The hospital says you should take out a loan to pay for your ER visit? That urine test costs $17,850? I’m Shefali Luthra, a reporter at Kaiser Health News, and our newsroom is focused on helping consumers navigate the high cost of health care in t...

For as long as I can remember, we've been talking about the outrageous costs of health care. As far as I can tell, there's near universal agreement that health care costs are ruining lives, holding back companies from growth, and crippling state government. Yet nothing ever seems to get done.

From your research, are there a few relatively simple changes we can make to the system that would give us meaningful improvements? Or is the only solution to scrap the whole thing and start over with some form of single payer or nationalized health insurance?

Great question. Health care costs are a big, big public policy concern, and they have been for quite a while! But alas, in health care, nothing is ever simple. (The ACA was more than 900 pages!)

A lot of wonks have studied this: The big issue is that, compared to other countries, we simply pay a lot more for hospitals, for outpatient care, for prescription drugs, etc. Some people say single-payer, or an expanded public option is a good way to address this.

The ACA also pushed some experiments to try to pay hospitals for better outcomes, or to penalize them if people kept coming back sick. It also built an “innovation center,” whose whole job was to experiment with new ways to pay more efficiently for health care – moving away from the so-called “fee for service” model and instead “paying for performance.” We have seen some results start to trickle in, but nothing revolutionary yet. This week, though, officials from the Trump administration signaled they’re interested in trying to continue those experiments. So that could be something.

Drug costs are also of course a big concern – but so far, no one really knows WHY drugs cost as much as they do. (This is why states are pushing “drug price transparency” laws.) Other nations, like Canada, have cost controls, but those also come with their own tradeoffs.

Tl;dr: there are no “simple” changes to fixing the cost of health care. It’s a big issue, and one that lawmakers could tackle, but it requires lots of serious thought, effort, and time!

I work in healthcare as a FF/EMT and have worked in hospitals. I have noticed the industry uses a blanket type coverage to bill patients. Even I have been to the emergency room and later received a bill which included medication I did not accept at the time of the service. I also know if a patient goes into the ER for cardiac related problems and the “crash cart” is needed, even if they only use one medication from a drawer it could end up costing the pt tens of thousands of dollars. How has the effect of outrageous medical costs caused people/organizations/government to rethink the structure of billing? What would be the most common sense approach to make this a reality today?

Two thoughts on this, mostly on the front of how people can and are rethinking billing structure:

1) This is where we come back to being a sharp consumer. Even after an ER visit, you patients can – and probably should! – try to negotiate, see what was actually provided, what other health plans pay for this care, etc. You can probably end up paying less than appears on the billing statement.

2) KHN is actually diving into the very question of medical billing. We’ve been partnering with NPR to crowdsource patients’ medical bills and then try to investigate what actually happened, why they cost so much, and what sort of weird charges and such get added on. It’s a fascinating project – our first story is the one about the $17,850 urine test, and the next will come out later this month. If you want to help us answer this very question, please send us your crazy bills! https://khn.org/send-us-your-medical-bills/

I'm a little confused by this. A lot of the discussion around inflated medical bills has demonized hospitals and healthcare providers, but a lot of cause of this seems to be based on historical negotiating practices by managed care plans, and gross charges aren't relevant to most of the population (true self-pay may be the exception, but in my experience there is a sliding scale or self-pay discount policy already in place for most facilities).

If the hypothetical ER visit statement was for charges, then almost everyone is by default paying less than that because your insurer has already negotiated that for you, and if you are true self-pay then there is almost universally a discount or sliding-scale policy already in place by the facility. Are you suggesting that patients should try to negotiate further?

This is an important point to consider. Hospitals have what's called the Chargemaster rate – which is the list price. This is a far higher price than what insurers pay or what Medicare pays. If someone is simply paying for a service out of pocket and a) doesn’t ask a question and b) doesn’t get financial assistance, that person could easily be billed the full Chargemaster rate. (Hospitals are required to offer financial assistance for lower-income patients, but many don’t discuss it until the patient asks.)

My editor, Elisabeth Rosenthal, wrote a series on this when she worked for The New York Times. It’s great. https://www.nytimes.com/interactive/2014/health/paying-till-it-hurts.html

You couldn’t have come at a better time!

My husband and I have very similar names, they’re literally the male/female versions of each other’s names. This sometimes creates confusion with mail, but it’s never caused a problem till recently.

I had our 2nd baby in July 2016. At the time, I was on some low-income type insurance for pregnant women in California, and that should have covered the cost of the birth.

