One Emergency Begets Another
December 23, 2018 1:55 PM Subscribe
I read 1,182 emergency room bills this year. Here’s what I learned. — A $5,571 bill to sit in a waiting room, $238 eyedrops, and a $60 ibuprofen tell the story of how emergency room visits are squeezing patients. [Sarah Kliff, Vox 12/18/2018]
It should be illegal for any medical facility to bill itself as accepting a particular insurance plan but employ doctors who don't actually do that. Lots of things about the U.S. medical system are crimes against humanity but this one seems like it should be banned even under current law -- how is that not false advertising?
posted by Holy Zarquon's Singing Fish at 2:49 PM on December 23, 2018 [61 favorites]
posted by Holy Zarquon's Singing Fish at 2:49 PM on December 23, 2018 [61 favorites]
It doesn't detract too much from the article, but this map (the map of the distribution of the bills) made me grumble because it doesn't provide any useful information.
It's just a picture of the relative population of each state! It would absolutely make sense that the population of each state submitted bills at an approximately equal rate. What does this add to our knowledge of the topic of the article? The insidious implication someone could walk away with might be that California has worse ERs than other states, but the article doesn't make any claim about the best or worst place to go to an ER and there's no reason to believe more populous states should be better or worse.
It's a great example of how to mislead with statistics and it has no other purpose in the article.
posted by LSK at 3:28 PM on December 23, 2018 [15 favorites]
:format(webp):no_upscale()/cdn.vox-cdn.com/uploads/chorus_asset/file/13625037/ER_Bills_map.jpg){kind=link}
It's just a picture of the relative population of each state! It would absolutely make sense that the population of each state submitted bills at an approximately equal rate. What does this add to our knowledge of the topic of the article? The insidious implication someone could walk away with might be that California has worse ERs than other states, but the article doesn't make any claim about the best or worst place to go to an ER and there's no reason to believe more populous states should be better or worse.
It's a great example of how to mislead with statistics and it has no other purpose in the article.
posted by LSK at 3:28 PM on December 23, 2018 [15 favorites]
It seems like someone needed a graphic for their article to round it out, keep attention, whatever, and this was the easiest to make. "I dunno I mention that I've got them from all the states, can you make something with that?"
posted by wellifyouinsist at 3:33 PM on December 23, 2018 [3 favorites]
posted by wellifyouinsist at 3:33 PM on December 23, 2018 [3 favorites]
It should be illegal for any medical facility to bill itself as accepting a particular insurance plan but employ doctors who don't actually do that. Lots of things about the U.S. medical system are crimes against humanity but this one seems like it should be banned even under current law -- how is that not false advertising?
This, this, this! Doctors, anesthesiologist, hospital, etc send a single bill that covers everything and if they want to work on a different rate then the hospital has that’s between the hosipital and themselves not me. I have no control over the “independent contractors” that the facility hires, I have no control over the rates or the ability to replace them or deny their services. They may be independent to the hospital but not to me.
posted by jmauro at 3:43 PM on December 23, 2018 [40 favorites]
This, this, this! Doctors, anesthesiologist, hospital, etc send a single bill that covers everything and if they want to work on a different rate then the hospital has that’s between the hosipital and themselves not me. I have no control over the “independent contractors” that the facility hires, I have no control over the rates or the ability to replace them or deny their services. They may be independent to the hospital but not to me.
posted by jmauro at 3:43 PM on December 23, 2018 [40 favorites]
We need price transparency in health care.
Basically, hospitals determine their facility’s operating expense then factor in how much volume they expect, estimate who their patients will be, who all their payers are and what the relative mix is and what each particular payer is contracted to pay (a negotiated industry secret), which payer is going to reimburse for what service, how many patients will go to collections and how much will get written off as bad debt, then they set their fees based on what will balance the budget.
It would be like ordering a car from Toyota without knowing how much it cost and then after it was delivered you get a bill that reflects the price fluctuation of steel at the time of manufacturing, how much Hertz negotiated for their fleet of cars that year, the cost of the cars that couldn’t be sold because of poor quality control, and whether they were losing money on a bunch of other luxury models that didn’t sell. And then you were forced to pay the price they determined you should pay. And if you complained about the bill by saying that it isn’t what everyone else is paying, they deflected that by saying “Well Hertz didn’t buy steering wheels for their fleet and your steering wheel costs $7000. It’s too late because we already added that on.”
If we can’t have a big centrally controlled health care system in the US because of our zealous devotion to the almighty free market, then we should have a free market. There is a house bill that is essentially dying in committee right now to require price transparency and the hospitals giving a reasonable estimate of out of pocket costs prior to service, but this would be a huge revolution in how hospitals are paid and no surprise the AHA is against it. A few forward thinking hospitals are attempting this right now and I’ve spoken with administrators about what a huge headache this is for them.
What the ACA did was accomplish a few important first steps — bring a lot more healthy and uninsured people into the system, set a baseline list of covered services including preventive services, and eliminate a few egregious practices like not covering pre-existing conditions. In the enormous ideological rift between the extreme right and the progressive left about health care reform, price transparency is an important meeting point from where we can take the next steps, whatever we decide they are. You simply have to know how much shit costs and what the reasons are for such insane differences.
This project grew out of the Vox podcast The Impact and they are providing an important service trying to engage the public about healthcare. It’s really hard to breakdown such a complicated issue but it’s so important. The ACA was written by a bunch of The Right People who knew what they were doing without a strongly political tilt and ultimately it was a very modest piece of reform legislation because that was what was possible when the baseline level of American discourse on the subject was “Death Panels!”
So good on Vox.
posted by Slarty Bartfast at 3:45 PM on December 23, 2018 [74 favorites]
Basically, hospitals determine their facility’s operating expense then factor in how much volume they expect, estimate who their patients will be, who all their payers are and what the relative mix is and what each particular payer is contracted to pay (a negotiated industry secret), which payer is going to reimburse for what service, how many patients will go to collections and how much will get written off as bad debt, then they set their fees based on what will balance the budget.
