Free market medical care versus the status quo

[TexasHusker]

So my son was here last weekend from college. He had an appointment with his primary care physician on Friday morning regarding headaches he had been experiencing. So his doctor called and said "he needs an MRA of his brain before he goes back to school if at all possible to rule out an aneurysm." I got the call at about noon on Friday.

So his PCP originally referred him to a local hospital for the MRA. I called the hospital and asked them how much the MRA would cost. They were taken aback at the question, and asked if I had insurance. I said "sure, but my deductible is $7500...what's your cash price?" They couldn't give me a straight answer and said someone would have to call me back. They also wouldn't be able to schedule him for 5 days.

So I called another company here, an independent imaging company. I asked her how much the MRA would be, and she said "$550 including the reading fee." I asked her how soon she could schedule him, and she said "Can he be here within an hour?" So by 2:30pm, he already had the test done and I wrote a check for $550. By 8am the next day, they called with our result, which was thankfully negative.

This is the way free market economies are supposed to work. We need less government intervention in medical care, not more. The carnival "peanut shell game" on medical pricing has to come to an end. The consumer needs to be put back in charge of paying for their medical care. Only then will costs be contained.

Can you imagine what your homeowner's insurance would cost if you had a $20 copay for everything? If it covered every faucet drip, broken window, and rodent problem? And if you were totally removed from the pricing of the remedies for all of these?

It would be about like your medical insurance is today - a train wreck!

[disneysteve]

I called the hospital and asked them how much the MRA would cost. They were taken aback at the question, and asked if I had insurance. I said "sure, but my deductible is $7500...what's your cash price?" They couldn't give me a straight answer and said someone would have to call me back.

So I called another company here, an independent imaging company. I asked her how much the MRA would be, and she said "$550 including the reading fee."

This is the way free market economies are supposed to work. We need less government intervention in medical care

While I don't necessarily disagree, how did you come to the conclusion from this episode that it had anything to do with government involvement?

We've had a lot of conversations here about the need for price transparency. This story is a perfect example. You should be able to ask how much something will be and get an answer, if not immediately at least within a short period of time. This is more important than ever as more and more people move onto high deductible health plans. I wouldn't necessarily expect the person scheduling imaging studies to have that information at their fingertips but they should have been able to get it or transfer you to the person who had it.

I recognize, of course, that there is a huge difference bureaucratically between a hospital and an independent imaging company. Odds are the independent place handles all of their own affairs from scheduling to billing. The hospital, on the other hand, is a far bigger operation, especially if it's part of a larger system. The hospital system I work for now has at least 5 hospitals (I might be forgetting one), 8 urgent care centers, and dozens and dozens of outpatient practices and facilities. I think we employ somewhere around 15,000 people. The imaging place might employ 30. It's always going to be a lot easier to get an answer at the small place than at the huge company. It's like the difference between walking into a mom and pop hardware store with a question and walking into Home Depot with the same question. But as more patients have more financial responsibility for the cost of their care, the system needs to adapt to that. Price transparency is one obvious way that adaptation is happening.

As for government involvement, do you think things would be clearer (not necessarily cheaper but clearer) if we had a single-payer system? Part of the problem now is that we have thousands of payers and they all have different rules and regulations and guidelines and pricing structures. Wouldn't it be simpler to have one? I know that it's far easier dealing with Medicare than it is dealing with Aetna or Cigna or United Healthcare or any of the other private insurance companies. Medicare has one set of rules and that's it. There aren't hundreds of different plans and fee structures within Medicare. There's one.

[Smallsteps]

[QUOTE} This is the way free market economies are supposed to work. We need less government intervention in medical care, not more. The carnival "peanut shell game" on medical pricing has to come to an end. The consumer needs to be put back in charge of paying for their medical care. Only then will costs be contained.

Can you imagine what your homeowner's insurance would cost if you had a $20 copay for everything? If it covered every faucet drip, broken window, and rodent problem? And if you were totally removed from the pricing of the remedies for all of these?[QUOTE]

I completely agree.
People need to be making REAL choices as if they were paying out of pocket. They NEED to be involved in choice of what treatments / tests costs as well.

I have watched people spend weeks comparing notes, reading reviews and looking for the best deal on items like furniture or car stereos ....... but do not even look into any information on doctors/ clinics or COST of / or alternative treatments.

Why..... because they are often to far removed from the real bill. The real insanity is when they get the bill for their co-payment amount (80/20 or 70/30 etc), they get furious that 20% or 30% added up so fast.

