health care

The Maddening World of Hospital Pricing

"How much does this cost?" shouldn't be a stumper.

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How much do three stitches in the emergency room cost?

For David Fleming, whose 14-year-old son Aiden needed sewing up after a laser-tag accident in June, the answer was $1,897… And $2,526.34… And $3,455.68… And $2,881. And…

The first amount was the original bill from Henrico Doctors' Hospital. But then Fleming's insurance company, Coventry, pointed out that it has an agreement with the hospital that sets the contracted rate for the service at $4,221. In other words, his insurance company already had agreed to pay more than Fleming was billed.

Suddenly he was being asked to pay the balance of his $4,000 deductible. Along with a percentage of charges over the deductible. And a percentage of a physician's charge—minus the square root of his son's birth date when multiplied by his age plus 3.7… Or at least that's how it looks to anyone who's not employed full time in hospital billing and coding.

Fleming is no babe in the woods when it comes to health care. He heads up Donate Life, an organization devoted to increasing the frequency of organ and tissue donation. But he couldn't get his mind around the idea that he owed more for three stitches with insurance than without it. The problem, says Aetna, which bought Coventry in 2013, is the lack of generally common contractual language stipulating that the insurer will pay the "lesser of" a billed or contractually agreed-to rate. Henrico Doctors and its owner, HCA, declined to comment.

Fleming has been persistent. He's been arguing over the bill almost since the incident happened. And he has gotten some satisfaction. After a lot of to-and-fro, Henrico Doctors has agreed to accept a lower payment and let the matter go.

So, good for Fleming. But his story raises a lot of questions. For instance, what about other people in similar circumstances? How often do policy holders find their insurance companies bargaining their bills up, rather than down?

The bigger question relates to hospital price transparency generally: Why isn't there any?

Call a half-dozen hospitals or urgent-care clinics and ask what they would charge for three stitches. You'll have better luck collecting hen's teeth. They won't tell you. Not only that, they'll tell you that they can't tell you, even if you ask for the cash price without insurance.

That's because there is no cash price, even for something as simple as three stitches. The closest thing hospitals have is the chargemaster price list. That's a file listing charges for thousands upon thousands of services and supplies, from Tylenol to a pediatric-care bed ($1,724.29 a night at Cedars-Sinai in Los Angeles). If you go in for gall bladder surgery, the hospital will use the chargemaster to look up its price for every blood test, half-hour of anesthesia, and bag of IV fluid you use, then total them to produce your final bill.

Trouble is, the chargemaster is completely untethered to two important considerations: (a) reality and (b) cost. Its figures are completely arbitrary. In California, which requires that chargemasters be made public, one San Francisco hospital lists a codeine pill at $16; another San Francisco hospital lists the same pill at $1.

This is not an anomaly, but the norm. A couple of years ago the Center for Medicare & Medicaid Services released prices for 130 common procedures at more than 3,000 hospitals. Scroll through the thousands of lines in the spreadsheet, and you find the estimated charge for a level-2 debridement (removal of dead tissue) at UVa Medical Center is (or at least used to be) $152.68. At Bon Secours DePaul Medical Center in Norfolk, it's $515.57. At Carilion Roanoke Memorial: $69.28.

This is not fraud in the classic sense. And there is nothing inherently unethical about different institutions charging vastly different prices for similar products and services. You can get a hamburger for a buck at McDonald's. A burger at DB Bistro in New York could cost you $140. Nothing wrong with that.

On the other hand, you know the price of the burger when you walk in the door. How many of us would eat out if restaurants refused to say what an entree cost until after it was eaten? How many people would frequent McDonald's if one franchise estimated the price of a Big Mac as between $3.50 and $7.25, while another franchise estimated it as between $6 and $23?

Most people would consider such a policy at least a trifle shady. Very few would consider it defensible, and many likely would agree with Arthur Caplan, a medical ethicist at New York University's Langone Medical Center, who recently called U.S. health care "the most obtuse, dense, incomprehensible pricing structure ever created by humanity."

Yet if you're willing to invest a big chunk of time, you can track down pricing estimates for some services. For example, HCA has a web page with estimates at Henrico Doctors' Hospital. But it provides some price ranges so wild they're useless. Treatment for atherosclerosis could run an uninsured patient anywhere between $16,000 and $68,000, depending on how long he or she stays. And just in case that doesn't provide enough wiggle room, HCA stipulates that "Henrico Doctors' Hospital makes no guarantees regarding the accuracy of the pricing information provided by this website. A final bill for services rendered at Henrico Doctors' Hospital may differ substantially." In other words, the price could be just about anything.

