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The Hospital Charging Games  
User currently offlineKen777 From United States of America, joined Mar 2004, 8191 posts, RR: 8
Posted (1 year 2 months 3 weeks 3 days 11 hours ago) and read 2732 times:


Some good examples:

There has been a huge amount of complaints blaming President Obama for all the increases in private health insurance. This week the public is finally getting some real data on the charges from various hospitals around the country and it's easy to see why people (and companies) paying health insurance premiums are hit with huge costs.

One of two WaPo articles is rich in comparisons and provides the ability for you to check your won state:

Quote:

For the first time, the federal government will release the prices that hospitals charge for the 100 most common inpatient procedures. Until now, these charges have been closely held by facilities that see a competitive advantage in shielding their fees from competitors. What the numbers reveal is a health-care system with tremendous, seemingly random variation in the costs of services.
Quote:

In downtown New York City, two hospitals 63 blocks apart varied by 321 percent in the prices they charged to treat complicated cases of asthma or bronchitis. One charged an average of $34,310; the other billed, on average, $8,159.
Quote:

Elsewhere, Las Colinas Medical Center just outside Dallas billed Medicare, on average, $160,832 for lower joint replacements.

Five miles away and on the same street, Baylor Medical Center in Irving, Tex., billed the government an average fee of $42,632.

It helps to remember that Medicare pays set fees regardless of the rip off prices some hospitals hope for. It's the uninsured individuals without insurance that take the list price hits. And they cannot pay those high rates. Private insurance companies negotiate discounts in the 25% to 33% levels - but that still leaves them paying big time for some of those rip off prices. That $160,832 bill in Texas is still a big hit for private insurance companies.

Looking at those numbers makes it clear that it's not all "ObamaCare". The insurance industry hasn't really cared about price increases in the past because they simply pass the costs on to you. Now days employers are passing on some of that nanny care cost onto the employees, as well as (obviously) paying less in wages & salaries.

63 replies: All unread, showing first 25:
 
User currently offlineDocLightning From United States of America, joined Nov 2005, 19420 posts, RR: 58
Reply 1, posted (1 year 2 months 3 weeks 3 days 2 hours ago) and read 2665 times:

Quoting Ken777 (Thread starter):
It helps to remember that Medicare pays set fees regardless of the rip off prices some hospitals hope for. It's the uninsured individuals without insurance that take the list price hits. And they cannot pay those high rates. Private insurance companies negotiate discounts in the 25% to 33% levels - but that still leaves them paying big time for some of those rip off prices. That $160,832 bill in Texas is still a big hit for private insurance companies.

One hospital was charging $7 for an alcohol pad that costs 1¢. Why someone isn't in jail over that is beyond me.


User currently offlineseb146 From United States of America, joined Nov 1999, 11536 posts, RR: 15
Reply 2, posted (1 year 2 months 3 weeks 3 days 2 hours ago) and read 2665 times:

Quoting DocLightning (Reply 1):
Why someone isn't in jail over that is beyond me.

It's private corporations. And, private corporations should be able to charge "market value" for products. The right does not care about people as long as corporations can profit off human suffering. No one will be in jail as long as corporations profit.



Life in the wall is a drag.
User currently offlineDocLightning From United States of America, joined Nov 2005, 19420 posts, RR: 58
Reply 3, posted (1 year 2 months 3 weeks 3 days 2 hours ago) and read 2656 times:

Quoting seb146 (Reply 2):
It's private corporations. And, private corporations should be able to charge "market value" for products.

Yah. Especially when there is a 70,000% markup (did I get my zeros right) and the patient is there not by choice and has no opportunity to comparison shop.


User currently offlinemoo From Falkland Islands, joined May 2007, 3884 posts, RR: 4
Reply 4, posted (1 year 2 months 3 weeks 2 days 22 hours ago) and read 2619 times:

Quoting seb146 (Reply 2):
The right does not care about people as long as corporations can profit off human suffering. No one will be in jail as long as corporations profit.
Quoting DocLightning (Reply 3):
Yah. Especially when there is a 70,000% markup (did I get my zeros right) and the patient is there not by choice and has no opportunity to comparison shop.

And yet why is there such a big issue in the US about the government providing medical services for you, in place of private companies?

You can bitch and moan about the NHS all day long with valid complaints, but I'd still take it over any other healthcare service in the world. I can walk into any A&E in the country, get my ailment treated and not have to worry about any bill at the end of it. I cant believe some people don't want that...


User currently offlineQFA380 From Australia, joined Jul 2005, 2060 posts, RR: 1
Reply 5, posted (1 year 2 months 3 weeks 2 days 20 hours ago) and read 2596 times:

That is one of the problems with hospitals, comes down to simple economics in that there is price inelasticity with high market power for the hospitals due to their location. You pay what the hospital closest to you demands. Not only that the 'you' is not the consumer of the healthcare, it is the consumers of the healthcare insurance. Naturally people have absolutely no incentive whatsoever to care about the price the hospital is charging when it can just be passed onto the insurance company. This is all fine and dandy when the payer of the healthcare is simultaneously the provider in the case of government run systems in Australia, the UK etc but in the US there is a massive misalignment of incentives.

Quoting Ken777 (Thread starter):
Now days employers are passing on some of that nanny care cost onto the employees, as well as (obviously) paying less in wages & salaries.

This is necessarily a good thing. By passing the costs onto the actual consumers you are reducing the agency costs of someone else determining the characteristics of your care and what you pay for that care.

One of the problems however is that insurance companies and hospitals are in cahoots. Your insurance company should be ensuring that you receive the best treatment for the lowest price, trying to keep premiums down, but again it comes down to the fact that for an employer there is high switching costs to a cheaper plan who bargain more effectively. If you were directly paying for your insurance, you'd ensure you were paying the lowest you had to.