My daughter had an extremely rare condition, I got the basic "Insurance company would review but no guarantee they would cover" line.
I scheduled the surgery..... for ONE because my surgeon wrote the book on the surgery and the could not refute his claim it WAS necessary treatment
#TWO and MOST importantly I negotiated discounts and payment plan based on (IF) insurance was denied.
In the end the insurance paid but i was prepared.......... and the insurance company actually got a discounted rate i had worked out.

People can become very resourceful when presented with at the very least ballpark estimates.

I really do not think most medical places want clear pricing because people may start asking questions about mark-up.
I watched a standoff between a specific hospital and insurance group ( i worked for).... ...ended badly for hospital when insurance company was TRANSPARENT and published hospital charges from hospital X compared to other hospitals in the area.
It made people stop and think and guess what they lost a lot of customers. Transparency cost that group ALOT.

Just look at something like Good-rx or other pharmacy price apps..... even their commercials show with insurance an item was $67...... but the friendly pharmacist shows them with price matching good rx and without insurance item was $8.90 Makes many wonder what justifies that difference.
A lot may be middleman costs but being payments and paperwork administered by government bureaucracy will not solve that cost.

Look up the Size and cost of administration in the NHS of the UK or why are other single payer countries are more and more allowing people to opt out of govt. system and buy their own insurance and are often having contracts for private companies do the admin paperwork that works out cheaper then a bunch of government employees.

[disneysteve]

they are often to far removed from the real bill. The real insanity is when they get the bill for their co-payment amount (80/20 or 70/30 etc), they get furious that 20% or 30% added up so fast.

I negotiated discounts and payment plan based on (IF) insurance was denied.
In the end the insurance paid but i was prepared.......... and the insurance company actually got a discounted rate i had worked out.

I completely agree that people simply don't think about the costs because in their minds, they aren't paying them. The insurance company is. Of course, the reality is that we are all paying those costs at least indirectly in the form of higher premiums. Plus, there's your point about the patient share of 80/20 or 70/30 or whatever. If you shop around and find the lower costs, it saves you money too. Paying 20% of $3,000 is a lot better than 20% of $5,000. And if you have a deductible of more than a couple hundred dollars, even more so.

[TexasHusker]

While I don't necessarily disagree, how did you come to the conclusion from this episode that it had anything to do with government involvement?

We've had a lot of conversations here about the need for price transparency. This story is a perfect example. You should be able to ask how much something will be and get an answer, if not immediately at least within a short period of time. This is more important than ever as more and more people move onto high deductible health plans. I wouldn't necessarily expect the person scheduling imaging studies to have that information at their fingertips but they should have been able to get it or transfer you to the person who had it.

I recognize, of course, that there is a huge difference bureaucratically between a hospital and an independent imaging company. Odds are the independent place handles all of their own affairs from scheduling to billing. The hospital, on the other hand, is a far bigger operation, especially if it's part of a larger system. The hospital system I work for now has at least 5 hospitals (I might be forgetting one), 8 urgent care centers, and dozens and dozens of outpatient practices and facilities. I think we employ somewhere around 15,000 people. The imaging place might employ 30. It's always going to be a lot easier to get an answer at the small place than at the huge company. It's like the difference between walking into a mom and pop hardware store with a question and walking into Home Depot with the same question. But as more patients have more financial responsibility for the cost of their care, the system needs to adapt to that. Price transparency is one obvious way that adaptation is happening.

As for government involvement, do you think things would be clearer (not necessarily cheaper but clearer) if we had a single-payer system? Part of the problem now is that we have thousands of payers and they all have different rules and regulations and guidelines and pricing structures. Wouldn't it be simpler to have one? I know that it's far easier dealing with Medicare than it is dealing with Aetna or Cigna or United Healthcare or any of the other private insurance companies. Medicare has one set of rules and that's it. There aren't hundreds of different plans and fee structures within Medicare. There's one.

The system began this process of spiraling out of control when Big Brother invented Medicare and effectively slapped price controls on all providers. That forced providers into a shell/peanut game with the remaining payors, because payments from Big Brother weren't enough to cover the overhead.

It is a very similar effect as the government inserting itself into higher education with guaranteed student loans, and with the housing crisis whereby the government insured low-down and no-down loans.

Single Payer would quickly become rationed care ala Canada and Europe. We would have a huge doctor shortage due to huge slashes in income, closing of hospitals/consolidation so that each hospital would be packed with patients, and a drastic cut in R&D at big pharma. It doesn't have to be that way.