It would be like ordering a car from Toyota without knowing how much it cost and then after it was delivered you get a bill that reflects the price fluctuation of steel at the time of manufacturing, how much Hertz negotiated for their fleet of cars that year, the cost of the cars that couldn’t be sold because of poor quality control, and whether they were losing money on a bunch of other luxury models that didn’t sell. And then you were forced to pay the price they determined you should pay. And if you complained about the bill by saying that it isn’t what everyone else is paying, they deflected that by saying “Well Hertz didn’t buy steering wheels for their fleet and your steering wheel costs $7000. It’s too late because we already added that on.”
If we can’t have a big centrally controlled health care system in the US because of our zealous devotion to the almighty free market, then we should have a free market. There is a house bill that is essentially dying in committee right now to require price transparency and the hospitals giving a reasonable estimate of out of pocket costs prior to service, but this would be a huge revolution in how hospitals are paid and no surprise the AHA is against it. A few forward thinking hospitals are attempting this right now and I’ve spoken with administrators about what a huge headache this is for them.
What the ACA did was accomplish a few important first steps — bring a lot more healthy and uninsured people into the system, set a baseline list of covered services including preventive services, and eliminate a few egregious practices like not covering pre-existing conditions. In the enormous ideological rift between the extreme right and the progressive left about health care reform, price transparency is an important meeting point from where we can take the next steps, whatever we decide they are. You simply have to know how much shit costs and what the reasons are for such insane differences.
This project grew out of the Vox podcast The Impact and they are providing an important service trying to engage the public about healthcare. It’s really hard to breakdown such a complicated issue but it’s so important. The ACA was written by a bunch of The Right People who knew what they were doing without a strongly political tilt and ultimately it was a very modest piece of reform legislation because that was what was possible when the baseline level of American discourse on the subject was “Death Panels!”
So good on Vox.
posted by Slarty Bartfast at 3:45 PM on December 23, 2018 [74 favorites]
There are some states that have laws that attempt to mitigate some of this out of network provider nonsense. I had this happen to me (went to an in network ER after a fall with a concussion, got a bill for the out of network ER doc) and wrote the instance company citing PA law that if you go to an ER with an injury, you can't be liable for an out of network provider employed by that hospital. Insurance paid my bill in full.
posted by soren_lorensen at 4:13 PM on December 23, 2018 [21 favorites]
posted by soren_lorensen at 4:13 PM on December 23, 2018 [21 favorites]
It should be illegal for any medical facility to bill itself as accepting a particular insurance plan but employ doctors who don't actually do that. Lots of things about the U.S. medical system are crimes against humanity but this one seems like it should be banned even under current law -- how is that not false advertising?
They also shouldn't be able to pressure people with brain injuries into reading and signing documents regarding the possibility of treatment by out of network doctors in order to receive treatment.
posted by srboisvert at 4:33 PM on December 23, 2018 [17 favorites]
They also shouldn't be able to pressure people with brain injuries into reading and signing documents regarding the possibility of treatment by out of network doctors in order to receive treatment.
posted by srboisvert at 4:33 PM on December 23, 2018 [17 favorites]
Facility fees should be banned. Period.
posted by MartinWisse at 4:44 PM on December 23, 2018 [7 favorites]
posted by MartinWisse at 4:44 PM on December 23, 2018 [7 favorites]
Lord knows the Canadian health care system has plenty of shortcomings, but the grand lifetime total I have paid out of pocket for emergency room visits is $0.00 and the only thing I find scarier than stories like these is the knowledge that there are monied interests up here who look south and view the Canadian health care system as a source of untapped profit.
posted by The Card Cheat at 5:10 PM on December 23, 2018 [37 favorites]
posted by The Card Cheat at 5:10 PM on December 23, 2018 [37 favorites]
It should be illegal for any medical facility to bill itself as accepting a particular insurance plan but employ doctors who don't actually do that.
I went to an ER that was in-network, and while I was completely out of it, with hemoglobin of 6, they transferred me to an out of network hospital. Add that to your list of things that shouldn’t be allowed.
posted by greermahoney at 5:38 PM on December 23, 2018 [31 favorites]
I went to an ER that was in-network, and while I was completely out of it, with hemoglobin of 6, they transferred me to an out of network hospital. Add that to your list of things that shouldn’t be allowed.
posted by greermahoney at 5:38 PM on December 23, 2018 [31 favorites]
> Slarty Bartfast: This project grew out of the Vox podcast The Impact...
Here is Sarah Kliff’s main Vox project page (with links to related articles): Hospitals keep ER fees secret. We’re uncovering them.
posted by cenoxo at 6:02 PM on December 23, 2018 [8 favorites]
Here is Sarah Kliff’s main Vox project page (with links to related articles): Hospitals keep ER fees secret. We’re uncovering them.
posted by cenoxo at 6:02 PM on December 23, 2018 [8 favorites]
It doesn't detract too much from the article, but this map (the map of the distribution of the bills) made me grumble because it doesn't provide any useful information.
Speaking as someone currently working on a PhD in statistics, it’s honestly not a bad figure. It gives you a valuable piece of information: namely, that you’ve gotten a pretty representative sample of ER bills. There can be astoundingly huge amounts of regional variation in healthcare, so being able to rule out that, for example, nearly all the bills came from NY and other Northeast states, is good to know. Like they say—you’ve gotta start somewhere.
If anything, I’m not a fan of the continuous scale used to represent the statewise Ns (would prefer binning based on quantiles) and the transparency of the dots could be a function of their local density, so you can visualize their distribution a bit better. But I don’t think it’s true to say that the map is misleading.
posted by un petit cadeau at 6:04 PM on December 23, 2018 [8 favorites]
Speaking as someone currently working on a PhD in statistics, it’s honestly not a bad figure. It gives you a valuable piece of information: namely, that you’ve gotten a pretty representative sample of ER bills. There can be astoundingly huge amounts of regional variation in healthcare, so being able to rule out that, for example, nearly all the bills came from NY and other Northeast states, is good to know. Like they say—you’ve gotta start somewhere.
