As someone familiar with insurer, provider, and facility IT systems, I'd offer an alternate explanation -- the data is bad because healthcare IT is understaffed (and often incompetent).
These are businesses that have squeezed most costs out, and IT is definitely a cost.
Imagine banking... if there were much less competitive pressure and an inability to offer services across state lines without substantial additional effort.
They received a mandate.
They tried to respond in the way that required the least amount of effort.
From someone in the industry, it's entirely plausible this is the best they can do.
Which usually means it takes CMS threatening to drop them for them to launch a multi-year project to finally fix the issue (somewhat).
(My qualifications to make this statement: 15 years in healthcare IT, including UHG/Optum, and 8 years as CTO of a large clinical organization that included primary through tertiary care, research, and an insurance operation.)
Dealing with them right now feels like dealing with the government might as well just have the government run it
Assuming this is true for the sake of argument, saying that this sort of thing isn't malicious compliance is a sad kind apologistics for bad behavior that seems to regularly appear on HN.
What's the cost of an X-ray? Did you know they used to do a FREE X-ray at the shoe store back in the day to check fit? Yeah, don't tell me they squeezed out most of the cost.
That’s because their negotiating power is mainly due to the size of their buying power, not special knowledge or skills. Health “insurance” is basically the lamest, most economically perverted form of collective bargaining ever.
Brokers, medical billing staff, and other middlemen serve no purpose other than increasing cost (in order for an inefficient, openly colluding private cabal to invest premiums, deny claims, and collect profit) because everybody needs access to medical treatment.
t. licensed broker / agency owner
Now can you make a cogent argument for why more than one federal / national union should exist? Why does Europe allow multiple unions?
You should be able to go back to the hospital and say - based on the hospital public fee schedule , total FFS for CPT should be (very low number) . Therefore, my deductible payment is overstated, please reduce my bill dramatically.
A lawsuit would follow, which would make it very interesting. Chief argument:
The customer can clearly say its fraud - he/she looked at the public rate schedule and believed the charges would be based off the public rate schedule.
Ultimately, the disconnect between published rates and the EOB is going to come back to bite hospitals, once people shop around using the data.
They just suck in different manners, different countries have different degrees of "suckness" and so on.
And then there's the big problem beyond the question of who is paying: How much is being paid.
Healthcare costs in the US are absurdly high both on relative terms (things are way more expensive) and on absolute terms (more of the same things is needed because the American population is relatively too unhealthy for what you'd expect in a developed country with similar demographics). You need to ask why relatively inexpensive stuff like insulin is so much expensive in America than say, Germany or the UK.
If you don't solve this issue, a single payer system would probably become more similar to the terrible situation in most Latin American countries, where you have terrible supposedly universal public healthcare systems, but where in practice if you can pay for private insurance, you will do it.
Must be that law of economics that says the more you make of something the more expensive it gets.
Yes, and let's also imagine all of the existing single-payer systems (de facto or otherwise) work as advertised and didn't have elites-with-means flee to other nations for quality care.
Let's also imagine these systems provide stellar quality care and more importantly, timely care.
We can daydream all we want - but the reality isn't so obvious or absolute.
For those who are really in the know... the US already is a socialized medicine nation. Look at how much of the US annual budget is blown on medical care. Hint... it's larger than the military budget.
I flee the U.S. to have all my medical related tests and work, out of pocket, in the E.U. And it is cheaper and much much better experience. (And I don't get different treatment compared to any members of my family that are insured in Europe for paying out of pocket.)
First of all: I speak with a doctor. Not a nurse, an administrator to size me up, to see if I am in actual need of an appointment, but a doctor. (Yes, this has happened to me in the U.S. I find it unacceptable, especially given that I was apparently in much more dire situation than I even thought, and was lucky to be seen by a doctor, otherwise I would have joined the disabled group of individuals.)
I am not sure why people in the U.S. keep bringing up the UK [Edit: -- not sure if that is what you are implying but most people are in other comments]. Pick any EU country. Sure, you might not have a 5 star doctor's office, but you are going to be treated by a doctor efficiently. And that is what matters. Don't waste money on administrative tasks and fees.