Virginia Health Information, a nonprofit that collects data under a contract with the commonwealth, provides slightly better information. It lets you know, e.g., that a colonoscopy could run you anywhere from $1,500 at a doctor's office to $3,200 at a full-service hospital.

You probably can get better data from Vapricepoint.org, established by the Virginia Hospital and Healthcare Association, which allows you to look up aggregate pricing information for specific hospitals. The average charge for a knee replacement at Bon Secours St. Mary's, for instance, is $76,962. That is less than the $100,000 average for all hospitals in the Richmond region generally, but more than $66,000 for Virginia hospitals as a whole. Want a bargain? Go to Wellmont's Lonesome Pine Hospital in Big Stone Gap, where the average price for a knee replacement is less than $40,000.

Pricinghealthcare.com does something similar at the national level, by ferreting out prices at hospitals that provide them and posting them to its website. The information tends to be scant, however. In all of Virginia, Pricinghealthcare.com has information from only one institution, Monticello Community Surgery Center. An ACL reconstruction there will cost you $8,200 if you pay cash.

Researching prices for elective surgery is one thing. Someone having a heart attack might not want to spend the time. Between those two extremes, however, lies vast room for improvement in price transparency.

But this brings up a second, related issue: Hospitals often have no idea what their costs are. As The New York Times reported early last month, a few years ago University of Utah Health Care CEO Vivian Lee asked her staff what the things the hospital system used, like operating rooms and MRI machines, actually cost. Nobody knew. In fact, "they chuckled when she asked."

So she told them to find out. After much digging, Utah Health Care knows "the cost per minute in the emergency room (82 cents), in the surgical intensive care unit ($1.43), and the operating room for an orthopedic case ($12)." Because of such research, the system's expenses have fallen by half a percentage point a year during a period when expenses at other academic medical centers have risen 2.9 percent a year.

Many hospitals, however, have no clue. And if they have no idea what their goods and services cost, then the prices they set have zero relationship to their expenses. Again, this is not unethical. When you sell a house, you get as much as you can for it, not some fixed markup on the price you paid yourself. But the point is still worth noting when hospitals insist, as they frequently do, that they need more public funding because they are going broke. Maybe they should get a grip on their own costs before they ask the taxpayers for more handouts.

Changes going on now might force more hospital systems to start doing so. One of them is a shift, encouraged by Obamacare, away from fee-for-service billing in favor of paying for an entire course of treatment. Under that approach, if a hospital doesn't get it right the first time and has to re-admit a patient, the hospital rather than the insurer foots the bill.

Another change is the reduction in payments for charity care. Medicaid expansion was supposed to compensate hospitals for the loss of those funds, but two-thirds of states declined to expand Medicaid. This is forcing hospitals to cut costs and look hard for efficiencies.

A third change is a move toward higher deductibles. That will put more patients in the situation that confronted David Fleming: having to pay thousands of dollars for one of the simplest possible treatments. Many of them, like Fleming, will not supinely acquiesce.

Nor should they. Drive around the city and you can see billboards posting up-to-the-minute wait times at various emergency rooms. Clearly, hospitals think they can gain competitive advantage by providing such information. They also compete on the basis of quality, by advertising the various accolades they receive. But prices? They remain a riddle, wrapped in mystery, inside an enigma.

Granted, most health-care consumers will never need to know how much a  tracheotomy costs. But competitive pricing needn't be that specific. Rating systems that rank hospitals on affordability should not be too hard (and the personal-finance company Nerdwallet already does some of that). Consumers don't need to know the sticker price on a specific Porsche on a specific dealer lot to know they're better off shopping for a Honda. A general sense that Alpha Hospitals is no-frills, while Omega Health Care puts fresh orchids in every room each morning, would improve consumer decision-making.

And the public shouldn't accept the excuse that providing such information is too hard. The U.S. health care system provides some of the most advanced care on the planet, delivered by some of the best doctors on the planet, overseen by some of the smartest administrators on the planet. There is no good reason they can answer nearly any patient question except: "How much is this going to cost?"

This column originally appeared at The Richmond Times-Dispatch.

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  1. Free market healthcare is working out great.

    1. Where? I’d like to see if the US could model after it!

      1. If you’d like to see glibertarianism in action, you really can’t do better than Somalia.

          1. Somalia has no government, you guys hate government, why don’t you want to live in Somalia? Think about how much freedom they have!!

