I think this is a total red herring. People don't make health decisions on the basis of cost (assuming they can pay for it at all), they follow the advice of their doctors.

If my doctors says to take drug X at a cost of $100,000 per year am I going to say "that's too expensive, I prefer to take drug Y which is cheaper"? Of course not, I'm not an expert on what is the best course of action. Will telling me that the doctor makes more money on X than on Y affect my decision? I doubt it, either one trusts one's doctor or one goes elsewhere (where available). People have no concept of what a fair compensation for a doctor should be in any case.

I get monthly statements from my health insurance company which show exactly how much was billed and how much they paid. What am I supposed to do with information - tell the doctor he is overcharging at my next visit?

Where there is no transparency is over what the insurance really pays (especially hospital charges) compared to what is billed. No insurance company is going to reveal this, it would give their competitors too much information.

The high costs of heath coverage are caused by excessive overhead and a useless layer of middlemen, over priced drugs and medical equipment, pointless end-of-life treatments and a failure to improve the public health system so that preventable conditions are actually prevented.

Why are cigarettes still legal? Why are high sugar foods marketed to children? Why is sugar added to everything from oatmeal to salad dressing? Why are sugar producers subsidized? Why does the bulk of the agribusiness dollar go to those who make industrial food products instead of the farmers? Why are there millions of under served people?

Can we move on to the tough issues?

--- Policies not Politics
Daily Landscape

Re: Where there is no transparency is over what the insurance really pays (especially hospital charges) compared to what is billed. No insurance company is going to reveal this, it would give their competitors too much information.

???
Insurance companies are required to send out EOBs detailing what they pay on any given bill in great detail. There is nothing secretive about it. I will grant you though that the sheer complexity of the statements can be pretty daunting.

Let me know how the whole "negotiate rates" with your insurance company thing works out. I'll wait.

--- Policies not Politics
Daily Landscape

Okay, knowing the price of things is good.  As others have pointed out, though, it probably won't change anyone's health care choices. I can see how this type of disclosure could be important ground work for later things, so okay.

But another wrinkle occurs to me.  Sometimes there are complications.  So it's not going to possible to know the cost of, say, a birth beforehand.  There might be the "normal" cost, but if there's a procedure that needs to happen NOW, I don't think anyone is going to wait for disclosure.

I also don't understand what the emphasis on pricing is about?

It should be free.

Socialized medicine. Like they do it in every other industrialized nation.  

The emphasis on pricing makes this seem like a capitalist, free-market scheme. Capitalism has not worked for health care. We have already decided that it would not work for our police department, fire department, libraries, or anything else that's considered a public good.

Why should our health be something different? 

(Yes, these are all Michael Moore's talking points in SiCKO, but they make so much damn sense...) 

If we had it, we'd have to keep Republican hands off of it, you're right. They'd probably purposefully underfund it just to prove that it doesn't work.

thosethingswesay.blogspot.com

I'm with the majority above, knowing the price of medical care solves very nearly nothing. And, I agree with cscs that we need to bite the bullet and call it social health care or some such terminology that admits it is a socialistic program. We can't fool anyone by pretending it is just a better form of capitalism.

Hoppy in Sacramento

Re: It should be free.

Oh good grief, no wonder the Right has such a field day! There's no such thing as free healthcare. Somehow, someone is going to be paying the bill. That's why we have to debate how to fund healthcare.

The last time you pulled into your corner gas station to fill ‘er up, you probably noticed the price-per-gallon on the the huge sign out front or on the pump when you got out. Every other driver saw the price, too, and knew that they were paying exactly the same price as you were for exactly the same amount of gas. -- Congressman Kagen

And if I don't like the price and think I can get a better deal somewhere else, I can drive around, from gas station to gas station, until my tank's empty. If I hadn't found anything that suits me before then, I'll need to call AAA to come and tow me to the nearest one, which may end up being the most expensive of all (and never mind all the gas I've wasted driving around, looking for a better deal). Or I re-learn how to walk.

In the same way, I can price-shop for health plans or for off-the-shelf drugs/supplements. But, if I'm caught short before I find something that I can afford, I end up in an emergency room or dead. Not quite the same thing, since, while the visit to the emergency room can be compared to being towed by AAA, being dead doesn't compare to re-learning how to walk.

Transparency per se is good (I'd be happy to see the amount of profit Mobil or Exxon or my insurer are making on every galllon of gas I use and on every pill I take) but, applied as you suggest, doesn't seem to solve any problems at all.

Like everyone else, I'll be waiting to see the next installment in hopes that there'll be something more substantial there.

This is just silly. Sorry. One might expect more from someone who is both a Congressperson and a physician.