At the birth, I used no meds, no IV, no pain drugs, nothing, and the baby had no birth problems, so the postpartum care was very routine and we left the hospital the next day.

We have received a bill from that birth, stating there were costs for doing all the newborn tests, testing his blood, delivering him, and a cost for me holding him for 1 hour (they said the mother needs to hold the baby , skin to skin, for 1 hour after birth, so I did). However, this bill came for my HUSBAND. It states HUSBAND came into the hospital in labor, HUSBAND gave birth, HUSBAND did skin to skin.

My husband didn’t have Kaiser. I did. I tried calling and telling them they mixed our names, but they wouldn’t listen. They are trying to charge us for everything out of pocket because he was uninsured while giving birth.

What can I do?????

Wow! That is such a fascinating story. Would you be interested in submitting it to our bill of the month project? Our team of reporters is investigating crowd-sourced medical bills and trying to shed light on what happened and what consumers can do. (Link to submit here, if you're interested: https://khn.org/send-us-your-medical-bills/)

Do you believe there could be merit in eliminating medicine from being advertised, through media or through doctors, making it illegal for doctors to take money to recommend a certain pill?

I cannot see how it possible contributes to the state of health of people in a country, while pharmaceuticals spend gigantic amounts of money on this. Then they feel justified to recoup that money by hiking prices to unrealistic amounts, screwing the people in need over some more..

Direct-to-consumer advertising is such a controversial issue, especially when it comes to pharmaceuticals.

We’ve seen drug companies use this to market drugs when they aren’t universally recommended or needed. Meningitis B is one example I’ve written about – it’s an uncommon disease that can be deadly (but is also treatable!). The vaccine is not universally recommended, because it’s such a rare disease (and such an expensive vaccine!). So its manufacturers (Pfizer and GSK) have pumped up advertising. It’s made doctors and some industry watchers pretty uneasy, and some experts argue that this kind of approach bolsters sales of health care that maybe isn’t necessary.

Many pharmaceutical companies and doctors would argue that money / donations don’t influence prescribing decisions. But it’s controversial, and there have been steps toward addressing it. The ACA created an Open Payments database that requires drugmakers to report what they give to doctors and hospitals, and it publishes them online.

There’s also been some really good journalism on this. ProPublica, another nonprofit news outlet, did a fantastic project called Dollars for Docs: If you want to see whether your doctor has gotten money from a drug company, I recommend their database! https://projects.propublica.org/docdollars/

I’m also linking to two stories KHN did on direct-to-consumer advertising – my meningitis B story and another by my colleague, Julie Appleby: https://www.nytimes.com/2017/09/07/business/meningitis-b-vaccines.html https://www.nytimes.com/2017/05/12/business/media/pseudobulbar-affect-drug-advertising-sales.html

There was a local news story in the Seattle WA area about a local channel buying 1 million of medical debt for $12,000. They then forgave the debt.

http://www.kiro7.com/news/local/1-million-in-medical-debt-forgiven-in-washington-by-kiro-7-jesse-jones/695985538

But how can this happen? This seems like people who pay their bills are slow shouldering the weight for all non payment. If hospitals can sell this debt for pennies on the dollar.

So I don’t know a lot about this specific case, and I would be hesitant to weigh in on particulars. But this latter idea has always been the argument advocates use to tout expanding health insurance – the idea is that if more people are covered, then there’s less uncompensated care, and the cost burden is more evenly shared.

Thanks for doing this AMA and providing a more in-depth perspective on your article! I have two questions:

• What's the legality of asking someone to sign loan documents while they're under the influence of either shock and fatigue and/or pain medication?

• How do these practices interact with hospital price transparency laws like the one in Ohio? (context)

1) Legality. Great question. And honestly, the answer isn’t too clear. That ambiguity is a big part of why Laura, the woman I spoke to for my story, waited until she was home and not under any obvious duress / shock / fatigue / meds before committing to anything. I’d say rather than get into any legal uncertainty or lack of clarity, her approach is the best one to follow. You don’t want to risk being committed to something you aren’t prepared to take on!