            1. Could you please provide a citation for the thinking you’re cutting and pasting?

              Your work sounds awfully familiar.

            2. Yup, and N. Korea has LOTS of Government Almighty, and it is a Living Socialist Paradise!

            3. I’m not so sure Somalia qualifies as having “no government”, since it’s current power structure is the result of a civil war in which belligerent parties were vying for the reigns of a state. The country is a de facto patchwork of small fiefs ruled by warlords and militant theocrats.

              1. Googling “libertarian somalia” produced about 350,000 hits.

                I wonder if credit for intellectual work has been socialized and redistributed with this crowd.

            4. You don’t understand the fundamental difference between anarchists and libertarians.

              Libertarians believe in the rule of law, anarchists don’t. Simple as that.

              To have rule of law, there MUST be effective law-enforcement, which means there must be a government. Libertarians do believe in government, just keeping that government as small as possible.

              Somalia is an anarchy (as a whole–it really is a large collection of warring tribes and fiefdoms, all of which are authoritarian). Libertarians would never want to live there.

              On top of that, if you think what we have here is free market healthcare, you are absolutely deluded. What we have is crony corporatism where the oligopolist healthcare companies are totally in bed with the government, working out deals that benefit them and lock in insanely high prices and profits. It’s one step away from actual state-ownership of the healthcare industry.

              Before you ridicule, get your perception of reality straight.

              1. Yeah Dude or Dudette, well put! Excellent!

                The FDA is a PRIME culprit here, as is the AMA, lawyers, licensing, on and on, all involving Government Almighty…

              2. Libertarians believe in the rule of law, anarchists don’t. Simple as that.

                So you’ve clearly not read up on a single theory of anarchism to make such a broad absolute claim. Some anarchists are libertarians, but not all libertarians are anarchists. Whatever you think of free market anarchist schools of thought aside, you’re claiming that they don’t favor the rule of law, which you’d know to be false if you read even the book cover on a single theorist’s work.

                Somalia is an anarchy (as a whole–it really is a large collection of warring tribes and fiefdoms, all of which are authoritarian).

                You just described a square circle, congratulations.

                I’m not even going to take the time to go into all the ways you are wrong, other than informing you that your assertions about libertarianism and anarchism are categorically untrue.

              3. Well said. When I finally found out about the LP, it was infested by loudmouthed legalize murder “former” Soviet-commie anarchists, so I joined the Libertarian Defense Caucus for the longest. When the Soviet Union collapsed, most of the commies-in-libertarian drag vanished with them. Just as “liberal” meant low-tariff mercantilist a century ago, and has since been corrupted to mean looter, anarchist meant bomb-throwing communist… just the thing voters want to lynch! I am all for these creeps joining the Weathermen and blowing themselves up learning to set bombs. Meanwhile I place my chips on the spoiler vote lever that forces looter politicians to repeal bad laws or lose elections.

        1. Have you been there?

          Somalia is actually quite liveable. Safer than living in New Orleans. Or Baltimore. Or many other cities in the United States.

          Somalia just gets a bad rap because it apparently sells newspapers.

      2. It’s actually working just fine in the U.S., the problem is it’s a fairly small (but growing) free market alongside the dominant third-party payer/government-directed system. I write about it here: http://selfpaypatient.com/, and you’ll see that there are doctors, imaging centers, hospitals, surgical facilities, and alternatives to conventional health insurance that work just fine.

    2. You forgot the quotations around “free market”.

      1. The general trend of less governmental involvement in the American healthcare system produces horrors that are unknown in, say, Sweden.

        1. Where do you get better prices and services, at your local grocery store, or at hospitals? Your Ford dealership, or the department of motor vehicles, for your license?

        2. Which “trend of less governmental involvement in the American healthcare system” are you referring to? Obamacare? Medicare? Medicaid?
          The American healthcare system is in way a free market. The few procedures not covered by insurance, such as Lasik surgery, have dropped in price, because that is a free market.

          1. all healthcare that is free market-ish outperforms the more regulated healthcare. Plastic surgery is an excellent example. Pricing and inflation are low and transparent. LASIK is a good example, as is dental and eye care generally. Although those areas aren’t unregulated, they’re much more user-pay than most healthcare, and it shows in pricing.

            1. Ditto for veterinary care… If I had my way, I’d be able to sign a disclaimer (“will not sue”) and go see my vet for health care… And get a VAST cost cut!!!