There is so much wrong here I am not sure where to begin. First, the fact that gas stations post their prices in no way prevents oil companies from fixing those prices and manipulating the market. As recent large fluctuations in gas prices unrelated to other market forces prove, it just doesn't. Also, when one needs medical care, especially emergency medical care, one does not have the luxury of driving around looking for the best deal. Have a heart attack or a stroke? Just get on the internet, or drive to a few hospitals to check the costs of the treatment, posted right there outside. Sure.

Even shopping for insurance is frought with so many technicalities, fine print, exceptions, co-pays, deductables, "in network" restrictions and so forth that it is beyond even the most savvy consumers to figure it out, not to mention that since for some unknown reason employers provide most health care coverage, most consumers don't even have much of a choice to begin with.

Competition is not a "uniquely American concept." either. It exists everywhere even in the most basic and primitive marketplaces and has for thousands of years. In fact it may exist in a purer form in those venues than here.

The fact is that provision of modern medical care, most of which is technically complex and not readily understood by those "buying" it, is a really poor example to rely on the marketplace. It has been proven not to work, unless you think the system we have now is fine. Most people don't. The only reasonable solution, proven to work, is that which the entire industrial world uses -- a form of single payer or highly government controlled insurers (such as in Germany), functionally equivalent to single payer, that insures everybody. No matter what. At contollable costs. The question is not the solution, it is how to get there in the most reasonable way.

Anything else will not solve the problem. Your idea is like being served a toxic stew at a bad restaurant and then being told the whole mess can be fixed if we add a little parsley to the plate.

As a doctor, you must know that parsley won't cure food poisoning.

Thanks rdf:

You are correct in stating that there is no transparency, and that is exactly my point. Without knowing the real price being accepted as full payment, there is no real marketplace.

Cost does matter - especially in health care. The cost of prescription drugs, for example, determines their availability.

The impossible costs for health care today are largely due to the fact that there is NO open marketplace.

When we enact a federal law mandating Open Disclosure, everyone will see the real lowest-price of an insurance policy, AND insurance companies will be forced to compete against one another in the open - not behind closed doors.

So, do you agree that all prices in health care should be Openly Disclosed?

Thanks SteveA:

I have not yet signed on to Chairman Conyer's bill, nor have I signed on to any others. I beleieve it can be improved, and as I indicated to you yesterday, I am working hard on it everyday.

And I am not a member of the association you mention above.

Support for the essential elements in my initiative comes from the fact that when it is implemented nationally, it will reduce the "profit/overhead" of insurance companies - immediately - by forcing them to compete for our business in a competitive medical marketplace.

About single-payer - if I understand you correctly, you're implying that in a "single-payer" system there will be only one coverage policy that determines who will or will not receive whatever treatments become approved. Will such coverage be determined by your own physician, legislatures, the Executive Branch, hospital administrators or some other as yet undetermined government-associated committee?

We Openly Disclose everything else in our markets - why shouldn't we reveal the real lowest-price for prescriptions, for insurance policies, for doctor and hospital services?

The essential elements in my initiative will establish universal coverage at prices we can all afford to pay - everywhere in these United States.

It all begins with establishing Open Disclosure of all health care related prices.

Thanks mjshep. I appreciate your comments.

Please help me to understand what you are thinking.

1. What is it about Open Disclosure that you disagree with?

2. What is wrong with establishing a standard health insurance policy that covers you from your head-to-your-toe - without allowing insurance companies to discrimination against any citizen due to any pre-existing conditions?

3. If you can Google prices for other purchases - don't you want to be able to do so for health care products and services as well?

4. If I just paid $1 for a pill at a pharmacy, would you want to pay anything but $1 for the same pill at the same store that day?

In my view, Open Disclosure begins to create a real marketplace in which we will all benefit by leveraging down prices for all health care services and products.

Thank you for your considerate responses, ideas and input.

No, Robert, I don't want "someone else" to pay for it.

I want ALL AMERICANS to pay for it.

Take it out of everyone's taxes. Simplify the whole damn thing.

I want socialized medicine. Not the failed, capitalistic approach that we've already tried. Profits and health care do not make sense. It should be a completely non-profit approach, just like the police department.

"Thank God George Bush is our president." -Rudy Giuliani

I'm not an idiot.

When you go to the doctor, get treated, and leave without paying, and without getting a bill later on, that's free.

We should all pay it.

We seem to put up a lot of lip service in this country to things like patriotism, nationalism, how we're the "greatest country on Earth."

Yeah, and 18,000 people a year die because we've been bamboozled into thinking health care is a "benefit," something that shouldn't be just free for everyone to have when they need it.

"Thank God George Bush is our president." -Rudy Giuliani

Unfortunately, there are a number of healthcare funding models, Medicare DRGs being one and capitated service models being another, where complications are explicitly not considered. Perhaps worse are unfunded mandates such as EMTALA, whhere there is no consideration whatsoever of cost prior to providing required services.

