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I thought this was a pretty good, rambling discussion on the Peter Attia podcast.  Discussion really kicks in about an hour in.  Focus is more on the sheer stupidity of the current approach than specific policy recommendations.  This guy's new book, The Price We Pay, may be worth a look.

Having recently had back surgery priced at about 50K, I saw most of the nonsense in my EOBs.

https://peterattiamd.com/martymakary/

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2 minutes ago, tantric superman said:

I thought this was a pretty good, rambling discussion on the Peter Attia podcast.  Discussion really kicks in about an hour in.  Focus is more on the sheer stupidity of the current approach than specific policy recommendations.  This guy's new book, The Price We Pay, may be worth a look.

Having recently had back surgery priced at about 50K, I saw most of the nonsense in my EOBs.

https://peterattiamd.com/martymakary/

Can you provide any information on the cost breakdown? Who got what?

Edited by David Dennison

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8 minutes ago, David Dennison said:

Can you provide any information on the cost breakdown? Who got what?

Not really.  22 separate EOBs.  Monitoring and anesthesia took big chunks.  But the surgicals EOBs were just long lists of "services".  I was worried about one denied medical equipment claim $990 because it never got approved and I thought there might be the collection activity, but when I called the provider, they said that they never attempt to collect and it appeared to be something that the surgical hospital would just write off.

One of the discussion points was the simple fact that the get a whole lot of $$$ by simply asking for it and getting no push back.

 

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8 minutes ago, tantric superman said:

Not really.  22 separate EOBs.  Monitoring and anesthesia took big chunks.  But the surgicals EOBs were just long lists of "services".  I was worried about one denied medical equipment claim $990 because it never got approved and I thought there might be the collection activity, but when I called the provider, they said that they never attempt to collect and it appeared to be something that the surgical hospital would just write off.

One of the discussion points was the simple fact that the get a whole lot of $$$ by simply asking for it and getting no push back.

I read somewhere that you should never pay a hospital or medical bill before you get the applicable EOB. I wonder how much money hospitals and doctors make off of people who just pay the bill by the due date before reading the EOB and discussing the denied charges with their insurance provider. Like you said, it's probably a whole lot.

Edited by David Dennison

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My wife has some health issues and it’s damn near a full time job dealing with doctors and insurance companies. I’m not sure how she would be able to do it if she had a more demanding job. She works from home and can work while she is on hold for 45 minutes at a time.

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Ultimately, these docs were skittish about single payer, but whatever the ultimate fix, they really did focus on the huge issues created by the lack of cost and price transparency in the US health care system.

Had an interesting side comment about how the Amish/Mennonite in Lancaster, PA will invariably take the train down to Mexico for care for serious health issues in part because they hate the BS of the US system.

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What the medical “industry” is doing in the US is criminal. Why does an MRI in the US cost 20 times more than in Japan?

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47 minutes ago, XYZ said:

What the medical “industry” is doing in the US is criminal. Why does an MRI in the US cost 20 times more than in Japan?

Probably because insurance companies and the federal government have agreed to pay what medical service providers charge.

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There is also the fucking mystery why it is 4 weeks lead time to get an MRI or other advanced testing and than most of the times I have shown up to a completely empty waiting area.  Yet the appointment is 20 min behind schedule.

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On 9/2/2019 at 11:16 AM, tantric superman said:

I thought this was a pretty good, rambling discussion on the Peter Attia podcast.  Discussion really kicks in about an hour in.  Focus is more on the sheer stupidity of the current approach than specific policy recommendations.  This guy's new book, The Price We Pay, may be worth a look.

Having recently had back surgery priced at about 50K, I saw most of the nonsense in my EOBs.

https://peterattiamd.com/martymakary/

I assume  you have employer-sponsored health insurance? What was your portion of that?

And if you know, what is your monthly premium (total, yours + employers)?  Big group plan?  Small?

I'm just curious how employer-sponsored insurance compares to ACA these days.

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Not sure what employer's portion is.  About $4500 in premiums for me and one child.  PPO.  7K yearly max out of pocket. Big company/BCBS.