            2. Forget LASIK and plastic surgery (seriously – most people don’t consider them “real” health care and you’re never going to get very far arguing with those examples). There’s a free market for primary care, hernia repair, open heart surgery, and pretty much everything else you might need. Here, for example, is the Surgery Center of Oklahoma, where they charge a simple “all inclusive” price and don’t take insurance: http://www.surgerycenterok.com/

        3. Horrors like better 5 year survival rates for most cancers, more early screening, and better access and compliance on chronic medications like statins and hypertension drugs?

          Oh and the general trend is more government spending/involvement in healthcare, not less.

        4. Sweden sets prices. Sweden also does things like provide free (or very low cost) medical educations. So the doctor starting out doesn’t have hundreds of thousands of dollars in student debt to pay off. They do the same thing in Germany, some other countries.

          Then the cost of care is spread out through out the entire population by taxes. The “value added tax” used in most countries has the same effect as a sales tax does here. So the health care services received are “paid for”, just not entirely by the individual concerned.

          Also I believe these countries often use lesser trained people to do medical services that here in the US are performed by MD’s. Which is “overkill” on our part for a lot of things.

    3. We have the world’s most money grubbing doctors, dentists, hospital administrators, and drug company executives. What do we expect from such money grubbing punks. For example, a bottle of Tylenol that costs two dollars at a store would cost over a 100 dollars in a hospital. Our greedy healthcare fat cats are ripping us of. No wonder why costs keep skyrocketing!

    4. We don’t have market health care nor is it likely we ever will, unless someone can explain how to draw a supply curve for it. Markets require specific and rigourous conditions to exist so blaming markets for failure where those conditions don’t apply is less than useful.

  2. There is no good reason they can answer nearly any patient question except: “How much is this going to cost?”

    From their perspective, in a crony system, obfuscation is an advantage.

    1. Why should they?

      They are used to a system where the patient is not the entity paying. It has been two bureaucracies working out payments between them. If course it got Byzantine.

  3. Arthur Caplan, a medical ethicist at New York University’s Langone Medical Center, who recently called U.S. health care “the most obtuse, dense, incomprehensible pricing structure ever created by humanity.

    Do you not deal with the IRS Arthur?

    1. The IRS publishes its tax rates. Medical services on the other hand are “negotiated” prices where the price can vary a great deal depending upon the payer.

      1. The reference to the IRS was in jest, but let’s continue the comparison for yucks. Yes, the IRS publishes tax rates, but tax rates are not analogous to prices. The analogous “prices” for the IRS are what you pay in taxes for your particular financial situation. Call up the IRS, explain every facet of your financial situation to them and ask how much you have to pay in taxes. If you ask ten different IRS “experts” you will get ten different answers. Why? Because the Internal Revenue Code is obtuse, dense and incomprehensible. And that is after the “transaction” has taken place. At least with a hospital, once the transaction has occurred they give you a price. With the IRS you are given the incomprehensible pricing table and told to compute the price yourself, under penalty of fines and incarceration if you get it wrong.

  4. I know it’s extremely rare for someone in these comments to say “there ought to be a law”, but…

    Does anyone else think that there should be a law that hospitals must make their prices for elective surgery available to the public? It’s obvious that if you want a truly free market in any commodity, you must allow consumers to compare prices. That absolutely cannot happen in healthcare at this point.

    1. Or, maybe just have the government pay for everything.

      1. The government would, but it’s too busy paying half a trillion dollars every year for “free security”.

      2. “Or, maybe just have the government pay for everything.”

        If you think medicine is expensive now, just you wait till it is “free”!!!

        I lived in a city where trash pick-up was privately run. They changed it to be run by the City (I never voted for that, never got the chance!). Pick-up qty max was cut in half, and prices tripled. Expect the same in “free” health care?

        1. The old “if you think health care is expensive now, just wait until it’s free!” line is a good one — I’ve used it myself several times. Didn’t P.J. O’Rourke make that line famous?

          Anyway, I stopped using the line not long ago when I realized that the U.S.A. has the most expensive health care in the world now — and has for a very long time. There are a few other developed countries in the world that have excellent health care and they manage to spend far less than the U.S.A. Some have a version of single payer, others have an insurance mandate, and others yet have a two tier system.

          Our system is a mess and has been for decades. Poking fun at systems with “free” health care seems sort of stupid when the quality of their care is as good as ours, when they spend less per capita for that care, and they provide universal (or nearly) coverage for their citizens.