EMTALA, which is the basic Federal legislation that requires emergency service providers (ERs, ambulance/EMS, etc.) to provide, at the least, "stabilization" services without making a determination of the ability to pay. I suggest that understanding the economics associated with the goal of EMTALA, and coming up with ways to handle it without cost-shifting to a virtually random part of the population, may be more informative than disclosure.

EMTALA deals with the demand side of some very real healthcare issues. Imagine you are an emergency physician, and an ambulance rolls up and delivers an automobile accident victim, unconscious, clothes and personal effects burned away, and with rapidly developing airway obstruction from inhaling hot gases. That airway needs to be stabilized now, or the patient will die.

You have no way of finding if the patient is Bill Gates or someone with absolutely no financial resources. If you wait to verify the means to pay, the patient may die due to the delay. If you do rapid sequence intubation, attach the patient to an advanced ventilator, and start IV fluid replacement, but later find out the patient is penniless, do you shut off the life support and allow the patient to die?

EMTALA doesn't answer how to pay for the penniless, or less well-insured victim's care. Instead, it applies the negative reinforcement that if EMTALA-mandated care is not given, all Federal funding to the provider will be cut off. In other words, while it addresses a social good, it is an unfunded mandate with only negative consequences from the political system.

Since the provider has expended real costs, what happens when the patient can't pay? Right now, hospitals shift cost not to the general public, but to those patients who can pay something. Typically, the uninsured self-pay, who do not always have the resources of Bill Gates, pay "retail", and the clients of larger insurers pay "discount".

I don't see how knowing what a hospital charges for succinylcholine or pancuronium, typical drugs used in airway management, is going to contribute to the healthcare funding debate. Until cost shifting is addressed, there are more fundamental issues.

--
Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

Fine, but that does not make it "free".

That said, I bet that ninety percent of the people that hear "universal health care" think that someone beside them will be paying for it.

How is the common defense funded?

Alternatively, how is it that it is a proper tax-supported police function to prevent me from being shot in a drive-by, but not to be immunized against the tetanus that killed me after the police didn't stop the bullet?

--
Howard

*equal opportunity offense to both extremes*

I don't think people in this country are idiots. I think they get that the money to pay for socialized medicine comes from taxes.

It's not rocket science.  

"Thank God George Bush is our president." -Rudy Giuliani

"We have already decided that it would not work for our police department, fire department, libraries, or anything else that's considered a public good."

A) Health is partly a public good (contagious diseases) and partly a private good (innumerable examples, like a kidney stone or a broken arm).

B) Many of the services you identify are not wholly public. Fire departments are often volunteer; fire insurance is private. You are required to incur expenses when you build a structure to comply with a fire saftey code so as to minimze the risk to impose losses upon the rest of the community - those are private expenditures. Police services are augmented by private security forces in building lobbies, and prisons are privatized in many states. Education is a mix of public and private options. Libraries are one places to get books, but bookstores are another; one is public, the other is private; note that libraries ration book consumption per diem and often has only limited supply in any genre - do you still like the analogy? By your analogy, libraries would give everyone as many books as they want to hold onto as long as they wanted. Do you seriously think your community would long fund such a library?

C) ultimately, over the long term, you get what you pay for. The ability to deliver free health care for multiple generations is nil; the economy is no longer that strong. Please join the reality based community.

Strawman? Strawman? Sir, as one of neodruidic tradition, I shall speak for Wicker Men, and nothing less.

Apropos of calling things "free", would you be so good as to point out where I called anything "free", other than in response to your use of the term? Let me think about posts I've made today, and if any of them called anything "free":

--
Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

Agreed, and they feel confident that someone else will be paying those taxes.

Thank you for your reply. I'll try to answer your questions.

1. What is it about Open Disclosure that you disagree with?

I don't disagree with it, I just do not think it addreses the primary problems we face. In my opinion whatever effects it would have would be, at best, marginal.

2. What is wrong with establishing a standard health insurance policy that covers you from your head-to-your-toe - without allowing insurance companies to discrimination against any citizen due to any pre-existing conditions?

Nothing is wrong with that, but it was not what was discussed in your article. Perhaps you speak to it in a later post. We must realize, though, that such a standard policy is only a part of the solution. We must also take into account how it is paid for, who provides it and what it would cost. I am afraid that if we leave this up to private insurers, without stringent guidelines and controls, it will end up being mostly a guaranteed income stream for them, not a cost effective solution for the public. It also needs to be universal policy, so all are covered.

3. If you can Google prices for other purchases - don't you want to be able to do so for health care products and services as well?