You come around to one of the biggest issues being the fact that there are disincentives for consumers to choose their own plan. You don't pay tax if your employer pays but you do if you pay for it. Even if the same plan costs you $2000 more than it would elsewhere, having the employer pay saves you $3000 that you would have paid in taxes. Naturally the insurers would not want insurance to be tax deductible, then employers would give their employees a pay rise and cut their plan. Plenty would opt for a cheaper plan with lower coverage and naturally the insurers want to make sure that a 25 year old male is paying for IVF coverage.


User currently offlinefr8mech From United States of America, joined Sep 2005, 5370 posts, RR: 14
Reply 6, posted (1 year 2 months 3 weeks 2 days 20 hours ago) and read 2593 times:

Quoting DocLightning (Reply 1):
One hospital was charging $7 for an alcohol pad that costs 1¢. Why someone isn't in jail over that is beyond me.


How much does it cost for the hospital to apply that pad? Salary for the nurses, the nurses assistants, the doctors, the orderlies, the insurance, etc? You know, the overhead for operating a hospital.

I'm not saying that $7 is the right number, but, I really don't think $.01 is the right number either.

The blame for this falls squarely on the shoulders of the insurance companies, the medical provider industry and the consumer. How's that for a broad net?

The insurance companies have leveraged their market power to "force" providers to accept negotiated rates. Don't accept our rates: you're out of network. I'm going to guess that these rates, sometimes, don't cover the actual costs of the service, nor provide for an adequate profit for the hospital and its investors.

The medical providers will charge what, amounts to, confiscatory fees for services provided to non-insurance patients. They know they won't get a bunch of that money. They know they'll get only a fraction of it, in many cases. So, they get to write-off the loss or petition the government (state and/or federal) for relief.

What about us? Show of hands: how many of us actually shop for our non-emergency medical care? Elective surgeries? Or, do we just talk to our doctor, get them to set it up, clear it with the insurance folks and have it done?

I tried to shop around when I had a vasectomy and then again when I had a partial mastoidectomy (cholesteatoma). And, it was darn near impossible to nail the providers down on a price. And, understandably so. Way too many variables. Yeah, my insurance company's website had some information about common and customary charges, but, is that the negotiated rate or the rate the provider would charge if there weren't all the external factors?

I called the hospital where my surgery was to be performed and asked if someone could tell me what the basic per hour cost was for the use of an operating room? I'm sure that the person looked at the phone like I was some kind of three-eyed, purple question-asking monster. What I found out was that, first, they charge per minute and second, until a surgery is booked and the insurance, including Medicaid/Care is, checked, they would be unable to give me a basic rate. My mastoidectomy ran about $175/min for what turned out to be a 5 hour (300 minute) surgery. If I think about it, I'll see if I can find the detailed billing and see what the "insurance write-off" was.

It seems to me that those of us with insurance don't seem to care very much about how much a procedure costs. We are disassociated from the actual cost, the charged cost and the actual payment to the provider (except for some co-insurance or co-pay or deductible). I really can't think of any other industry where this is the case.

And, short of scrapping the whole system and starting from the beginning, I don't know how to fix it or if it can be fixed.

I can tell you that putting more people under an insurance umbrella where even more folks are disassociated from the true costs, isn't going to help. Neither is shutting them away from healthcare.

I found that when we went to an HSA type insurance, we are a lot more careful about our medical spending. I had a conversation with my doctor about his rates and compared them to other providers...again, a lot of those guys were unwilling..or in some cases...unable to provide me with a rate schedule, except in very broad terms.

Have you guys noticed that a lot of practices, at least in this area, have started to affiliate themselves, and taking on the name, of large medical providers? Baptist Health and Norton's are big here. More and more general practices are affiliating themselves with one of these two corporations? Why?

My guess is because the bigger medical provider networks (corporations) have been pushing back against the insurers and demanding higher negotiated rates to more accurately reflect the level of service provided. It's the market trying to exert itself in a highly regulated and irregular market. It may reach balance, but I'm afraid there are too many external forces involved for the medical market to find balance anytime soon.

Ken, you call it a game or games, I call it medical providers adapting to external costs and factors that they have little or no control over.

[Edited 2013-05-10 06:03:29]


When seconds count...the police are minutes away.
User currently offlinefalstaff From United States of America, joined Jun 2006, 6075 posts, RR: 29
Reply 7, posted (1 year 2 months 3 weeks 2 days 19 hours ago) and read 2570 times:
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Quoting fr8mech (Reply 6):
The blame for this falls squarely on the shoulders of the insurance companies, the medical provider industry and the consumer. How's that for a broad net?

You bet. My doctor charges $65 for a for an office visit if you pay cash, my insurance company is charged $120.

I know all you lefties hate Rush Limbaugh, but he made a good point a few years ago when he was in the hospital, in Hawaii. He paid his bill in full personally and the hospital knocked something like $30,000 of his bill because there was no insurance. Why is that? Sounds to me like their are a lot of costs associated with insurance billing.

I think a lot of the high cost of health care is the fact that health care providers can jack up their price because they health insurance companies will pay. I don't see "Obamacare" helping the problem; I can only see it getting worse. If the government or a private insurer has to pay a private firm for their services they can charge whatever they because they know they'll get it.

Quoting fr8mech (Reply 6):
How much does it cost for the hospital to apply that pad? Salary for the nurses, the nurses assistants, the doctors, the orderlies, the insurance, etc? You know, the overhead for operating a hospital.

A lot of people don't think about stuff like that. Just like when they get their car repaired; people always complain about the labor rate. Nobody want to pay anyone for their time.



My mug slaketh over on Falstaff N503
User currently offlinemoo From Falkland Islands, joined May 2007, 3884 posts, RR: 4
Reply 8, posted (1 year 2 months 3 weeks 2 days 19 hours ago) and read 2564 times:

Quoting falstaff (Reply 7):
Why is that? Sounds to me like their are a lot of costs associated with insurance billing.

