Item — HN Reader

> Consumers, meanwhile, buoyed by insurance and tax breaks, have little idea how much they are really spending and little incentive to know underlying costs.

Almost weekly there's another post showing that consumers literally cannot find out costs usually because the provider cannot supply it. It's time to put a stake in the heart of the recurring blame-the-consumer trope.

6 comments

I don't read it as "blame the consumer" but "the system is opaque".

The consumer doesn't know and can't find out. Articles have been written for, I don't know, a decade or more decrying the opacity of the "Chargemaster", etc, and how if you call a hospital to ask the charge for a procedure, they probably can't give you a quote.

If you have certain kinds of insurance, you're not even incentivized to care - you tolerate the opacity. But I don't think it's really blaming the consumer so much as blaming a system way off the rails.

Additionally, the first thing you have to do when you go to the doctor in the US is sign that paper that basically says “I agree to be responsible for the bill, no matter what it ends up being.” Which is ridiculous given you can’t know what the bill is until after you’re charged.

Imagine going to the grocery store and there are no prices on anything. You load up your cart and walk out and the grocery store sends you a bill months later. The bill is enormous because the grocery store has a signed statement from you agreeing to pay whatever they want. That’s the system we have for healthcare.

The problem I have with the "blame the consumer" trope is that there's the implicit "and if consumers had full pricing knowledge, The Market(tm) would correct all of the other issues, and healthcare in the US would be fixed." I assert this mostly through anecdotal evidence based on where these conversations tend to go.

I also find it to be some of the most disingenuous handwaving I've seen in recent memory. No one is going to comparison-shop when they have a ruptured appendix. Worse, if they think they can just "tough out" the abdominal pain because they can't afford the doctor visit _or the treatment that might result from it_, they'll just die.

Just to head something off... if your answer to "What if people still can't afford healthcare?" is "If you can't afford healthcare, then you're not contributing enough to society to receive healthcare.", then I thank you for your candor and your ideological consistency, and have you considered that you might be a sociopath?

>The problem I have with the "blame the consumer" trope is that there's the implicit "and if consumers had full pricing knowledge, The Market(tm) would correct all of the other issues, and healthcare in the US would be fixed." I assert this mostly through anecdotal evidence based on where these conversations tend to go.

If the consumer had full pricing knowledge beforehand then the market would certainly correct some of the other issues, probably not all but certainly some. Take a look at dental for example.

>I also find it to be some of the most disingenuous handwaving I've seen in recent memory. No one is going to comparison-shop when they have a ruptured appendix. Worse, if they think they can just "tough out" the abdominal pain because they can't afford the doctor visit _or the treatment that might result from it_, they'll just die.

Getting ripped of because you couldn't afford the time to shop around is par for the course in many industries. Yes, some peoples' appendices will rupture without warning but many more people will have conditions that give ample warning and allow comparison shopping. I think this there is a very good comparison to automotive repair in these scenarios (albeit higher dollar amounts and consumers being more willing to have work done up front to avoid more later).

> a system way off the rails.

I agree.

Obviously some situations are complicated or don't lend themselves to doing so in a timely manner, but my healthcare/insurance provider (UWHealth and Quartz) has a priceline and online message center for immediate quotes without insurance. I use it even though I have insurance, especially before appointments where I anticipate what tests the doctor is going to order. They're usually reasonable, at least by American standards. Surgery has been more difficult to pin numbers down for because of the facilities.

I agree, but I think they are talking about a different aspect of "not knowing". Which is, I get health coverage from my employer, I go to the doctor, I get some sort of bill that seems high but not crazy, I assume that is the cost of visit. But I am not seeing the transactions behind the scene between doctor/insurer/employer that may be several times what I am directly out of pocket, but pay indirectly.

there are other kinds of problems. You are in the hospital, you feel queasy after surgery, nurse asks if you would like medication for that. "how much is it?" If you even think to ask that, usually they will not know, and can't or will not find out for you. So you can't make a rational decision about whether to deal with the discomfort or not.

Similarly, doctors often won't know the cost difference between various medication options, and those costs are always extremely difficult to figure out since there are usually various coupons that last for various amounts of time, which if you are willing to sort through you can game the system a lot. But in the long run it would be better if those games didn't exist. Switching asthma meds as you run through coupon time limits isn't really the healthiest thing anyway.

Or you are hit by a car, an amublance shows up "what will the bill be? Oh I'll call a different service" no, you can't do that while you are bleeding out, nor will you have any way of knowing which hospital will have the best rates to fix you, you don't even know what is wrong yet!

One might conclude that private, free markets don't make sense in this domain at all, perhaps.

