You should take a look at the prices of medical procedures not covered by insurance, such as plastic surgery. The prices are reasonable, and the reason is that when procedures are not covered by insurance, consumers shop around. When consumers spend out of pocket, they are very much interested in seeing the price before they do the procedure, and hospitals can't and don't hide the price.
> The prices are reasonable, and the reason is that when procedures are not covered by insurance, consumers shop around.
You are doing some extremely heavy lifting here with this sentence alone by trying to connect two unrelated clauses. Consider the following: Is Water expensive? Is it expensive due to an innate characteristic of water, or is it expensive due to scarcity?
Now with that in mind, why is water the first thing price gouged during a crisis? People need fresh and clean water and you have individuals selling water at a premium.
The same principle applies for healthcare. Plastic surgery is optional and on an indefinite timeline, so there is no patient lock in. If you have a severe injury or a heart attack or a stroke you cannot shop around. You cannot pre-shop for conditions you don't know you have. And so you pay the crisis premium.
> You cannot pre-shop for conditions you don't know you have.
In some ways you can. When hospitals acquire a reputation for being pricey without offering better care, people tend to avoid them, and even in a crisis the hospital's name won't be the first that pops into your head.
You jest, surely, but keep in mind that one of the most financially significant decisions to be made is going to be the hospital which the ambulance transports you to. Some insurance plans charge a premium for mileage when it's not the "closest available", and you can imagine the damage if the chosen facility is "out of network" or not otherwise covered.
I am trying to not take your comment personally. I understand that many medical services are not urgent. Part of the problem in the US at least is that ERs are obligated to stabilize any patient that walks through the door, regardless of ability to pay. So you end up with people misusing the ER for chronic non urgent care.
I have sat in an ER for hours. I’ve also had nurses at an ER clear the floor for my family when my wife was in septic shock due to a botched surgery, or when my son was run over by a car (both are fine now, not looking for sympathy just pointing out I have experienced this before)
Focusing on the uncommon situations needing immediate attention implied that you haven't actually dealt with the system much. If your original comment wasn't reflective of your personal experiences, then don't take it personally. When people talk about the ability to compare prices (as one can do in basically every other industry), it's nonsensical to direct focus towards the small amount of cases that require (and generally get) immediate attention, rather than the bulk of the medical system that shamelessly books appointments months away.
If there were well-defined prices, it would clearly be horrible to use that fact to further cement a fiction that a contract has been created with someone under medical duress (or further justify high prices when supply is being limited by the cartel). But reforming the industry has to start somewhere, and price signals are basically the only way we've found to coordinate large scale distributed behavior - regardless of who might be paying.
I’ll be honest when I don’t have an urgent issue it’s hard to layer on additional mental load to compare prices. When my wife was diagnosed with cancer, how do I realistically compare prices? What services should I ask them to quote? How do I know what to ask for? How do I realistically compare two offers? What if they left out an important part of care that the other side included? What single entity even has all the information I need? For example even for a single outpatient surgery you have to include the hospital cost, the surgeons cost, the anesthesiologist, and that’s just what I can think of off the cuff. each one of those entities has their own billing department, costs etc. so who do I call?
You're still buying into their paradigm wherein they've created endless needless complexity to confuse the market. The entire point is that this complexity needs to be nipped in the bud with singular prices for each significant line item, just as every other industry operates.
The equivalent would be when you're hungry and need to buy food at the grocery store, asking how you can manage that since you are going to have to pay for the food cost, the shelf space cost, the trucking cost, the refrigeration cost, the cashier, the bagger, etc. In actuality, the grocery store comes up with a single price that they're comfortable selling an item of food for, puts in on the shelf, and you can take it or leave it at that price.
The only way the medical industry can get away with their ridiculous bullshit is seemingly through a bunch of laws they bought whereby they can saddle people with debt without actually having done the work of forming a contract. Hence why you can visit a single business, and then end up getting a slew of bills from arbitrary providers that you had no relationship to. That simply cannot happen in other industries, where the only basis for billing is having formed a contract.