I do know that there can be a wait of up to a year between the hospital submitting the bill and receiving the payment from the insurance companies, so getting paid immediately is a huge thing for them.


User currently offlineaaron747 From Japan, joined Aug 2003, 8039 posts, RR: 26
Reply 9, posted (1 year 2 months 3 weeks 2 days 19 hours ago) and read 2564 times:

Quoting DocLightning (Reply 1):
One hospital was charging $7 for an alcohol pad that costs 1¢. Why someone isn't in jail over that is beyond me.

The series that ran in The Atlantic a few months ago had incredible chargemaster fees at one particular hospital in Texas. $70 for a gauze pad on the itemized billing, when you can get a box of 50 at Wal-Mart for $6.

Quoting moo (Reply 4):
You can bitch and moan about the NHS all day long with valid complaints, but I'd still take it over any other healthcare service in the world. I can walk into any A&E in the country, get my ailment treated and not have to worry about any bill at the end of it. I cant believe some people don't want that...

That's the best thing about it - the peace of mind. People can focus on what they need to without having to stress over what kind of bills they will be saddled with.

I'll admit the tax hit for the NHS in Japan is a pretty big bite, but it's still a hell of a lot cheaper overall than comparable coverage I've had in the US.

Quoting fr8mech (Reply 6):
What about us? Show of hands: how many of us actually shop for our non-emergency medical care? Elective surgeries? Or, do we just talk to our doctor, get them to set it up, clear it with the insurance folks and have it done?

That's the great thing about living under a system like this one. Need something your doctor can't do? Talk to them, they'll set up a referral, get an appointment and you go. Nothing else you need to do. No permission to seek. Nothing to clear. And the billing won't change.



If you need someone to blame / throw a rock in the air / you'll hit someone guilty
User currently offlinefr8mech From United States of America, joined Sep 2005, 5370 posts, RR: 14
Reply 10, posted (1 year 2 months 3 weeks 2 days 19 hours ago) and read 2554 times:

Quoting aaron747 (Reply 9):
That's the great thing about living under a system like this one. Need something your doctor can't do? Talk to them, they'll set up a referral, get an appointment and you go. Nothing else you need to do. No permission to seek. Nothing to clear. And the billing won't change.

Actually, my insurance is set-up the same way. I don't necessarily seek permission from my insurer. Of course, while my procedures may not have been absolutely medically necessary (vasectomy and the mastoidectomy), they also weren't cosmetic in nature.

I don't have to seek permission because I am more invested in my health care costs because of my HSA and the high deductible that comes with it.

Quoting moo (Reply 8):
so getting paid immediately is a huge thing for them.

Especially when you are only allowed to charge right at or below your margin.

Quoting aaron747 (Reply 9):
$70 for a gauze pad on the itemized billing, when you can get a box of 50 at Wal-Mart for $6.

Can you get the doctor, nurse, insurance, hospital setting, antiseptic and everything else that comes with a medical professional in a medical setting applying that dressing for the other $64 at Walgreens?
When you look at it from that perspective, maybe $70 isn't really that much.



When seconds count...the police are minutes away.
User currently offlineaaron747 From Japan, joined Aug 2003, 8039 posts, RR: 26
Reply 11, posted (1 year 2 months 3 weeks 2 days 18 hours ago) and read 2539 times:

Quoting fr8mech (Reply 10):
I don't have to seek permission because I am more invested in my health care costs because of my HSA and the high deductible that comes with it.

Yeah but I'm getting exactly the same as everyone else, without having to shop for plan A or B. If I want even more options, there are private options my employer provides.

Quoting fr8mech (Reply 10):
Can you get the doctor, nurse, insurance, hospital setting, antiseptic and everything else that comes with a medical professional in a medical setting applying that dressing for the other $64 at Walgreens?
When you look at it from that perspective, maybe $70 isn't really that much.

Except that it is. The $70 gauze pad is in addition to the $250 injection of lidocaine, $120 saline drip, $1100 blood panel, and on it goes. The chargemaster markup is applied by the hospital billing system to every last facet of that hospital setting, and it is set well above the actual cost of services rendered.



If you need someone to blame / throw a rock in the air / you'll hit someone guilty
User currently offlinefr8mech From United States of America, joined Sep 2005, 5370 posts, RR: 14
Reply 12, posted (1 year 2 months 3 weeks 2 days 18 hours ago) and read 2524 times:

Quoting aaron747 (Reply 11):
Yeah but I'm getting exactly the same as everyone else, without having to shop for plan A or B. If I want even more options, there are private options my employer provides.

Exactly, you are getting the same thing everyone else is getting, whether you need it or not. One size can not fit all. You may be subsidizing someone else's bad habits, or vice-versa.

I'm not going to get into a discussion about socialized medicine or the Orwellian-named Affordable Care Act. It is the law. I will comply with it as well as I can and I (as well as everyone else participating in this economy) will suffer or enjoy its consequences as the case may be. I truly hope that I am wrong and everything comes up roses and daisies, but I have my doubts.

Quoting aaron747 (Reply 11):
Except that it is. The $70 gauze pad is in addition to the $250 injection of lidocaine, $120 saline drip, $1100 blood panel, and on it goes. The chargemaster markup is applied by the hospital billing system to every last facet of that hospital setting, and it is set well above the actual cost of services rendered.

As it should be. Look, I can't quantify how much overhead should be applied to a bandage vs. a unit of blood vs. cardiac intervention during a heart attack. There are bean-counters that do that. The best I can do is monitor what is happening and make sure it is accurate.

Again, I think it goes back to the disassociation we have with the actual and true cost of care and the fact that insurance companies leverage their position and drive the reimbursement rate down. That's not necessarily a bad thing, but, I'm thinking that a lot of insurance companies try to flat-rate (one size fits all) a lot of procedures and I don't think medicine, especially hospital based medicine, lends itself very well to that kind of business model.