          Perhaps the good citizens of Switzerland (individual mandate) poke fun at us in the U.S.A. for spending 35% more per capita than they do without meeting their own quality standards or coming close to their goal of universal coverage. Perhaps the Swiss say “if you think health care is expensive here – just imagine how much worse it would be if you were in the U.S.A. with its multi-tiered mess of tax-favored employer provided plans, individual plans, Medicaid, Medicare, HMOs, PPOs, MSAs, and HSAs. It’s a nightmare!”

          We can do better — and that does not mean “socialized medicine”.

          1. Perhaps, but it’s usually comparing apples and pears. For example, those metrics focus on “outcomes.” But outcomes typically do not take into account wait times. But I would say that waiting 12 months to get a bad knee replaced is not the same outcome as waiting one month. And it’s not the same quality of care, in my opinion. Plus, whoever is rating systems has to make decisions on what things to rate. Not everything can be. There are too many. I’m not saying our system is definitively better, just that I would take with a big grain of salt any comparisons. Lies, damn lies and statistics….

        2. Depends upon the nature of government in question. Here locally we have a city government that elects and reelects the same bunch of politicians year after year because the voters only will vote for one political party for those positions that actually make the decisions for everyone.

          This is why we have a saying: “There is a right way to do things, and the way that the City of ****** does things.”

  5. Why does a steak at Denny’s cost less than a steak at Daniel’s Broiler?
    Why is airline ticket pricing like an encryption protocol?
    If you could shit solid gold after eating at Taco Bell, would you sell it for the spot price of gold, or what it cost to eat at Taco Bell?

    Medical care, like everything else, is a commodity to be sold for the highest price you can get for it. If you want to figure out why the pricing is so stupid, first figure out what the infinitude of regulations are doing to the industry.

    1. True. I write bids for jobs, and as soon as the bid has to include bureaucratic stuff I simply increase the cost to make the thing nearly unworkable and strengthen the integrating clause. When I was roofing my way through college some bureaucrats tried to force us to buy licenses and whatnot. Local contractors actually managed to get the mess repealed. One of the public meeting examples was the city’s own contract requirements–stuff only a fool would sign, and then for an arm and a leg. That–not lack of regulation–was the problem affecting taxpayers.

  6. Two words: Uber Doctor.

    1. Three words: American Medical Association

      1. One word: Medicare.

        1. AMA appoints a board of technocrats to recommend the various prices of what Medicare will pay for medical procedures. Those recommendations are accepted over 90% of the time, and once accepted by Medicare, those prices then become a benchmark for insurance companies to follow.

          The short version: the AMA is indirectly responsible for centrally planning the prices in the healthcare industry.

          1. Just as the UAW used to set the level of wages and benefits in the auto industry.

  7. It’s an absolute nightmare trying to get price information from hospitals and even the more private(ish) clinics. On one occasion a doctor told me that a certain bloodtest to see if I was a carrier of the gene that causes cystic fibrosis, would cost me between $100 or $200 at most. I thought this price was outrageous, but my wife’s constant worrying wore me down and I got the test. They sent me a bill for $2,000.

    On the second occasion I had to get a bloodtest test that was more necessary in nature, I asked the 40-something female bureaucrat in scrubs behind the desk how much this bloodtest would cost and at first she flat out refused to tell me. Said that’s not her job and that I don’t actually have a right to know. Then she told me that no one really knows until the bill is issued. Still I persisted because I refuse to ever get another $2,000 ass reaming. So she had me wait for a full hour, hoping I would just go away. After I promised to come back everyday until she gives me the rate, she scrabbled together some arbitrary numbers on a post-it note that she gleaned from the internet.

  8. NH is a bit ahead of the curve here. The state is collecting price details from insurers and publishing them on a website.

    1. Those are estimates. They’re useless (see Free Society above).

      1. Wow, what a compelling argument! Such comprehensive data provided too!

  9. You can’t get prices for a dentist either.Try going in for a cleaning and asking the price so you can pay when your done. They’ll look at you like your from Mars.That happened to me in the 90’s,they wanted to bill me,yeah ,right..

    1. I’ve actually had a very easy go of it getting price information from dentists. Their industry is much more private and a they make do with a customer base who have a lot less insurance. I’ve never encoutnered a dentist’s office that wasn’t able to give me detailed pricing when asked.

      1. but they do suffer from the same insurance company influence that makes health care a pain. my dental plan covers 80%…. but if i use an in network provider, they pay the same amount as i do. 60% of the list price is mark up.

