[HN Gopher] Open-source hospital price transparency
___________________________________________________________________
Open-source hospital price transparency
Author : sl-dolt
Score : 378 points
Date : 2022-12-06 16:20 UTC (6 hours ago)
(HTM) web link (www.dolthub.com)
(TXT) w3m dump (www.dolthub.com)
| [deleted]
| car wrote:
| I would suggest to now compare the prices for standard procedures
| in the US to the GOA[0,1], which is the German central medical
| fee list for anything medical as agreed between doctors and
| insurance companies.
|
| Hilarity will ensue, since US pricing is an unbelievable rip-off.
|
| Edit: In addition to procedures, there is a list for fixed drug
| cost [2]. The site hosts a PDF with pricing for any drug.
|
| [0]https://de.wikipedia.org/wiki/Gebuhrenordnung_fur_Arzte
|
| [1]https://www.ottonova.de/en/expat-guide/health-
| wiki/medical-f...
|
| [2]https://www.bfarm.de/EN/Medicinal-products/Information-on-
| me...
| ElijahLynn wrote:
| Direct link to the hospital price database >
| https://www.dolthub.com/repositories/onefact/paylesshealth
| timsehn wrote:
| This is just a database of hospital price URLs. If you want
| actual prices we have that as well but it's from the beginning
| of the year:
|
| https://www.dolthub.com/repositories/dolthub/hospital-price-...
| ryanfreeborn wrote:
| Tangentially related, Russ Roberts of econtalk had a good
| interview a few years ago with the founder of a free market
| hospital in Oklahoma. Super interesting.
|
| https://www.econtalk.org/keith-smith-on-free-market-health-c...
| EamonnMR wrote:
| I really wanted to build something like this but never found the
| time. The challenge was ETL-ing all of the data provided by
| hospitals.
| einpoklum wrote:
| While I'm sure the transparency is a good idea, I'm guessing is
| only important because US hospitals mostly charge individuals
| rather than health insurance providers / healthcare provider
| organizations ("sick funds") - and thus people are surprised by
| exorbitant fees and hospitals have a motivation to overcharge,
| rather than the fees being negotiated and agreed in bulk.
| lotsofpulp wrote:
| >I'm guessing is only important because US hospitals mostly
| charge individuals rather than health insurance providers /
| healthcare provider organizations ("sick funds")
|
| No, they charge the insurance, but US healthcare providers are
| still required to show individuals the billing details.
|
| This is important because people still pay for amounts up to
| their deductible and out of pocket maximum, so for non
| emergency healthcare, a patient still has incentive to compare
| healthcare prices from different providers.
| einpoklum wrote:
| > This is important because people still pay for amounts up
| to their deductible and out of pocket maximum
|
| In many world states, if you have health insurance, and are
| referred to hospitalization, or come in with a wound or other
| obviously serious condition, your deductible/out-of-pocket
| for being in the hospital is exactly 0. Israel is in this
| category for example. This doesn't cover 100% of hospitals
| but all the big ones and your "sick fund"'s hospital-grade
| facilities.
|
| In other countries (e.g. the Netherlands), a lot of health
| care expenses are charged through to you from the get-go, but
| - your annual out-of-pocket maximum is low, e.g. 500 EUR or
| 700 EUR or something like that (EUR ~= 1.05 USD right now,
| was higher when I was in the Netherlands). So, you might be
| interested in what hospitals charge, but it's not like you
| would save all that much anyway.
| manv1 wrote:
| A discussion of healthcare pricing would take hours, but here's
| a TL;DR:
|
| Most insurers pay negotiated rates, which have no real
| relationship to list price (uninsured pricing). The law is
| supposed to (1) make it easier to compare costs, and (2) shame
| providers into lowering their list prices.
|
| Obviously the industry has been fighting these regulations for
| years.
|
| The annoying thing is al the games they're playing. Everyone
| already has a list of prices by CPT code, because it's what
| billing uses. Just list all prices by CPT codes. The industry
| refuses.
| einpoklum wrote:
| And IIRC, the insurers are for-profit, right?
|
| What about the hospitals? Are they mostly for-profit or non-
| profit entities?
| yamtaddle wrote:
| Perhaps confusingly, they charge both. Most insurance requires
| substantial "co-pays" where you pay a good chunk (20% is
| common, but it varies, often even within a plan depending on
| what you're paying for) of just about every bill until you hit
| some very-high "out-of-pocket max" (usually there's one for
| individuals, and a higher one for families) and then insurance
| picks up everything, _or_ you pay 100% until some total-
| spending value for the year is reached, then it becomes like
| the prior situation until the out-of-pocket max.
|
| Though most insured people don't really have options to shop
| around. You go to the few places your insurance covers, which
| is usually 30-60% of providers in a small geographic area.
| Which is why the "we want to protect your choice!" opposition
| to healthcare reform is so damn weird. Most people already have
| very little choice, in practice, and a lot of the "choice" we
| do have isn't anything desirable ("which of these shitty
| insurance plans I can barely understand and am not confident I
| can meaningfully compare, would I like to suffer through?").
| insane_dreamer wrote:
| Hospitals charge insurers negotiated prices. So these prices
| mostly impact:
|
| - what insured persons pay until they reach their deductible
| (and how high that is depends on the insurance plan they have,
| cheaper plans have higher deductibles)
|
| - uninsured persons
| insane_dreamer wrote:
| Important work. Thanks to those working on this.
| danesparza wrote:
| I'm confused. Is this already a searchable database? Or is this
| in the 'data gathering' phase?
| culi wrote:
| Seems like this is the actual db, but the only table I see is
| "hospitols" which just has the websites and... a link to
| `cdm_source` which seems to be the pricing info for each
| hospital
|
| Not sure what they mean by "bounty"
|
| > This bounty will be run in 5 parts of 1 week each
|
| Is this some sort of crowd-sourced effort? Like GasBuddy but
| for hospitals? Their GitHub also some "example" apps with
| React, Lit, and Next
|
| https://github.com/onefact/payless.health/tree/main/examples
|
| I guess I should try building one of these examples first
| culi wrote:
| Funny that they obviously have the resources for making
| example apps in multiple frameworks but all their main
| websites are just the MarkDoc template with different text
| haha
| kingsloi wrote:
| Great idea!
|
| I'm working on something similar, digitising my daughter's 213
| pages of medical bills by building an app specifically for
| digitising printed medical bills.