When seconds count...the police are minutes away.
User currently offlineAesma From France, joined Nov 2009, 6539 posts, RR: 9
Reply 13, posted (1 year 2 months 3 weeks 2 days 16 hours ago) and read 2489 times:

Quoting aaron747 (Reply 9):
That's the best thing about it - the peace of mind. People can focus on what they need to without having to stress over what kind of bills they will be saddled with.

Also true for doctors not having to worry about getting paid, or worse denying care because a patient can't pay.

In fact there is a trend here of young doctors not even wanting to own their office, they'd rather be employees of a company or even a city, get a good salary (but probably 1/10th of a US doctor), not too many hours, vacations, colleagues...



New Technology is the name we give to stuff that doesn't work yet. Douglas Adams
User currently offlineDocLightning From United States of America, joined Nov 2005, 19420 posts, RR: 58
Reply 14, posted (1 year 2 months 3 weeks 2 days 14 hours ago) and read 2469 times:

Quoting moo (Reply 4):
I cant believe some people don't want that...

Actually, I'm a big fan of copays. And higher copays at the ER than at the office. They save money not directly (the copay is usually nominal), but by reducing the number of inappropriate ER visits for things like babies with colds.

One of the big issues in this country is the amount of ER visits that wind up being over stupid stuff. And for patients on Medicaid, the ambulance and ER is free. So you can call 911 over a baby with a cold ten times a year and get taken to the ER where the doctor will prescribe tylenol that you will get for free. A $600 bottle of Tylenol. A simple $10 copay for EMS and $10 copay for the ER isn't going to kill anyone (those of us who work for a living get $200-500 copays for using the ER, even if for legitimate reasons) and will cut down on unnecessarily expensive medical encounters.

Another elephant in the room that nobody wants to talk about is incompetent doctors. Case in point: I have a 2yo patient to whose parents I finally had to say: "He is going to get lung cancer. It will be decades, but it will happen." Why? Because every single time the kid gets a cold they haul him to the ER (reference above) and then the idiot ER doc orders a CBC, CMP, blood cultures, a cathed urinalysis, and an X-ray. The child then gets diagnosed with a pneumonia that doesn't actually exist and gets a shot of ceftriaxone (a "big gun" antibiotic) and a prescription for amoxicillin at a spectacular underdose.

The 2yo in question has had 16 chest X-rays in his life. Each of which is actually 2 X-rays (one lateral, one postero-anterior), so 32 X-rays in his two years on this mortal coil. He has been diagnosed with pneumonia ten times, been given ceftriaxone five times, and had god-knows-how-much blood drawn. And while I certainly fault his parents for not understanding that 2yo kids get sick and get fevers and manage to survive, I also fault ER docs who can't recognize a cold.

And it's not malpractice insurance that's the issue. The case described above is malpractice. The doc may think he's covering his butt, but what he's actually doing is increasing his risk. I could TEAR HIM APART on a witness stand. "Blood cultures and injected antibiotics are appropriate if you suspect one of two things: complicated pneumonia or sepsis. In either case, the child should be admitted. You chose to discharge him home, although your actions suggest you thought he had one of these diagnoses. Why? You instrumented this child's genitals, although he had fever with a clear source (nasal congestion and cough). Why?" (There is no correct answer to those questions)

I submit that it is incompetence and that this is a major reason why healthcare is so expensive. I am NOT arguing that hospitals overcharging is not also an issue. They are by no means mutually exclusive.


User currently offlinefr8mech From United States of America, joined Sep 2005, 5370 posts, RR: 14
Reply 15, posted (1 year 2 months 3 weeks 2 days 12 hours ago) and read 2444 times:

Quoting DocLightning (Reply 14):
Actually, I'm a big fan of copays. And higher copays at the ER than at the office. They save money not directly (the copay is usually nominal), but by reducing the number of inappropriate ER visits for things like babies with colds.


I fully agree. I'd go so far as suggesting that the co-pay/co-insurance be higher if the ER determines that it was not a true emergency...but, that does get a bit subjective. Wishful thinking.

Quoting DocLightning (Reply 14):
Medicaid, the ambulance and ER is free.


I didn't know that. Needs to be fixed.

Quoting DocLightning (Reply 14):
And it's not malpractice insurance that's the issue. The case described above is malpractice. The doc may think he's covering his butt, but what he's actually doing is increasing his risk. I could TEAR HIM APART on a witness stand.


Is it incompetenace or defensive medicine? Proabably a little of both.

Like I noted above, there are a lot of externalities that go into the pricing of medical services and to make the blanket statement that hospitals (or other providers) are gouging patients or playing games is jumping to conclusions. They could be, but then again, they may not be.



When seconds count...the police are minutes away.
User currently offlineDocLightning From United States of America, joined Nov 2005, 19420 posts, RR: 58
Reply 16, posted (1 year 2 months 3 weeks 2 days 8 hours ago) and read 2410 times:

Quoting fr8mech (Reply 15):
I fully agree. I'd go so far as suggesting that the co-pay/co-insurance be higher if the ER determines that it was not a true emergency...but, that does get a bit subjective. Wishful thinking.

I used to think that, but that opinion quickly got bashed down by this argument: "So are you telling me that you want to deal with the patient arguing and begging and pleading and threatening you to get to sign off that it was a medically necessary visit?"

Yah. Good point. I figure that the copay needs to be roughly commensurate to the income. If you're on medicaid, then $10 is a six-pack that you have to give up to go to the ER. If you're Blue Cross, then $150 is a really nice night out on the town.

Quoting fr8mech (Reply 15):
Is it incompetenace or defensive medicine? Proabably a little of both.

30% defensive, 70% idiocy would be my guesstimate, but the result is to increase exposure to malpractice, not decrease it.


