I broke my foot recently. Calling around and asking for quotes ranged from a straight up "I don't know" to "Here is the cash price. We won't know your HDHP insurance price until after we bill them, which could be good for you or could be bad. It will probably be bad, because there are more middlemen."
I tried paying the cash price. They inadvertently billed my insurance anyway. Turns out, I actually saved like 33% using the insurance price ($180 vs $120 for an xray + analysis).
They said the only way to get a copy of the x-ray was to pay $5 for a CD. None of the computers I still use have a CD reader.
The whole system is such a clusterfuck. I understand the aversion to giving a governmental bureaucracy more control (esp over something as important as healthcare); however, it's hard to imagine a worse way to pay for care than what we have now.
I just got billed $5000 for a routine echocardiogram at Stanford, and in the process of fighting it. My insurance is supposed to cover preventative care 100% (not even a copay). They billed $18000 total (yes, for a 1-hour ultrasound) and insurance is leaving me to pay $5000.
This is about the 6th time this has happened. It's always 15+ e-mails back and forth, then threatening lawyers, then they back off.
I'm wondering if it would be faster if I just take it directly to a small claims court. I am insured and it is preventative care, so I believe I'm entitled to pay nothing. Advice welcome.
My son had strep throat. Stanford billed us just shy of $50K, but not before sending us a letter letting us know they had stopped accepting our insurance (BCBS) a few weeks prior. Obviously, more done than just a throat swab for the 50K, but whole thing was insane.
Agree. After seeing the trauma some of my friends went through, I do my bit to recommend against going to Stanford. The standard of care is poor, and the cost is exhorbitant.
Yeah, they kept him for a night. Kid complained about sore throat so my wife took him to doctor (regular pediatrician was busy, so another doctor). Kid kinda mentioned a stiff neck, and doctor told my wife to get him to the ER immediately, b/c meningitis. Wife took him to Stanford ER, they were all omg we’re kinda sure it’s meningitis, but we need to do a spinal tap first. While prepping for that they put him on an IV and after ~20min he perked up a bit. A nurse noticed that and said it wasn’t normal if really meningitis, and put spinal tap on hold. Then doctor said there was a chance of an abscess in his throat/neck and wanted to rule it out; ordered a CT scan. Once that returned negative, they were like, oh yeah, it’s just strep… but, let’s prescribe an uncommon liquid antibiotic that tastes like trash reheated. Kid refused to swallow it, despite efforts of 3 nurses trying to waterboard him with the liquid. So the only way to deliver the antibiotic as prescribed was intravenously. Learned several lessons about advocating during that ER trip.
I had the same experience with a endoscopy/colonoscopy at Palo Alto Medical Foundation / Sutter Health.
We should crowdsource a guide to navigating healthcare in Northern California, it’s utterly fucked up.
Even getting a primary care physician is impossible, nobody is taking patients and the websites of any place (sutter, ucsf etc) don’t reflect any accurate info about who could actually become a primary care provider for you.
The best healthcare situation I experienced was via Cedar Sinai while we lived in Los Angeles.
I got a physical in Oct 2020, but the coronavirus spiked and it took me until April 2021 to go in and do the labs. One Medical screwed up the billing, coding them as diagnostic instead of preventative (or however that works).
I got nasty letters from both LabCorp and One threatening to send me to collections and ding my credit and all that. I'd text One and they'd be like "oh, just ignore those. We'll fix it." Months go by. "Just ignore them. We'll get to it."
I'm from Germany and just recently got a preventative coloscopie.
I'm not 50 years old yet, so I had to pay for it myself. A magical experience, since it's the first time I ever saw a medical bill in my life.
It was two pages long. Everything from taking blood to the medication and doctor was listed there, but the price at the end was only 200€. I thought it was a joke and expected a lot more.
Imagine the fact it would be cheaper to take a plane trip to Germany, also account for lost hourly work cost that takes out of your work schedule, and still be cheaper than doing it locally.
How or why do you think an echo is preventative care? While insurance plans are free to define any additional menu of services as preventative - an echo is not included in the minimum set required by the federal government - which are procedures based off of US preventative services task force guidelines - there are no published guidelines that include an echo.
I wish you luck on your billing problem but I think you’re going to hit a wall on your own definition of “preventative”.