| https://kingsley.sh/posts/2022/digitising-213-pages-of-medic...
|
| Everyone kept saying "make sure to check your statements", but
| when the statements came, they're 9pt font, 50-70 line items per
| page. 1 page, yes, 10, maybe, 213 is impossible.
|
| In the middle of working on it last week, I got a $3000 medical
| bill, for my daughter who passed away 1.5+ years ago, for part of
| her 7 month ICU stay 2+ years ago.
| supernova87a wrote:
| Just like the problems with pay transparency / publishing in job
| listings, what good is the publishing of hospital costs, if they
| inflate the rack rate prices to handle people who walk in without
| insurance, but discount everyone else to the Medicare rates? It
| doesn't give you any real comparable reference point between
| hospitals, does it?
|
| As an example, you get a bill for $100k for a one-night hospital
| visit for an emergency, but it gets knocked down to $15,000 at
| Medicare reimbursement rates, and then you only pay $1,000. Which
| price should be shown? It is any use to show the $100k figure?
|
| Or am I missing something that has changed? I mean, I'm all for
| these efforts but if there is no consistency / meaning behind the
| numbers being used, it's no good.
| jaan wrote:
| You're right! We're linking this data to the negiotated rates
| :) and building the search engine for both of these at
| payless.health.
| bumby wrote:
| This is cool and, I believe, a necessary step.
|
| I know that some hospital price data has been previously
| available for years on govt websites listed by billing code. You
| could, for example, see the price differential between getting a
| procedure done in Alabama vs. Oregon. This article states that
| hospital data was only available after 2019. Is the distinction
| that the previous data was only based on Medicare/Medicaid
| reimbursements? Or that they weren't itemized lists?
| wswope wrote:
| Sounds like you're talking about Medicare rates. A lot of
| hospitals and payors use them as the basis for their price
| lists, but unless you're an actual Medicare patient it's
| probably not what you're actually paying.
|
| This data is collected from hospital "chargemasters" - which
| lay out the maximum amount a hospital will charge for a given
| procedure. However, hospitals have negotiated rates with payors
| that are almost always less than the chargemaster rate and are
| kept private.
|
| As a broad generalization, you can think of Medicare prices as
| the minimum a hospital will normally charge, and the
| chargemaster rate as a legally-enforced maximum.
| ww520 wrote:
| This is amazing work. All hospital pricing should be public and
| transparent.
| killjoywashere wrote:
| This law was insanely helpful for my wife as she tried to
| establish pricing for her own small business. Going from a drone
| to your own boss, it's hard to wrap your head around how much
| more you should be charging. It's a lot. Like, multiples.
| jrd259 wrote:
| Now what is needed to get data on outcomes as well? I would
| likely choose to pay more for a increased chance of success.
| (Recall the recent coverage in HN of the professional musician
| for whom retaining ability to play saxophone was of great
| importance.) I recognize that some hospitals either serve more
| impaired populations or take on more high risk cases, so the
| comparison is not at all easy.
| jaan wrote:
| Yes! We are working on this and integrating with the OMOP
| common data model, to be able to link the health outcomes in
| our data partners' clinical repositories to the cost of care.
| For example, we work with the NIH All of Us study for outcome
| data (joinallofus.org -- I signed up both to contribute to this
| science and to get my whole genome sequenced free!)
| jordanmorgan10 wrote:
| My first job out of college was creating long term facility
| software, like Epic if you're familiar with that world.
|
| After my second or third major project to support ICD-10 codes, I
| knew this was an industry I really didn't want to create software
| for, but also that it was an industry that definitely could use
| some quality solutions.
| erex78 wrote:
| "it was an industry that definitely could use some quality
| solutions."
|
| >> Check us out! augusthealth.com
| raiyu wrote:
| The reality of is that for profit insurance companies want an
| opaque and high pricing structure. This allows them to charge
| higher premiums across their entire set of customers meanwhile
| the number of people that are getting seriously sick or injured
| is small allowing them to create huge profits.
|
| So these higher prices, create higher premiums, which create
| higher profit, so there is no actual incentive for the insurance
| companies to get hospital prices down because the majority of
| their insured users are not going to be getting massive bills
| throughout the year and also they can still litigate or pass
| healthcare costs back to the customer due to coverage issues and
| let's not forget deductibles.
| atourgates wrote:
| This seems very cool.
|
| But, at the risk of seeming extra dumb: is there a way to
| contribute to this project for people who don't know how to work
| with SQL?
| tomrod wrote:
| I've seen dolthub's work progress in this space from afar --
| they are solving a hard problem!
|
| One of the most frustrating things is that insurance companies
| seem to push for strategic bitrot, making it difficult to
| programmatically or frequently collect the information from a
| large group of payors.
| htrp wrote:
| obtuse data pipelines are a strategy..... if the government
| forces you to make something available, it doesn't
| necessarily have to be easy to get
| zachmu wrote:
| Sure, SQL knowledge is helpful but optional.
|
| There are ways to import CSV or other flat files, either on the
| command line or on dolthub. You just need to make your file's
| schema match the table's.
| hahamrfunnyguy wrote:
| Thank you for doing this. It's good to know that this information
| is publicly available. I was not aware of the 2019 legislation
| and it would be helpful to know what the name of the law is.
|
| I went to urgent care back in 2021 to have a few different tests
| run, pretty standard stuff. I asked for a price quote and they
| refused to give it to me. There is no other industry where sleazy
| practices like this are accepted.
| TedDoesntTalk wrote:
| Why is AI necessarily for this?
|
| > One Fact to feed these files into their artificial intelligence
| pipeline and figure out how much hospitals charge for different
| procedures
| culi wrote:
| It seems like their database[0] has a column for the `cdm_url`
| of all of these hospitals. The challenge is like being able to
| read all these HTML, PDF, XLXS, CSV, etc pages of very
| different formats and turn them into usable data
|
| Just my guess
|
| [0]
| https://www.dolthub.com/repositories/onefact/paylesshealth/d...
| jaan wrote:
| Nailed it! :)
| jaan wrote:
| If you look at the files, many of them are not compliant, and
| so we need to figure out what the associated line item
| corresponds to: a CPT code? HCPCS code? ICD code? etc :)
|
| Here's an example NLP tool I helped build we're using to do
| this: https://arxiv.org/abs/1904.05342 -- it's in several
| pipelines now for data annotation and crowdsourcing.