So, not an entity which by its very nature spends other people's money and can never run out? I agree, sounds like a great idea, but someone will have to invent such an entity first. The ones we have would not meet the requirement.
... what's that? The entire OECD has more centralized government control of healthcare than the US, ranging from extensive price controls, to de-facto or de-jure monopsony, to outright direct control of the healthcare system, and nowhere is there a strong populist movement to ditch that for a heavily free-market-based solution? And literally all of them are way cheaper per-capita than our system? And outcomes remain between pretty-good and great? And instead of the bureaucratic billing mess we have, that's all nice & simple and takes up almost none of the time of sick people and their families? This makes no sense, I read several columns on mises.org proving from first principles that this is impossible!
I’m not trying to excuse the other bad behavior, but within the data itself, he’s experiencing a combination of health insurers’ incompetence, the kludged up data models they’ve had to build to represent the output of the multiple generations of claims processing systems and other administrative processes, and the general mess that provider identifiers are. Every payor calculates values differently. Every payor uses different codes (beyond the standard CMS and CPTs). Every payor has different arrangements that are difficult to represent in standard schema, eg capitation in Florida, delegation in California, or the oddness that are Taft-Hartley plan.
There is a link in the article to a discussion with CMS. Another participant in the discussion works for IQVIA, a long-time claims data aggregator (and CRO and a bunch of other things), and clearly understands what’s going on. It would be extremely difficult to do this work at all without significant experience working with multiple payors’ data, which requires time and access, and pays well once you do have that specialized experience.
I absolutely don't believe this complexity is inherent in the problem space, because it very much looks like it is not. I'd believe that one or more actors in our healthcare system really like for it to be this way, though.
If the meaning of these prices is only decipherable by an elite priesthood that is too busy to work on the problem, there is no real public transparency.
Take an example like this https://github.com/CMSgov/price-transparency-guide/discussio...
I don't know how closely you've worked with this data -- you clearly have some kind of expertise -- but how do you explain this?
The insurance companies had 18 months to talk to the CMS and ask for a better data model. If they're not able to explain how much things cost with 5 different negotiated types -- negotiated, percentage, derived, fee schedule, and capitation -- then they should have asked for another one.
The hospital and insurance rates are both fee-for-service base rates for items billed individually. If there's some nuance in interpreting how "fee for service" "dollar amount negotiated" goes, definitely write to me and let me know. I talked with experts in healthcare pricing before I published this.
You can write to me at alec@dolthub.com if you wanna hit me with more questions.
I've worked within the health insurance industry (workers' comp, specifically); I know what a shitshow it is. As a fairly green programmer, I was tasked with creating a flat file export from our IBM mainframe's database for a new/changed regulatory requirement, and within just a few weeks (including a bunch of time spent waiting for return files from overnight batches), my export complied with the stated spec better than the agency's own files did.
But the health insurance industry makes absolutely jaw-dropping profits. The only reasons they can't harmonize their systems and produce something at least resembling standard outputs are because it would cost them slightly (on their scales) more money than just continuing to do what they're doing now, and because the higher-ups are (as with many industries) chronically unwilling to commit to one particular standard if it will make it even a little bit harder for them to change their minds whenever they want.
When you get an x-ray, you would expect to see 3 claims (again, simplifying).
—— One is the x-ray tech taking the picture. That gets a professional claim with a CPT code and is straightforward.
—- One is the interpretation by a radiologist of the imaging. That is a professional claim with a CPT and a modifier.
—- The last depends on the place of service. If it’s in a hospital, or at an outpatient facility, or at an ASC, then you get a facility claim to go with it.
Next, under what circumstances did the x-ray occur? Was it during an inpatient stay? If so, the payor might pay based on a DRG, which is basically a bundle of all the services that occur during the stay. How do you decide how much of the cost to allocate to the various parts of the x-ray? There are more variations on this.
Next, how are the providers contracted? Are they participating providers? Par vs non-par have different payment rates.