It's fully preventative in my case. I have heart issues (I'm a cardiac arrest survivor) and an echo is recommended every 2 years to spot any possible future issues early.
As to the original question, unfortunately I don't know where you got the idea that all possible preventative healthcare interventions are covered under the "free" rule - ie no out of pocket - but in the US that just isn't a thing - the free coverage applies to the list I posted prior (ie ACA Preventive Care) - its a bunch of consensus primary and secondary preventative primarily screenings and medications that are thought to have the greatest impact on public health.
> It's fully preventative in my case.
Fully preventative is not a term of art either for delivery or billing - but there is a difference in categorization between screening tests given to the entire population (ie colon, mammo) and screening given to those with personal risk factors or family history (LD chest CT, echo for congenital HD), and then further on surveillance for personal history of a pre-disposing condition (ie surveillance echo for prior potential fatal arrhythmia).
This is where it starts to get complicated - but the need for an echo every 2 years is not normal. I can't really divine your specific history from the information given - and it isn't necessary - but a history of cardiac arrest alone is not an indication for serial echocardiography. There are numerous specific circumstances where it is recommended, and then there are the cases where it is not consensus recommended but there is controversy. I assume because your insurance company is willing to touch it at all it falls in the former - but we are way off the ranch here in terms of the scope of routine preventative care/health maintenance.
As to whether it should be this way, probably not. If a surveillance echo is clearly indicated to prevent costly sequelae (unfortunately answering this question isn't nearly cut and dry as most think), then it makes sense that an insurance or public health agency would want to do this.
Curious if you know if your indication for serial echocardiography falls under the European guidelines? Maybe move there /s. Is Stanford your only reasonable place to obtain an echo?
There are two categories of healthcare right? Palliative and preventative. Which one would an echo be in this case? If he had violent symptoms it would clearly be palliative, but in this case it can only be preventative
> There are two categories of healthcare right? Palliative and preventative.
The simple answer to this is that “preventative” in the case of billed medical services has a specific and clearly defined meaning - it does not even mean all services that ever would be considered preventative. This definition will be found in your insurance paperwork and corresponds at least to the site I posted - so a further philosophical discussion is irrelevant.
To your actual question - No, the echo is usually pallative. However, right off the bat I'll say this is an overly reductionist and not terribly useful schema for classifying the delivery of medical care. While it might be good as a way for the general public to think about prevention, it’s way too oversimplistic to be useful beyond that.
An aside, palliative has a specific and different meaning within medicine: roughly, treating symptoms without a goal of cure. Reducing a broken arm or removing an inflamed appendix is not palliative care in that sense.
But even if we widen the scope of palliative to be treatment an echo would be neither. An echo is diagnostic - it doesn’t prevent nor treat heart failure or disease. Often when an echo is ordered it leads to some form of treatment for some found disease, in which case if we’re going to stick to the simple classification would be “palliative” - we’re using it to guide treatment, we can’t prevent something that we already see.
> If he had violent symptoms it would clearly be palliative
It's just not that simple. Echos are sometimes used to further evaluate or manage asymptomatic disease, for instance A-fib or a concerning murmur. We're using the echo to rule out suspected coexisting conditions, that's not prevention, and it's not treatment either at that point.
Also, echos usually have some symptomatic indication - and they don't have to be violent, whatever that means.
> it can only be preventative
Can you actually think of a disease that an echo would be used to prevent?
But again, in practice we don’t think of delivery of medical care in such grossly general terms - it’s doesn’t simplify in a useful way.
> Can you actually think of a disease that an echo would be used to prevent?
Yes, checking the extent of mitral valve prolapse (which I have, doesn't warrant valve surgery yet but it's expected I may need valve repair in 10-30 years if it gets worse), ejection fraction, early detection of dilated cardiomyopathy (which I'm known to be genetically predisposed to), etc.
Checking the extent of MVP is not really preventing or treating MVP, is it? The echo isn't preventing the mitral valve prolapse, it is also not an intervention - it is a diagnostic tool to guide further intervention. Yes, this could be considered a type of tertiary prevention - but hopefully it should also be clear how this is more usefully classified as diagnostic. Pretty much all medical care is to some extent preventive, even reducing the broken arm - so it becomes a meaningless word if it is loosely defined as any intervention that can potentially prevent sequelae. That means it’s ultimately going to be defined with some restrictive set of criteria. Is the US ACA definition very restrictive, yes, but that’s how it is.