If anything, I’m not a fan of the continuous scale used to represent the statewise Ns (would prefer binning based on quantiles) and the transparency of the dots could be a function of their local density, so you can visualize their distribution a bit better. But I don’t think it’s true to say that the map is misleading.
posted by un petit cadeau at 6:04 PM on December 23, 2018 [8 favorites]
I had ankle surgery a few years back, out-patient, under for like an hour. The doc needed a staff member to help roll me over to get in the right angle.
They tried to get me to pay since I didn't refuse and the 'board' determined using a staff member who wasn't covered under my insurance for all of 20 seconds wasn't medically necessary.
posted by 922257033c4a0f3cecdbd819a46d626999d1af4a at 6:06 PM on December 23, 2018 [2 favorites]
They tried to get me to pay since I didn't refuse and the 'board' determined using a staff member who wasn't covered under my insurance for all of 20 seconds wasn't medically necessary.
posted by 922257033c4a0f3cecdbd819a46d626999d1af4a at 6:06 PM on December 23, 2018 [2 favorites]
The problem is certainly magnified by the medical coders that sit at the interface between hospitals and insurance providers. These are skilled tradespeople, employed by hospitals and trained on the ICD code, and their job is to make sure that everything done for patients is billed at the maximum rate possible while still being coded accurately.
I've a relative that does this work and regularly brags about the extra millions of dollars that she's been able to secure for her employer.
I'm not saying that human coders are the cause, but it troubles me that there's room in the system for them to do this work.
posted by qbject at 6:11 PM on December 23, 2018 [25 favorites]
I've a relative that does this work and regularly brags about the extra millions of dollars that she's been able to secure for her employer.
I'm not saying that human coders are the cause, but it troubles me that there's room in the system for them to do this work.
posted by qbject at 6:11 PM on December 23, 2018 [25 favorites]
My husband broke his hip 8 years ago. Went to the ER. (There’s really only one hospital for non-military folks in town.) The orthopedic surgeon on call in the ER was a “locum” doctor, because there aren’t enough orthopedic surgeons in town, so this guy flies up for a week at a time from near Anchorage or something, is the on call doctor for a week, and then goes back to his normal practice.
So anyway, he was in network at his normal practice, but out of network when he was working as a locum surgeon at the in-network hospital. You know, where people have so much choice for which doctor to use.
It took me the better part of 6 months to sort out how to not pay the extra $6000 that they were trying to charge me for the balance billing for the out of network charges. And In the end i had to appeal the insurance’s decision and then send that denial to the hospital and sign a form that the hospital provided saying they would waive the charges.
posted by leahwrenn at 6:13 PM on December 23, 2018 [5 favorites]
So anyway, he was in network at his normal practice, but out of network when he was working as a locum surgeon at the in-network hospital. You know, where people have so much choice for which doctor to use.
It took me the better part of 6 months to sort out how to not pay the extra $6000 that they were trying to charge me for the balance billing for the out of network charges. And In the end i had to appeal the insurance’s decision and then send that denial to the hospital and sign a form that the hospital provided saying they would waive the charges.
posted by leahwrenn at 6:13 PM on December 23, 2018 [5 favorites]
You know, I wanted to say this isn't news. This has been common knowledge forever. We even know how this results from negotiations with insurance companies. But it really should be. Why do we let this happen?
This does bring up a question I often have about economics: When economists say something like "Hospitals lose $10 million a year to X," or "The Healthcare industry loses $3 billion on Y a month," what does it mean? For instance, if hospitals didn't charge $65 for ibuprofen, would someone say that $4 billion was lost that year?
posted by es_de_bah at 6:20 PM on December 23, 2018 [12 favorites]
This does bring up a question I often have about economics: When economists say something like "Hospitals lose $10 million a year to X," or "The Healthcare industry loses $3 billion on Y a month," what does it mean? For instance, if hospitals didn't charge $65 for ibuprofen, would someone say that $4 billion was lost that year?
posted by es_de_bah at 6:20 PM on December 23, 2018 [12 favorites]
The single worst fact here is that no laws were broken. This is the "greatest healthcare system in the world" working as designed.
posted by dances with hamsters at 6:35 PM on December 23, 2018 [6 favorites]
posted by dances with hamsters at 6:35 PM on December 23, 2018 [6 favorites]
For instance, if hospitals didn't charge $65 for ibuprofen, would someone say that $4 billion was lost that year?
Yes, exactly. If the hospital only gets $1 for that ibuprofen, that’s a $64 “loss.” Furthermore, they then put that $64 into their annual report as uncompensated care provided to the community, ie “charity.”
posted by Slarty Bartfast at 6:35 PM on December 23, 2018 [16 favorites]
Yes, exactly. If the hospital only gets $1 for that ibuprofen, that’s a $64 “loss.” Furthermore, they then put that $64 into their annual report as uncompensated care provided to the community, ie “charity.”
posted by Slarty Bartfast at 6:35 PM on December 23, 2018 [16 favorites]
Ah, “charity.” During the original ACA debate I had a conversation with a person well versed in economics (he had been an econ professor). He didn’t see a need for universal health care, as poor people can simply walk into the emergency room for treatment. His claim was that this should be no more expensive than providing “free” health coverage for a doctor’s office or clinic visit.
I’ve consistently also heard health care providers warn about how healthcare costs will skyrocket if we provide coverage for all.
It boggles the mind that none of these folks can fathom taking the profit motive out of the equation in the name of a healthy populace.
posted by SteveInMaine at 7:27 PM on December 23, 2018 [5 favorites]
I’ve consistently also heard health care providers warn about how healthcare costs will skyrocket if we provide coverage for all.
It boggles the mind that none of these folks can fathom taking the profit motive out of the equation in the name of a healthy populace.
posted by SteveInMaine at 7:27 PM on December 23, 2018 [5 favorites]
And emergency rooms are loss leaders.
How can it be that a department can be a loss leader while charging these numbers?
With single payer, the driver of this problem disappears.
posted by billjings at 7:45 PM on December 23, 2018 [2 favorites]
How can it be that a department can be a loss leader while charging these numbers?