Next, was the service in-network or out-of-network, defined by the patient’s insurance benefits?
Does the patient’s PCP participate in a capitated arrangement (fixed fee to the PCP’s office per month)? If so, what is the allocated cost for the service based on the submitted encounter?
What about fees for network rental? Sorry, this one is esoteric, but it’s another factor.
And so forth and so on. It’s a mess.
Riiiiiight…
This data should be verified by matching it against claims data.
https://github.com/CMSgov/price-transparency-guide/tree/mast...
Along with this fantastic guide:
https://github.com/CMSgov/price-transparency-guide
I recommend them to anyone who wants to see good examples of price transparency.
> No one can produce the corrected/missing rates but the insurance companies themselves. All we can do is point out when we’ve found rates/patterns that don’t make sense. E.g. https://github.com/CMSgov/price-transparency-guide/discussio...
Would a free market be better? Probably overall, but the bar is very, very low. Instead of running another decades-long experiment, perhaps just use a model proven to work? There are many to choose from.
Insurance companies are a problem, and they've grown fat skimming a fair fraction of this nation's GDP for no observable value provided. Our healthcare system is more expensive and has on average worse outcomes than other first world economies.
It truely was impressive how these forum members unearthed massive savings and really, once you knew what to do, didn't seem all that invasive or difficult.
We are writing more groups using Referenced Based Pricing. Good idea.
Fine, "you don't know" how much things will cost. We can figure it out for you. No thoughts, head empty, just post and sign every bill you generate as it comes.
There should be fine a 1% of annual revenue for every day these companies are in non compliance with prison for the ceo if they are non compliant for over thirty days.
Due to the cost I was curious, and found out that I could literally purchase all of the FDA-approved* lab equipment for my house and run tests on myself for less cost than it was to go to a physicians office. The physician (i.e. expertise) is irrelevant here (almost always are) as the most input I've ever seen provided by one amounts to 'take an Aleve if you're hurting'.
Home labs are likely where the future is headed, and it's the fault of the medical industry being so utterly useless. I've been through most medschool (neurology-focused) courses, and most physicians or any medical professional uses essentially zero of that knowledge.
(In fact, my local hospital has pretty great lab prices for this exact reason, so I'd assume this kind of price competition for simple tasks might already be a thing in some urban areas.)
It's lives on the line. In a somewhat realistic ideal world, any monies that exchange hands at that level should be to cover costs plus a moderated profit.
The lack of moderation and accountable oversight on the profit centers of healthcare is a real issue that we could solve, but too many people would rather have a 0.00000001% greater chance of becoming a millionaire in their lifetimes rather than put checks on unchecked capitalism.
At DoltHub, where we build databases like codebases, we're running a data bounty, collecting rates for popular medical procedures for all US hospitals. Then we'll release the data under CC. Find out more here.
The health insurance industry is quietly and uniquely one of the darkest markets in the world.
I am not sure why this is even a divisive topic. Sure discuss how a doctor decorates their office. Who cares. When you are dying or are in pain, nothing but treatment at any cost matters.
Oh, sure, in a crisis you need care immediately. What about all the other circumstances? What about the possibility of making pre-arrangements in event of crisis, some sort of “insurance” even? Not to be confused with the comprehensive health care delivery product called “insurance” in the US (which, hey, also exists as a model and could persist in a market.) Maybe some markets are still monopsonies, but surely not all. I can surely find a variety of GPs, allergists, physical therapists, …
A sound argument for or against a market health system recognizes that emergency care is only one circumstance of many, a minority of health care costs, and it’s possible we might be better off if it does not drive the overall design of healthcare.
His nominal role is to assist with Medicare-related matters, but given that the ostensible goal here is to compare rates (and most payors define rates as a percent of Medicare), I think the request wouldn’t be too much of a stretch.
Similarly, might be possible to get some congressional offices to lend their weight. Happy to personally lend a hand with the outreach if there’s interest.
The second big problem is that they are being forced to buy it.
So you have something that isn't what people want, but that they are legally obligated to "purchase"... Is it any wonder most people are dissatisfied with it?