If you want the government running housing, higher education, and health care, move to Paris.

[Smallsteps]

I completely agree that people simply don't think about the costs because in their minds, they aren't paying them. The insurance company is. Of course, the reality is that we are all paying those costs at least indirectly in the form of higher premiums. Plus, there's your point about the patient share of 80/20 or 70/30 or whatever. If you shop around and find the lower costs, it saves you money too. Paying 20% of $3,000 is a lot better than 20% of $5,000. And if you have a deductible of more than a couple hundred dollars, even more so.

i wish the average Joe or Jane would see that ......yes, in the end they ARE paying it.

People yell at premiums and if they have a medical issue .....some treat it like NOW they will make up for all those premiums. Like trying to justify a room cost at the breakfast buffet at a hotel.

I have watched when faced with a crisis some people say "whatever it takes" and then after patient improves and by the long billing process and they finally get the bill months later the panic and whatever it takes attitude has passed and they say " this seems like too much for this or that".
If outcome is bad perhaps someone passes, then some seem to think well they did not fix the issue so i don't think i should have to pay.
Does that work if a mechanic cannot fix a car ? Nope

Perhaps if there was a cash register in plain site people would be better shoppers and look for a Groupon LOL

[TexasHusker]

i wish the average Joe or Jane would see that ......yes, in the end they ARE paying it.

People yell at premiums and if they have a medical issue .....some treat it like NOW they will make up for all those premiums. Like trying to justify a room cost at the breakfast buffet at a hotel.

I have watched when faced with a crisis some people say "whatever it takes" and then after patient improves and by the long billing process and they finally get the bill months later the panic and whatever it takes attitude has passed and they say " this seems like too much for this or that".
If outcome is bad perhaps someone passes, then some seem to think well they did not fix the issue so i don't think i should have to pay.
Does that work if a mechanic cannot fix a car ? Nope

Perhaps if there was a cash register in plain site people would be better shoppers and look for a Groupon LOL

Many of the providers can't tell you what they charge for something. The answer is, they'll charge as much as they can get paid. Part of the game.

[disneysteve]

If outcome is bad perhaps someone passes, then some seem to think well they did not fix the issue so i don't think i should have to pay.
Does that work if a mechanic cannot fix a car ? Nope

We just talked about this at our provider meeting this morning. Patients sometimes complain if they come to urgent care and after being evaluated the provider sends them to the ER. They want their urgent care copay returned. Uh, no, you were registered and examined by a medical professional who spent time with you and evaluated your condition and determined your problem needed a higher level of care than we could provide. You still need to pay for that evaluation.

[Smallsteps]

Many of the providers can't tell you what they charge for something. The answer is, they'll charge as much as they can get paid. Part of the game.

I have asked for prices ... i have gotten them or at least in my case fairly close ballpark estimates.
The word Can't is misleading .. Sure i have had someone tell me "we do not know or we can't" and i just go up the chain of command sooner or later they realize i am not the average Jane that will just take the brush off answer.
I am NOT saying in other areas or situations maybe that is the normal i am just saying when pressed most can and Will come up with pricing.

if ANY other person tried to sell you a service but refused to tell you how much ( or ballpark) just find out later who would use that service?

[disneysteve]

The word Can't is misleading .. Sure i have had someone tell me "we do not know or we can't" and i just go up the chain of command sooner or later they realize i am not the average Jane that will just take the brush off answer.

As I said earlier, you also want to be sure you're asking the right person. If your doctor says he wants you to have a blood test for XYZ and you ask how much that test is, odds are he doesn't have a clue. Why? Because he isn't the one doing the billing. The lab is. So you would need to call the lab and ask them how much the test will be. Same for an x-ray. When I send a patient for a CT scan, I have absolutely no idea how much that will be, plus it depends on where you go for it. Every site is different.

[TexasHusker]

As I said earlier, you also want to be sure you're asking the right person. If your doctor says he wants you to have a blood test for XYZ and you ask how much that test is, odds are he doesn't have a clue. Why? Because he isn't the one doing the billing. The lab is. So you would need to call the lab and ask them how much the test will be. Same for an x-ray. When I send a patient for a CT scan, I have absolutely no idea how much that will be, plus it depends on where you go for it. Every site is different.