      2. My mother recently broke a tooth and I had to call around to every dentist in town inquiring about pricing. I asked for estimates for an evaluation, X-rays, a crown, and possibly root canal. Of the 7 or 8 dentists I called, all of them gave me an exact dollar figure on the evaluation and X-rays, and all but one gave me an exact dollar figure on the crown and root canal. Granted, I was asking for cash prices since she isn’t insured.

    2. My dentist gives me a price in advance for every procedure. Dental work is much easier for providers to price out.

  10. Mr. Hinkle:
    Seriously, there are people who are breaking this mold in healthcare, yet I never see Reason cover them. Here is an alternative worth a look from Reason.

    I’m a big proponent of what Atlas MD has been doing, and believe their solution to be about as close to free market as possible (while I’m not a Rand fan, the name of the company is an homage). They charge their patients $50 a month for unlimited visits, and home visits, provide testing and prescriptions at cost, and more.

    https://www.youtube.com/watch?v=bGZaRnC1wNg

    http://atlas.md/wichita

    1. In all fairness, Reason HAS given coverage to certain private healthcare providers who are thinking outside the box to deliver cheaper care:

      https://reason.com/reasontv/2012/11/15/ the-obamacare-revolt-oklahoma-doctors-fi

      (Remove the space… Reason apparently thinks that a link to their own site is spam)

      1. Thank you for the link. I note it is from 2012, which is before I found Reason. I will moderate my statement by saying that they “rarely see Reason cover them.”

        BTW, he actually mentions a case of someone getting stitches in the video, and how it saved time and cost.

    2. Thanks for the objectivist physicians tip. My doctor in Austin runs a similar show and he is an old hippie socialist. He kids me for appreciating Ayn and I kid him over Fidel, but we’re on the same side when it comes to creeps like Richard Nixon and his party.

  11. OT: How would a free market emergency room work, in your opinion?

    It’s obvious that ambulatory and elective surgery could work just fine (if it were not so encumbered by protectionist regulations) but what about ambulance and emergency services?

    If someone is unconscious and in critical condition, there’s no way they can choose which emergency room they go to or which ambulance picks them up, so emergency rooms could charge exorbitant amounts, offer crappy service, and still probably end up with an ample stream of customers.

    Thoughts?

    1. Exorbitant profits for crappy service with an ample stream of customers sounds ripe for competition. You can then let those around you know your preference for emergencies.

    2. A lot of time an urgent care center would be adequate for many of the things people go to the ER for. On the other hand the ER is open 24-7-365. And the ER will treat those unable to pay at the time of service. There is also the issue of insurance. Which may pay for one and not the other.

      1. A lot of times a fucking Walgreens would be adequate for the things some people go to the ER for.

        But, discounting having to sit in the waiting room for 36 hours for unspecified “abdominal pain”, a pregnancy test is “free” at the ER, and isn’t at Walgreens. (Protocol in basically every ER anywhere in the country: Female patients between 10 and 60 will get a pregnancy test when they present at the ER for “abdominal pain”, because ectopic pregnancy needs to be ruled out, because they can kill the pt and no ER wants to be sued for not administering one if that happens.)

    3. There is such a thing as Italian “family” doctors for gunshot wounds and politically-incorrect pregnancy terminations, but you hardly expect to find them in the Yellow Pages. Like most responses to prohibition, I would not look there for discounts.

    4. If someone is unconscious and in critical condition, there’s no way they can choose which emergency room they go to or which ambulance picks them up

      Probably can’t make that decision on the spot, however, having preferred emergency providers (which assumes there’s more than one hospital nearby) set in advance, could give the patient some level of control over who treats them.

      It’s substantially trickier to get working than the rest, so I’d expect this to be the last problem that gets solved.

      1. That approach would fall apart when minutes could be the difference between life and death. The ambulance personnel are told to go to the nearest hospital in those cases, so far.

  12. While there may be no answer to the question “How much do three stitches in the emergency room cost?” there is an answer to the question “How much does a cut less than 1″ cost to suture” if you know where to go (which may or may not be an option depending on where you live): $135.

    There’s a small but growing free-market of health care providers who have opted out of the insane system described accurately here, such as Dr. Robert Berry in Greenville, TN (he’s the one with the $135 charge for that 1″ cut, price sheet here: http://www.patmosemergiclinic……2-1-14.pdf) There’s quite a few docs like this, as I’ve written about in my book and report on (not as regularly as I’d like) at my web site, http://www.theselfpaypatient.com. And there are hospitals and surgical facilities that likewise offer real prices, not the “chargemaster” obscenities.