| duffpkg wrote:
| I wrote Hacking Healthcare for O'Reilly and I've spent the bulk
| of my career as a CEO and senior executive operating large health
| systems. It is a meaningful step forward to have most of this
| data in the public sphere but I think it is still early and that
| a lot of work has to continue to shape and analyze this
| information in a way that is more meaningful and practical for
| patients.
|
| Appreciate the complexity of billing codes, these are not created
| by hospitals but by by the American Medical Association, Center
| for Medicaid/Medicare and a soup of other organizations. There
| are tens of thousands of procedure and drug codes (things that
| are done or given) and tens of thousands of diagnostic codes
| (reasons justifying the procedure), creating a space well into
| the quadrillions of possible routine combinations. That's a large
| restaurant menu.
|
| There are a number of other comments comparing hospital pricing
| to retail type interactions. It is also important to consider
| that hospital interactions involve unexpected and unknown things
| that aren't easily captured in a pricing context before you get
| there.
|
| From an instution standpoint there are some bad apples but a lot
| of organizations that are not complying are not complying because
| they are facing technology and operational issues that are
| stopping them from complying. From the trenches in my consulting
| practice one example is an institution whose has a core element
| of their billing system, that is largely a black box even to
| them, using technologies that are decades old. Why would someone
| continue to rely on that? Because it has direct integration with
| critical partners and counterparties that was set up decades ago
| and that continues to work.
|
| Replacing it is underway but is costing 8 figures and taking
| years. The potential fines are small relative to that and there
| isn't much they can do to comply in the immediate term anyway.
|
| For context understand that Medicare billing routinely involved
| actual physical dial-up modems somewhere in the chain (even if it
| was invisible to you) until late 2018.
| tinglymintyfrsh wrote:
| Outside of elective surgical realms, I've also seen and heard
| of trends of expensive non-treatment treatments that prolong
| misery. Take orthopedics with routine cortisone and/or
| hyaluronic acid injections: delaying the "inevitable" and
| sometimes hurrying it along.
|
| Then there's the outright Medicare fraud of orthotics, braces,
| and all sorts of overpriced, shoddy paraphernalia that's mostly
| concerned with coding (billing) rather than patient comfort or
| wellbeing.
| boplicity wrote:
| > Appreciate the complexity of billing codes, these are not
| created by hospitals but by by the American Medical
| Association, Center for Medicaid/Medicare and a soup of other
| organizations.
|
| Indeed. This "complexity" hides so many obvious scams.
| Errr...well, rather, it sometimes hides these scams. For
| example, they billed my wife for an "ER Visit" when she gave
| birth. Even though the ER was in another building. (Well,
| except for a little sign that said "ER" over the door to the
| admitting room. We spent 5 minutes in that room, but it
| resulted in a multi thousand dollar bill.)
|
| This happens regularly and intentionally.
|
| Sure, there's the unexpected things that happen. But, the
| complexity of billing lets the experts (hospital
| administrators) deceptively game the system, and get away with
| it without any recourse. Enough things happen on a recurring
| basis that its shockingly easy for them to create "policies"
| about what to code and when to code -- policies explicitly
| designed to maximize revenue. (Even if they're stretching the
| truth.)
| temporallobe wrote:
| > This happens regularly and intentionally.
|
| And there are absolutely zero consequences for this, which is
| why it will never stop. It's not even negligence, it's
| straight up fraud; and if you refuse to pay, your credit can
| be ruined, so in effect you're being intimidated and coerced
| into just paying it "or else". I sure wish _I_ had the power
| to send someone a bill for non-existent goods or services and
| that it could be legally backed by governments and
| corporations.
| manv1 wrote:
| Realistically speaking, this is bullshit. Billing has all the
| data that's required for implementation. The fact that most
| health systems don't want to publish that data is a reflection
| of the nature negotiated rates and not a technical problem.
| prepend wrote:
| > From an instution standpoint there are some bad apples but a
| lot of organizations that are not complying are not complying
| because they are facing technology and operational issues that
| are stopping them from complying. From the trenches in my
| consulting practice one example is an institution whose has a
| core element of their billing system, that is largely a black
| box even to them, using technologies that are decades old.
|
| I recognize this is the reality. But it seems insane that they
| have not fixed this in decades and instead charge people based
| on a "black box."
|
| I'm sure the fact that they make more money this way has
| nothing to do with their inability to comply.
|
| From my perspective, as a patient and taxpayer who funds these
| things through Medicare and Medicaid, I think those who are
| incompetent and shady are the same to me.
|
| I'd almost rather have a health system try to cheat than so
| stupid they don't know what's happening. The company that
| cheats on billing seems more likely to be competent than the
| one who doesn't know how to cost their care and hasn't known
| for decades.
| mistermann wrote:
| It seems like a classic "just so" story to me, perfect for
| keeping the public in the dark. I'd think a serious and
| honest country would develop standard systems that is capable
| of serving the needs of the majority of users (providers and
| customers) and then charge proportionally for usage, or else
| just leave it as funded by the government.
| maxerickson wrote:
| If it's a Medicare requirement that routine combinations be
| billed a certain way, how is it complicated?
|
| Or is the idea that routine combinations are always used to
| justify the billing code with the highest possible revenue?
|
| I was pretty pissed off when the local ER and traveling doctor
| used the CT scan I got to justify a more complicated case, when
| what happened is that the radiologist made a definitive
| diagnosis for $20 and basically eliminated any liability for
| sending me home with a prescription for antibiotics.
|
| (a sinus infection irritated the nerves in one of my teeth and
| I became concerned about the degree of pain during the night on
| a weekend...not a particularly grave condition in the end, but
| easy enough to become concerned about pain radiating through
| your jaw)
| ghufran_syed wrote:
| doesn't the fact that the CT scan was ordered make it a more
| complicated case? vs one that involved no testing?
| heywire wrote:
| What are your thoughts on insurance companies like Surest (now
| owned by UHC, formerly named Bind), who hide this complexity
| behind a single all-in copay amount with no surprise billing
| and no deductible?
|
| My employer offered this plan during open enrollment this year
| and I've decided to give it a try after a few years of getting
| burned on our HDHP with HSA.
