kaiser. I've mentioned it before, though I was criticized for it. They own their own doctors offices, pharmacies, hospitals. There are never any bills. You pay the co-pay (for me $20) to see the doctor, to buy any medicine, and even to get an operation (actually I think the copay for this is higher, maybe $100?).

I agree. I chose my own doctor because of the office she works for- it is a combined clinic with almost all outpatient specialties working under one roof. It's great when they have what I need. Not so great when they don't.

The downside is that in the Kaiser system, you are kind of stuck with what they offer. Evidence based medicine is great at keeping populations as healthy as possible, but it suffers a bit when you have outliers. A $20 copay is great, but if I need (or even prefer) a medication they don't approve of, I would have to get soaked for the retail cost, no?
posted by gjc at 11:37 AM on August 11, 2013 [1 favorite]


OK. Pet subject for me here. Which I went into in more detail on my blog. But the entire US system is a turducken of problems right from college fees onwards.
posted by Francis at 11:39 AM on August 11, 2013 [5 favorites]


To sum up my perspective, the insurance side is pure blatant evil from hell, and the providers (at least specialists) are playing the devil's game and effectively joining the dark side.

For example, there's a "Care Quality Measure" that Medicare wants providers to submit data on in order to get reimbursed for "Meaningful Use" of their electronic health record system. This particular measure is a numerator / denominator percentage where the denominator is the total number of patients who reported with back pain, and the numerator is the total number of patients in the denominator who did NOT have an imaging study (X-ray, CT, etc) within 28 days of the diagnosis.

Now the purpose here is to identify over-use of expensive tests. Medicare provides a white paper that explains the intent of the measure, which is heavily supported by research. The gist of it is is, "every time a patient comes in with low back pain and you start fucking around with imaging studies too early on, the whole healthcare system gets gouged." Sort of like the premature mammogram issue. The thing is, low back pain resolves itself more often than not and has a ton of causes that will not show up on imaging. What will show up are false positives that get the patient operated on unnecessarily followed by decades of revisions or pain management.

It's completely fucked, so you give the patient 28 days, and chances are they're fucking stressed out or whatever and they don't need you to open pandora's box and start fucking up their anatomy. So anyway, I talked to one medical practice who said that in order to "meet this measure" they were going to perform X-rays on ALL PATIENTS WITH LOW BACK PAIN. First of all, there's nothing to "meet" -- it's just raw data they want. But if you're trying to impress them, don't do the exact opposite of what they're looking for.

It's common with orthopedists to perform X-rays on basically anyone who walks in the door. They feel they are specialists and that the patient came to see them for a reason (whether or not they've seen a primary care / GP doctor) and skip right to the imaging studies. X-rays for everyone! MRIs for...well, anyone with Cadillac insurance! Health insurance should not come into determining the quality of care you get, but I've overheard doctors weighing a patient's insurance into whether or not they should order an MRI or surgery more than once.
posted by lordaych at 11:48 AM on August 11, 2013 [2 favorites]


The land of opportunism
posted by lordaych at 11:57 AM on August 11, 2013 [1 favorite]


Slarty Bartfast: "In my dingey little community health practice now, we do ten times as much medicine for a third the cost. There is no doubt in my mind I won't ever go back to dealing with private insurance. I just hope the time comes when more doctors realize what they've given up to allow this dysfunctional system to continue to exist."

Bless you, man.


Ah, you're mistaking me for someone who cares about patients. I just hate motherfuckers in business suits getting rich off my hard work and the suffering of others.
posted by Slarty Bartfast at 12:05 PM on August 11, 2013 [12 favorites]


lordaych: while kaiser relies on evidence and research rather than catered lunches from busty pharmaceutical reps to make a decision.

Lest you get jumped on for this comment, my office is in the middle of a large cluster of medical offices and support buildings for the two big hospital systems in my area. You can tell the pharma reps from a mile away in the lobby, an attractive woman who looks like she just walked out of a magazine, pulling a rolling briefcase.
posted by dr_dank at 12:22 PM on August 11, 2013 [4 favorites]


Hi, I used to work in medical insurance.

There are two issues here:

1. It's not exactly possible to have a set price for every procedure. Simple stuff like a blood panel, sure; you could definitely make a case for one price. But childbirth, or a heart transplant, that kind of thing is going to vary depending on the patient and the types of procedures being used. And what goes wrong or doesn't. Human bodies are not widgets.

2. Every price is up for negotiation in a for profit system. These include:

a. Price employer pays to insurance provider for employees
b. How much employees themselves pay
c. Copays and deductibles employees pay (influenced by how much they've already paid that year)
d. What hospitals charge/what insurer pays hospital for certain procedures
e. What doctors charge/what insurers pay doctors in hospitals for certain procedures
f. What doctors charge/what insurers pay doctors in their offices for certain procedures
g. What labs charge/what insurers pay for certain tests
h. What walk-in clinics/ERs charge/what insurers pay for certain procedures, and when

There's probably a few I'm missing. But each doctor or group of doctors and each hospital or hospital system negotiates with each insurer for what they charge/get paid. There are many lawyers involved. This part of the process may be entirely opaque, because this is considered confidential contract information.

You cannot possibly untangle it and price-shop, in this scenario. There are too many variables, too many of which you will never ever be able to find out.

I am really glad to be in a totally different field now.
posted by emjaybee at 12:37 PM on August 11, 2013 [4 favorites]


I was on the receiving end of Kaiser twice in my life. It was my step-dad's health plan when he was a social worker in San Francisco. In those days doctors even did HOUSE CALLS!
Later on AFDC, there weren't house calls, but there were competent doctors available any time. Was it perfect? No. Was it good? Yes.
posted by Katjusa Roquette at 1:00 PM on August 11, 2013


The only time I went to a US based ER, a doctor took one look at my gold plated company insurance and tried to upsell me from a broken arm into a complete ball-and-socket elbow replacement. And he was going to get me admitted right away, so I could while away my time in a private hospital room for a couple of days while they made surgical arrangements. "But...it's just a broken arm. The metal steps on the subway were slippery with the rain and I wasn't being careful." He pointed out that the break -- which was presented before us on comically oversized 24 by 36 xray film from three different angles (seriously, it was at least twice actual size) -- was near the elbow and had a risk of not healing properly, thus he was recommending replacing the lot with a prosthetic.