User currently offlinefalstaff From United States of America, joined Jun 2006, 6075 posts, RR: 29
Reply 17, posted (1 year 2 months 3 weeks 2 days 7 hours ago) and read 2396 times:
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Quoting DocLightning (Reply 16):
$10 is a six-pack

Two and a 1/2 cheap six packs in Detroit. The kind of guy who buys a $10 six in these parts likely has good insurance.

Quoting DocLightning (Reply 14):
One of the big issues in this country is the amount of ER visits that wind up being over stupid stuff. And for patients on Medicaid, the ambulance and ER is free. So you can call 911 over a baby with a cold ten times a year and get taken to the ER where the doctor will prescribe tylenol that you will get for free.

and that causes long response times for an ambulance. In Detroit the wait time for an Ambulance is 30-40 minutes usually. Just down the road in Taylor, our response time is less than 6 minutes. "They" say the slow response times in Detroit are due to the unnecessary emergency calls.

A friend of mine used to be a EMT, in Detroit, before she quit to be a stay at home mom. She told me stories of ambulance runs where the "patient" had a yeast infection or a splinter in their finger. Sometimes people just wanted a ride to the hospital to visit somebody. I'd like to think only Detroit is that screwed up, but I know better.

My aunt is a retired emergency room head nurse, in rural western Pennsylvania, and she always talked about the huge numbers of people who had no serious problems clogging up their emergency room with non emergencies. She would see the same people over and over and over and over again.



My mug slaketh over on Falstaff N503
User currently offlineDocLightning From United States of America, joined Nov 2005, 19420 posts, RR: 58
Reply 18, posted (1 year 2 months 3 weeks 2 days 4 hours ago) and read 2375 times:

Quoting falstaff (Reply 17):
My aunt is a retired emergency room head nurse, in rural western Pennsylvania, and she always talked about the huge numbers of people who had no serious problems clogging up their emergency room with non emergencies. She would see the same people over and over and over and over again.

The best one I ever saw was a 5yo boy: "He was complaining his ear was hurting earlier today, but then it went away." I should add that it was 4AM. They had woken the comfortably sleeping child up at 0400 to take him to the ED because he mentioned that his ear hurt 12 hours earlier. By EMS. No, I am not making it up.

I am guessing that they got high, got paranoid, and then decided to call 911.


User currently offlinefr8mech From United States of America, joined Sep 2005, 5370 posts, RR: 14
Reply 19, posted (1 year 2 months 3 weeks 1 day 21 hours ago) and read 2347 times:

Quoting DocLightning (Reply 16):
I used to think that, but that opinion quickly got bashed down by this argument: "So are you telling me that you want to deal with the patient arguing and begging and pleading and threatening you to get to sign off that it was a medically necessary visit?"


Yeah, that's why I said it was wishful thinking. But, the problem has to be fixed.

I'm still floored by:

Quoting DocLightning (Reply 14):
And for patients on Medicaid, the ambulance and ER is free.


It's ridiculous. It's like telling a drunk he can get a state-paid-for ride to the liquor store. Why not take advantage of it?

It's the same old thing...we are incentivizing bad behaviour. And, that drives up the cost of healthcare. Not just because someone has to pay for that crap, but because it uses valuable resources and time that can be better spent elsewhere.

Again, it's not the only reason, but it's a chunk.

Quoting falstaff (Reply 17):
and she always talked about the huge numbers of people who had no serious problems clogging up their emergency room with non emergencies


So, 10 or so years ago, I'm in the ER because I took the tip of my finger off with a table saw and I'm sitting talking to one of the triage nurses (a friend of mine) when in WALKS a guy complaining of a numb leg and foot and "oh yeah, I'm having trouble breathing". Guess who gets to go to the front of the line? People know how to game the system.



When seconds count...the police are minutes away.
User currently offlineRedd From Poland, joined Jan 2013, 96 posts, RR: 0
Reply 20, posted (1 year 2 months 3 weeks 1 day 19 hours ago) and read 2332 times:

Quoting moo (Reply 4):
You can bitch and moan about the NHS all day long with valid complaints, but I'd still take it over any other healthcare service in the world. I can walk into any A&E in the country, get my ailment treated and not have to worry about any bill at the end of it. I cant believe some people don't want that...

I'm with you 100% on that, I don't see how any government can allow basic health care to be for profit. It's a conflict of interest and a basic right as a tax payer and as a human being IMO.


User currently offlineaa757first From United States of America, joined Aug 2003, 3347 posts, RR: 8
Reply 21, posted (1 year 2 months 3 weeks 1 day 16 hours ago) and read 2322 times:

Quoting Ken777 (Thread starter):
It helps to remember that Medicare pays set fees regardless of the rip off prices some hospitals hope for. It's the uninsured individuals without insurance that take the list price hits. And they cannot pay those high rates. Private insurance companies negotiate discounts in the 25% to 33% levels - but that still leaves them paying big time for some of those rip off prices. That $160,832 bill in Texas is still a big hit for private insurance companies.

Depends on the market. In markets with strong payors (ie, one insurance company, many hospitals), the discount is huge. In markets with strong providers (ie, many payors, few hospitals), the discount is less.

I live in a strong payor city and I think my acute care eye exam was about 50% off the charge master price, or $85.

Of course, who really gets screwed in this are the private practice doctors. My health system probably negotiates on behalf of 1,000 physicians in the area and we probably have about 1,500 beds. We can negotiate. Drs. Patel & Smith, P.C. can't because they're just two physicians. They get the base contract and they can either sign or not sign.

The argument that uninsured patients pay the charge master price is ridiculous. You can charge an uninsured patient $4,000 for an ER visit, but guess what, they can't probably can't pay that much. So the charges usually get reduced to around what an insured patient will pay.

Quoting Ken777 (Thread starter):
Looking at those numbers makes it clear that it's not all "ObamaCare". The insurance industry hasn't really cared about price increases in the past because they simply pass the costs on to you. Now days employers are passing on some of that nanny care cost onto the employees, as well as (obviously) paying less in wages & salaries.