| freedomben wrote:
| Why don't we see some doctors opting out and just doing away
| with all that stuff? I.e. refuse all insurance and just bill
| for their time (and supplies)?
|
| I would expect the majority to continue with the current
| system, but it surprises me that (if it's not about money but
| rather is about complexity) there aren't doctors opting out.
| duffpkg wrote:
| There are. In fact this is a quickly growing segment. Often
| these folks cater to richer patients and are called
| "Concierge Doctors". Atlas MD in Kansas is a very interesting
| system aimed at all levels of income and they call it "Direct
| Primary Care".
| tryptophan wrote:
| If the gov takes 1k in and another 1k goes to insurance
| companies, it kinda hard to get people to pay 1k(say a Dr
| offers a service outside both the gov and insurance) to do
| whatever when they have already paid 2k and gotten nothing.
| This is despite that just dealing directly with the dr is a
| 50% discount...
| tomrod wrote:
| High opex. Most doctors are also joining provider networks
| and are somewhat shielded from the ever increasing
| complexity.
| helpfulclippy wrote:
| They are. They call it direct primary care. I pay my doctor a
| flat monthly rate, on top of whatever the price is for any
| supplies. No insurance accepted.
| devilbunny wrote:
| Outside of that DPC model others mention, it's very difficult
| for doctors to do.
|
| And while most people think of going to a doctor's office -
| family medicine, internal medicine, pediatrics, or OB/GYN -
| as what doctors do, they're actually a minority of doctors,
| and OB/GYN's do a lot of their work in the hospital. Some of
| us - I'm an anesthesiologist, but also radiologists,
| pathologists, critical care doctors, and so forth - don't
| _have_ a clinic at all. Nobody 's going to pay me a monthly
| or yearly fee, and establishing a billing relationship that
| doesn't involve insurance would be a real nightmare.
| billiam wrote:
| >From an instution standpoint there are some bad apples but....
|
| He makes it easy to tell where he is coming from by using the
| straw man for all apologists for system failure, those pesky
| few bad apples.
|
| Fortunately he also states clearly the main problem with a
| healthcare system run in a semi-corrupt, neoliberal developed
| country (think aging population):
|
| >I've spent the bulk of my career as a CEO and senior executive
| operating large health systems.
| alfalfasprout wrote:
| While it's great that you've been working in the space for a
| while, this comment does smell of "hand wringing" of the
| problem as "too complex to solve".
|
| At the end of the day, people just want a "good enough"
| estimate of what a hospital visit will cost in the typical case
| for their reason for visiting the hospital. In the event
| there's variability, that's fine. Just surface that. Knowing
| several doctors who have seen what has actually been charged
| for their patients... the vast majority of procedures aren't
| going to have wild variability for most patients.
|
| Let's look at one common issue that people face: they get
| charged $400 for a pill of ibuprofen or $2k for a bag of saline
| with no meds. Even exposing consumable prices is a step in the
| right direction.
| duffpkg wrote:
| I am in agreement that it is reasonable for most patients
| most of the time to be able to receive some sort of useful
| estimate to make decisions with. The passage of the "No
| Surprises Act" was a very positive development in my opinion.
| https://www.cms.gov/nosurprises
| dools wrote:
| Imagine if the government just paid for healthcare!
| paws wrote:
| Thanks for sharing! Billing codes certainly seem like a
| significant source of complexity. Another area that seems
| problematic to me is an apparent surfeit of middlemen.
|
| What conclusions might we draw from the fact e.g. a "Pharmacy
| Benefit Manager" is a job that exists only in the US [0]? Why
| does it feel like my insurance premiums pay for lots of things
| that are difficult to attribute to actual improved health
| outcomes?
|
| Appreciate your insight.
|
| [0] https://www.goerie.com/story/opinion/2021/06/12/op-ed-
| when-c...
| duffpkg wrote:
| Something that is very little known to most lay people but
| has profound implications on how the industry is structured
| are laws loosely called "Corporate Practice of Medicine"
| (CPOM). A little more than half the states have some version
| of them. Simply put they require that the organization
| legally practicing medicine must be owned and operated by
| people holding medical licenses only. This defacto creates a
| medical entity for that purpose and a sistered non-medical
| entity for business operations. Not speaking to the broader
| reasons of why those laws can potentially be good, the
| practical result of those laws all but requires many "middle
| men" in the operation of medical organizations.
| paws wrote:
| TIL about CPOM, thanks!
|
| Another question I'm curious about, if you don't mind, is
| why there is no apparent urgency in fixing the painful
| billing experience for patients. (aka "why don't billing
| coordinators seem to coordinate with the patient front and
| center?") Seems like lots of people are fearful of medical
| billing, and not only because it's expensive.
|
| I realize providers may be out of network, carriers take
| time to adjust claims, etc. Still, the staggered/surprise
| billing seems unique to medicine and a 2nd order effect
| might be people avoiding preventive care to their own
| detriment.
|
| Say a patient goes to get some procedure done, the medical
| work is completed in one day. Shortly afterwards they
| receive bill A. OK, that's fine. But then X months later,
| they receive bill B with more charges from some provider
| that they may not even remember.
|
| I thought avoiding that was supposed to be the job of a
| billing coordinator. Presumably coordinators are
| constrained by "things" -- what are the factors that make
| this experience so dreadful for patients and why are they
| not being changed?
| duffpkg wrote:
| I'm not sure the short answer is adequate but a few
| things:
|
| 1) US healthcare is absolutely huge, it's perhaps 20% of
| the total macro economy. Changing anything in 20% of the
| entire economy is going to take a long time.
|
| 2) There has been really significant changes regarding
| price transparency and "surprise" billing in the past 5
| years, so there is momentum to improve the patient
| experience but see #1
|
| 3) Regarding hospitals, many hospitals might appear to be
| one thing but are not (some systems are fully vertically
| integrated). They are much more like medical malls, often
| as a result of CPOM. What you percieve as one thing
| actually involved dozens of different business entities
| and hence very discoordinated billing.
| jsmith45 wrote:
| Its not immediately clear to my why such laws should
| require crazy corporate structures with many middlemen when
| there exists similar rules that law firms can only be owned
| by lawyers, and they almost always just have a fairly
| straightforward partnership scheme for their firms.
| soitgoes511 wrote:
| I hope this succeeds. My daughter was born with many medical
| issues and understanding the billing was always near impossible.