 

Edited by tantric superman

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18 minutes ago, tantric superman said:

Not sure what employer's portion is.  About $4500 in premiums for me and one child.  PPO.  7K yearly max out of pocket. Big company/BCBS.

 

Actually sounds pretty comparable to a Bronze Plan.  Not sure how it would work with dependent but not spouse, but kind of "averagey" ACA with spouse in Texas is 1000-1500/month premium and 10000-14000 deductible.

You may have more stuff "covered" than ACA, which is about nothing.  One $250 annual physical, no labs.

I love it, before I get dollar one of reimbursement, I'm in for 29,000 of premium and deductible.

Edited by TwiceHorn

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Slightly more on topic, I switched providers in November to avoid a premium near-doubling.  Went from Oscar to Molina, i.e. sorta shitty to really shitty.

Then broke my collarbone and a bad mallet finger in December.  Oscar capped my ortho visits in December to ~$100 each depending on xrays.

Collarbone ortho recommends consult with hand ortho on mallet finger surgery.  Both recommend.  Surgery on Jan 10.  Out of network for Molina and also not "cleared" through PCP.  

I look at getting an appointment with the (one) Molina hand ortho and have to wait until March.  Fuck all that.

So I become a cash customer for the surgery.  Which gets me a 30% discount from ortho practice and surgery center.  $1100 to ortho, $2400 to surgery center.  Cash up front, homey.

After the fact, get a $2000 bill from anesthesiologist.  None of this is itemized and there's no EOB.

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14 minutes ago, bad_teammate said:

single-payer healthcare now

 

Hospital bills are absolutely absurd and nonsensical and fantastical. Their actual out of pocket was $500. All of that appears to be related to meeting their deductible or co pays. 

Edited by Anastasis

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11 minutes ago, Anastasis said:

Hospital bills are absolutely absurd and nonsensical and fantastical. Their actual out of pocket was $500. All of that appears to be related to meeting their deductible or co pays. 

lol our system is so fucking dumb

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I’m just a schlub municipal worker and got through chemo and multiple surgeries with little OOP. Guess I just got lucky.

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14 minutes ago, bad_teammate said:

lol our system is so fucking dumb

Hospitals are the biggest crooks in the game. The ED is a straight up fucking shake down. 

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I’m a doctor and I was still shocked by my medical bills after a cut got badly infected last year - 2 nights in ICU, debridement surgery etc.  

Shit is out of control.  Mind you our group makes money taking on risk/value so it’s a completely different model but I did think about how sweet the other side is...

Just bill your ass off and retire in 3 years, not 20.  The whole system is so fucked but it is changing for the better - slowly.  

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31 minutes ago, Anastasis said:

Hospitals are the biggest crooks in the game. The ED is a straight up fucking shake down. 

This.  They’re constantly lobbying so they can do shit a stand alone medical center can’t.  They bill 10x what that medical center / sx center does.  It makes zero god damn sense.  

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13 minutes ago, ChiTownDoc said:

This.  They’re constantly lobbying so they can do shit a stand alone medical center can’t.  They bill 10x what that medical center / sx center does.  It makes zero god damn sense.  

So where do things like CVS buying out Aetna come into play?

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I had knee surgery to fix a torn meniscus as well as a calcium phosphate injection to address cartilage loss in February. The total bill for the 8 hour hospital stay & surgery was $120k. 

The medical center where the surgery was performed was a single $89k line item. The insurance company ended up paying $15k for the entire procedure while my portion was $2k. 

I realize I went to a highly rated surgeon but I don’t understand the pricing scheme at all. 

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On 9/8/2019 at 9:08 PM, smokebomb said:

I had knee surgery to fix a torn meniscus as well as a calcium phosphate injection to address cartilage loss in February. The total bill for the 8 hour hospital stay & surgery was $120k. 

The medical center where the surgery was performed was a single $89k line item. The insurance company ended up paying $15k for the entire procedure while my portion was $2k. 

I realize I went to a highly rated surgeon but I don’t understand the pricing scheme at all. 