> there are other kinds of problems. You are in the hospital, you feel queasy after surgery, nurse asks if you would like medication for that. "how much is it?" If you even think to ask that, usually they will not know, and can't or will not find out for you. So you can't make a rational decision about whether to deal with the discomfort or not.

followed by

> One might conclude that private, free markets don't make sense in this domain at all, perhaps.

is an odd conclusion to draw, since the agent primarily responsible for the inability for providers to provide transparent prices to privately insured patients is, ironically, Medicare.

>is an odd conclusion to draw, since the agent primarily responsible for the inability for providers to provide transparent prices to privately insured patients is, ironically, Medicare.

I'm not sure how you can be so certain that is the 1st order reason. The pricing situation seems to often be obfuscated by our private insurance companies as well. When people have different insurance plans, with different back room deals on rates, and different customer out of pocket rules, or none at all, how is the doctor to know what your price is going to be? How does erasing medicare from the equation fix that?

Even if you got complete disclosure of costs, there is no incentive for consumers to negotiate costs because of insurance coverage. Sure, rates go up but that's a detached and opaque process.

A piece of anecdata on what happens when it's not as opaque: I took the script for a lumbar MRI to a standalone imaging chain advertising low costs. The phone quote was 1/10th the price quoted by the hospital. What puzzled me was that although the imaging place accepts my insurance it asked for $395 if I wanted payment to apply against my insurance deductible but only $275 if I paid without going through the insurer. Was the delta reflecting the imager's cost to file a claim? They couldn't tell me. I wish there were ombudsmen to turn to.

The price differential is based on the cost of filing an insurance claim, the risk that the insurer will deny the claim (or require changes before approval), and the delay in receiving payment. A cash payment today is a sure thing.

Actually there's at least 2 incentives: 1) even with insurance coverage you have a deductible, and unless you have a year with a lot of doctor visits or procedures, you're probably going to end up paying almost everything out of pocket, 2) higher medical bills drive insurance costs, if you can get lower bills you can reduce your insurance costs (not even negotiating with the insurance, but just simply switching to a different/cheaper plan with lower coverage).

The govt needs to rip out the tax deduction for employers, which is a big band aid. Until this is done nothing will change.

Your company doesnt pay for your car insurance or home insurance, why does it pay for your health insurance?

Agreed this needs done asap. Benefits hold unsatisfied workers captive, get rid of this bandaid -- and maybe we can afford Medicare for all.

One other option -- make Hospitals be both insurer/provider. They get recurring monthly income, they'd pay 'other' providers when you're travelling out of network, but they'd be more able to bring down costs, the government should set limits though on surgeries and their needs to be more transparency in pricing.

You'd subscribe to your local hospital and pay a % of your income to the hospital they'd take everyone regardless of income level.

If this is all that's done and companies stop paying for insurance, I would expect employers to use the opportunity to pocket most of the savings and only pass on a pittance to their employees.

Also, uninformed consumers will opt for cheap plans without checking for (or realizing their personal susceptibility to) major pitfalls that the ACA used to protect against before the Republicans pulled it apart.

I have a reason to partly blame consumers.

Recently I went in for a consult to see about an operation. Before the consult, they asked for a pee sample. After the consult I got a bill, including the lab work. I never got the operation.

The doctor never needed that lab for the consult. I don't think they even performed it that day. They just threw an extra step into the procedure, knowing that most patients would just accept it rather than interrogate the doctor or nurse as to why this was needed. The nicest way to view this is the office is operating with unnecessary procedures that drive up cost. A less charitable interpretation is they're jacking up their fees.

The blame falls on me here because I put blind faith in the doctor's office and did not fully investigate everything being done and approve or deny things based on my questions.

Now, do I think I should have to do this? Hell no. I'm not qualified to speak to their procedures. But the only way I can see doctors change how they operate is to start demanding it, in addition to regulatory change to provide a fee breakdown before doing anything. I know this would probably only make everything more expensive and slower, but I don't have a better idea. Hopefully somebody else does.

> The blame falls on me here because I put blind faith in the doctor's office and did not fully investigate everything being done and approve or deny things based on my questions.

The thing you are describing is not the problem. In a normal healthcare system patients aren't expected to second-guess and interrogate doctors.

Sure, but we don't have a normal healthcare system, and we can't just convert it into a normal one, either.

It's a bit like big distributed systems. Before it is built, you can design it the way it should be done. After it is built, you can completely rebuild a new one from scratch, and migrate over to it over time. But it is incredibly costly, difficult, and impractical to retrofit the existing system to the point that it operates in a completely new ideal way. You can patch it, but the more patches you add, the more of a Frankenstein's Monster it becomes, getting slower, uglier, costlier, and buggier.

As much as it would be great to just upgrade the system per-state, the medical industry (as I understand it) is basically a national monolith. What I'm proposing, unfortunately, is patches. But I don't see a way around it other than rebuilding from scratch.

> Hopefully somebody else does.

Copy what works well in the rest of the world?

It's not an either-or. Those two things are closely related.