Ejection fraction is not a disease, but let's call it heart failure. An echo evaluating for heart failure is a good example where we can use it as a diagnostic tool to prevent further progression - but again through other interventions - and if we're evaluating for abnormal ejection fraction we haven't prevented it.
Another example might be evaluating for a shunt to prevent stroke. However we don't routinely screen everyone for this.
Echo for inherited cardiomyopathies is a good example of primary or secondary prevention.
There are definitions within medicine that matter for defining appropriate use criteria, but all this preventive vs palliative is arguing loose semantics - the people you’re up against have already put in place the policy to avoid most of that.
Hospital IT systems are incredibly locked down, especially from a network perspective. And DICOM images (the format things like x-rays are stored in) are very large, and not readable by most image readers. I honestly don't know if there are even free DICOM readers out there, but there probably are.
CD is honestly the easiest way for them to send the images to you, because you can give them to any doctor and they can load them within minutes. For the hospital to send them directly to another hospital would literally take weeks (at a minimum) of back and forth between two overworked and incompetent IT teams.
There are multiple free DICOM readers, but each imaging device manufacturer has its own interpretation of what a "DICOM" file is, so there are a lot of quirks.
I've worked with DICOM files from at least 10 different sources. I was able to eventually parse/view all of them. I seem to remember trying almost as many open source libraries in the process, however. That's one of the many problems in healthcare - even the standards have competing standards.
> For the hospital to send them directly to another hospital would literally take weeks (at a minimum) of back and forth between two overworked and incompetent IT teams.
Last time I had imaging done, my doctor gave me a list of nearby imaging services, and the one I selected was able to electronically send files back to my doctor.
Heck I've witnessed my old dentist send x-rays over to my new dentist, it took like 5 minutes. Then again it seems like dentists are better at technology all around.
I can't speak at all to dental stuff as I've never worked with it. But to your first point, that's sort of expected - they're on a list already, the access has already been configured. They've already gone through all the nonsense.
The point is to send it to any arbitrary doctor they've never spoken to before, which requires offline media.
I'm not sure if "proper" DICOM files are different (DRM?) but during my undergrad I had a medical imaging class working with anonymized DICOM files and we used Pydicom (With Jupyter Notebook) to display the images and annotations: https://pydicom.github.io/pydicom/stable/index.html
There’s (luckily) no such thing as DRM in DICOM, but there is a billion ways to interpret the standard. Pydicom does work for the more common things but there’s some rare types of DICOM it unfortunately can’t handle.
> the purchaser does not know the price of something at the point of purchase.
This is only solvable for the cases where what needs to be done is completely known and certain in advance. Which for very complex human biological systems would not be the majority of cases, unless providers decide to only deal with health issues that fit that criteria and send everybody else to someone else.
I think the problem of not being able to accurately predict the required care is an intrinsic part of health care. Some of it actually is taken care of in some way, for example, if you go to ER they will only fix any immediate urgent issues and then send you home. Or, they send you home after n days in the hospital no matter what (example links: https://www.ombudsman.org.uk/sites/default/files/page/A%20re... or https://pubmed.ncbi.nlm.nih.gov/12568426/).
> When consumers are informed and can force suppliers to compete with each other,
Uhm... how do you imagine this would happen? Genetical engineering so all humans become standardized clones with identical completely predictable issues? I think you severely underestimate the inherent unpredictability. Simple stuff like teeth cleaning can be a price known in advance, or coming in only to renew a prescription for a known health problem, but many, most?, of the "real" issues are not.
OR, what would happen if you enforce this is that the MDs would be forced to press the cases into the pattern. They may think they should order an additional test or imaging procedure after actually looking at the patient, but since it's not in the pre-approved plan it would not get paid, so they don't, only things that were known before any doctor looked at the person get treated and only using the predicted methods.
When you take your car in for repair, you also can’t know for sure what the cost will be, because cars are complex systems and every car is unique in its own way. But if the garage overcharges you then you will figure this out and you will not go there again.
In the US healthcare system because of the lack of price transparency it seems to be impossible to know which hospital or doctor overcharges, and so a free market cannot arise. It is not even possible for a competitor to advertise better prices, because there is no practical way to check that their prices are indeed better.