After a back and forth that started with me politely questioning and progressed until I was openly belittling his inability to perform cub-scout medicine, he relented, finally set the bone (the discussion was also literally painful for me) and got me into a removable cast that was little more than an elbow pad with straps, a paper sling, and sent me on my way. I healed just fine, it's just as strong as my other arm. I was initially billed $2000US, which I grudgingly paid while cursing the radiology department.

A few months later, I got a letter from the insurance company saying that they had gotten word that as my injury technically occurred on subway property [note: I only said the s-word once, verbally with the doctor], they needed my signature to proceed with a suit against the city on my behalf, and reminding me that my continued coverage was dependent on complying with their procedures to reduce and recover costs. I refused to sink to this level of shysterism because of a simple accident. They tried sending me several five figure bills in response (for a damn cast?!?) and I eventually had to get corporate HR to make them go away.

In short, the US healthcare system can go to hell, as far as I'm concerned. It's easier to find an honest mechanic.
posted by ceribus peribus at 1:34 PM on August 11, 2013 [18 favorites]


Countries with socialized medicine squeeze the prices of things down, so the US is stuck footing the bill for a lot of the worldwide research.

Ha ha ha. No.
posted by MartinWisse at 1:48 PM on August 11, 2013 [10 favorites]


1. It's not exactly possible to have a set price for every procedure. Simple stuff like a blood panel, sure; you could definitely make a case for one price. But childbirth, or a heart transplant, that kind of thing is going to vary depending on the patient and the types of procedures being used. And what goes wrong or doesn't. Human bodies are not widgets.

This is exactly what Rosenthal addresses in the second article, though, about childbirth. Many countries do have a set price for vaginal birth and a set price for a c-section, and ... that's what it costs.

In almost all other developed countries, hospitals and doctors receive a flat fee for the care of an expectant mother, and while there are guidelines, women have a broad array of choices. “There are no bills, and a hospital doesn’t get paid for doing specific things,” said Charlotte Overgaard, an assistant professor of public health at Aalborg University in Denmark. “If a woman wants acupuncture, an epidural or birth in water, that’s what she’ll get.”

It's only in the current US piecemeal system that we "can't" have a set price. And by not having a set price but instead charging for each little thing, we've set up incentives for doing more and more interventions, which makes it harder to set a standard price because we're convinced that all sorts of unexpected interventions are the norm.
posted by jaguar at 1:59 PM on August 11, 2013 [9 favorites]


It should be illegal to provide medical care in non-emergencies without giving the patient a not-to-exceed estimate and a meaningful opportunity to choose cheaper alternatives, object to proposed charges, and seek cheaper treatment elsewhere. That estimate should include insurance benefits.

I can't for the life of me figure out why we don't do this.


It's fairly simple. This may have been already addressed, but fuck did i want to say something about this.

If i had been asked if i consented and given an estimate, they wouldn't have given me a CT scan i probably didn't need when i was in the hospital for a throat infection. I went in, had someone look in my throat, a supervising doctor said they might as well scan me, and i was sent back to my room and given a scrip for antibiotics.

$3500 later, i'm back at my house. The default assumption is "Meh, they have insurance, do some stuff that'll let us bill them a decent amount".

That $3500 is guaranteed money for them too. Not dischargeable by bankruptcy, and it'll follow you around forever. Someone is going to pay it, or they're going to ruin your life over it. I managed to apply for charity care and get it reduced by about 2/3rd, and now they get to write me off as one of their "operating losses". I have an extremely hard time believing they're not still making a profit on that amount as well. They might only get some percentage of the money out of you, but if they do then not only did they get money, probably more than enough to cover their costs, but they got to parade you around in a welfare queen type way to go "See, we're bleeding hearts! We sacrificed ourselves monetarily to help this poor wayward soul, aren't oyu going to give us money city/state?"

You can't think of why they don't give estimates? Because they want implicit consent from everyone and for them to have used the service before they know how much it'll cost, so when they go "hey what the fuck!" it's too late, you already used their goods and services. They can just go "but we've incurred a cost by treating them! are we not allowed to ask for money now that they've cost us money?".

They're playing the same con as those for-hire flat rate taxi cabs that have no meter. You get in, say where you're going and don't get a price until you're stopped. They're supposed to have a fair book or give you an estimate, but they generally get really wishy washy when you try and get specific prices about anything. The difference is that the hospitals are playing the same con on a scale that the cab drivers and cab companies dream of one day being able to pull off. It's like that corny old internet picture of the ice cube lifting weights dreaming of one day being an ice berg.

I can't think of any other industry besides shady taxi services where not at least getting an estimate, if not the exact cost beforehand is the norm. I myself work in an inspect/estimate/work field as a side job(laptop/phone/etc repairs) and i can tell someone generally spot on exactly how much something will cost beforehand. None of this shit is experimental procedures, and yet they're saying that it would be impossible and might leave them hanging on some costs? In every other field it's normal to come back with another estimate if you realize much more work might be required.

There's serious fraud going on here at tens of levels.
posted by emptythought at 2:43 PM on August 11, 2013 [2 favorites]


I'm sure there is fraud, but I also think it's important to factor in American litigiousness, too. I suspect that the vast majority of the "Well, we may as well run X test" thinking is due to fear of lawsuits if they miss something rather than due entirely to money-grubbing.
posted by jaguar at 2:53 PM on August 11, 2013


1. It's not exactly possible to have a set price for every procedure. .. Human bodies are not widgets.

Bullshit. Just do that part of the "insurance" on the provider's side, like they do everywhere else in the world and in every other industry. Apple does not worry about whether you'll call about every stupid detail when they sell you a computer or warranty.

A health care providers time is a person's time, just like a widget seller's time, that's all that matters from the pricing perspective.

2. Every price is up for negotiation in a for profit system.

Bullshit. Insurance pushed the providers into this by saddling them with varying and stupidly complex contracts. Yes, the providers fought back, but the insurance companies started the ball rolling.

Germany handles insurance through commercial institutions too, but they do not let the insurance companies write the contracts. If you want to sell insurance, then most coverage is dictated by law, and you can try to sell small add ons for services not related to non-life threatening situations.
posted by jeffburdges at 3:03 PM on August 11, 2013 [2 favorites]


It's fairly clear that one extremely efficent healthcare reform for the U.S. would be simply outlawing health insurance, aside from Medicare and Medicaid. We'd fix all the billing really fucking fast and finagle need based care as well.