I personally think you're pointing the finger at the wrong party. It's the health systems that are really driving up costs. Every so many years, every payor sits down with a participating health system and they hammer out a deal. The insurer tries to drive the costs as low as possible and hospitals do the opposite. How it plays out in your city depends on the strength of the payors.

Quoting fr8mech (Reply 6):
I found that when we went to an HSA type insurance, we are a lot more careful about our medical spending. I had a conversation with my doctor about his rates and compared them to other providers...again, a lot of those guys were unwilling..or in some cases...unable to provide me with a rate schedule, except in very broad terms.

HSAs: good idea, but the system isn't compatible with them. In my last job, I had some patient contact in an outpatient office. When HSA patients called up to get a quote I couldn't give them any information at all. The system just doesn't allow for it at this point. Hopefully that will change, but until it does, HSAs aren't that useful.

Quoting fr8mech (Reply 6):
Have you guys noticed that a lot of practices, at least in this area, have started to affiliate themselves, and taking on the name, of large medical providers? Baptist Health and Norton's are big here. More and more general practices are affiliating themselves with one of these two corporations? Why?

My guess is because the bigger medical provider networks (corporations) have been pushing back against the insurers and demanding higher negotiated rates to more accurately reflect the level of service provided. It's the market trying to exert itself in a highly regulated and irregular market. It may reach balance, but I'm afraid there are too many external forces involved for the medical market to find balance anytime soon

One reason is, at least theoretically, there are economies of scale to be gained. But, like you point out, it also allows for better negotiation. I don't know much about medical billing, but I also understand that the outpatient visits can bill a facility charge if they're associated with a hospital.

By the way, most of these provider networks are, at least nominally, 501(c)(3)s.

Quoting falstaff (Reply 7):
I think a lot of the high cost of health care is the fact that health care providers can jack up their price because they health insurance companies will pay. I don't see "Obamacare" helping the problem; I can only see it getting worse. If the government or a private insurer has to pay a private firm for their services they can charge whatever they because they know they'll get it.

Exactly. It's like Milton Friedman said: the best, most efficient way to spend money is to spend your money on yourself. The worst way to spend money is spending someone else's money on someone else, which is pretty much what health insurance does.

Quoting aaron747 (Reply 9):
That's the best thing about it - the peace of mind. People can focus on what they need to without having to stress over what kind of bills they will be saddled with.

I have that too and so do most Americans. My employer's health care costs $30 a paycheck, has low copays and allows me to see any licensed provider in the world. If I were to be admitted to one of my employer's hospitals, the inpatient bill would be $0.

Quoting DocLightning (Reply 14):
I submit that it is incompetence and that this is a major reason why healthcare is so expensive. I am NOT arguing that hospitals overcharging is not also an issue. They are by no means mutually exclusive.

Have you ever read Redefining Healthcare? One of the author's key points is something like 30% of the medical care Americans receive is unnecessary. I think consumers having some financial interest in the game would change this. Imagine if a doctor had to explain the value of every test to a patient. Now, of course, they don't care because their insurance company will pay for it. But even if they just had to pay, say, 10% of the cost of each test, I feel like they'd think more about the tests they're having done and force their doctor to think like that as well.

Quoting Redd (Reply 20):
I'm with you 100% on that, I don't see how any government can allow basic health care to be for profit. It's a conflict of interest and a basic right as a tax payer and as a human being IMO.

Most healthcare in the United States is neither delivered nor financed by a for profit corporation.


User currently offlinemdsh00 From United States of America, joined May 2004, 4124 posts, RR: 8
Reply 22, posted (1 year 2 months 3 weeks 1 day 15 hours ago) and read 2310 times:

Coming late to this thread...

Quoting DocLightning (Reply 14):
The 2yo in question has had 16 chest X-rays in his life. Each of which is actually 2 X-rays (one lateral, one postero-anterior), so 32 X-rays in his two years on this mortal coil. He has been diagnosed with pneumonia ten times, been given ceftriaxone five times, and had god-knows-how-much blood drawn. And while I certainly fault his parents for not understanding that 2yo kids get sick and get fevers and manage to survive, I also fault ER docs who can't recognize a cold.

And it's not malpractice insurance that's the issue. The case described above is malpractice. The doc may think he's covering his butt, but what he's actually doing is increasing his risk. I could TEAR HIM APART on a witness stand. "Blood cultures and injected antibiotics are appropriate if you suspect one of two things: complicated pneumonia or sepsis. In either case, the child should be admitted. You chose to discharge him home, although your actions suggest you thought he had one of these diagnoses. Why? You instrumented this child's genitals, although he had fever with a clear source (nasal congestion and cough). Why?" (There is no correct answer to those questions)

How prevalent is this in the Peds side or does it also happen because of overbearing parents? I remember as a medical student, I would see residents getting chewed out when they wouldn't prescribe Abx for a URI, and on the flip-side see a good deal of LPs on babies with moderate fevers.

Once as a med student I had this mom bring her 4 year old into the ER for what was clearly a viral URI. I explained to her and she goes hysterical and was like: "OH MY GOD BUT SHE DOESN'T WANT TO EAT!!!. (while the kid is drinking some apple juice)." Because I was just a med student at the time, I felt like asking her if she feels hungry when she has a cold.



"Look Lois, the two symbols of the Republican Party: an elephant, and a big fat white guy who is threatened by change."
User currently offlineKen777 From United States of America, joined Mar 2004, 8191 posts, RR: 8
Reply 23, posted (1 year 2 months 3 weeks 1 day 12 hours ago) and read 2269 times:

Quoting DocLightning (Reply 3):
Especially when there is a 70,000% markup (did I get my zeros right) and the patient is there not by choice and has no opportunity to comparison shop.



At some point we might see national politicians growing a pair and addressing this problem. Pulling tax-exempt status is one really big way to get their attention. As are windfall profit taxes.