| Nothing could be gleaned from the bills which would arrive 6
| months to a year later (sometimes 2 years) from the insurance
| company. In what world can I not know the price of something
| before hand? If I go to a restaurant and see hamburgers cost
| 6000$, I wouldn't buy one. But with medical it is always a
| surprise.
| duffpkg wrote:
| I hope your daughter is doing well now. I wrote Hacking
| Healthcare for O'Reilly, yada, yada. If you still have these
| bills and would consent to sharing them with me they may make a
| good example to share publicly (redacting any private info) to
| help explain what happened, what's there and why.
|
| You can email me at du@50km.com .
| soitgoes511 wrote:
| Thank you for asking. She is 24 hour ventilator dependent
| (spina bifida, chiari malformation, etc.. etc..). She just
| celebrated her 5th birthday last month. My wife and I hope
| she will be able to breath on her own someday too. As for
| bills, I would be shocked if I could not find any as we have
| piles of them. We have relocated to France, but had no
| outstanding balances before leaving. I have noted your email
| and will check our files for bills this weekend. I have
| absolutely no problem sharing them. Anything to bring light
| to the insanity and opaqueness of the US medical system.
| mwerd wrote:
| Because the price you pay is determined by your diagnosis at
| discharge, which is a medicare concept that all health
| insurance plans adopted and follow. If healthcare, as an
| industry, could tell you what the price was upfront, then they
| could also tell you what was wrong with you before you were
| examined.
|
| It would be nice to suspend reality and solve problems with
| magic, but until then, we would do well to consider
| https://fs.blog/chestertons-fence/
| throwup wrote:
| Why can't they at least give you an estimate like every other
| industry?
|
| If you take your car to a mechanic, they might charge $100 up
| front to diagnose the problem and then estimate another $1200
| to replace your transmission. At that point, you either say
| go ahead and agree to the price, or say no and get your car
| back and take it somewhere else.
|
| That seems fair for everyone involved.
| lotsofpulp wrote:
| As of Jan 1, 2022, US healthcare providers are required to
| provide good faith estimates, and the final bill can only
| be $400 more than the estimate:
|
| https://www.hhs.gov/guidance/sites/default/files/hhs-
| guidanc...
|
| https://www.hhs.gov/guidance/document/guidance-good-faith-
| es...
|
| When I went for my annual wellness exam, the doctor's
| office had me acknowledge that my wellness exam would cost
| $350 or something in the event insurance did not pay for
| it, and there were posters up informing people that they
| have a right to ask for a good faith estimate.
| lcnPylGDnU4H9OF wrote:
| I think that's going to be true of many things but there seem
| to be at least some things for which pricing can be listed. I
| had to get an x-ray of my arm recently and there was
| absolutely no pricing to see whatsoever.
|
| Regardless of the pricing model being per image, time-based
| for the radiologist, or whatever else, it was simply not
| available to the person spending the money. Even if it's a
| different model everywhere you go, it is a near-constant that
| the consumer does not get to see it.
|
| (I do agree with the points you bring up otherwise!)
| hn_throwaway_99 wrote:
| > It would be nice to suspend reality and solve problems with
| magic
|
| I would be careful about being this condescending when there
| is so much about your post that ignores critical problems
| regarding the complete lack of price transparency in US
| healthcare.
|
| All of the following are extremely difficult if not
| impossible at the moment in the US:
|
| 1. Get an explanation of how one product, e.g. something as
| simple as a bag of saline, can have wildly different and
| grossly outrageous costs.
|
| 2. A hospital may not know what your final diagnosis may be
| when you first show up, but literally every other industry I
| know of is able to give you reasonable estimates, and
| possibilities for different outcomes. Trying to get these in
| US healthcare is like pulling teeth.
|
| 3. There are few other industries that I can think of that
| require you to essentially write a blank check when you first
| step in the door. There have been many widely reported horror
| stories of patients, who had good health insurance, went in
| for surgery, _and then unbeknownst to them while they were
| under anesthesia_ , had another "out of network" doctor come
| in to "consult", often for just a few minutes, and then added
| tens of thousands to the patient's bill. This is obscene and
| abusive.
|
| Portraying people who demand sane transparency and at least a
| reasonable level of consistency in pricing as wanting to
| "solve problems with magic" is asinine.
| nonameiguess wrote:
| Exactly 3 happened to me, but thankfully the provider just
| dropped the charge and I never had to pay. I had a nerve
| transplacement surgery in my elbow and wrist, and
| apparently some neurologist called into a video conference
| for ten minutes from the east coast and tried to charge
| $14,000 for that, and my insurance said no way.
|
| Honestly, I might have even consented to it, considering
| they gave me like 10 forms to sign as I was already in the
| gurney with an IV in my arm and the anesthesia drip had
| already started.
| bilsbie wrote:
| Yet car mechanics give us prices all the time.
| GrinningFool wrote:
| > It would be nice to suspend reality and solve problems with
| magic, but until then, we would do well to consider
| https://fs.blog/chestertons-fence/
|
| This seems disingenuous. Yes, there are times when you don't
| know what's wrong, and this all gets uncovered along the way.
| I don't think that's what is being discussed here.
|
| There are plenty of times when you do and the situation is
| the same. When dealing with some medical issues for my son,
| we had a diagnoses more or less right away - everybody knew
| what we were dealing with. The process we were following (and
| follow up treatment) was well established - everyone was able
| to tell us what was going to happen next, out to weeks (or
| even years) in advance.
|
| Yet the bills still kept rolling in for months after the
| fact, and certainly nobody was able to tell us up front what
| all of these known treatments would cost.
| mwerd wrote:
| I can't imagine the stress of having a loved one,
| especially a child, in a life threatening state. Adding
| byzantine medical documentation, coding, billing, and
| collections on top is certainly insult to injury. As a
| patient and consumer, we just really shouldn't have to
| care.
|
| If your daughter's treatment had complications, such as a
| hospital acquired condition and/or sepsis during treatment,
| her diagnosis at discharge may change. That would change
| the cost. It's not disingenuous to say that you don't know
| what a final claim will say until all of this complexity is
| adjudicated. The existing billing system exists for good
| reasons. I am not particularly in favor of them, but there
| are real constraints that must be considered before we can
| improve. I think the burden on clinicians is unreasonably
| high and the regulations, driven by Medicare, are so
| complex that they require an army of clerical staff to
| navigate. That's the reality of the situation and if the
| cost and customer experience of healthcare matters to you,
| I believe you need to confront that reality instead of
| dismissing it.
