So dumb, tacky, and aggressive?
He said Murica, not my style in high school.
Some good and interesting news at the state level: California Assembly Bill 72, which took effect on July 1st, prevents consumers in CA from being billed by out-of-network providers if the consumer obtained service at an in-network facility. This prevents âsurprise billingâ and âbalance billingâ where a consumer goes to an in-network facility but the facility then has out-of-network providers that do some of the treatment.
This is good news for CA consumers as this kind of ass-hattery is a good example of whatâs wrong with the âmarket-basedâ American health care system.
It is also interesting news from a health wonk perspective b/c of how it regulates the interaction between providers and health insurers. If the consumer canât be billed for the out-of-network charges, does that mean the health insurance just has to pay whatever ridiculous inflated sticker price the provider slaps on a service? No, under AB 72, the health insurance will pay either the âaverage contracted rateâ (which is the average of what the insurance companies pay per their fee schedules) or 125% of the Medicare rate, whichever is greater. This is a somewhat weaker version of the âall-payer rate settingâ concept I mentioned above.
Whatâs interesting about it is that, although it is on the weak side (a stronger version would not be the average or 125% Medicare, but whatever is lowest), is that it is a form of meaningful health care price reform, the first I am aware of in CA. Itâs an example of how we can make changes to health care pricing to offset the inelasticity of demand and increase rationality in health care pricing.
Itâs a baby step in terms of health care pricing reform, but itâs a baby step in the biggest state in the country. Iâll take what I can get.
That set-up could encourage these provider groups to actually contract with the payors instead of, you know, not doing that. The facility doesnât usually have a choice in this matter. They canât force these groups to be employees, but they also canât do say surgery without anesthesia.
And that seems so crazy that anesthesia is somehow separate from the whole procedure. it would be like buying a car, but having to pay separately for the seat beats, doors and wheels. It was the weirdest part of moving from the Netherlands to the US.
Itâs not the drug, or really the procedure⌠itâs the person. If say the anesthesiologists are not employed by the hospital, the health system⌠you canât force them to be employees. They can get more money, autonomy, something that has them practicing outside the hospitals. Itâs the same with some of the ER physicians. Sometimes theyâre employees, sometimes theyâre a group you basically bring in and they can bill separately. Sometimes itâs a mix of the two.
I mean we would sometimes have a clinic, a center, park themselves literally across the street from the hospital in direct competition with the hospital. This can happen sometimes because a provider group might get paid more for the exact same procedure if they bill it under their group and not say under the hospital. They tell what facility it is based on different numbers you put on a claim, like an NPI.
So you have this procedure, say like kidney dialysis, just an example. For whatever reason, Medicare decides itâs going to pay more for the service, a service the hospitals have been providing all along⌠suddenly hot dog it pays enough for some group to park across the street, they start offering the service, make a profit. A couple of years later, they drop the price, maybe the hospitals pointed out that hey you pay this group more now, weâve been providing for years, but now you just created a situation where a service that was barely profitable or maybe not even profitable at all suddenly becomes worthwhile. Then they drop the price, the center or clinic fold or maybe once the gravy train is over they go to the hospital and say hey, weâve got a practice, weâve got patience, we kind of prefer a steady paycheck and want to take advantage of your economies ⌠what do you say, and boom, youâve got more clinical staff. You may or may not have the building, itâs often leasedâŚ
But you canât force physicians, clinicians or other providers to work for you. If all the local anesthesiologist contract out, the you have to contract with them. You can try and employ them but there is usually something the stops that.
Heck my little nephew was in the NICU, something you never hope to have happen, and my sister took almost 3 years to get all that straightened out. The hospital and the nursery were in network, but the staff in the NICU were not. The NICU has specialized staff. When they quote you, theyâre not going to say hey if your baby is really sick or small the NICU is different. That provider, the physician, theyâre choosing not to contract with the insurance providers and they were probably not house staff. Hospitalists tend to be house staff.
In short⌠itâs complex.
It is, but itâs also not. The reasons we got to this situation may be complex, but the result is simple.
Simply immoral and broken. I want to break the backs of people who practice this shady accounting scam.
Well I am using anesthesiologist as an example, but I believe theyâre schooling is around 8 years, at least, so that puts them around 300k for student debt. In addition, thatâs a pretty risky practice, their insurance is going to be sky high. I mean if you look at procedures that donât require basically âgoing underâ and those that don, weâre not just talking about just the price of someoneâs service that makes that jump up.
Iâve worked for 3 different healthcare systems now, each is a combination of clinics and hospitals, and because of my application experience, I have done some professional billing but primarily hospital, the system side. Iâm IT not billing. I donât recall anyone of that specific specialty being employed by those systems.
In my area, there was one, literally one, very high risk baby doc, to put it simply. This guy, he not only could command his price but he ran his practice in away that pretty much every system he worked with did it his way. They did not want to make this physician mad by not accommodating him. We had entire workflows built just for him. Everyone I know who used him hated his bed side manner, he wasnât pleasant to work with, very rude but if at any point during your pregnancy you had an issue that made your âregularâ physician nervous, this was the guy. Very, very good at what he does. He kept getting chosen, by patience and referring physicians for a reason.
This is true in every industry; employment in this country is by consent.
This begs the question: why is the health industry different? The answer is primarily inelastic demand.