The medical billers know they are going to wnd up with 10 cents on the dollar billed.  So they bill a joke of a rate.

A shitload of paper gets shuffled.

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Walmart does this:

 

Quote

Located in Dallas, Georgia, directly adjacent to a remodeled Walmart supercenter, the new “Walmart Health” held its grand opening on Friday, Sept. 13. The 10,000-sq.-ft. facility offers an array of services — primary care, laboratory tests, X-rays and diagnostics, counseling, dental, optical, hearing, health insurance information and enrollment, and community health education with online education and in-center workshops — all under one roof. A second location, in Calhoun, Georgia, is scheduled to open early next year.

Walmart Health is designed to provide “low, transparent pricing” for key health services, regardless of insurance status. Customers will be notified as to the estimated cost of their visit when they book their appointment.

The cost of services is detailed in a price sheet on Walmart’s website. (The retailer noted that charges shown for a few specific services, such as dental crowns, are averages, with actual costs to be determined on a case by case basis.)

A primary care office visit costs $40; annual checkups cost $30 for adults and $20 for youth; and flu, strep and mono tests cost $20 each. On the counselling side, new patient therapy intake is priced at $60, while individual (45-minute) counseling services for existing patients is $45.

Dental services start at $25 for an exam that includes X-rays and go up to $225 for in-office teeth whitening. A filing costs anywhere from $75 to $125. Optometry services include $45 routine vision exams and $55 contact lens fittings.

“The customer is at the heart of everything we do, and that focus is reflected in the new Walmart Health center,” said Sean Slovenski, senior VP and president of Walmart U.S. health and wellness. “For the past year, a team of healthcare experts and visionaries inside and outside of Walmart have been working hard to bring this concept to life in Georgia, and the journey we’ve been on is just the beginning as we aim to bring quality, accessible healthcare to our customers.”

Walmart said it is using technology to streamline the clinic’s scheduling, check-in and payment processes, allowing customers to get estimates on the cost of their services and do other activities without paperwork.

...

https://www.chainstoreage.com/store-spaces/first-look-walmart-debuts-freestanding-health-center-format/

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I've heard our nation described as a health care system with a military.  That's not wrong.

Nothing about how we do health care in this country, as a modern 1st world nation, makes a lick of sense.   In DC, I tell every young person who wants to do policy:  learn healthcare, everyone is always hiring.  It's complex and nobody likes working on it.

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On 9/9/2019 at 8:54 AM, bad_teammate said:

single-payer healthcare now

 

I gave been told birthing centers in the Philippines charge $50 to locals and $80 or $90 if they find out the dad is a foreigner. Hospital births can be 5 to 10 times that.

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1 hour ago, Bateshorn said:

I've heard our nation described as a health care system with a military.  That's not wrong.

Nothing about how we do health care in this country, as a modern 1st world nation, makes a lick of sense.   In DC, I tell every young person who wants to do policy:  learn healthcare, everyone is always hiring.  It's complex and nobody likes working on it.

I usually call us an old folks home with a military, but same difference. 

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Our system is crazy. 

I take an MS drug that gets billed to the insurance company at $120k+ for the drug and infusion costs twice a year. I pay nothing now b/c the drug company pays for it, up to $20k for the drug and $2k for infusion costs both annually. Our deductible is $6500. So premiums and anything that arises before my first injection each year are all we pay. 

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5 minutes ago, TX Panic said:

Our system is crazy. 

I take an MS drug that gets billed to the insurance company at $120k+ for the drug and infusion costs twice a year. I pay nothing now b/c the drug company pays for it, up to $20k for the drug and $2k for infusion costs both annually. Our deductible is $6500. So premiums and anything that arises before my first injection each year are all we pay. 

What a helluva deal!  Sorry about your condition, best wishes!

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I support single-payer healthcare. It is the most cost-effective method to guarantee at least a base level of competent healthcare for all. Anything less is inhumane and a moral stain on a society this wealthy. Yeah, whatever model you want to point out, be it the Canadian, British, German, etc. has downsides. Nothing is perfect. But they are all vastly superior to a system that leaves 15 percent of its population completely SOL and millions more "covered" in name only, simply because covering them isn't deemed profitable.