Ah, you're mistaking me for someone who cares about patients. I just hate motherfuckers in business suits getting rich off my hard work and the suffering of others.

In the long run, that's exactly caring for the community or patients in aggregate. </evopsych-gametheory>
posted by jeffburdges at 3:12 PM on August 11, 2013 [1 favorite]


Countries with socialized medicine squeeze the prices of things down, so the US is stuck footing the bill for a lot of the worldwide research.

Boooooolllllshiiiit.
posted by five fresh fish at 3:17 PM on August 11, 2013 [5 favorites]


I'm sure there is fraud, but I also think it's important to factor in American litigiousness, too. I suspect that the vast majority of the "Well, we may as well run X test" thinking is due to fear of lawsuits if they miss something rather than due entirely to money-grubbing.

This is one of those things that is plausible and makes sense on paper. It might even be true, but it's also a pretty fallacious thing in the sense that they get to go "Hey, it's not our fault, we didn't start the fire".

It's "just following orders" kind of assholery. They must love this excuse to do stuff that really isn't needed and make more money.

As i said, there's no way in hell they aren't still making a profit on every single thing they do even if the bills get reduced once in a while. It's an absolutely "getting you coming and going" situation.

It also completely ignores the fact that poor people stay far away from the legal system unless someone opens the door of the limo and an outstretched hand pops out. Unless they get invited into a class action or something, none of the people who really get fucked by this type of thing are going to be suing anyone. It's not just about having money for a lawyer as one may take up a malpractice situation on contingency, i'm sure, but it's not even knowing you can or having any knowledge of the system that comes from the social aspects of being working class(or even mid-lower middle class and uninsured, etc).

"Oh, we'll just sue them" is something you only really hear from actually upper middle class+ people. Possibly those who have legal representation provided in certain situations by their employer(for example, microsoft employees above a certain level). This isn't a real concern on their part for the patients most effected by this shit, it's just a straw man for them to jump behind that has a lot of plausible deniability if the opponent isn't going to think it through much.

A lot of discussions about predatory practices in banking, the healthcare industry, etc get saddled with this kind of crap that sounds great as a soundbyte, but isn't actually a real concern to the people on the side that's benefitting from all this or at the very least deeply imbedded in the machinery of it all.
posted by emptythought at 3:17 PM on August 11, 2013 [5 favorites]


Every time someone starts arguing that healthcare just too complicated to follow the same system that EVERY OTHER COUNTRY IN THE WORLD DOES

blah blah blah American exceptionalism ....

I start frothing at the mouth and my eyes roll into the back of my head.

This thread has been a really rough ride for me.

I mean seriously, how has it not sunken in, for every single person that has ever visited a hospital in the United States, that we pay the most and we get the least. We are the problem, not the solution.
posted by hobo gitano de queretaro at 3:18 PM on August 11, 2013 [13 favorites]


For the record, I wasn't saying I approved of how insurers bill or write contracts. Just that calls for price transparency are going to hit those obstacles.
posted by emjaybee at 3:24 PM on August 11, 2013


The first thing that providers do is "register" patients and get their insurance information. What kind of price transparency (and, I'll argue, consistency of quality of care) do you expect from a business that first asks you how much money you have before they'll start to figure out what their service costs?
posted by ceribus peribus at 3:32 PM on August 11, 2013


emptythought - I think the stakes are different in medicine than in other areas of life. You are required by law to carry malpractice insurance if you want to practice in most states, in most medical facilities. It is enormously expensive, and gets more expensive if you start getting sued. On average, every doctor gets sued a few times, simply because they see tens of thousands of patients over a lifetime.

And a single really unlucky case, or one bad decision can result in a lost license, forever. I literally can't count the number of times I've heard a doctor say they're ordering X, Y and Z not because it's indicated, but just to cover their ass. It costs them nothing, but skipping it could cost them everything. It's classic economics.

Out of the several dozen doctors I'm discussed this with in the private sector, malpractice insurance ranges from 15 - 70% of their salary. Frequently hospitals will throw this in, but lifetime insurance with retroactive tail policies can cost millions of dollars over a lifetime of practicing medicine. This is not an insignificant additional cost of healthcare. Other countries have professional panels that set awards on a sliding scale for medical error, and attempt to implement systems engineering to decrease the incidence of that category of mistake, rather than our current system of deliberately fostering bad blood between patient and doctor, where the physician feels like they're amongst enemies.

Outpatient clinics tend to do too many diagnostics and labs because of naked greed, and maybe habit, and laziness because they don't want to get the results from other doctors. Hospitals and other inpatient settings, it is generally more to never get caught in a situation where you didn't meet whatever the standard of care will be in ten years from now, and the only way to do that is to always exceed what it is currently.

I agree with the articles, there are a lot of diagnostic procedures being ordered that all happen to bill exceedingly well, but in my experience very little actual diagnostic work gets done. Everyone's just looking for the bingo card indication that will allow them to order their favorite high reimbursement rate procedure, then it's patient lost to follow up. Specialists do the procedures, order the tests, and just treat empirically without really narrowing it down to the exact pathophysiology. Very little impact on the doctor's side of things, but potentially massive implications for the patient, who might never know the difference. It really is a disaster.
posted by hobo gitano de queretaro at 3:35 PM on August 11, 2013 [3 favorites]


1. It's not exactly possible to have a set price for every procedure. .. Human bodies are not widgets.

Oh yes it is.

A list of all the medical procedures covered under Australia's public health care system . Click on a number-link to see the RRP and the rebate returned to patients. While doctors can charge more than the RRP, many charge only the RRP or even only the benefit amount. ER charge only the benefit and bill the government directly - ie: all ER visits are bill-free for the patient.

This system has been in place since 1984.
posted by Kerasia at 3:44 PM on August 11, 2013 [14 favorites]


Debaser626: "My insurance has a deductible of $5,000 on ER visits, so it was cheaper to call and ask the hospital to charge me as uninsured, as thye have a built in 35% discount for that situation."

I'm curious if that's part of a qualified "high deductible" plan. High Deductible Health Plan premiums are cheaper, and users are expected to defer at least the difference into a tax advantaged account to offset expenses, if not the full yearly deductible. It carries over, so this gets easier as you build up savings. The economic goal of this system is to put patients back into the price loop while still covering disasters. I.e., instead of going to an Emergency Room, you locate an Urgent Care facility.