Quoting QFA380 (Reply 5):
You pay what the hospital closest to you demands.

Actually I don't. Surgery for a ruptured cervical disk was at a private hospital a few miles past my "local hospitals", as was the private hospital I went to for surgery for kidney cancer. Both were under Medicare + Medigap and both hospitals were happy to take the government payment.

Because I have MediGap I don't have to worry about the costs, but I know Medicare pays set fees so going to a small private hospital didn't cost more. If I was still paying for private insurance then I would focus on what I would have to pay. The $1,000 deduction and 20% of amounts over that.

Quoting QFA380 (Reply 5):
Naturally people have absolutely no incentive whatsoever to care about the price the hospital is charging when it can just be passed onto the insurance company.

If I was still paying for private insurance then I would focus on what I would have to pay. The $1,000 deduction and 20% of amounts over that can add up to a large amount of money and people do learn to focus on those costs.

Quoting fr8mech (Reply 6):
How much does it cost for the hospital to apply that pad? Salary for the nurses, the nurses assistants, the doctors, the orderlies, the insurance, etc? You know, the overhead for operating a hospital.

Look at the cost of a room - those hospitals are not competing with Motel 6. Their daily rate is more than sufficient to cover minor supplies like an alcohol pd or a bandaid. Same with Tylenol. The room cost is more than sufficient.

Quoting fr8mech (Reply 6):
It seems to me that those of us with insurance don't seem to care very much about how much a procedure costs.

I used to watch bills come in when I was paying for private care. With a $1,000 deductible and then 20% co-pay I was actually pretty interested in the costs.

Quoting fr8mech (Reply 6):
We are disassociated from the actual cost, the charged cost and the actual payment to the provider

Not if you have a 20% co-pay.

Even with Medicare I look at the CMS statements - especially after surgery and satisfy myself that the bill is legitimate.

Quoting fr8mech (Reply 6):
And, short of scrapping the whole system and starting from the beginning, I don't know how to fix it or if it can be fixed.

It is a step by step process for the US. There are a few major steps being taken with Obama Care. Pre-existing conditions is huge and should have been done generations ago. The other huge change is expansion of the Medicaid umbrella to cover people who are under 133% of the poverty level. Currently there are states (like Alabama and Louisiana) that consider a family makes too much if they make over $275 a MONTH. That should make any moral person gag. It's clear that those states might have an umbrella but they basically keep it closed.

Hopefully the next step will be to bring all Medicaid plans into Medicare, eliminating the need for those 50 state level administrative costs.

Quoting fr8mech (Reply 6):
I can tell you that putting more people under an insurance umbrella where even more folks are disassociated from the true costs, isn't going to help.

If there is universal care under a Medicare system then costs are what Medicare says they are - just like today. That leaves those who want private insurance. As shown in Australia private insurance costs takes a huge dive when the burden of paying for the uninsured is taken off their backs. That's why my Aussie insurance was 80% LESS than my US insurance. I paid FIVE times MORE for the US policy that was not as comprehensive as the Aussie one.

That lower private insurance premium puts significant pressure on hospitals to lower prices. Large hospitals needs to be competitive, or the small private hospitals will take their patients away.

To really put pressure on massive overcharging you also need to let Medicare offer a public option for "private insurance." Medicare Private in Australia works really well.

Quoting fr8mech (Reply 6):
Ken, you call it a game or games, I call it medical providers adapting to external costs and factors that they have little or no control over.

Actually it is a game - just look at the different in costs in the story linked

The picture & cost breakdowns in Miami Florida present a different story than you are taking. Those two hospitals are around 1,000 feet apart - the CEOs can wave to each other from their office balconies while having their morning coffee & Danish. The University of Miami Hospital has plenty of control on what they charge and they charge big time.

And it's the same with M D Anderson in Houston. That is part of the University of Texas System, but with a compensation package of over $1 Million the CEO of MDA makes more than the President of the University of Texas itself.

Wanna bet on how big time MDA charges?

Quoting falstaff (Reply 7):
My doctor charges $65 for a for an office visit if you pay cash, my insurance company is charged $120.

WHich is probably what he would eventually get from your insurance company after discounts. What's the difference? You simply paid more than you should. Let the insurance company pay and keep your cash.

Quoting falstaff (Reply 7):
. I don't see "Obamacare" helping the problem

If you have a kid with a pre-existing condition. are a uni graduate still trying to find a job, can't get coverage in backward states like Alabama & Texas because you earn over $300 a MONTH - but can't even begin to afford private insurance, etc then ObamaCare is helping big time. If you are one of those getting a refund check because of insurance companies overcharging then ObamaCare is going to look even better to you.

Quoting falstaff (Reply 7):
If the government or a private insurer has to pay a private firm for their services they can charge whatever they because they know they'll get it.

That is changing and the public disclosure of pricing differences in the article is simply another step in bringing sanity back to the system.


User currently offlinefr8mech From United States of America, joined Sep 2005, 5370 posts, RR: 14
Reply 24, posted (1 year 2 months 3 weeks 1 day 11 hours ago) and read 2259 times:

Quoting Ken777 (Reply 23):
Look at the cost of a room - those hospitals are not competing with Motel 6. Their daily rate is more than sufficient to cover minor supplies like an alcohol pd or a bandaid. Same with Tylenol. The room cost is more than sufficient.


So, now you're an accountant and actuary for a medical provider. Unless you are an insider or sift through a 10Q (if the provider is publicly owned) and the associated financial documents, you can't possibly know how much it costs to apply a band-aid in a hospital setting by a professional.

Quoting Ken777 (Reply 23):
As are windfall profit taxes.


Ah yes, the Liberal battle cry. Make too much money and we'll tax you more. Make way TOO much money we'll tax you even more and teach you a lesson for being efficient or innovative or progressive or for making good decisions or for just being lucky.