    1. The military uses a material similar to super glue which can seal the sort of cuts that would require several stitches to close. There is a “liquid bandage” that is both antiseptic and seals. It’s not as good as superglue which I have used successfully on cuts that would have required several stitches to close. (out fishing, middle of the lake). The only risk was infection which wasn’t a problem. I used to keep some in my tackle box just in case…

    2. Good blog. In Brazil I pay about $10 per year to join the physicians union (though I am not a physician) and get sizeable discounts on self-pay doctor visits. Even with airfare this works out to be way lower than paying US barrier-to-entry rates.

  13. Re one thing or another,I’ve been wrong before,and I could be wrong here too. That being said,it strikes me that what appears to be the “dealing from everywhere but the top of the deck”, another way to describe the game that is Health Care Billing, other readers might choose other titles, is tantamount to an act that could bring criminal charges, when perpetrated by John Smith, Ordinary Citizen. How come,one wonders, is it that the medical profession, including hospitals and health insurers manage to get away with scams so obvious?

    1. It has been estimated that medical fraud costs us between 40 billion and 100 billion a year.

  14. A burger at DB Bistro in New York could cost you $140. Nothing wrong with that.

    Uh… says you.

  15. The problem is caused by a “closed market” due to government regulation. When the free market is prohibited by law from operating, then prices tend to rise to a level far higher since the consumer has no choice but to pay what is asked. Then too, the insurance company might be making “sweetheart” deals of one kind or another. Or there is a system of “kick backs” in operation being done “under the table”.

    The more regulated something is, the more likely the price will be higher than it would be without regulation depending upon the level of consumer choice available. “Natural monopolies” where any competition is difficult will have higher prices than those similar businesses where entry is open to all. Then there is the factor of economic efficiency along with “gentleman’s agreements” which is why gasoline prices tend to rise and fall at the same time despite the fact that that some likely have lower costs than others do.

    1. Good points, but oil companies do keep close tabs on the real value of the currency for which they sell their product. Gas prices rise before the much more costly Coca-Cola because of these close tabs. Two years ago Brazilian money was worth fifty cents. Politicans have printed up so much of it that it is now worth a quarter even in depreciated US currency. But the teevee audience thinks “prices are rising.”

  16. We have the world’s greediest doctors, dentists, hospital administrators, and drug company executives. They will fight like hell to keep the system the way it is. And their lobbyists in government see to it that nothing ever changes. So, if you have a heart attack, get ready to fork over your home and all of your assets. They want to cash in on your misery. Just like the personal injury lawyers, after you cause an accident.

  17. We have the world’s greediest doctors, dentists, hospital administrators, and drug company executives. They will fight like hell to keep the system the way it is. And their lobbyists in government see to it that nothing ever changes. So, if you have a heart attack, get ready to fork over your home and all of your assets. They want to cash in on your misery. Just like the personal injury lawyers, after you cause an accident.

  18. I took my wife to the nearest hospital and they made us wait outside for over half an hour before deigning to make us fill out “screw-me” forms and ask what was the matter. We never found out what was the matter but they tried to bill us $90 a minute for the time we were in there, and had billing leeches just across the state lines send us threatening notices. I went straight to the bureaucrats who issue medical licenses and began filing papers to have their licenses suspended pending investigation, and the “foreign” bills stopped and we settled for an extravagant sum only just bordering on extortion. Cuba trained lots of platoon medical corpsmen back when setting communist mines in Angola was still fashionable. (See Reason article on Jonas Savimbi). Today they are exporting them as doctors, whose PACs may account for the shrillness of Republican shrieks against immigrants.

  19. There is one place that does post their prices. Surgery Center of Oklahoma. It is the closest to the free market in healthcare that I know of.

    http://www.surgerycenterok.com/

  20. A market-driven solution is emerging to make it easy to “shop around” for health care. I’m reposting something I wrote on David D. Friedman’s “Ideas” blog a couple years ago:

    It is true that, for various reasons, it has traditionally been very difficult for consumers to acquire and compare cost and quality information about health care providers. Fortunately, this is now changing.

    Because many employers want and encourage their employees to be more careful shoppers for health care services [since employers pay part of the cost], they contract with companies like (for example) Castlight Health to gather and provide this information. Employees can go online to get both price and quality information (including patient testimonials) about doctors, hospitals, labs, etc. and the various services they provide. [Apparently, health care providers cooperate in providing this information as a condition of being in the employer’s network of “preferred providers” that the employer encourages employees to use via coverage incentives — e.g., a lower deductible when you use a preferred provider.] I know of one person who was able to save 95% of the cost of a test by going to one provider versus another, as a result of getting this information online.