These plans are a good fit for certain demographics, but there's plenty of people who wind up with them without realizing how very, very different they are. And it requires a lot more sophistication on the part of the consumer; I have no idea in your case which visits would be better served in the ER vs urgent care vs whatever else is available. Or how you negotiate prices with someone who refuses to give you a quote.
posted by pwnguin at 3:54 PM on August 11, 2013 [1 favorite]


I fucking love the NHS. I would marry it if I could.
posted by goo at 3:57 PM on August 11, 2013 [2 favorites]


It's "just following orders" kind of assholery. They must love this excuse to do stuff that really isn't needed and make more money.

I think you're ignoring the other side of the systematic issues, though. There's a total paranoia in the medical community about lawsuits, because, as hobo gitano de queretaro said, one lost suit can mean a loss of your ability to practice your profession. So you've got a system in place in which:

1. Doctors and hospitals and clinics make more money when they order more procedures; and
2. Doctors can lose their careers if they misdiagnose or miss something that could have been caught by one more test; and
3. Americans are really big into technology and tend to believe that more tests are better than fewer tests; and
4. Most Americans aren't paying directly for their care.

What on earth would the incentive be for any one doctor to hold back on ordering tests? They'll lose money, increase their probability of being sued, and lower patient satisfaction.

I hate it when these discussions veer toward "evil fraudulent doctors," because I don't think it's the doctors' fault. They're just doing what makes sense in a completely unreasonable system. And I don't mean that in a "just following orders" way, I mean that in a "I would like to be able to put food on my table, so this is what I'm stuck with" way.
posted by jaguar at 4:27 PM on August 11, 2013 [3 favorites]


jaguar--thanks for your last paragraph--the demonization of individuals or subgroups with in this bizarre system is just about as useful as any other kind of stereotyping. That is, it makes for an ill informed judgement and does not solve any problem. I thought this was an extremely well put together article that fairly laid out some of the major problems and provided some direction for moving ahead. Thanks Again
posted by rmhsinc at 4:36 PM on August 11, 2013 [1 favorite]


I'm sure there is fraud, but I also think it's important to factor in American litigiousness, too. I suspect that the vast majority of the "Well, we may as well run X test" thinking is due to fear of lawsuits if they miss something rather than due entirely to money-grubbing.

I would point out the vicious-circle nature of the system here as well; from a patient's point of view, in the US, the medical system is a giant for-profit corporation and/or a really rich doctor type with deep pockets, the treatment is likely to be thousands or tens of thousands of dollars, and if the malpractice leads to further complications, that can cost hundreds of thousands of dollars over a lifetime. In the developed world, the medical system is a government branch and likely no money changed hands for the treatment, and in many cases none for any further treatment due to malpractice. The incentive to sue is much lower.

In the five year period 2005-2010, there were 4,524 malpractice lawsuits in Canada, about 900 a year. In the US, in the year 2000, there were 86,480 malpractice lawsuits. Keeping in mind that Canada has 10% of the population of the US roughly, that's 10 times the rate of malpractice lawsuits in the US versus Canada. It's hard to conclude that the US system is better, if Canadian doctors have 10% as many malpractice suits.
posted by Homeboy Trouble at 4:53 PM on August 11, 2013 [5 favorites]


I literally can't count the number of times I've heard a doctor say they're ordering X, Y and Z not because it's indicated, but just to cover their ass. It costs them nothing, but skipping it could cost them everything. It's classic economics.

If this is true as you say, there are a couple of interesting logical consequences.

1. If it is a doctor's judgement that a diagnostic procedure is not required but they do it to "cover their ass," what this logically implies is that if your life is on the line, it isn't worthwhile but if their own financial future is on the line, then it is justified. There is no change in their estimation of the risk of misdiagnosis. The only difference is who's life is at stake. In other words, the doctor places little value on your miserable life compared to their own life.

2. Most diagnostic procedures contain some risk of side effects or harm. For example unnecessary X-rays and CT-scans increase the risk of cancer. Exploratory cardiac catheters have a risk of stroke, etc. Yet doctors admit that they perform these risky procedures not for the patient's heath but for their own benefit "to cover their ass". This is called medical malpractice. It is ironic that in arguing their case about the evils of malpractice litigation that doctors freely admit that they routinely perform medical malpractice.
posted by JackFlash at 4:57 PM on August 11, 2013 [3 favorites]


The only way you can give any kind of reasonable envelope of costs is within a much more tightly integrated, limited-payer, limited point-of-delivery system with much more constrained "choice" over delivery mode.

I refuse to believe that this is true. I think you're interpreting my demand as being more ambitious than it is. I'm not suggesting that when a patient first shows up for a cancer screening, that the internist should be able to give them a bill for their entire course of cancer treatment before anything is done. That'd be impossible.

But what I am saying is that before any particular exam, procedure, test, hospitalization, or indivisible set thereof is begun, that the patient needs to be presented with that estimate. Can the hospital tell you how much your whole course of treatment is going to cost? No. Can they tell you how much today is going to cost? The way things are right now, probably not, but you know what? Fuck them. Make something up. It's what they're basically doing now, isn't it? And if this is supposed to be the free market, well, innovate or vacate your market position for someone who will. It absolutely is possible to tell a patient how much an imaging study, or a doctor's visit, or even a serious surgery, is going to cost before it starts.

Complications, you say? Hell, why shouldn't hospitals buy insurance for that sort of thing? Price the cost into each procedure. Give everyone the price of an uncomplicated procedure plus a fee for complications insurance. Sure beats whatever the hell it is that we're doing now...
posted by valkyryn at 5:21 PM on August 11, 2013 [1 favorite]


Also, let's not overlook why patients frequently sue for malpractice -- because the cost of managing their condition is absolutely prohibitive, and they don't have the money to pay for it. If you have a difficult or obstructed birth, for example, and the baby suffers from oxygen deprivation during the birth and ends up with cerebral palsy and the attendant monstrous medical bills, it may not be financially feasible for the family to do anything other than sue the attending OB for malpractice. If we had a more sensible health care system, they might not be forced into that choice.
posted by KathrynT at 5:25 PM on August 11, 2013 [12 favorites]


It's hard to conclude that the US system is better, if Canadian doctors have 10% as many malpractice suits.