|
| edit: changed son to daughter, my mistake.
| nostrebored wrote:
| But this is _not the case_ in other countries. In South
| Africa, if you go into a private ER, there are buckets of
| severity and a clear price tag. If they are going to do
| something to you that might change the price at
| discharge, they will tell you. If you have a discrete
| problem like 'my ear hurts and I want to go to an ENT
| doctor' then they tell you what the price will be
| upfront.
|
| It does not have to be a gigantic mess. Being back in the
| US, I just went to the ER and it was shocking being
| discharged and not being able to know what I owe.
| yamtaddle wrote:
| > It does not have to be a gigantic mess. Being back in
| the US, I just went to the ER and it was shocking being
| discharged and not being able to know what I owe.
|
| One of the outright-grossest things about US ERs is they
| have dedicated vulture-like staff wandering around to
| extract billing information from the sick, injured, and
| distraught, but those folks can't even tell you anything
| about what it's going to cost (and neither can anyone
| else).
| GrinningFool wrote:
| I agree to a point. Complications come up in treatment,
| and of course nobody can know those ahead of time.
| However I called out your comment as disingenuous because
| it added a lot of variables to what was originally
| described, then more or less said "Well, of course we
| can't know what the cost will be ahead of time."
|
| So let's take it as a given that because we're not
| prescient, it is not possible to give a 100% guaranteed-
| accurate price up front[1].
|
| Even in the presence of those variables, the system
| should not prevent providers from saying "here's what we
| normally have to do in this case, and here's what those
| procedures should cost. Less often, we run into these
| other things - we'll get into them if we need to, but the
| cost for those can range from _ to _. Of this, your
| insurance plan will _usually_ cover $_ to $_."
|
| I'm not dismissing the history behind the brokenness, but
| that doesn't mean it's not broken. The fact that it's
| broken for complicated reasons doesn't mean it can't be
| made significantly better.
|
| I'd like to understand, but nobody is really explaining.
| "Regulations are expensive to comply with" doesn't really
| explain why those costs can't be predicted and
| incorporated into the up-front pricing. On the other
| hand, different prices for different payers seems like
| something that would add a lot of unpredictability to
| pricing.
|
| [1] though this doesn't explain why prices aren't
| disclosed for common, fixed procedures - diagnostics,
| removing a mole and having it biopsied, etc.
| Hermitian909 wrote:
| My understanding is that often times procedure costs vary
| wildly even while following well established tracks. e.g.
| surgeries some surgeries take between 2-4 hours with time
| not easily determinable before it begins. Consultations can
| take varying amounts of time, cost of materials may vary
| significantly over a two month timespan etc. The latter
| issue can be hard to keep down compared to other businesses
| because waiting may be fatal.
|
| None of this is to imply the current system is desirable,
| but that price inconsistency is something all healthcare
| systems will need to contend with.
| nradov wrote:
| Surgeons don't generally bill by the hour. The charges
| allowed by payers are based mostly on procedure
| complexity rather than the number of hours that a
| particular case ends up taking.
| AuryGlenz wrote:
| Sure, but the same is also true when I hire a plumber.
| They can still at least give me an estimate.
|
| Also, an MRI, mole removal, sleep study, etc. should
| always be the same but you still will have a hell of a
| time getting a price for it.
| yamtaddle wrote:
| With a plumber you have 100 options and can just reject
| any who refuse to give you an estimate.
|
| With healthcare providers, your insurance only covers 3
| in your area, and they _all_ refuse to give estimates of
| any kind (and usually act like you 're a huge asshole for
| even asking, and like you're the first person in the
| history of the universe to ever ask).
| nradov wrote:
| In certain circumstances, healthcare providers are
| legally required to give you a good faith estimate of
| expected charges.
|
| https://www.cms.gov/nosurprises/consumers/understanding-
| cost...
| geerlingguy wrote:
| Alternatively, I go in for a routine operation and/or surgery
| with known variables, and have no clue what I will be billed
| and who will be billing me, and whether the random
| anesthesiologist who tagged along with the main one is even
| covered by insurance--until about 6 months later when I get
| an invoice in the mail.
|
| I could understand more if you're talking about a surprise ER
| visit, but it's like this for everything.
| mwerd wrote:
| I wouldn't say a surgery could be considered routine until
| it's complete. That's hindsight bias. Most hospitals can
| provide an estimate for these types of surgeries now, it's
| built into Epic, the most common electronic medical record
| system.
|
| Out of network providers are a real issue and certain
| specialties, frankly, have the hospitals by the balls. The
| hospitals would love to employ those anesthesiologists.
| Good luck finding ones who will accept that job offer. We
| have the 'no surprises act' now that's supposed to address
| this issue but it's not working very well
| https://www.hfma.org/topics/hfm/2022/october/no-surprises-
| ac...
| adrian_b wrote:
| While what you say is true, in many countries the prices
| for many kinds of surgeries are fixed and known in
| advance, even if the work of the surgeons can indeed vary
| from case to case, so they are presumably based on some
| kind of average work.
| vlunkr wrote:
| This still isn't that unique to the medical industry.
| What about software contracts? Sometimes things go over
| time/budget, but this scenario should be worked out
| beforehand. You don't tell a client "Sorry we had to
| bring in an outside consultant, so we'll be charging you
| 5x our agreed price."
| jyrkesh wrote:
| > I wouldn't say a surgery could be considered routine
| until it's complete. That's hindsight bias.
|
| Ehhhh, not if said surgery has a really high success rate
| and a really low rate of additional complications.
| There's all sorts of surgeries--say, LASIK eye surgery--
| that have a 99%+ success rate. And actually, LASIK is a
| great example of an operation that has lots of price
| transparency, competition, and where folks have the time
| to shop around, and it's fairly cheap as a result (~$2-3k
| per eye).
|
| We can do this with more in the healthcare industry.
| mindslight wrote:
| The exact same ambiguity happens when you take your car to a
| mechanic, and yet that industry is perfectly capable of
| giving estimates, posting shop rates, having deterministic
| markup on parts that come from a more efficient market, etc -
| ie "time and materials".