Pretty much every aspect of the health care pricing issue points back at the underlying market imperfections in health care. In a healthy market, providers couldnât hide their prices the way they do. Can you imagine a store refusing to give you a price on a console before you contracted to buy it? In a healthy market, this surprise out of network issue would not exist. Can you imagine taking your car or PC or any other mechanical device in for repairs at a set estimate and then getting a surprise bill for 3X to 5X b/c an âoutside expertâ had to be brought in? For a repair, if extra work or specialized work is required, this is disclosed to the consumer, and express advance consent is required. Thatâs not the case in hospital care, b/c the patient is usually not in a position to make that decision, or to handle a delay. And that illustrates the fundamental problem: patients, especially hospital, surgical and critical care patients, are not typical consumers. They are not in the position of a typical consumer, for a variety of reasons. The health care market, for the high cost items like hospitalization and surgery, does not function like a normal consumer market.
So we have to stop treating health care like a normal consumer market. We have to stop relying on a purely market pricing mechanism, as that has been proven to be deeply flawed for health care.
There are a range of options to address this, from the fairly modest pricing reforms in CA AB 72, through various âall-payerâ rate concepts, up through formal government price regulation. In the short run, I tend to favor exploring all-payer options, but we definitely need to try various solutions to determine the most effective.
Iâm not sure how this is relevant. That 300K in dept will yield net lifetime earnings (all in current dollars) of about $7.5 million, which is about $6 million more than the average US worker. Itâs also about $3 million more than the net lifetime earnings of a GP. Medical specialists in this country, even after accounting for overhead, malpractice insurance, etc., have extremely high net earnings. The figures I am using do factor in the shorter working career and longer educational time of doctors as well.
So you have to compare an education cost of $200K to $300 to lifetime earnings that are $3 million to $6 million higher than the average American. Any way you slice that, itâs a truly fantastic return on investment.
But your comparing a product to a service. When I call a plumber or an electrician they might post their prices but what does that really tell me. If this person is 92 dollars for a diagnostic and 50 an hour and this guy is free diagnostics but 75 an hour⌠what does that mean really? How good are they? What if this one takes longer than the other. Am I getting good experience. Am I being charged for something that isnât even broken. Healthcare is more a service, I think, than a product, and there are a lot of services where the advertised price does not necessarily tell you itâs a good deal or how much it will cost, and I donât know about you, but I donât hit Craigslist to find the cheapest electrician I can find. And when I need an electrician, the demand is pretty damn inelastic.
I have the illusion of choice but not the transparency. I can try and use something like Yelp and word of mouth, but most the time they tell me the same thing⌠I canât tell you without looking at first, 100 bucks just for showing up.
Letâs say you get diagnosed with, idk, cancer in your head.
You do everything youâre supposed to do. You go to a specialist oncologist, because itâs an unusual cancer. You haul your ass out to that specialist, because sheâs the person youâre told is the one to go to in this region. You pay out the ass for her diagnosis. You almost fucking die because the surgery to resect the cancer is invasive as fuck and has a bunch of side effects.
Thatâs all great. You re-affirmed with your insurance company that she and her hospital (these are often different billing entities, btw) are in-network. So they cover it at the whatever rate, and pay for everything past your out-of-pocket limit (thanks, Obama).
But then you get a bill for another $30,000 for a consulting neurologist who hung out during the 12 hours you were in surgery for. Youâve never met him. Youâve never consented to his services, or his price scale, or any goddamned thing about him.
Under United States law, this is totally fine and you just need to suck it up for #FREEDOM.
(Except for the last part, the whole story is very personal and very accurate. But I was warned at every step of the way that it was MY RESPONSIBILITY to make sure the last thing didnât happen to me. Because thatâs what a newly diagnosed cancer patient fucking needs.
And yeah, there was exactly that consulting neurosurgeon in my OR. Never met him. But honestly Iâm lucky he didnât decide to bill in a different way, because that could very well have been my $30,000 and my bankruptcy to make sure that his boat was immaculate as fuck.)
I dare anyone to defend this setup as anything but blatantly fucking evil in 2017 in the United States. Please.
Please donât try to make these facile comparisons between healthcare and any other service. Youâre right that itâs a service and not a product, but the relationship between consumer and service is entirely different than any other service.
Just because you donât like the comparison, doesnât make it irrelevant. Services are harder to get a cost comparisons for than products. The price doesnât always reflect the service I am getting either. Thatâs a fact. I had 4 different quotes this summer for the same service from different companies with wildly different prices. Itâs a fair comparison. Just because your emotions are more raw with health care than they are with lawn replacement services doesnât make it not fair.
Youâre example isnât that much different than the NICU example I gave by the way. Not many really plan to have their babies hang out in the NICU. Itâs not something you can easily, if at all plan for. And ACA did try and assist with surprise costs with the maximum out of pocket limits and getting rid of the life time and annual maxes, in and out of network.
lol wait
wait
wait
âŚwaaaaaaaaaaiiiiiiiiittttt
Yeah when youâre not drunk anymore, please let me know.
Okay when youâre not comparing your lawn service to someoneâs life-or-death-or-bankruptcy choice under extreme duress, let me know.
I know it pays your bills, but that doesnât make it right.
Not only do you know very little about me, you clearly donât want to understand healthcare in this country or any other place. Is this the part where I say please and then tell you to fuck off or do I wait for some other response and then do it? I need clarification so I can follow your fine example.
Itâs still insane. Here is a great article from the NY Times that shows how screwed up our hospital system really is. Itâs about travelling to belgium to get a cheaper procedure.
The description of the procedure in Belgium -
The description of a second service provided in the US.
I agree with the general premise : that part of the reason why US healthcare is also expensive is that average âqualityâ of care is too high and people pay through the nose for it.
Itâs fine to have an expensive option for those who want to pay for it but there needs to be a standard tier that is more accessible.