I do not know how this affects the argument, but, in Ontario at a least, doctor's malpractice insurance premiums are paid for by the provincial government (about $100 million a year). Doctors pay an annual membership fee to CMPA that does not fluctuate even if there are claims files against the individual doctors and any awarded claims are paid by CMPA. So there are no financial penalties for Ontario Doctors that face malpractice claims/suits. Since the awards for compensation are relatively small (because they do not need to cover medical expenses) there is not too much incentive to file suit in the first place. Also, are you sure about the 900 lawsuits a year? I thought there were only 96 lawsuits that went to trial in 2012 across Canada.
posted by saucysault at 5:35 PM on August 11, 2013 [1 favorite]


If i had been asked if i consented and given an estimate, they wouldn't have given me a CT scan i probably didn't need when i was in the hospital for a throat infection. I went in, had someone look in my throat, a supervising doctor said they might as well scan me, and i was sent back to my room and given a scrip for antibiotics.

$3500 later, i'm back at my house. The default assumption is "Meh, they have insurance, do some stuff that'll let us bill them a decent amount".

That $3500 is guaranteed money for them too. Not dischargeable by bankruptcy, and it'll follow you around forever. Someone is going to pay it, or they're going to ruin your life over it. I managed to apply for charity care and get it reduced by about 2/3rd, and now they get to write me off as one of their "operating losses". I have an extremely hard time believing they're not still making a profit on that amount as well.


For the record you can find the UK price list for entire hospital stays here.

At an educated guess your throat infection would, in the UK, have come under the tariff category FZ31F: Disorders of the Oesophagus with length of stay 1 day or less. £397 + Market Forces Factor* for the entire spell. Or $600 plus a percentage for location. Not just for the CT - but for everything up to and including one night on a ward. (Not that most patients ever see anything of the cost).

One of these days I'll try to put together a blog post explaining the UK hospital billing system for anyone interested.

* Market Forces Factor is an allowance for the cost of living in a given area, ranging from 0% in Cornwall to 25%-30% in Inner London
posted by Francis at 5:41 PM on August 11, 2013 [1 favorite]


There is another factor with malpractice - appallingly bad self-policing by doctors. It is extremely hard for a doctor to have his license pulled, and it's rare for other physicians to report a bad doctor. Bad practices are covered up, doctors are shifted around or skip around themselves, and there aren't any decent systems to keep track of troubled physicians. I'm not saying there is something inherent to doctors being bad as humans, it's exactly the same as in any professional association - think White Wall of Silence equivalent of Blue Wall of Silence. It might be in the collective interest of doctors to police their own, but on an individual basis there is less of an incentive to stick out your neck - another tragedy of the commons.

In contrast, when you have single-payer systems, it's easier to keep track of doctors and their records compared to the utterly fragmented system in this country.

If we could catch problem physicians earlier, I bet you the need for malpractice, and hence premiums would go down considerably.

Another thing in more integrated systems, is that it's easier to establish a more uniform standard of best practices, based on evidence and outcomes, which means there is a bar of care which needs to be reached by a physician, and having reached that, automatically insulates you somewhat from lawsuits. Again, having fewer standards and more fragmentation leads to more opportunity for lawsuits and higher malpractice premiums. Having evidence based standards would lead to both better and cheaper care.

So this whole malpractice insurance crisis is merely another symptom of the dysfunction inherent in the present fragmented system.

Single payer FTW.
posted by VikingSword at 5:42 PM on August 11, 2013 [10 favorites]


So this whole malpractice insurance crisis is merely another symptom of the dysfunction inherent in the present fragmented system.

Absolutely. It's all coming from the same "The market will sort it all out" mindset. The US has decided on a system where personal lawsuits are supposed to be how we police corporations and medical systems and all the rest, because somehow having the government do it is anti-American. It's totally fucked up.
posted by jaguar at 5:50 PM on August 11, 2013 [1 favorite]


It's common with orthopedists to perform X-rays on basically anyone who walks in the door.

I went to see an ortho last year, for the first time, for what I self-diagnosed as a bad case of tennis elbow. I was expecting the doctor to interview me and do some range of motion tests and tell me what I should do to help it heal over time. But instead, I was whisked into the X-Ray room before I even saw the doctor. And guess what, the MD told me the X-Rays were normal so I had tennis elbow and instructed me to buy one of those arm band things and take some aleve. And then today I hurt my lower back doing squats at the gym. And people are asking me if I am going to see the doctor. My response has been "hell no". What would be the point? I pulled a muscle. If I go to the doctor, they will give me X-Rays which I don't need or want. So I will just ride it out with some ibuprofen. And it gets better. My urologist wants to see me again this fall---a year after dealing successfully with a bad kidney stone issue. He told me last year he wants to take more X-Rays this fall to check on another stone. And I am thinking, why? If I have a stone, there is nothing you are going to do about it. If I have an attack, then we will deal with it. So I think I will cancel the appointment. Enough with the X-Rays! And don't even get me started about the dentist. Oh...and I had my 1st routine coloscopy last year. Everything was fine. When the gastroentorologist took my medical history I mentioned that my older brother had a number of polyps removed a few years prior during his 1st colonoscopy. And he says, alarmed, "your brother had polyps? That means I will want to do another colonoscopy in less than 5 years!" And I said to myself "there is no way that is going to happen".

And I say all of these things as somebody with cadillac level health insurance for which my empoyer pays 80% of the premium! When I have X-Rays, or procedures, it costs me NOTHING. I never even see a bill. But yet, I don't want all these X-Rays and procedures. It makes me want to avoid doctors to protect my own health. And that can work if you are healthy or have only minor ailments that can be treated at home so to speak. But that kind of cynicism on my part may not be good in the long run if I avoid doctors when I really should go see one. The entire system and what it does to each and every player in it is a complete train wreck. And the idea that some people like to claim that it is the best system in the world leaves me speechless. These people confuse the presence of well trained doctors and medical technology as a good system. It isn't the same thing.
posted by Seymour Zamboni at 6:03 PM on August 11, 2013 [2 favorites]


valkyryn: "Before any particular exam, procedure, test, hospitalization, or indivisible set thereof is begun, that the patient needs to be presented with that estimate"

I think that's a great idea, in principle. But the reality in the US's borked system is that there are so many potential exclusions that the estimates for many of these could end up looking like enormous branching Bayesian contracts.