Quoting Ken777 (Reply 23):
Even with Medicare I look at the CMS statements - especially after surgery and satisfy myself that the bill is legitimate


Good for you. I wish everybody would do that. When I requested detailed billing from the hospital, they tried to charge me $5. I challenged them to show where I agreed to that provision in all the pre-admission/op paperwork I read and signed.



When seconds count...the police are minutes away.
25 aaron747 : What would happen after being admitted to the nearest facility on an emergency basis and needing several days' worth of critical care? People often f
26 Post contains images DocLightning : I am blaming the doctor because in my office I don't have an X-ray on-site and I prescribe antibiotics (for all reasons) maybe 1-2x/wk during the win
27 Ken777 : I've taken enough accounting courses over the years to be able to make a simple, rational statement on overheads. I've also worked with my wife some
28 fr8mech : I've got a minor in accounting and my wife is a CPA and I'm not comfortable make that "simple, rational statement" on health care provider overhead.
29 bhill : Costco should open hospitals...and PHARMACEUTICAL factories....Admin overhead..CEO salaries...and drug costs...those are the largest health care costs
30 Post contains images DocLightning : I find that figure shocking. Pleasantly shocking. I'd have put it at 60%. I don't like the idea of single-payor healthcare. So what happens when the
31 Flighty : Medicine has nothing to do with market value at all. That is why it is so inefficient and organizationally dysfunctional, even if individual doctors
32 fr8mech : Ask yourself why? My understanding is that the Canadian government either caps the prices or subsidizes the cost. My guess is it caps the price and t
33 Ken777 : I'm very comfortable with my concept of overhead in health care, but then, as I said before, my wife worked in a PT Department - and was Department H
34 aa757first : The insurance covers all licensed providers. There would just be an out-of-pocket charge. Even very restrictive HMO plans allow a patient to seek eme
35 Ken777 : But not all licensed providers accept all insurance companies. When I went to MD Anderson for a second opinion they told me (the day before the appoi
36 DocLightning : Not necessarily. Look at the NHS. OMG, I'd hate to be a physician in that system. I rotated there for a month and I left thanking the lord I didn't h
37 aa757first : True, but I've personally never come across a hospital that didn't accept BCBS. Well, what else was he going to say? I work for a large, academic med
38 Ken777 : IIRC, there are "private doctors" who do very well. Just like other countries. Too bad you couldn't have gotten a rotation through New Zealand - my w
39 Post contains images DocLightning : And that is where we have a clash of definitions. We may well be in violent agreement. I define "single-payor" as: "there is one insurance that pays
40 melpax : That pretty much sums it up with the public system here, the same applys also if you're treated as a private paitent in a public hospital. However th
41 mad99 : Are you saying you've worked as a physician in the UK? The way i interpret your comment on Spain, its sounds as if you are saying its better than the
42 bhill : Well, with respect Doc, if healthcare keeps going in the same fashion, you are not going to have ANY patients to pay for your services, that 50% of ba
43 DocLightning : They do, but they have to compete. If BC/BS decides to unilaterally cut reimbursements by 30%, I can just drop them and their patients. As will just
44 Post contains images Ken777 : It may well be. What I really want to see is a system where people can afford to get basic care in appropriate settings (not always the ER) and where
45 bhill : Melpax, if what you say is true, and following the "supply and demand" belief, then why have'nt health care costs come down? As for waiting times, see
46 Ken777 : There are a lot of factors related to costs of health care and advancements are a big part of the costs. My last surgery started when an ultrasound i
47 DocLightning : I wonder, to get back to the original topic, why nobody has gone after the hospitals using criminal law. OK. You're in a car accident. You get taken t
48 Ken777 : The only realistic approach is to expand Medicare to cover all public health care - like Australia. That results in Medicare establishing the fair co
49 Dano1977 : A friend of mine was ski-ing in Colorado, and being an idiot wrecked his knee quite badly. He contacted his travel insurance, and within 12hrs they h
50 Post contains links melpax : The Medicare levy is 1.5% of your taxable income. Everyone who pays tax here pays this. However, if your income is over $84K for a single person, or
51 pvjin : Why not just pay some more taxes and let the government cover most of the healthcare services? That would sure keep the prices down for an individual,
52 Ken777 : Our basic Medicare is far more than that basic 1.5% - a result of cost shifting. Until we expand Medicare to cover everyone at a core level of care w
53 Flighty : Colorado sees a ton of that. Skiiers are often youngish and might not have a corporate or government career at the moment. Horrors, how dare they, bu
54 starbuk7 : Sorry, I am tired of 'paying more taxes'. Been doing that for the last several years watching my paycheck going down, no pay increases and all my oth
55 bhill : pvjin, because the Health Insurance lobby would never allow it, it's why Obama had to make the concessions he made and why the GOP could never get ref
56 DocLightning : No you haven't. You've been paying LESS taxes for the last several years. There have been NO tax hikes unless you make over $250K and even that was m
57 Ken777 : You work for a company that hands out nanny care then you can see why costs are going up. But then you probably have VA Medical available since you'r
58 mirrodie : Agreed and wholly agree on the waste that I see on the medicaid end of it. Like you, Doc, I see a ton of issues in everyday practice that have my SMH
59 casinterest : I personally still love the fact that Doctors can " Mess up Royally" and still get to practice and charge more to fix what they didn't fix in the firs
60 mad99 : That's interesting. My experiences with the NHS are positive but, touch wood, I've never had any serious health problems. Here in spain we've had two
61 starbuk7 : Yes, they have, and I do not make near that much. Just this last January first Medicare and Social Security deductions went up to the toon of $75 buc
62 Post contains links bhill : Damn, I stumbled upon this today...... http://www.opensecrets.org/lobby/top.php?indexType=i&showYear=2013 "Better life through chemicals...." Inde
63 aaron747 : Again when you start mentioning network and out of network, that's where I lose interest. In this country, any provider, public or private, is accept
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