The equivalent for cancer is they'd lay out several treatment options (as they're already doing while ignoring prices), listing the price for each, the price and recommended frequency for followup monitoring, etc. You could then ask different providers for how much their treatment cost. Ideally the places administering treatment would be unbundled from the doctors doing the diagnosis, and the diagnosing doctors' office could give you a list of competing treatment providers. I know I'm hand waving away a lot of details here, but the whole point is that the intrinsic complexity of the problem needs to be modeled around cost, rather than treating it as an afterthought, creating a bunch of accidental complexity that ignores cost, then trying to manage it after the fact.
(And note that this is still orthogonal to who is ultimately paying, whether legitimate insurance to pool risk, subsidies for those who can't pay, etc. It's easiest to see what the current system is lacking when you look at things that "insurance" doesn't cover. For example a hospital stay, I would guess most people here would pay $100/night to have a single room rather than a shared room with a roommate always setting off their bed alarm etc. But there's simply no way to express that to the system currently, creating a zero-sum environment of scarcity, rather than a positive sum environment of abundance)
I love what you say, but how does one realistically implement this today? I can’t exactly call up a hospital and say “cut the bullshit. I need a single price for procedure x”. They’ll just laugh and hang up the phone. (I’ve tried- most recently for a vasectomy). As you say, the industry is fat and happy and has no reason to bend to my will no matter how much sense it makes in the long run.
My point is that we have a whole bunch of policy nerds hand waving this complexity away and saying “enjoy your hsa- go forth and price compare as the invisible hand of the free market will provide!” Unless there is force from above, there certainly is no way the masses can navigate the system and force change themselves.
And the truth is that stuff does happen that’s not anticipated. My wife’s surgery was supposed to be routine. I would have had no idea ahead of time that there would be a lingering internal infection afterward. Multiple subsequent visits where we shared complications with the surgeon were handwaved away as “you’re just not used to recovery from surgery”.
If a tradesman screwed up a plumbing job, he would be called back to fix it at no cost. Instead I’m (or in this case my insurance) is stuck with >$100k of bills from the ICU to bring her back from the brink. I consulted with several malpractice attorneys who basically said unless the surgeon was drunk and slurring his words while operating, there is no case. The standard of care is so low.
I'm definitely not hand waving away regulatory things that need to change to make things sensible, especially in a way that doesn't just bless the current corrupt system with a new veneer of justification.
High level points, from what I can tell -
1. The laws/regulations enabling the current system/cartel need to be scrapped. This includes the ability for providers to unilaterally assign arbitrary debts to patients, and the regulations enshrining the existence of HMOs (I assume these exist because HMO "networks" look exactly like what an 80's Coase fallacy drunkard would think constitutes competition)
2. New regulation / anti-trust enforcement needs to be applied to providers, such that they must publish clear prices for standard services that are comparable across providers, and straightforward hourly rates for anything that cannot be captured on there (with any nonconforming bills being considered attempted fraud).
3. New regulation / anti-trust enforcement needs to be applied to insurance companies, outlawing "provider networks" and rephrasing all insurance coverages purely in terms of prices, applying to any medical service from any licensed medical provider. That parallel "medically necessary" approval system needs to be entirely eliminated.
> Multiple subsequent visits where we shared complications with the surgeon were handwaved away as “you’re just not used to recovery from surgery”... The standard of care is so low
Routinely experiencing that dynamic of poor care [0] from the medical industry is exactly what makes me shake my head at the simplistic "fix it by having the government take it over" narrative. Ballooning costs and individual ability to pay is a problem, yes. But the much larger problem is the utter waste of medical talent, because the system has been designed around terms of top-down paperwork-filling rather than responsiveness to patients. The doctor should have been working for you, and you should have been able to get more time/attention for the doctor to have taken you seriously. But that was impossible because the "insurance" company dictated that you got one tiny follow up appointment, with the doctor focusing on filling his seat during that appointment, doing the bare minimum that conforms to the top-down standard of care, and avoiding doing anything extra that might create legal liability.
[0] Although not as much malpractice and completely avoidable as yours. I'm sorry for what you both went through.
In my experience, ER in the US can bill you at the highest rate pretty frivolously.
I've been in the ER for "difficulty breathing", which was billed at the highest level, although still made to wait ~2 hours in waiting rooms before seeing _any_ medical professional.
I've also been in the ER when brought in by an ambulance, in which case I was seen immediately.
These were both billed at the highest level, when the 1st case clearly shouldn't have been.