That said, we can debate healthcare delivery and cost 'til we're blue in the face, it doesn't matter until the root causes are addressed. Poor diets; sedentary lifestyles; shitty, toxic workplace culture with low pay, unnecessarily long hours, and active shaming of time off; weak social safety nets; celebration of ignorance and a devaluing of education; environmental degradation - It's all there. We've created a society that tailor made for poor health outcomes.

Edited by gmr548

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14 minutes ago, gmr548 said:

That said, we can debate healthcare delivery and cost 'til we're blue in the face, it doesn't matter until the root causes are addressed. Poor diets; sedentary lifestyles; shitty, toxic workplace culture with low pay, unnecessarily long hours, and active shaming of time off; weak social safety nets; celebration of ignorance and a devaluing of education; environmental degradation - It's all there. We've created a society that tailor made for poor health outcomes.

One of the few useful things about Marianne Williamson is that she actually talks about this view as centrally important vs. policy wonkery.

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9 hours ago, gmr548 said:

That said, we can debate healthcare delivery and cost 'til we're blue in the face, it doesn't matter until the root causes are addressed. Poor diets; sedentary lifestyles; shitty, toxic workplace culture with low pay, unnecessarily long hours, and active shaming of time off; weak social safety nets; celebration of ignorance and a devaluing of education; environmental degradation - It's all there. We've created a society that tailor made for poor health outcomes.

None of that addresses why in the US you get charged 20 times more for an MRI than in Japan.

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None of that addresses why in the US you get charged 20 times more for an MRI than in Japan.

The crazy thing is that with some effort you can find a reasonably priced m MRI in most big cities in the United States, which you can get in Japan. But without effort you can also wind up getting a ridiculously and inexplicably expensive MRI, which you cannot do in any other first world country.

 

I’m getting spit roasted by my GI doctor in a couple of weeks (combo upper endoscopy and colonoscopy in the same visit) - yesterday they presented me with an estimate of charges from my doctor which is about $3k plus some non-sensible line item charges, discounted to about $800, not including bills for anesthesia and the facility along with a “a few other things”, for which I will receive a separate bill. The practice organizing this gang bang can’t tell me if any of the other entities are in-network or not, or what their charges will be.

 

Based on averages, the whole thing will probably be about $6k.

 

In most advanced countries this whole thing would be less than $2K, and if I travelled to Mexico and went to one of the places that cater to American medical tourism* it would be about $1000-$1500.

 

 

 

 

 

 

 

 

 

 

 

 

*which, incidentally, is about 6X as common as Canadians traveling abroad for care, because we have the worst healthcare system in the world.

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The major benefit of single-payer is that it gives the purchaser some leverage against the providers.  Currently, there is nearly none, and add in distortions from Medicare/aid and private insurance, and you have really anomalous and arbitrary pricing.

Based on that alone, I'm coming around to single-payer.

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6 minutes ago, TwiceHorn said:

The major benefit of single-payer is that it gives the purchaser some leverage against the providers.  Currently, there is nearly none, and add in distortions from Medicare/aid and private insurance, and you have really anomalous and arbitrary pricing.

Based on that alone, I'm coming around to single-payer.

Single payer, kinda like Military Procurement?  

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Just now, Incredulity said:

Single payer, kinda like Military Procurement?  

Mhm.  Lol.  Fuck.  We are so fucked.

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13 hours ago, TwiceHorn said:

The major benefit of single-payer is that it gives the purchaser some leverage against the providers.  Currently, there is nearly none, and add in distortions from Medicare/aid and private insurance, and you have really anomalous and arbitrary pricing.

Based on that alone, I'm coming around to single-payer.

Twice:

I think you are missing the bigger issue here, which is that hospitals have learned that they can commit egregious crimes on a daily basis with impunity. Lady gets billed $80k for scorpion anti-venom that the hospital paid $400 for. The problem here is not “leverage”. It’s that the administrators of that hospital should be in prison, but the justice system flat out refuses to prosecute these crimes. Because evidently it’s a prerogative of the American government to be “business friendly”, no matter the consequences.