With single payer, the driver of this problem disappears.
posted by billjings at 7:45 PM on December 23, 2018 [2 favorites]
I took a friend to the ER recently. They have Medicaid. (I also do) It was such a relief to not have to stress about money and bills on top of the baseline stress and worry about your health. We were treated like human beings, not like customers. It was still the ER, it wasn’t fun, but not needing to think about billing was an immense relief. If I had to go to the ER myself and thought I might get hit with medical debt I might stress vomit.
This dream of free health care, that we “know” is politically impossible to make work here because our system is so dysfunctional - it already exists here. Maybe that’s why the GOP is fighting so hard to kill medicaid. It’s really, really fucking good insurance and it’s practically a crime that most people are trapped in the for-profit system with deductibles and copays.
posted by cricketcello at 7:51 PM on December 23, 2018 [7 favorites]
This dream of free health care, that we “know” is politically impossible to make work here because our system is so dysfunctional - it already exists here. Maybe that’s why the GOP is fighting so hard to kill medicaid. It’s really, really fucking good insurance and it’s practically a crime that most people are trapped in the for-profit system with deductibles and copays.
posted by cricketcello at 7:51 PM on December 23, 2018 [7 favorites]
I spent 8 months arguing with BCBS about in network emergency rooms with out of network doctors. I got pre-approval for that hospital before I went. I got preapproval for the reason I was going. I asked at the front desk and was told my provider was in network. (This ain't my first rodeo.) But, the radiologist, who wasn't at the hospital, but some processing company somewhere in the world, was not in network, and sent a bill for almost two THOUSAND dollars for reading an xray.
How, in the name of all that is sharp and pointy, am I supposed to control where the hospital sends xrays? Especially when they have chosen to send them somewhere where apparently they are being read with solid gold light boards.
posted by SecretAgentSockpuppet at 8:12 PM on December 23, 2018 [23 favorites]
How, in the name of all that is sharp and pointy, am I supposed to control where the hospital sends xrays? Especially when they have chosen to send them somewhere where apparently they are being read with solid gold light boards.
posted by SecretAgentSockpuppet at 8:12 PM on December 23, 2018 [23 favorites]
This...is so hard and crazy. How are people experiencing a medical emergency supposed to treat it like they're shopping for cars? And ask at every stage and then still get billed? That's so stressful.
I broke my leg at this time last year and I did have to wait about 24 hours for surgery because of the queue in front of me but I had adequate to good care the whole time and my cost was $0. I have no idea what any part of my care cost from the painkillers to the nursing to the orthopedic surgeon. I agree the Canadian system has its issues but I can't imagine the stress dealing with all this stuff every time something bad happens.
posted by warriorqueen at 8:29 PM on December 23, 2018 [15 favorites]
I broke my leg at this time last year and I did have to wait about 24 hours for surgery because of the queue in front of me but I had adequate to good care the whole time and my cost was $0. I have no idea what any part of my care cost from the painkillers to the nursing to the orthopedic surgeon. I agree the Canadian system has its issues but I can't imagine the stress dealing with all this stuff every time something bad happens.
posted by warriorqueen at 8:29 PM on December 23, 2018 [15 favorites]
Maybe that’s why the GOP is fighting so hard to kill medicaid. It’s really, really fucking good insurance and it’s practically a crime that most people are trapped in the for-profit system with deductibles and copays.
From a business perspective, though, it’s not. Medicaid pays between 30 and 50% what private insurance pays and it’s part of the reason why ibuprofen costs $65 if you are uninsured or have Cadillac private insurance. The hospital is trying to balance the books capturing whatever revenue they can. Hospitals take Medicaid to maintain their non profit status and to recoup some revenue where they would otherwise get none. But if you have too many Medicaid patients and not enough higher paying patients you are in serious financial trouble. Many private practices opt out of Medicaid altogether if they can. Places like county hospitals and community health centers get direct government subsidies or enhanced Medicaid reimbursement rates just so Medicaid patients don’t run out of places to go. It’s true that the individual nurses or providers taking care of you may not know if you’re a Medicaid patient and they just treat you like a patient, but the hospital administration sure as hell does and if you are costing too much money, like not getting well fast enough or going to the ER too much, they will act. It’s created a two tier system and is part of the reason there’s all this action on the part of hospitals to aggressively bill people as much as they can. As well as the insurers taking retaliatory action to aggressively not pay as much as they can. And the thing that allows all of this is that hospitals don’t commit to a particular charge as long as they can get away with it, they assume that each patient is going to pay a different amount and so to deal with that they charge these crazy amounts that don’t correspond to anything anyone actually pays. And prices overall get inflated and no one can “shop” effectively for health care.
The whole idea that people can actually do cost comparison in seeking care is a whole different argument, but what we have now is neither an efficient system nor market based, so what is it? It’s a system that employs a huge administrative middle man to negotiate while keeping insurers and hospitals as profitable as possible without regard to things like effectiveness or efficiency.
posted by Slarty Bartfast at 8:41 PM on December 23, 2018 [29 favorites]
From a business perspective, though, it’s not. Medicaid pays between 30 and 50% what private insurance pays and it’s part of the reason why ibuprofen costs $65 if you are uninsured or have Cadillac private insurance. The hospital is trying to balance the books capturing whatever revenue they can. Hospitals take Medicaid to maintain their non profit status and to recoup some revenue where they would otherwise get none. But if you have too many Medicaid patients and not enough higher paying patients you are in serious financial trouble. Many private practices opt out of Medicaid altogether if they can. Places like county hospitals and community health centers get direct government subsidies or enhanced Medicaid reimbursement rates just so Medicaid patients don’t run out of places to go. It’s true that the individual nurses or providers taking care of you may not know if you’re a Medicaid patient and they just treat you like a patient, but the hospital administration sure as hell does and if you are costing too much money, like not getting well fast enough or going to the ER too much, they will act. It’s created a two tier system and is part of the reason there’s all this action on the part of hospitals to aggressively bill people as much as they can. As well as the insurers taking retaliatory action to aggressively not pay as much as they can. And the thing that allows all of this is that hospitals don’t commit to a particular charge as long as they can get away with it, they assume that each patient is going to pay a different amount and so to deal with that they charge these crazy amounts that don’t correspond to anything anyone actually pays. And prices overall get inflated and no one can “shop” effectively for health care.