That's nice, but under a single payer system, or even universal coverage from private insurers, it would be unnecessary, since my costs would be covered in any case. It would be up to the provider, either the government or the regulated private insurer, to be concerned about the price. I would go to the doctor, get treated, and not worry about the bill. Just like in France, Canada, Germany, England, Italy, Spain, Sweden, etc.

4. If I just paid $1 for a pill at a pharmacy, would you want to pay anything but $1 for the same pill at the same store that day?

Once again this assumes that these costs will be out-of-pocket to me. If they were, or some portion of them was, then I would like unitary pricing. This still does not get at the substance of the problems our health care delivery system has.

In my view, Open Disclosure begins to create a real marketplace in which we will all benefit by leveraging down prices for all health care services and products.

Cost control is only a part, albeit an important part, of the health care crises. If there is one area, for reasons of lack of consumer discretion in choosing, the specialized knowledge required to make an intelligent choice, and the often immediate, life or death nature of the decisions involved, where the so-called "free market" or "the marketplace" is not a reasonable alternative, it is health care. A free market consists of a informed buyer and an informed seller, neither under any form of coercion. That just doesn't exist in the health care field, just as it doesn't exist when your house is on fire. You call the fire department, and you don't worry about the cost, because it is picked up by the society as a whole.

Health is partly a public good

Not at all. Less people with health care costs us all more in the end. A healthier society on the whole costs us less than a sick one.

Police services...do you still like the analogy? By your analogy, libraries would give everyone as many books as they want to hold onto as long as they wanted.

That's not my analogy.

The NYPD is my analogy. Non-profit, works pretty damn well. 

And no one is "holding onto health care" as long as they want. You get sick, you go to the doctor. This idea that if we had universal healthcare, all kinds of people would just be clamoring to see a doctor for no reason at all is very contrived. Just like the example in the other post, that people would start riding motorcycles at 80mph without helmets. It's contrived. 

ultimately, over the long term, you get what you pay for. The ability to deliver free health care for multiple generations is nil; the economy is no longer that strong.

The economy can no better sustain the mess we have now.

You're defending a failed system. Every other industrialized country has universal health care.

They all pay less, and are more healthy.

Seem like a no brainer.

The cult of capitalism has got you in its grips. Read Marx; he's good. Your commodity fetish will start melting away... (heh) 

Wow, I really touched a nerve.

I don‘t object to a debate about what goods and services should be considered public a which should be delivered by the free market. When someone refers to a public good as being “free” I am going to call a foul, sorry.

I do think that a pitfall of publicly delivered goods is that the consumers do no recognize their cost and as such do not tend to hold those institutions delivering those goods accountable. That does not make them free loaders, it’s just human nature.

“You continue to harp on "free", avoiding specifics by announcing it was a response to cscs.

My intent was simply to gently remind cscs that health care would not be free, publicly funded of not. I didn’t mean to drive you into a foaming at the mouth rant. Why not have a nice glass of wine and get a good nights sleep. If you don’t feel better in the morning, consider some anger management courses.

The high costs of heath coverage are caused by excessive overhead and a useless layer of middlemen, over priced drugs and medical equipment, pointless end-of-life treatments and a failure to improve the public health system so that preventable conditions are actually prevented.

Do you have any data to support this assertion? Drug costs are typically about 5 cents of the dollar spent on healthcare. BTW you left out the astronomical costs of pro-life neonatal care due to the increasing number of 'litter' births by humans due to the failure to undergo utereo reduction.

It should be free.

C'mon.....nothing in life is free. Not even water. You pay for water each month when your receive your bill.

When you go to the doctor, get treated, and leave without paying, and without getting a bill later on, that's free.

Let's see, so using this logic...you believe that public schools are free and kids go and learn without paying and without getting a bill later on, so education is free?

What we all know is that public education costs. It costs the taxpayers. What Americans decided is that they were willing to pool their resources to pay for public schooling so that individuals could send their children to school without needing to pay the costs of private education. It's not free...residents pay with their tax dollars.

The same will be true for any healthcare plan. The costs will be borne by the public.  It will not be free.

Well said. Even with its problems, public education tends to be seen as an investment. Some of the most cost-effective medical expenditures are in preventive care and aggressive chronic disease case management, but these are rarely presented as investments. Aside from benefits of a healthier society, I find it ironic that for all the scare tactics about covert bioterrorism, privacy-protected data mining of electronic health records is a key to early detection.

From a pure economic standpoint, private insurers, who expect significant "churn" of their subscribers, hate to pay for preventive care whose savings are likely to benefit some other company. These are not the only reimbursement issues. I continue to be amazed at the increasing level of training of pharmacists, the greater use of hospital pharmacists as part of inpatient care, but the lack of reimbursement of cognitive services for the community pharmacists who are often most in touch with compliance issues.

--
Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]