I'm not sure cars as an example work for health care. Each model has orders of magnitude less complexity, it's not living tissue, and variability within a model is very small. And it's all logically engineered instead of the mess that is biological systems (I have a small bit of background in life sciences - only studies, not work). But that's only an aside that I don't want to concentrate on.
> a free market cannot arise
A free market is not the best model I think, because even if you had perfect price transparency, people don't have nearly enough knowledge to evaluate the suggestions of doctors. Sure, they will select one the like more, but base don superficial information, not based on actual medical knowledge. For some truly "free market" you really want easily comparable and quite equal things to shop for. Medicine is too individual. Yes I know the desired model is you go in with your list of symptoms, get a few tests based on it, then an algorithm, right now in an MDs head, selects the appropriate treatment - time for the next patient in the overcrowded waiting area. It seems to me, and I had personal experiences with this model's limitations too, that there is a lot of dissatisfaction with this model not least with burned out medical professionals. But it sure is something the business-minds like, you can optimize processes and manage the heck out of such a system beautifully.
I - German (but I lived in the US for a decade and also had a bit of regular contact with various health providers, such as Stanford hospital or a Berkeley orthodontist for minor - and predictable, as you say - stuff like straightening teeth and hypo-sensitization) - am certainly not against a free-market component. I grew up in the GDR and we had a small bit of it even there! As a child my parents and grand parents actually did shop around for some specialists for some very reasonable amount of money, for my eyes for example (it worked out great, I stopped needing glasses as a late teenager, I ran around with one side of the glasses covered for a few years very early in childhood, for example, to strengthen one eye).
I think a little bit of that helps to reward those who care a bit more about their health and go about looking for solutions to problems more diligently and intelligently than others who just go with the flow. But I think this works best in small doses, not with the entire system set up this way.
> I think a little bit of that helps to reward those who care a bit more about their health and go about looking for solutions to problems more diligently and intelligently than others who just go with the flow
But caring about pricing is entirely different than caring about the right solutions
The majority of healthcare is for routine and known in advance procedures, not for emergency or exploratory procedures.
Sure, the GP might want to order tests, but the cost of the test will be known in advance, the cost of the consultation was already known by the patient.
The patient can tdecide which radiologist they want, using price as a criteria if they want to.
The existing method is basically "you can only know what the cost is after you owe it to us", which is, frankly, insane. It allows the sellers to set a price that the ma let cannot bear, which results in secondary markets that provide insurance and skim even more off the top.
> The majority of healthcare is for routine and known in advance procedures
Yes what kind of procedure is needed often is known in advance. The details often only emerge after it's been started though. Just because it's routine does not at all mean it's all predictably-in-advance the same throughout, except for really basic stuff, which in turn is unlikely to be the big cost driver.
> Yes what kind of procedure is needed often is known in advance. The details often only emerge after it's been started though. Just because it's routine does not at all mean it's all predictably-in-advance the same throughout, except for really basic stuff, which in turn is unlikely to be the big cost driver.
I dunno that I'd call a broken leg "really basic stuff".
This is what I responded to and what I quoted in my original post:
> "Here is the cash price. We won't know your HDHP insurance price until after we bill them, which could be good for you or could be bad."
So, yeah, the supplier currently knows in advance what it costs to fix a broken leg. There is no reason for the price of more mundane medical care to be opaque at all.
Broke my finger and did the whole CD thing to. I accidentally laughed on the phone when they told me what I had to do. Felt a little bad. I had to drive to the urgent care to get the CD and then drive it to the orthopedic specialist days before the appointment. As I was driving I just thought to myself, here is everything that's wrong with the medical industry, synthesized in a 700Mb metallic disk I'm holding in my hand.
I tried paying the cash price. They inadvertently billed my insurance anyway. Turns out, I actually saved like 33% using the insurance price ($180 vs $120 for an xray + analysis).
They said the only way to get a copy of the x-ray was to pay $5 for a CD. None of the computers I still use have a CD reader.
The whole system is such a clusterfuck. I understand the aversion to giving a governmental bureaucracy more control (esp over something as important as healthcare); however, it's hard to imagine a worse way to pay for care than what we have now.