The whole idea that people can actually do cost comparison in seeking care is a whole different argument, but what we have now is neither an efficient system nor market based, so what is it? It’s a system that employs a huge administrative middle man to negotiate while keeping insurers and hospitals as profitable as possible without regard to things like effectiveness or efficiency.
posted by Slarty Bartfast at 8:41 PM on December 23, 2018 [29 favorites]
I went to the ER with a burst ovarian cyst about eight weeks ago. I made absolutely certain the ambulance took me somewhere in network (St. David's). Didn't matter because Blue Cross Blue Shield isn't even negotiating favorable rates on the basics under my current plan but I only found out after the fact. The hospital charged me $465 for a pee on a stick pregnancy test and the in-network rate I paid out of pocket was $182 for the single test. Medicaid reimburses $8.61 for that. Walgreens sells them in a 2 pack box for $10. Would have been the same if I went to the other major hospital chain, most likely, and there was no way of knowing my insurance was this bad until I landed in the ER. This hospital, which is only one of two major hospital groups in the city of Austin, is profiting to the tune of >$100 on every single woman between the ages of 10-50 who walks in their ER doors no matter what else is wrong with her; pregnancy testing is automatic in women of child bearing age and the fact that I could have had appendicitis instead and still been charged more than a man with identical symptoms and treatment is salt in the wound. I had an ultrasound, a CBC and a handful of other labs, no surgery, and met my $3K deductible. The ACA was supposed to level the cost burden between men and women, but that's impossible under high deductible fee-for-service care, which is what most American women like me have.
I called my insurer and the hospital and specifically asked where they got off charging me 22x the Medicaid rate on this particular test, and both people who answered the phone sputtered nonsense/indignation and refused to answer the question. Honestly, I would have been almost satisfied by someone just owning the price and telling me how they arrived at it. It was all I could do to not scream into the phone "just tell me how you're fucking me!"
posted by slow graffiti at 9:27 PM on December 23, 2018 [30 favorites]
I called my insurer and the hospital and specifically asked where they got off charging me 22x the Medicaid rate on this particular test, and both people who answered the phone sputtered nonsense/indignation and refused to answer the question. Honestly, I would have been almost satisfied by someone just owning the price and telling me how they arrived at it. It was all I could do to not scream into the phone "just tell me how you're fucking me!"
posted by slow graffiti at 9:27 PM on December 23, 2018 [30 favorites]
This hospital, which is only one of two major hospital groups in the city of Austin, is profiting to the tune of >$100 on every single woman between the ages of 10-50 who walks in their ER doors no matter what else is wrong with her; pregnancy testing is automatic in women of child bearing age
Just in case anyone is doubting the mandatory nature of pregnancy testing for women who go to the ER.
At my ER visit for suspected Benign Positional Vertigo
Doctor: “Is there any chance you’re pregnant?”
Me: “None. I’m a virgin and I haven’t been anywhere near a penis in the last 9 months.”
Doctor: “Okay. Please pee in this cup.”
Years later, for a sprained ankle
Doctor: “Is there any chance you’re pregnant?
Me: “My boyfriend has had a vasectomy, and in addition to that we always use condoms”
Doctor: “Okay. Please pee in this cup.”
Thankfully I am in Canada, so I don’t have to worry about being billed for these tests. I just roll my eyes and wonder why they even bother asking me the question if step 2 is always “Please pee in this cup” regardless of why I’m at the ER in the first place.
posted by Secret Sparrow at 10:25 PM on December 23, 2018 [14 favorites]
Just in case anyone is doubting the mandatory nature of pregnancy testing for women who go to the ER.
At my ER visit for suspected Benign Positional Vertigo
Doctor: “Is there any chance you’re pregnant?”
Me: “None. I’m a virgin and I haven’t been anywhere near a penis in the last 9 months.”
Doctor: “Okay. Please pee in this cup.”
Years later, for a sprained ankle
Doctor: “Is there any chance you’re pregnant?
Me: “My boyfriend has had a vasectomy, and in addition to that we always use condoms”
Doctor: “Okay. Please pee in this cup.”
Thankfully I am in Canada, so I don’t have to worry about being billed for these tests. I just roll my eyes and wonder why they even bother asking me the question if step 2 is always “Please pee in this cup” regardless of why I’m at the ER in the first place.
posted by Secret Sparrow at 10:25 PM on December 23, 2018 [14 favorites]
I'd be more impressed by economics-of-hospitals arguments if the total compensation for any individual were capped at 10x the pay of the lowest paid employee.
...oh, no, now the Humana CEO can't engage in philanthropy, what shall we do? Surely his (always a "his") excellence is the only reason why healthcare can exist!
posted by aramaic at 12:03 AM on December 24, 2018 [1 favorite]
...oh, no, now the Humana CEO can't engage in philanthropy, what shall we do? Surely his (always a "his") excellence is the only reason why healthcare can exist!
posted by aramaic at 12:03 AM on December 24, 2018 [1 favorite]
The VOX project is also tied to Elizabeth Rosenthal's writing about the US system. I read her book, An American Sickness, and it does a decent job of examining the growth of rent-seeking and profit-taking that has inflated the prices of health care here. Over the last several years I've read a lot about the US system from the perspectives of doctors and patients. It seems as if doctors and patients are both getting shafted, while insurance companies, medical device manufacturers, administrators, and pharmaceutical companies are gaming the system in every possible way.
I have worked at many major corporations and am familiar with how, in concert with the big accounting firms, these corporations take advantage of every loophole in tax and commerce laws around the world and use tax havens to minimize their taxes. Search "doing business in" and you will see globalization guides from E&Y and Deloitte.