"exam" - There are many of these kinds of exam. What if I find a significant cardiac murmur on a simple physical exam? Or dramatic areflexia or focal neuro lesion? Or a mass that needs imaging? For the murmur, am I going to call it a day, bill you, then let you go find a cardiologist to assess? Is that a separate bill, requiring more negotiation? Or for the neuro stuff, am I going to call an infectious disease expert or a stroke neurologist to do a more thorough exam? Again, roll that into my exam as a contractor fee, or leave you to follow up and re-negotiate? Or for the imaging, do I send it off to a radiologist or do I have someone locally? And then I get "clinical correlation required" on the read. Who does that? Do I? Do I have to negotiate an add-on fee with you?

"Procedure" - Oh so many things can go wrong here. To take a worst-case example, what if you stroke out or code during the procedure? Or it's simple fluid draw but I perforate? What if I'm right there and run the code until the code blue team gets there? Do I get to add on fees, or do I re-negotiate with you afterwards (or your heirs) or do I add a rider with a huge potential envelope?

"Test" - This is the most alluringly simple but the reality is different. Yeah, the hospital or lab can quote a fee to run the sample, and sometimes they roll in the phlebotomist fee or sometimes that's separate. But I get back one or more test results. Do you get an in-depth analysis for free? What if it's off, or atypical, or weirdly normal despite obvious clinical signs, and I have to call an endocrinologist or hematologist or specialist electrophysiologist? Do I add them on to your bill, or let you re-negotiate with them?

"Hospitalization" - Well, others have addressed this but there are so many services in-house that if you try to bill them as indivisible sets well, then, you have the US's most broken version of its health system in microcosm. That's why so many insurance companies want to move to simple capitation based on utilization reviews.

What I'm saying is that if you sit down to try to atomize and individualize all these elements, characterizing them into ontologies of products and services, then you find it quite difficult to assign meaningful price envelopes to them that can work in isolation. You've just embarked on re-inventing the fee-for-service model, which is part of what has failed so spectacularly over the past 50 years to both keep costs down and deliver good outcomes. So in your re-invented fee-for-service model, how would prices be set? hopeless romantique describes above how one version of fee-for-service estimates get set. The other is to rely on a completely deregulated "free market" of sellers and buyers. But I'm pretty sure such a market, with so many uncertainties, would quickly evolve similar panel-based fee setting for payers that after a period destruction, poor outcomes and massive bankruptcies of both buyers and sellers, you'd have arrived back at something very like the current U.S. model.

The RAND Insurance Experiment, which has been probably the most influential driver of the US health market for the last generation or so, actually had a version of fixed, banded pricing. It's often used to justify copays. But in the RAND experiement, the copays and fees were calculated on an income-based sliding scale. It found people in the lower tiers were more sensitive to being priced "out of the market" for needed procedures. So instituting a pure fee-based transparent system would seem to indicate that a significant portion of the population would reduce their health purchasing below an optimum level.

It may be that health care is simply not usefully amenable to pure market-based solutions such as discrete price atomization and a bid/ask exchange. It's simply too complex, too tied up with politics and culture, and too human. We have ample examples from dozens of industralized countries as to what kind of outcomes and costs different kinds of health care systems generate. One way of looking at the current politically led transformation of the U.S. system is that it's trying to push it from a from what looks like a Swiss fee-for-service model to something much more resembling a German capitation-weighted model and, in so doing, restrict the growth trajectory of the total GNP share over the next 20 years or so.
posted by meehawl at 6:48 PM on August 11, 2013 [2 favorites]


I had a class where the former CEO of one of the, if not the most powerful health care lobbying organization gave a speech on the state of the health care legislation, because he was the president when the ACA was being crafted. I approached him after class to ask him some more pointed political questions (who killed single payer, etc.).

He liked my knowledge of politics and opened up. We got to talking and eventually he said, "I don't know that I believe in conspiracies - but I have a sneaking suspicion that once it became obvious that single payer was not politically feasible, the democratic goal behind the ACA would become 'let's make something that's passable and if it works, that's great. But if it doesn't solve the fundamental problems, that's OK - because by that time the problems will be so large and the political climate different, that a single payer option will be on the table again, and the most attractive option by far when another round of reform happens (after 2020 at some point).'"

I am hopeful about certain aspects of Obamacare, but I think there is a good chance that the most lasting legacy of it will be the fact that it showed Washington that health care reform was something that could happen (it's been shot down many times before) - and thus it is politically feasible to try reform again, but with better results (single payer). It's unfortunate though, that the time period between now and this potential future reform will be a potentially painful one for millions of Americans.

Anyone that wants a better insight into why health reform is so difficult in this country should check out William and Carol Weissert's "Governing: The Politics of Health Policy."
posted by SouthCNorthNY at 6:55 PM on August 11, 2013 [4 favorites]


meehawl, the only reason it's sooo hard for us to list fees up front is because the overall system is broken to hell and back.
posted by Steely-eyed Missile Man at 8:04 PM on August 11, 2013 [1 favorite]


My uncle is a doctor. One of his daughters earned her MBA and got a job at his hospital. Guess who earned a higher salary.
posted by kat518 at 8:50 PM on August 11, 2013 [2 favorites]


Bad practices are covered up, doctors are shifted around or skip around themselves, and there aren't any decent systems to keep track of troubled physicians.

This American Life had an episode covering this.
posted by arcticseal at 1:41 AM on August 12, 2013 [2 favorites]


There was one case reported in an episode of This American Life, "More is Less" a couple years ago. For me it tied in so many different influences on care to show why health care has gone off the rails ...

A girl goes to the emergency room with a neck injury, and the doctor's diagnosis is that she is actually going to be fine. However, the girl's father insists that additional and expensive tests *must* be done in order to achieve the best care. However, in the doctor's opinion the test will do more harm than good. And this is where my jaw dropped. The doctor:
I said to him, you know, for me it really is the right thing to do the CAT scan. I said, you know, if I don't do the CAT scan, you're probably going to lodge a complaint about me. If I do the CAT scan, you're going to be really happy with me. I said, in addition, I'm almost certain that your daughter is fine. But there's maybe a one in a million chance that she isn't. That there really is a hidden fracture and I'm missing it. And if that's the case, the CAT scan will save my butt. And on the other hand, if I do the CAT scan and your daughter gets a cancer 20 years from now, no one will blame me. I said, in addition, I'm spending a lot of time talking to you here that I need to be going doing other things. If I get the CAT scan, I could do it in a second. It would be done with. It would be easy.