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21 minutes ago, XYZ said:

Twice:

I think you are missing the bigger issue here, which is that hospitals have learned that they can commit egregious crimes on a daily basis with impunity. Lady gets billed $80k for scorpion anti-venom that the hospital paid $400 for. The problem here is not “leverage”. It’s that the administrators of that hospital should be in prison, but the justice system flat out refuses to prosecute these crimes. Because evidently it’s a prerogative of the American government to be “business friendly”, no matter the consequences.

Hospitals are the biggest crooks in the system. Worse than Pharma. Worse than the insurance industry. Worse than any of the frontline providers and pharmacies than the others by a large multiple. 

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11 minutes ago, XYZ said:

Twice:

I think you are missing the bigger issue here, which is that hospitals have learned that they can commit egregious crimes on a daily basis with impunity. Lady gets billed $80k for scorpion anti-venom that the hospital paid $400 for. The problem here is not “leverage”. It’s that the administrators of that hospital should be in prison, but the justice system flat out refuses to prosecute these crimes. Because evidently it’s a prerogative of the American government to be “business friendly”, no matter the consequences.

Well, the first problem is that that isn't a crime.  And price control by criminal prosecution is no solution.

Healthcare is fucked ab initio because demand for it is almost completely inelastic:  it doesn't diminish as costs increase.  Compound that with the fact that many consumers are under extreme duress.

Then add in that most people are too stupid or lazy to negotiate or price shop and that it's difficult for even those inclined to price shop.  And then mix in that insurance disincentivizes shopping, but only has limited regional bargaining power to negotiate prices.  

Medicare is the big dog and negotiates some rock-bottom prices for olds.  But then that leaves everyone else to get gouged in an effort to recoup.  And then you get the real gougers as in the case you cite.

Single payer or mighty close to it provides the equality of bargaining power and knowledge to bring "market-ish" forces to bear to set reasonable prices.  And, healthcare has to be rationed in some fashion or resources will continue to be grotesquely misallocated as they are in many cases of the dying or near death.

One seemingly natural result of this is that hospitals and facilities will lose profitability and PE will exit that market with quickness.  They'll have to become public or quasi public entities.

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1 hour ago, TwiceHorn said:

Well, the first problem is that that isn't a crime.

Really? In any other line of business, if you refuse to tell your customer how much something will cost before they buy it, you would be violating antitrust law. If you charge different people different amounts for the exact same service or product, you would be violating antitrust law. But somehow the medical “industry” got to the point where they believe that no law applies to them because prosecutors for some very strange reason refuse to apply 100 year old law to them. I guess my question for you would be: why have you given up on the rule of law?

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5 hours ago, XYZ said:

Really? In any other line of business, if you refuse to tell your customer how much something will cost before they buy it, you would be violating antitrust law. If you charge different people different amounts for the exact same service or product, you would be violating antitrust law. But somehow the medical “industry” got to the point where they believe that no law applies to them because prosecutors for some very strange reason refuse to apply 100 year old law to them. I guess my question for you would be: why have you given up on the rule of law?

Companies are not allowed to charge different customer different amounts, or they are violating anti trust law?  Can you post some evidence for that claim?

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So every company is violating anti trust law as soon as one customer negotiates a lower price than other customers? 

The more you know...

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6 hours ago, XYZ said:

Really? In any other line of business, if you refuse to tell your customer how much something will cost before they buy it, you would be violating antitrust law. If you charge different people different amounts for the exact same service or product, you would be violating antitrust law. But somehow the medical “industry” got to the point where they believe that no law applies to them because prosecutors for some very strange reason refuse to apply 100 year old law to them. I guess my question for you would be: why have you given up on the rule of law?

Again, antitrust laws, and particularly whatever criminal provisions they contain, are a really clumsy way to handle it.

Moreover, while price discrimination can be unlawful, the circumstances under which it actually is are pretty narrow.  Robinson Patman doesn't apply to services, for one thing.

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