These same accounting firms are advising hospitals and various US medical facilities on how to wring the most possible profit out of the system. The really sad part is that I know some excellent practitioners who are leaving the profession because they are sick of all the insanity they have to endure that often gets in the way of providing good medical care. As so often happens in our culture, the pendulum swings to the extremes and we try to legislate away the necessity for us to use common sense and good judgement.
posted by Altomentis at 3:44 AM on December 24, 2018 [3 favorites]
I have worked at many major corporations and am familiar with how, in concert with the big accounting firms, these corporations take advantage of every loophole in tax and commerce laws around the world and use tax havens to minimize their taxes. Search "doing business in" and you will see globalization guides from E&Y and Deloitte.
These same accounting firms are advising hospitals and various US medical facilities on how to wring the most possible profit out of the system. The really sad part is that I know some excellent practitioners who are leaving the profession because they are sick of all the insanity they have to endure that often gets in the way of providing good medical care. As so often happens in our culture, the pendulum swings to the extremes and we try to legislate away the necessity for us to use common sense and good judgement.
posted by Altomentis at 3:44 AM on December 24, 2018 [3 favorites]
So anyway, he was in network at his normal practice, but out of network when he was working as a locum surgeon at the in-network hospital. You know, where people have so much choice for which doctor to use.
Oh, gods, I run into this duplicitous bs constantly. Around here, it's not unusual for doctors to split their work week between satellite offices (of the same medical group mind you). But, my insurer has them as being in-network in one office, but not the other office. For instance, I have an ENT who is in-network only at the office that is over 30 minutes away, but not in-network at her office just down the street from me. wtf??? It's the same. Damned. Medical group.
In another example, with the insurance I currently have, my gastrointerologist is in-network only at the hospital where he performs surgery, but not in-network at his office where he actually meets with and examines patients. How...???? I don't even...
posted by Thorzdad at 5:51 AM on December 24, 2018 [5 favorites]
Oh, gods, I run into this duplicitous bs constantly. Around here, it's not unusual for doctors to split their work week between satellite offices (of the same medical group mind you). But, my insurer has them as being in-network in one office, but not the other office. For instance, I have an ENT who is in-network only at the office that is over 30 minutes away, but not in-network at her office just down the street from me. wtf??? It's the same. Damned. Medical group.
In another example, with the insurance I currently have, my gastrointerologist is in-network only at the hospital where he performs surgery, but not in-network at his office where he actually meets with and examines patients. How...???? I don't even...
posted by Thorzdad at 5:51 AM on December 24, 2018 [5 favorites]
I took a friend to the ER recently. They have Medicaid. (I also do) It was such a relief to not have to stress about money and bills on top of the baseline stress and worry about your health.
Our 1 year old has what is basically Medicaid, and it's very possible that it has saved his life. He's had (minor if treated) breathing issues most of his life, and there's no way we would have caught it as early if we were running a bunch of mental math whenever we thought that he might need a doctor.
For that matter, we took him to urgent care for what seemed like a minor thing not too long ago, and we ended up getting triaged to the front of the line and then sent to the ER...and threatened with an ambulance ride there if I didn't pinky swear I would drive him straight there. All over something I almost didn't take him in for. I'm sure I would have waited a few days if we had to think about the financial implications of just checking if something was a problem.
posted by Nonsteroidal Anti-Inflammatory Drug at 7:22 AM on December 24, 2018 [7 favorites]
Our 1 year old has what is basically Medicaid, and it's very possible that it has saved his life. He's had (minor if treated) breathing issues most of his life, and there's no way we would have caught it as early if we were running a bunch of mental math whenever we thought that he might need a doctor.
For that matter, we took him to urgent care for what seemed like a minor thing not too long ago, and we ended up getting triaged to the front of the line and then sent to the ER...and threatened with an ambulance ride there if I didn't pinky swear I would drive him straight there. All over something I almost didn't take him in for. I'm sure I would have waited a few days if we had to think about the financial implications of just checking if something was a problem.
posted by Nonsteroidal Anti-Inflammatory Drug at 7:22 AM on December 24, 2018 [7 favorites]
Yeah, my teenager had an accident and needed to go via ambulance to the hospital, which is in-network. ER Doc #1 determined the situation was serious enough that he needed to be transfered to hospital #2, via ambulance. (First they did a stabilizing procedure, performed by ER Doc #2, who had to be called in from home.) Kid had surgery, was in the hospital for four days, had months of recovery via wheelchair, later crutches and brace. Endless rounds of PT. A second surgery. More PT.
Through all of this, the biggest bill that we were on the hook for? That single ER doc who said "We can't treat him here." That guy -- a SURPRISE! out of network guy at the in-network hospital -- sent us a bill for thousands. I fought it in a million different ways, but was still on the hook. Finally, long story short: got rid of that bill by posting a one-star Yelp review. Yep, that's what did it.
posted by BlahLaLa at 8:57 AM on December 24, 2018 [24 favorites]
Through all of this, the biggest bill that we were on the hook for? That single ER doc who said "We can't treat him here." That guy -- a SURPRISE! out of network guy at the in-network hospital -- sent us a bill for thousands. I fought it in a million different ways, but was still on the hook. Finally, long story short: got rid of that bill by posting a one-star Yelp review. Yep, that's what did it.
posted by BlahLaLa at 8:57 AM on December 24, 2018 [24 favorites]
> We need price transparency in health care.
No. We need a system where the patient and their family are completely free from any concern about any such details.
At most you just pay your totally-unmysterious small deductible or copay and let the providers and Single Payer worry about the rest.
posted by goinWhereTheClimateSuitsMyClothes at 9:48 AM on December 24, 2018 [10 favorites]
No. We need a system where the patient and their family are completely free from any concern about any such details.
At most you just pay your totally-unmysterious small deductible or copay and let the providers and Single Payer worry about the rest.
posted by goinWhereTheClimateSuitsMyClothes at 9:48 AM on December 24, 2018 [10 favorites]
We're not perfect over here in Aus by any stretch, but I'll leave this here as a counterpoint.
We just had our kid in a public hospital in Melbourne. The birth was normal enough but he ended up with a few temperature regulation issues and showed signs of infection, so he ended up spending a night in special care, spent two days longer than expected in hospital and had more tests done than you can poke a needle at.