And I said, finally, the really strange thing is that I'll get paid more if I do the CAT scan. Because the way that bills are made, you get paid more for more complex patients. And the insurance companies of the world think that it proves that the patient was more complex and more difficult if you had to do a CAT scan. So everything about this was pushing me to do the CAT scan. I said that to him.

And I said, there's only one problem, which is that when I decided to become a doctor, I made a pledge. And the pledge was that I would put my patient's interest in front of my own interest. And in this case, my judgment was that it was not in my patient's interest to do the CAT scan. And therefore, I can't do it.
It has become noteworthy when care is declined, even when it's in the best interest of the patient. We're so stuck in this idea that higher prices indicate better care.
posted by cotterpin at 1:57 AM on August 12, 2013 [6 favorites]


We got to talking and eventually he said, "I don't know that I believe in conspiracies - but I have a sneaking suspicion that once it became obvious that single payer was not politically feasible, the democratic goal behind the ACA would become 'let's make something that's passable and if it works, that's great. But if it doesn't solve the fundamental problems, that's OK - because by that time the problems will be so large and the political climate different, that a single payer option will be on the table again, and the most attractive option by far when another round of reform happens (after 2020 at some point).'"

That makes perfect sense, not even as a conspiracy, but just as a political reality. You do the best you can given the roadblocks in your way, and hope for the best. If it doesn't work out, lessons will be learned and improvements can be made.

People made similar implications when George W Bush did the medicare prescription benefit plan. He believed government didn't work, so he was going to create something so ridiculous, expensive and complicated to PROVE government doesn't work. While getting credit for helping old people.
posted by gjc at 4:53 AM on August 12, 2013


So everything about this was pushing me to do the CAT scan. I said that to him.

And I said, there's only one problem, which is that when I decided to become a doctor, I made a pledge. And the pledge was that I would put my patient's interest in front of my own interest. And in this case, my judgment was that it was not in my patient's interest to do the CAT scan. And therefore, I can't do it.

And all of the intellectual work performed by the doctor to not order that CAT scan isn't compensated at all by insurance. The system literally rewards doctors for being lazy or stupid. That was an amazing quote from an amazing TAL. Every doctor is guilty of this -- see comments about production pressure above. When it comes down to it, after a 12 hour day, I would really rather just order the CAT scan than deal with the conflict and time of not ordering it, and then maybe I'll get to see my kids for 30 minutes before they go to bed.

An anecdote from this morning, as I am going through my phone messages:

56 year old comes to see me in April after an injury at home. After taking a careful history and physical, I tell him "you have herniated your c5/6 disk on the right side. You have about an 80% chance of spontaneous recovery in 6 weeks. There's no convincing evidence that anything can be done to speed this up or improve your odds but we usually try steroids and physical therapy and it seems to help." The guy thanks me for my time and opinion and takes my prescriptions. 2 weeks later the guy's at work (where he's a painter --he's uninsured and destitute and can't take time off despite weakness in his dominant arm) and his boss insists he goes to the ER because he's not performing his work duties well enough and goddamn, the doctors need to fix his worker. He goes to House of God Hospital where a PA hears his story, doesn't examine him, and he gets an immediate MRI of his neck, which confirms the diagnosis which could have been made by you know, touching and examining the patient. And guess what? The PA has no new treatments to offer the patient with this information so he gets referred to Downtown Spine Surgery Associates. He comes back to see me because Downtown Spine Surgery charges $600 for a new patient consultation. At this point, the six weeks i gave him for spontaneous recovery has elapsed so I do some finagling and get him a referral to County Hospital where he'll get covered under sliding scale.

This morning I get a message from County Hospital's Spine Clinic. His last MRI is now 6 weeks ago and before they see him, they need a complete set of new MRIs at their facility. Ordinarily, I would just order it because he needs to be seen and if that's what the specialist wants, fine. But his thread has inspired me. I think it's worth a phone call to discuss the incredible waste and immorailty of repeating work and expense and maybe you'd like to lay hands on the patient before you spend $3000 of tax money.
posted by Slarty Bartfast at 8:19 AM on August 12, 2013 [15 favorites]


gjc: "The downside is that in the Kaiser system, you are kind of stuck with what they offer. Evidence based medicine is great at keeping populations as healthy as possible, but it suffers a bit when you have outliers. A $20 copay is great, but if I need (or even prefer) a medication they don't approve of, I would have to get soaked for the retail cost, no?"

Kaiser's a weird one, because the lines between the "insurance" side and the "care" side of their business are blurred. (You can count me as a fan though. I'm thoroughly convinced that Kaiser's model is absolutely the only tenable path forward for healthcare in the US)

In my case, I was able to convince my doctor that I was effectively being treated by a prescription that was outside of Kaiser's formulary (it had been prescribed by a previous physician). As a result, the insurance picks up most of the tab, although it can occasionally be a pain to get Kaiser's pharmacy to process refills. Because my doctor was also a representative of the insurance company, this exception was made and processed entirely during my office visit, with virtually zero fuss.

On the other hand, I've had...less pleasant interactions with Kaiser's integrated model. Last year, my employer forced everyone onto a high-deductible HSA, where we suddenly became responsible for most non-catastrophic expenses. Like most healthcare providers, Kaiser is completely unequipped to adequately serve patients who are subjected to this pricing scheme.

Like most healthcare providers, getting Kaiser to supply upfront pricing information has been like pulling teeth, and my plan's negotiated "retail" prices are occasionally insane. Last month, I placed an order through Kaiser's retail pharmacy for some fairly ordinary prescription-strength acne cream. A few days later, the pharmacist calls me to say "Uh. We just put this into our computer, and for some reason, this is going to cost $400 under your plan. I know for a fact that you can walk into a CVS and buy this without insurance for about $10. For your sake, can I cancel this order?"

Frustrating, but my employers were also forcing Kaiser to adopt a pricing model that was extremely at odds with their normal business model. Their doctors and employees have always been eager to help me reduce my costs, while providing me with effective (if not necessarily the most convenient) care.
posted by schmod at 8:34 AM on August 12, 2013 [1 favorite]


The thing that gets me about every health care reform discussion is the approach from naysayers that we need to reinvent the wheel. All because it's called "socialized" in other countries and we can't be "social" here.

Changing a profit driven system's details so that the profits are made differently isn't going to do anything much.