    No paperwork required, by the way!

    Continued …

  21. Continued …

    Employees are also encourage to use this information to plan ahead – where would they go in an emergency? A hospital ER? An urgent care center? Which specific one?

    If the bulk of health coverage were not provided by employers, it is still possible that this type of information could be gathered and sold to individuals, either directly or through their insurance companies, and the incentives for shopping around and saving would probably align even better.

    [End my quoting of myself.]

  22. Regarding Somalia: People on both sides of the debate here need to get educated about what they are arguing about.

    First, anarchists do recognize the crucial importance of law. But they differ with statists in their understanding of what law is, how it should be produced, and how people become obligated to follow the law. Look up “anarchic law” or “polycentric law” for details.

    About Somalia specifically: The Somalis have a saying (probably not a very old saying, but I have seen them say this more than once on various discussion forums): Somalia is not Mogadishu, and Mogadishu is not Somalia.

    Mogadishu is the former capital, in the south. There, and in some of the southern ports, the country is pretty violent. Not because of lack of government, but because this is the center of the efforts to “restore” a government. Various thugs are fighting each other for control here, so they can prove themselves to be the strongest, hence most “effective” and “legitimate,” leader in order to anointed as the new government by meddling outsiders and be supported by foreign aid.

    In the north, things are much more peaceful. Here, the Somalis are able to live by the traditional polycentric/anarchic clan-based law that preceded the establishment of a Somali “government” by the European colonials and their kleptocratic heirs in the south. Orderly anarchy works in the north. Attempts to establish a government are an ongoing violent, chaotic failure in the south.

    Continued …

  23. Continued …

    A recommended read: The Law of the Somalis: A Stable Foundation for Economic Development in the Horn of Africa by the late Michael Van Notten. Van Notten was a libertarian Dutch lawyer who married a Somali woman and lived as a member of a Somali clan for a decade or so (before he died of a heart condition).

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  25. Calculating the cost of a medical interaction may be complex, but it can not possibly be impossible. There are finite costs. Yes, there do have to be some choices: does the cost of that ibuprofen show as what the hospital paid for it, or does it include the pharmacy’s structural costs (rent and salaries), perhaps the nurse to carry it down the hall? Nothing is free, and that pill certainly has more cost associated with it than the one you purchased at Walmart the day before, but there is an upper limit too. Every patient is different certainly, but a price list for a shoulder scope or a colonoscopy could be the base price, and if you need something more along the way, that is inlcuded. But, there is a price.

  26. I had the Pelvic Ultrasound last December. It was a part of my yearly “Female Check.”
    I took about “5minutes” Ultrasound check in the exam-room.
    WE PAID OVER $750!

    Eventhough my husband has Anthem Blue Cross insurance and he pays over $350 every month!! Why does health insurance exist?!
    The cost we paid for the Ultrasound was too much even compared with fair costs in the U.S (Pelvic Ultrasound Total Fair Price in U.S. $254 Our local Fair Price: $290).
    The prices in Japan and France are about $20 with health insurane. England is FREE. Other develop countires are much cheaper than the U.S. WHY NOT AMERICA?!

    I am feeling all of examinations pricing in the ALL OF AMERICAN hospitals are SCAM.
    I wrote the Healthcare Fraud report to the Anthem Bluecross and got no response.
    Anthem was founded by AHA and I wonder they are in cahoots.
    (AHA’s LOBBYING ranks: 4 of 4,070, Over 1/3 AHA lobbyists in 2013-14 have previously held government jobs)

    HealthCare is a matter of life and death for all Humans.
    Can they use the high cost of healthcare as an excuse for their greed?
    Do they want to KILL people off with such high health-care pricing (compared to other countries around the world), except RICH Americans?

    We can’t afford to take important examinations for many things. Do they know it? Do they have human morals?
    SHAME ON THE GREEDY RICH AMERICANS !!
    They DESTROY people’s lives in America.

  27. Poor people. Yes, it`s so expensive to be ill in our country. What if you have problems with medical insurance and don’t have money for medicine? Then you must die because nobody will help you. As I know after crisis in 2008 we have a lot of people with low income. Lots of people are looking for ways to stay afloat and need to find a steady source of income but it’s easier for those who already have some job experience. Because of financial crisis many consumers check good online payday loan sites or other lending services to stay afloat and cover at least basic expenses.

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