We have a doctor friend here - an orthopedic surgeon - who keeps up with a top 10 or 20 most common things he sends out for, and keeps track of "cash" prices and lets his patients know. A few years ago my wife needed three separate CT scans. He told us to drive to Lubbock (120 miles) to a place that did them for $300 each. We did.

[disneysteve]

We have a doctor friend here - an orthopedic surgeon - who keeps up with a top 10 or 20 most common things he sends out for, and keeps track of "cash" prices and lets his patients know. A few years ago my wife needed three separate CT scans. He told us to drive to Lubbock (120 miles) to a place that did them for $300 each. We did.

That's great that he does that. That's going above and beyond for sure, especially if he's even getting price info from places a couple hours away.

[LivingAlmostLarge]

Just got my DK2 another speech evaluation. Said should I make a co-pay? They said uh no we have no idea what the insurance will cover it or how. I said before I drove her and pulled her from school middle of the day you said it was an office visit for $20. Now it's not? Okay so I said fine. Go ahead. I might SOL and have to pay 100% I have no clue. But at that moment I felt stuck between a rock and hard place. I had gotten an evalution last minute cancellation instead of 1 month out within the week. And I had pulled DK2 out of school for a couple of hours already. So what to do? Walk out? At that point I was like heck no.

Just like the orthodontist. DK1 when we signed a contract they said it's $5k for the 1st phase treatment. That's the price and we have no idea what your insurance will cover. Sign here. I signed. It didn't exactly matter what insurance covered because we had a limited window to move her crossbite jaw. Yeah. Turns out our insurance covered 50% up to $1k. Wow! I had more money in my FSA because of it.

But most places hold you hostage and a lot of it stems from being impatient. Waiting for your appointment. Dropping everything when you get an appointment. Then being unsure how it will be billed. You want to talk about rationing care? Care is already rationed. Have money? Walk in and get served no matter what. On insurance and it's crappy? Wait and call everywhere and see where can fit you in. Limited dr take your provider. Or your company changes providers and then you get screwed if you want to keep your drs. I have a lot of friends who stick with the OT, ST, PT, etc and pay 100% OOP because they have a schedule that works for the kids, they kids like them but their company switched or the provider no longer takes aetna or kaiser, or whatever. So what do you do?

I like the idea of true free market healthcare. I want it to not be tied to a job and we have to buy say HDHP and we get HSA. I'd be totally down with it. But until we uncouple it to jobs it's not going to happen. Right now people cling to employer provided insurance. For obamacare to really work we should all be kicked off and forced to buy our own insurance. That would be very interesting. How would companies handle not paying for our insurance? My mom, a retired medical hospital social worker, says HELL NO would they give us the $20k they pay to insurance to my DH to buy insurance. And would pre-exisiting conditions hold up? How would families manage with large number of kids? How does all of that work?

I would like it because I bet within 10 years we'd be on single payer because I don't think it would be more cost efficient. If it was more countries would be true free market healthcare. But they aren't because then care and death would be directly tied to how much you can afford. Oh sorry you are middle class? Well no cancer treatment for you. You make too much. Baby in NICU? Oh how will you pay? And costs won't come down so drastically that people can afford it OOP. It would be a death knell to any politician who truly wants free market healthcare.

I'lll gamble but I'll be honest that I think my family can afford most things and cut to front of the line. I don't think the average person will come out ahead. I also think that in the long run a free market health care will make the US a much more unequal society of the haves and have nots. And we'll be in a situation where you will be doing everything to make sure your kid ends up on the right side of haves.

[TexasHusker]

There's a lot of truth to that. The imaging company that I paid $550 to said "Oh if you're self pay we can get you right in!"

So yes, there is definitely a different medical environment for those with cash. Providers loathe the whole insurance game and give cash patients first priority. Can't say that I blame them at all!

As for ObummerCare, be careful what you wish for. I am required to buy it being self employed, and the last I checked it was $2500 a month for my family, and it wouldn't pay a dime until I had paid out over $40,000 in premiums and deductibles.

Luckily, there is a loophole where I have been able to get health insurance much cheaper through Medi-share. It's about one fourth the cost. It was exempted from ObummerCare due to its religious affiliation.

Those who would like to have ObummerCare, have never had ObummerCare.

[corn18]

ACA has been working out great for some retirees with very high net worth (millions in retirement savings). Lots of talk on the fora about how to stay under the ACA "cliff" while living on a paltry $150k / year. It's the difference between $200/mo and $2000+/mo for health care. Not sure that is the intent of the subsidies.