My thought has been as someone else mentioned...this is just a first pass to get it palatable and the second try will be better.
posted by sio42 at 10:38 AM on August 12, 2013


It's only in the current US piecemeal system that we "can't" have a set price.

I'm late to the party, but I'd like to point out that my son's birth, here in the US, was a set price. Of course, I had a midwife and gave birth at a dedicated birth center, not a hospital, but everything was covered under the set price I was quoted, even when the midwife sent me to see an OB specialist to rule something out. They had a deal where the midwife practice has the OB bill her practice, not me.
posted by anastasiav at 10:57 AM on August 12, 2013 [2 favorites]


It's obvious from the successes of other countries that it's totally possible to design a better healthcare system. What's hard is fighting the various groups lobbying to keep it from changing, who really have no business interfering with the worthy goal of better healthcare for less. Doctors have some pretty valid struggles like education costs and malpractice, but those could be dealt with as part of a move to single payer and price controls. Make med school free or heavily subsidized and merit-based. Get rid of the stupid long shifts for residents. There's no reason for anyone to be working in a hospital more than 8 hours at a time other than some kind of sick macho hazing. Create a federal malpractice insurance program that takes away the fear of bankruptcy for an honest mistake.

On the last point, people feel adversarial towards doctors and hospitals largely because of the terrible design of the system, outrageous billing, etc. Doctors shouldn't be in the business of, well, business. They should provide medical care. They'd do a better job and have more rapport with patients and less likely to get sued in the first place because they'd be focusing on the work they were trained to do. We might get a different group of people in med schools but that might be a good thing.

As far as the folks who are raking it in (drug companies, medical supply companies, various consultants that exist because the system is so complex). I think those are reasonable casualties to get a better system.

On the billing stuff people are talking about upthread, I can't even think about it without wanting to go berserk. One visit, one bill, with rate tables available online. That should be the law. Tough to figure out? Tough shit; my job is hard too. This stuff where I get bills trickling in over time for one procedure has no logical reason for existing and needs to die. If "American Anesthesiologists" wants to have their little club, they can bill the freaking hospital to get their cut. Apparently though hospital administrations are too incompetent to handle this.
posted by freecellwizard at 12:18 PM on August 12, 2013 [2 favorites]


Why an MRI costs $1,080 in America and $280 in France

There is a simple reason health care in the United States costs more than it does anywhere else: The prices are higher.
posted by Golden Eternity at 6:20 PM on August 12, 2013 [1 favorite]


The healthcare industry will always be for profit...that MRI cost comparison is a great example of why the system will not change any time soon.
posted by Robert Batchelder at 11:29 AM on August 13, 2013


This. Thread. Cannot. Die. It must live on until the American health industry changes.

What can I do? I can write a letter to my local politician, but those usually get a canned "sure, we're doing everything we can" bullshit response. Anyway what do I say? I cannot say "Obamacare sucks" because in many ways it doesn't and many ways it does. All I know is that a significant amount of my family's income is going to this industry and year-over-year, we are seeing increased cost and lower coverage. Makes no sense. I am hoping that the bubble will burst and we will start seeing a true free market of insurance with lower cost and higher sensible benefits, and free preventative care options.

Are there any grass-roots movements or lobby groups that are not tied to the insurance industry that I can support?

How do I get Kaiser to come to my state? Do I need to move states just to get Kaiser care? This might actually be an option for me.
posted by Monkey0nCrack at 12:06 PM on August 13, 2013 [1 favorite]


[With Kaiser]...There are never any bills. You pay the co-pay (for me $20) to see the doctor, to buy any medicine, and even to get an operation (actually I think the copay for this is higher, maybe $100?).

This may be true for your particular plan, but it is not true for everyone. I have Kaiser, and the plan I have has a 6,000 dollar maximum out-of-pocket with a matching deductible. When I sliced the tendon in my pinky earlier this year and had two subsequent surgeries to try to fix it you'd better believe the bills kept coming until I was out of pocket exactly 6000 dollars. Not to mention that the two surgery bills were magically adjusted to come out to just that amount!

And no, my finger does not work nor ever will.

Also, Kaiser is terrible if you go to a non-Kaiser emergency room or urgent care clinic. It was never explained to me that if I had an emergency I better damn well go to Kaisers own emergency clinic or suffer the nightmare of getting into their system for follow-up care. Huge headache there.

That all being said, my experience with Kaiser was still superior to anything else I have experienced in the US system. My pre-op testing was all done in one building and due to the kaiser card I carried, all my information was available to the different departments on their computers. Computers linked to a database with your health information?! It's like Europe!

I don't love Kaiser by any means...and I have still been conditioned to avoid the doctor or ER as much as possible here in the US, but Kaisers model does seem like the only sane way forward short of single payer.

Unfortunately the best policy in the US is still "Don't get sick, and if you do, die quickly"

Sad.
posted by jnnla at 11:10 PM on August 13, 2013 [1 favorite]


I listened to the NPR show and there was one thing the guest didn't address that I would love to read more about, and that's the doctor's perspective.

In the last year, two of my doctors have decided to stop accepting insurance and exclusively practice through private pay. One of these doctors was my therapist, who said she made the difficult decision to no longer accept insurance for several reasons: 1) the insurance companies were increasingly asking her to provide detailed treatment notes on her patients that she felt compromised her ethically, 2) the paperwork and phone calls required to get timely payment on claims was an increasing nightmare for her staff (she said one insurer hadn't paid its claims on several of her patients for over a year), 3) the amount of claims paid by insurance companies kept going down year by year.

As a patient of both these doctors, my initial reaction each time was anger at them. Anger at what I perceived as greed and a missing sense of fairness. But I know, for my therapist at least, that it was a very difficult decision that ultimately came down to the quality of her work life.

So, I guess what I'd like to hear more about is how doctors feel about the current insurance industry. Is it possible to make a decent living as a doctor and still accept insurance? How do doctors fit into this whole equation of profit margins and price-setting?
posted by megancita at 1:12 PM on August 14, 2013


Health insurance CO-OPs gear up
“[W]hat a historic opportunity it is to inject into the marketplace a member-governed, nonprofit health carrier that is building from the ground up, writing from a blank slate,” said John Morrison, a former Montana insurance commissioner and president of the National Alliance of State Health CO-OPs. “It’s exciting.”
posted by Golden Eternity at 8:15 PM on August 14, 2013 [1 favorite]


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