We won't pay a cent for any of this, there was never any question that we would. This is open to anyone that's covered by Medicare, which is most people in Australia and applies to broken legs and cancer as much as to babies. And overall as a country we pay less per capita on healthcare than you guys, for comparable quality. I'll state that again, doing things this way is cheaper.
posted by deadwax at 12:44 PM on December 24, 2018 [5 favorites]
We just had our kid in a public hospital in Melbourne. The birth was normal enough but he ended up with a few temperature regulation issues and showed signs of infection, so he ended up spending a night in special care, spent two days longer than expected in hospital and had more tests done than you can poke a needle at.
We won't pay a cent for any of this, there was never any question that we would. This is open to anyone that's covered by Medicare, which is most people in Australia and applies to broken legs and cancer as much as to babies. And overall as a country we pay less per capita on healthcare than you guys, for comparable quality. I'll state that again, doing things this way is cheaper.
posted by deadwax at 12:44 PM on December 24, 2018 [5 favorites]
Isn't part of the problem that there is no one with power who has any real incentive to make a more rational efficient system? Doctors don't want to take a cut in pay, administrators would like a raise, every nursing student wants to be a nurse anesthetist. Insurance companies...... Do doubt there are significant ways to wring more out of the system but in the end isn't the basic truth that everyone involved would have to have their ox gored to some extent if we were to have a sane health care system?
It seems to me that a lot of the most important people in the system are powerless, poorly paid, given shit status. Who? The CNA/caregivers. The people upon who the prevention of bed sores, infection, and broken hips depends.
posted by Pembquist at 4:00 PM on December 24, 2018 [2 favorites]
It seems to me that a lot of the most important people in the system are powerless, poorly paid, given shit status. Who? The CNA/caregivers. The people upon who the prevention of bed sores, infection, and broken hips depends.
posted by Pembquist at 4:00 PM on December 24, 2018 [2 favorites]
isn't the basic truth that everyone involved would have to have their ox gored to some extent if we were to have a sane health care system?
No. Remove the profit motive, and hospitals can collect enough to pay all the people what they need -- maybe even what they want. You just don't pay shareholders, and you don't pay executives whose sole purpose is figuring out what they can overcharge for to drive up revenue for a nonprofit's board of directors.
It may mean reductions in income for those doctors who relied on insisting on office visits instead of phone instructions, or who rake in money via referrals and endless tests. But for the most part, the ridiculous medical bills aren't caused by inflated paychecks. They're caused by weird profit collecting and the administrative costs required to seek profit and attempt to reduce costs while providing service to people who don't have the option of refusing if they want to stay alive.
posted by ErisLordFreedom at 4:55 PM on December 24, 2018 [5 favorites]
No. Remove the profit motive, and hospitals can collect enough to pay all the people what they need -- maybe even what they want. You just don't pay shareholders, and you don't pay executives whose sole purpose is figuring out what they can overcharge for to drive up revenue for a nonprofit's board of directors.
It may mean reductions in income for those doctors who relied on insisting on office visits instead of phone instructions, or who rake in money via referrals and endless tests. But for the most part, the ridiculous medical bills aren't caused by inflated paychecks. They're caused by weird profit collecting and the administrative costs required to seek profit and attempt to reduce costs while providing service to people who don't have the option of refusing if they want to stay alive.
posted by ErisLordFreedom at 4:55 PM on December 24, 2018 [5 favorites]
You underestimate the extent to which doctors who get a piece of the billing order unnecessary tests and procedures. They're doing it with Medicare, so why would we expect they aren't doing it to everyone else.
(Not all doctors, by any means, though it is near enough all in a few cities)
posted by wierdo at 6:48 PM on December 24, 2018
(Not all doctors, by any means, though it is near enough all in a few cities)
posted by wierdo at 6:48 PM on December 24, 2018
No. Remove the profit motive, and hospitals can collect enough to pay all the people what they need -
I read the link and I remain unpersuaded. It seems to be saying that doctors won't mind having their ox gored and everybody else doesn't deserve the money anyway. While they may well not the fact remains that most people are not going to go along with having their jobs eliminated or their pay cut. We cannot just wave a wand.
Trust me, I think the existing system is ridiculous but I don't think it is going to change without some economic casualties who will fight back hard.
posted by Pembquist at 7:53 PM on December 24, 2018 [2 favorites]
I read the link and I remain unpersuaded. It seems to be saying that doctors won't mind having their ox gored and everybody else doesn't deserve the money anyway. While they may well not the fact remains that most people are not going to go along with having their jobs eliminated or their pay cut. We cannot just wave a wand.
Trust me, I think the existing system is ridiculous but I don't think it is going to change without some economic casualties who will fight back hard.
posted by Pembquist at 7:53 PM on December 24, 2018 [2 favorites]
[WP] Health insurance in the United States > History:
posted by cenoxo at 10:28 PM on December 24, 2018
In 1935 the decision was made by the Roosevelt Administration not to include a large-scale health insurance program as part of the new Social Security program. The problem was not an attack by any organized opposition, such as the opposition from the American Medical Association that derailed Truman's proposals in 1949. Instead, there was a lack of active popular, congressional, or interest group support. Roosevelt's strategy was to wait for a demand and a program to materialize, and then if he thought it popular enough to throw his support behind it.It's a long, winding road with no end in sight and not enough guardrails.
His Committee on Economic Security (CES) deliberately limited the health segment of Social Security to the expansion of medical care and facilities. It considered unemployment insurance to be the major priority. Roosevelt assured the medical community that medicine would be kept out of politics. Jaap Kooijman says he succeeded in "pacifying the opponents without discouraging the reformers." The right moment never came for him to reintroduce the topic.[23][24]
posted by cenoxo at 10:28 PM on December 24, 2018
No. We need a system where the patient and their family are completely free from any concern about any such details.
I agree with you, but there is simply no way to enact any specific legislation for this when health care costs are a huge unknown. You can’t allocate money or make calculations about cost/benefit if hospitals and insurers are always able to game the system to take care of their bottom line.