|
| The only "Chesterton's Fence" here is the cancer of medical
| billing fake jobs. For every non-urgent service, if there is
| no up-front contract with well-defined consideration, there
| should be absolutely zero legal basis for a provider to
| demand payment. Something tells me the healthcare industry
| would magically find the ability to discuss prices ahead of
| time real quick.
| three_seagrass wrote:
| >In what world can I not know the price of something before
| hand?
|
| In a world where you're not the primary payer.
|
| The complexity of healthcare prices is an artifact of decades
| of negotiations between providers and insurers, with the added
| headaches of linked diagnosis and procedural dimensions.
|
| IME the pricing is so overtly complex that transparency into it
| isn't going to make much of a difference, it's just going to
| create more questions. If you want simplicity, switch to single
| payer.
| diob wrote:
| We also need to start acknowledging most medical care is urgent
| and not a choice.
|
| Happy to see some movement on at least price transparency
| though.
| Eleison23 wrote:
| mwerd wrote:
| Sure, that makes sense.
|
| We should also acknowledge that it costs money to deliver and
| we live in a resource constrained world.
| ealexhudson wrote:
| The cost of the thing is effectively irrelevant if you both
| need it and don't get the bills for weeks/months. If
| patients are expected to self-ration, they need the info up
| front...
| EMIRELADERO wrote:
| That doesn't seem to have stopped most other countries from
| having free or near-free healthcare. You shouldn't even
| have to think about money when dealing with hospitals.
| gwright wrote:
| This language isn't very helpful. It is likely paid for
| from general tax revenue. That might be a better
| implementation but it certainly isn't "free". And if it
| isn't explicitly paid for via tax revenue it will end up
| being paid for via inflation if the government spending
| is out of line with its revenue.
| EMIRELADERO wrote:
| By "free" I meant "free at the time of treatment". Of
| course nothing is free. Traffic lights aren't free. Road
| maintenance isn't free.
| olddustytrail wrote:
| The language is fine because that's what the word "free"
| means. Do you complain that a cloud provider's free tier
| isn't really free because it's paid for by other
| customers?
|
| It seems it's only with healthcare people forget the
| meaning of the word.
| coredog64 wrote:
| As is common in these discussions, I'll reference the
| French system as I experienced it.
|
| If you have to go to the hospital, that's not billed to
| you.
|
| If you see your GP, they charge you up front. There's no
| copay as in the US system, the doctor just charges what
| they want. The doctor doesn't keep any significant
| medicine on prem. If you need a vaccine, they write a
| script that you take to the pharmacy and return with. In
| either case, you submit your paperwork after the fact and
| get reimbursed. For office visits it's 80% of the
| "reasonable and customary" changes. For medicine it's
| usually 50-60%.
|
| You can purchase additional insurance that covers more of
| these costs, but I didn't see any value in it for my
| situation.
|
| When I left, French insurance companies were setting up
| US style networks with doctors. If you saw an in-network
| provider, you were reimbursed more.
|
| Only the truly indigent get "free" healthcare under the
| French system.
| maxerickson wrote:
| Government restricts the resources available for health
| care with the idea that it costs to much to have extra.
|
| So my local hospital just does whatever and charges
| Medicare their CAH rates, doesn't matter a lot if they suck
| or could be cheaper, no one else can open a hospital (both
| by state law and because Medicare probably wouldn't agree
| to pay them).
| nickff wrote:
| Is most medical care urgent? I dislike asking for citations,
| but that is quite the claim!
|
| Are you saying the majority of patient-practitioner
| encounters are emergency visits, or that the majority of
| spending is on emergency care, or something else?
| yamtaddle wrote:
| I'd expect the majority of people's encounters with big
| medical bills from hospitals before old age are either
| emergency, or childbirth related, so those are the two
| things you'll see young and middle-aged people complain
| about.
|
| But the biggest bills are probably near end-of-life, and
| mostly not emergency care.
| adam_arthur wrote:
| Most medical care is not urgent. In fact, emergency care is a
| tiny fraction of all medical spending.
|
| Thus the ability to "shop around" and thus subjectivity of
| medical care to price competition definitely exists in the
| majority of cases. If the system were setup to incentivize
| and support this. But due to lack of price transparency and
| skin in the game, there is no competitive pressure on pricing
| in practice.
|
| https://www.politifact.com/factchecks/2013/oct/28/nick-
| gille...
| three_seagrass wrote:
| Your link doesn't support your claim about shopping around.
|
| Most health insured patients can "shop around" in their
| network, which is a list of pre-negotiated priced providers
| that the insurance company has approved. Providers that are
| already vetted to be the lower cost for insurance, created
| through purchase power. And that's assuming it isn't an
| HMO, for which there is no shopping around.
|
| There are not enough options for real market competition in
| healthcare.
| adam_arthur wrote:
| My comment's point was that it's theoretically possible
| for healthcare to allow for shopping around, but in
| practice it's not. Due to lack of price transparency and
| lack of incentives for consumers to care (max out of
| pocket)
| diob wrote:
| I love how we go to theory instead of looking at other
| nations where healthcare works, like Australia. American
| exceptionalism at it's finest.
| adam_arthur wrote:
| America didn't become great by copying Europe. Or
| Australia.
|
| There are obvious flaws in the healthcare system that are
| apparent from first principles. No need to blindly copy
| others.
|
| Removing incentives for people to use the system
| efficiently leads to poor outcomes in different ways
| diob wrote:
| I never said blindly, but I do love that you admit to
| thinking America is great. What other countries do you
| think are great?
| diob wrote:
| Just like how we can shop around for our internet here :)
|
| It's wild to me how folks will continue to support the
| predatory healthcare industry here.
| adam_arthur wrote:
| Yes, increasing competition will lead to better results
| for society, in all markets.
|
| Through competitive pressures which drive down cost and
| encourage increases in quality.
|
| There is very little competitive pressure in healthcare
| from the consumer due to the issues already mentioned
| above
| diob wrote:
| You're not wrong that competition helps, but you're being
| naive if you think healthcare is a market, or that it
| would not eventually be captured like so much else in the
| USA.
|
| In fact, I think you'll find most of healthcare has
| already been captured by private equity, resulting in
| worse outcomes for the both doctors and patients.
| baby wrote:
| Hell I can't even understand what my dentist and orthodontist
| are billing me for, it just looks like they're making up all
| sorts of charges.
