Tuesday, May 9, 2017

The literal price of health care

Recently my daughter sprained her ankle. Because she's a bit of a drama queen, I took her to urgent care after she refused to put weight on it for a day. The x-ray didn't show a fracture and they gave her a crutch and an Aircast, which she used for exactly one day before she was better.

 A couple of months later, I got a bill for $150 for the crutch and aircast that we barely used.

Because of large deductibles and other reasons, we end up paying a lot of our outpatient healthcare expenses out of pocket. But the problem with that is that you have no idea what you're going to pay until the bill actually arrives. If they had told me it was going to be $150 for that stuff, I never would've taken it.

Think about how crazy it is. You would never go to a furniture store, buy a sofa, and just wait a few months until the bill comes to see how much you ended up paying for it. But that's what I'm constantly doing with my healthcare bills.

I can give multiple other examples. Recently, my own doctor ordered a lab test which I didn't think was entirely necessary, but I decided to let them get it anyway. The test ended up costing a shocking $300. I never ever would've approved it if I had any idea it would cost that much. And the clinician has no idea what these things cost, so no help there.

Fortunately for me, $300 won't break me. But there are plenty of families out there for whom $300 is a substantial chunk of money. They may go to the doctor and blindly accept any recommendations and then end up with a gigantic bill.

The solution? I'm not sure. We don't want people to forgo important task because they're expensive. But I also think that people have a right to know what they're paying before the bill comes in the mail.


  1. The solution is a public health system, but I cannot see America getting onboard with that any time soon.

    Another solution may be instant rebates. I swipe my national card and my health card, and how much I have to pay is spat out in a few seconds.

  2. How true. But unfortunately there you go using logic and common sense, both apparent anathema to the whole health insurance debates.

  3. No transparency in our health system, and the clinician is in the dark as much as we are. I agree, a public health system is the answer, but I don't see that happening anytime in the next 100 years.

  4. It is up to the patient to know their insurance plan etc. So, if you know you have a significant out of pocket - then you can call the lab (for example) and inquire what the charge would be for the test ordered. Once you know that- you can decide if you'd like to get it or not. Also, it may be cheaper to simply negotiate a "self pay rate" for the test than to have it go through your insurance company.

  5. So I just got my explanation of benefits for a ACL repair surgery. the hospital initially charged $58k for an outpatient procedure so that I could walk again. Because I had a PPO that the hospital had an agreement with, the hospital gave my carrier a $30k discount. My PPO covered the rest so my out of pocket for this procedure was 0, but I believe it shows a snap shot of some of the issues. Service providers know they won't get what they bill for services, so they jack up the prices. Payers know that the service providers jack up the prices so they negotiate lower percentage of payment. My belief is that the capitalist mindset doesn't work for healthcare. One cannot treat an essential service like a for profit business. People lose

  6. I agree with anon 8:25. But also as a clinician cost should always be a consideration. Maybe start asking yourself as a provider , is this something my patient absolutely needs? if not dont offer it. The aircast when no damage is shown?? Silly.

  7. could always remove the layers and layers of bureaucracy that is insurance, with the exception of catastrophic care. That would allow them to give you the price immediately. And since prices wouldn't have to be artificially inflated because of insurance, thing would be cheaper than you would think.

  8. And we're just stuck. My daughter's rheum ordered some tests, and I knew from prior experience that they're significantly less expensive at the local lab than at Children's Hospital where rheum works. So we went to local lab, and a month later got a bill from Childrens because, apparently, the local lab saw the order slip and sent everything to Childrens instead of running the tests themselves. If I hire a plumber/electrician/mechanic/etc knowing that person's rates, and the worker chooses to subcontract out the job to someone else, I don't get stuck paying the subcontractor. I pay the person I hired, and that person settles with the subcontractor. Not so in medicine. The system needs major corrections.

  9. The problem is not just the cost of the service. Sometimes I don't even get the bill from the mammoth hospital until 6-12 months later. It's hard to go back and question the charges after that much time

  10. Price transparency needs to be improved. As a doctor working for a large HMO system I can't even tell patients how much their CT or MRI or off-formulary prescription will cost.

  11. Most of the above sounds like what we covered in (I can't remember the class name, but I'll call it) my Healthcare Economics class in pharmacy school. What makes it worse is that has a healthcare *provider* one often doesn't even know how much a treatment, supply, or med is going to cost the patient. I may dispense several expensive meds for an inpatient, but even knowing the cost, I don't know how much we'll bill him for or how much he'll have to pay his insurance company.

    I think the whole issue of healthcare cost and affordability isn't going to go anywhere unless someone, probably the government, is willing to force all the various vested interests in healthcare to accept lower profits and lower wages.
    I think rent-seeking / profiteering is a big problem with the industry. Now, most of us as healthcare practitioners probably didn't go into the business with ONLY money in mind, but the salary was probably a big factor, and I don't think pharmacists (like me) or physicians are trying to bilk the system (nor are we the biggest problem). But HCPs in America make a fair bit more money than similar professionals in other countries. Our drug companies are also allowed to charge what they want, and even jack up prices tremendously when they see an opportunity for profit (doxy, vasopressin, phenylephrine, nitro tabs, colchicine, pyrimethamine, hydroxyprogesterone...). All the various insurance companies and their various executives also exact a price. (For a basic explanation of "rent-seeking," see https://devinhelton.com/2013/04/14/rent-seeking-economy .)

    I have NO IDEA how we might get from where we are to a healthcare system that allows the various participants a "fair" profit/wage without so much wealth being extracted in the process (and passed on to hapless patients), but the current system seems unsustainable, indeed.

    ---A comparison of physician incomes in various countries (TLDR: US physicians make more, especially specialists, but they aren't a very big chunk of HC costs): http://theincidentaleconomist.com/wordpress/physician-fees-and-salaries-in-the-us-and-other-countries/

    ---A two year-old comparison of pharmacist salaries in 5 countries (US is highest): http://www.pharmacytimes.com/news/5-high-paying-countries-for-pharmacists?p=5