I believe patients and providers should be acting without (much) concern for the bill, but you cannot create a system that automatically covers and compensates care when the cost of an appendectomy could be anywhere from $3000 to $30,000. Hospitals need to get used to the idea of providing care for a set price before we can get buy in to have a single payer or “Medicare for All” (note: Medicare, the way it works now is nearly entirely administered by private insurance companies) or whatever. People need to be thinking about the smaller steps that will get us from here to there before we just say “single payer!” Otherwise we continue in stalemate and the current mess just builds and builds. Mysterious charges are the next thing that needs to get fixed before we can do anything else.
posted by Slarty Bartfast at 10:34 PM on December 24, 2018 [5 favorites]
I agree with you, but there is simply no way to enact any specific legislation for this when health care costs are a huge unknown. You can’t allocate money or make calculations about cost/benefit if hospitals and insurers are always able to game the system to take care of their bottom line.
I believe patients and providers should be acting without (much) concern for the bill, but you cannot create a system that automatically covers and compensates care when the cost of an appendectomy could be anywhere from $3000 to $30,000. Hospitals need to get used to the idea of providing care for a set price before we can get buy in to have a single payer or “Medicare for All” (note: Medicare, the way it works now is nearly entirely administered by private insurance companies) or whatever. People need to be thinking about the smaller steps that will get us from here to there before we just say “single payer!” Otherwise we continue in stalemate and the current mess just builds and builds. Mysterious charges are the next thing that needs to get fixed before we can do anything else.
posted by Slarty Bartfast at 10:34 PM on December 24, 2018 [5 favorites]
Maybe people should bring their own clipboard and checklist to intake, for the hospital to complete.
People should also stop ignoring the Insurance Commissioner races in their states. It's on the ballot because it's politics, not just economics. Elections matter. Yes, a lot of this is Federal and emerges from having Medicare/Medicaid intertwined with the for-profit system but there is still a lot of influence to be exerted at the state level.
posted by snuffleupagus at 6:15 AM on December 25, 2018 [2 favorites]
People should also stop ignoring the Insurance Commissioner races in their states. It's on the ballot because it's politics, not just economics. Elections matter. Yes, a lot of this is Federal and emerges from having Medicare/Medicaid intertwined with the for-profit system but there is still a lot of influence to be exerted at the state level.
posted by snuffleupagus at 6:15 AM on December 25, 2018 [2 favorites]
the cost of an appendectomy could be anywhere from $3000 to $30,000
It says £3299 (no complications) to a maximum of £6205 (plus £293 per day after 9 days) here. $30,000 seems very expensive.
posted by ambrosen at 11:16 AM on December 25, 2018
It says £3299 (no complications) to a maximum of £6205 (plus £293 per day after 9 days) here. $30,000 seems very expensive.
posted by ambrosen at 11:16 AM on December 25, 2018
I talked with a biller at Seattle Children’s hospital for a paper I wrote last quarter and after doing a bunch of calculations that took her a week, a ruptured appendix with sepsis and surgery and a conservative 6 day admission, assuming no mechanical ventilation, no kidney failure, and a 2 day ICU stay would cost $60,000 here. In round numbers. God knows, with a complicated stay like that, they’d bill for things like anesthesia for pain management post op, GI consult, probably nutrition and social work consults. Even she was like “this is leaving out a lot of things we’d be looking at in the medical record.”
posted by Slarty Bartfast at 10:14 PM on December 25, 2018 [4 favorites]
posted by Slarty Bartfast at 10:14 PM on December 25, 2018 [4 favorites]
If we can’t have a big centrally controlled health care system in the US because of our zealous devotion to the almighty free market, then we should have a free market. There is a house bill that is essentially dying in committee right now to require price transparency and the hospitals giving a reasonable estimate of out of pocket costs prior to service, but this would be a huge revolution in how hospitals are paid and no surprise the AHA is against it.
This makes sense but it's so crazy to me. My cat is having a tough time, medically, and I've been working with my vet a lot lately, and every single time they do anything about anything I get a printed out price sheet showing exactly what they'll bill me for, with a high and a low estimate for how much of each line item, summed into a high and a low overall estimate. If a small vet's office can manage that, it shouldn't be hard for a large hospital to do so.
posted by vibratory manner of working at 11:48 AM on December 27, 2018
This makes sense but it's so crazy to me. My cat is having a tough time, medically, and I've been working with my vet a lot lately, and every single time they do anything about anything I get a printed out price sheet showing exactly what they'll bill me for, with a high and a low estimate for how much of each line item, summed into a high and a low overall estimate. If a small vet's office can manage that, it shouldn't be hard for a large hospital to do so.
posted by vibratory manner of working at 11:48 AM on December 27, 2018
Consider also that Ambulance trips can leave you with surprising — and very expensive — bills [WaPo, 11/20/2017]:
posted by cenoxo at 2:23 PM on December 29, 2018 [2 favorites]
[PHOTO — Devin Hall was billed more than $7,100 for an ambulance ride of about 20 miles. “These charges are exorbitant,” he said. (Heidi de Marco/Kaiser Health News)]Ambulance charges may be negotiable.
One patient got a $3,660 bill for a four-mile ride. Another was charged $8,460 for a trip from a hospital that could not handle his case to another that could. Still another found herself marooned at an out-of-network hospital, where she'd been taken by ambulance without her consent.
These patients all took ambulances in emergencies and got slammed with unexpected bills. Public outrage has erupted over surprise medical bills — generally out-of-network charges that a patient did not expect or could not control — prompting 21 states to pass laws over the years protecting consumers in some situations. But these laws largely ignore ground ambulance rides, which can leave patients stuck with hundreds or even thousands of dollars in bills and with few options for recourse, finds a Kaiser Health News review of 350 consumer complaints in 32 states.
posted by cenoxo at 2:23 PM on December 29, 2018 [2 favorites]
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[T]here are, as Slate has noted, patients who have had their bills reversed after journalists wrote about them. Our project, for example, has resulted in $45,107 in medical bills being reversed after Vox began inquiring about those charges.
posted by doctornemo at 2:45 PM on December 23, 2018 [12 favorites]