| tyingq wrote:
| Agreed, it's a huge mess. Often, you are also not always told
| when something is even a billable item at all. You can find
| examples of itemized bills including things like band-aids at
| crazy inflated prices.
| yamtaddle wrote:
| I've received bills from entities halfway across the country
| with no fucking clue what role they actually played in care.
| It's completely fucked. No other industry gets away with
| billing this messed-up and sloppy. And I'm 100% sure some of
| the errors are "accidentally on purpose".
| dig1 wrote:
| Probably because the US healthcare system has been so corrupt
| for many years that, sadly, people are taking it as the
| default/normal state. Going outside the US and seeing how other
| countries handle it is an eye-opening experience.
| missedthecue wrote:
| In my country, it's corrupt _and_ cheap!
| mightybyte wrote:
| I'm also really hopeful for this. A couple years ago I had a
| potentially serious injury and the local urgent care clinic
| said I needed a trauma center. The message got lost in
| translation and I ended up at a Northwell Health hospital that
| did not have a trauma center. First they ignored the documents
| that I gave them and let me get past their triage so they could
| bill be and then told me that I needed a trauma center. After
| signing a refusal of care form and paying something like $200
| to get out after getting zero care, I went to the nearest
| hospital with a trauma center where I was very quickly received
| by a full trauma team, got a CT scan, and determined that my
| condition was not serious.
|
| I got a bill from the trauma center hospital for something like
| $500. Based on what I've been conditioned to expect from the
| U.S. health care system that seemed pretty reasonable. Then I
| got a bill from Northwell Health where I recieved no care for
| more than $800! Around that same time the NY Times came out
| with a piece about Northwell overcharging
| (https://www.nytimes.com/2021/03/30/upshot/covid-test-fees-
| le...). It took me months of badgering both my insurance
| company and Northwell to stop sending me payment delinquency
| notices.
|
| Now, more than a year and a half later, they started sending me
| bills for that $800 again! So I'm very excited to see this kind
| of open source approach at this problem.
| OrvalWintermute wrote:
| It sounds like you inprocessed at Northwell Health, went
| through billing, saw a Nurse/PA/NP, got vitals taken, met
| with an ER Doc, and received a confirmatory diagnosis, and
| the ER doc spent the time to read your documentation.
|
| For a hospital, your care is not merely the interventional
| aspect of medicine, but also the vitals, diagnosis, charting,
| and time spent on reading your documentation by a medical
| professional with > 20,000 hours experience & training.
| amluto wrote:
| If I take my car to a shop, the shop contemplates my car,
| and concludes that they can't help me on that visit
| (because they're the wrong shop, they have the wrong part,
| etc), the usually charge me $0. Maybe $15.
|
| I have never in my life experienced an ER doing anything
| competent that remotely resembles reading documentation as
| part of triage. Why on Earth should they get paid more than
| a tiny nominal fee for the use of the waiting room and a
| bit of time spent by the triage staff?
| secabeen wrote:
| My understanding is that this is because the car repair
| market is heavily regulated, estimates are required for
| all repairs, and payment is based on a standard number of
| hours for each job, not actual time taken. The cost of
| estimates is already wrapped into the cost of the
| completed repairs, and estimates are required before work
| is done, so few places charge for declined estimates.
|
| https://www.bar.ca.gov/pdf/writeitright.pdf
| dboreham wrote:
| I think it's because car repair shops can't get away with
| being a total dick.
| mightybyte wrote:
| They had a full report from the urgent care clinic
| including x-ray and blood test results. They added
| precisely zero value. It was a completely inexcusable
| failure of triage, solely to extract money. I paid the $200
| or so on-site, and even that is not defensible IMO.
| tryptophan wrote:
| This is why you don't go to urgent care clinics. Half the
| time they don't even have doctors there, just NPs with online
| degrees.
| comprev wrote:
| The key difference is you don't need the burger but most likely
| do the hospital thing. This is where the exploitation lies.
| xboxnolifes wrote:
| If that was truly the only exception, then it wouldn't be the
| case that I am only told the price of routine, non-life-
| threatening visits _after_ visiting. Things like yearly
| doctor checkups, dental cleanings /checkups, vision checkups,
| specific x-rays/MRIs, etc.
| soitgoes511 wrote:
| Very true. The optional part comes in with the itemization of
| items in the hospital room like baby diapers or a tylenol. I
| would definitely bring my own if I knew the hospital would
| bill me (or my insurance), 800$ for a tylenol. I live in
| France now, so it is a different story (doctor shortage
| currently)..
| tapatio wrote:
| How were you able to do this if billing codes are copyrighted?
| Where did you get all of the billing codes? Also, isn't this
| pointless as the final pricing is highly dependent upon one's
| insurance policy? Also, the price differs if you pay cash versus
| with insurance.
| shmerl wrote:
| I'd guess factual information can't be copyrighted, it's not a
| creative work.
| tapatio wrote:
| The American Medical Association copyrighted it. I didn't
| know factual information can't be copyrighted. The
| "copyright" text on their website is rubbish then. Learn
| something new everyday. Thanks!
| shmerl wrote:
| I think simply a collection of facts can't be copyrighted.
| It must have some kind of creative added value for
| copyright to be applicable, like an encyclopedia presenting
| these facts may be would be an example.
|
| And yeah, it's not uncommon for some to slap "copyrighted"
| on something where it's not applicable.
| hunterb123 wrote:
| Won't work until the current administration enforces the law.
|
| Hospitals are defying it and not posting prices with no
| repercussions.
| atourgates wrote:
| Did you read the article?
|
| > In the three years since, disclosure of these price lists has
| been hit and miss. Some hospitals posted partial price lists,
| others none at all. (They were probably counting on not getting
| caught.) Two hospitals fined over $1M combined in 2021 for
| refusing to host these files (but since the penalty, have since
| taken a U-turn and published their prices.) This might have
| been to send a message to the other hospitals to get serious.
| hunterb123 wrote:
| Yes I did. Two hospitals being fined nearly two years ago !=
| enforcing all hospitals posting full price lists.
|
| You don't just "send a message" once, you fine hospitals not
| compliant, period. We do this for other regulations.
|
| So at this rate maybe in 2040 most hospitals will post their
| prices, maybe. If everyone feels like following / enforcing
| the law.
|
| Also, did you read the guidelines?
|
| > Please don't comment on whether someone read an article.
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