2) This story is a great one, by my fantastic colleague Rachel Bluth! And there is a lot of interest in making hospitals more transparent about their prices. A bunch of senators also put out an information request on this a few days ago, to learn more about the practice: https://www.cassidy.senate.gov/imo/media/doc/Cassidy%20Price%20Transparency%20Letter.pdf

But the important part here is that laws like this Ohio one didn’t actually take effect, and a lot of powerful lobbying interests oppose price transparency laws. Here’s a follow-up on what happened in Ohio: http://www.dispatch.com/news/20171122/doctors-back-new-ohio-health-care-price-transparency-bill

1) Legality. Great question. And honestly, the answer isn’t too clear. That ambiguity is a big part of why Laura, the woman I spoke to for my story, waited until she was home and not under any obvious duress / shock / fatigue / meds before committing to anything. I’d say rather than get into any legal uncertainty or lack of clarity, her approach is the best one to follow. You don’t want to risk being committed to something you aren’t prepared to take on!

2) This story is a great one, by my fantastic colleague Rachel Bluth! And there is a lot of interest in making hospitals more transparent about their prices. A bunch of senators also put out an information request on this a few days ago, to learn more about the practice: https://www.cassidy.senate.gov/imo/media/doc/Cassidy%20Price%20Transparency%20Letter.pdf

But the important part here is that laws like this Ohio one didn’t actually take effect, and a lot of powerful lobbying interests oppose price transparency laws. Here’s a follow-up on what happened in Ohio: http://www.dispatch.com/news/20171122/doctors-back-new-ohio-health-care-price-transparency-bill

Hello, thank you for your time!

How long until healthcare prices will be published for comparison shopping?

If I could predict this (or anything else), I would be much wealthier than I am.

There are some moves in this direction – for instance, insurance plans paying consumers incentives if they pick more cost-effective procedures (link here: https://khn.org/news/need-a-medical-procedure-pick-the-right-provider-and-get-cash-back/).

There are also some price-estimate shopping tools, but it’s not clear yet how reliable they are (https://khn.org/news/patients-want-to-price-shop-for-care-but-online-tools-unreliable/).

But consumers are responsible for more of their health care costs than they used to be. So it’s definitely worth keeping an eye to see whether and how efforts to promote this kind of shopping take off.

Is there anything one can do before getting treatment that will minimize the bill you will receive?

My boss, Elisabeth Rosenthal, has written a lot on this, and I think her advice is the best. If you can, always ask questions! Do I really need this treatment? How much will it cost? Why does it cost so much? Is it covered? Is this medical provider in my insurance network? Make sure the treatment is necessary, that it’s covered, and that you’re not being overchargeD. Doctors often don’t want to talk about costs, so it falls on the patient to bring it up, and make sure it’s addressed.

And don’t pay any bills right away, and especially when you are not covered or paying for a service out of pocket, don’t accept the list price as a given. It feels counter-intuitive to delay paying a bill, but wait until you’re home. Good advice I recently got: Find out what Medicare will pay for your service, and make sure you’re not being charged more than that.

Here’s a link, if you’re interested, to her talking about this issue further on NPR:

https://khn.org/news/listen-got-a-sky-high-bill-dont-write-the-check/

Thank you for doing this! Do you feel that the insurance industry, as a whole, contributes to the rising cost of healthcare through the process of re-insurers, malpractice insurance (which could also be blamed on our litigious society), and the such? Meaning, do you believe that there are significant factors outside of the primary service of healthcare (a nurse or doctor treating a patient) that contributes to the overall cost and if that cost has escalated at a faster rate than say the cost of the primary business of healthcare?

That’s a really great and interesting question. And we know that we spend more on overhead than do other countries with less complex health insurance systems. (I went on a reporting trip to Canada last fall, and that was a point that came up again and again – their billing and admin just costs a lot less than ours, because they need fewer people.)

BUT the issue economists point to again and again is the price per unit of medical care. It’s just higher here than it is in other countries. And if we’re interested in addressing health care costs in the United States, that’s the key area to emphasize.

A lot of health care journalists point to this famous paper, by a bunch of rock star health economists: It’s called “It’s The Prices, Stupid,” and I think it still very much applies today. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.22.3.89

I had an MRI a week ago, with insurance it was going to cost$2000 without and out of pocket it was $850. Why such a huge discrepancy for something like that?

So I can’t tell you about your specific insurance / hospital. BUT this is a pattern the Wall Street Journal has looked into, and their report is very much worth reading. It seems that some hospitals and health care providers are discounting services if patients pay cash upfront, rather than waiting for insurance to pay. One reason that I find particularly interesting: It cuts down on the administrative work of processing an insurance payment or collecting money later on.

https://www.wsj.com/articles/how-to-cut-your-health-care-bill-pay-cash-1455592277

why don't more states use all payer rate setting for hospitals like Maryland does?

Maryland’s system was put in place in the 1970s (when the politics were very different!) and it’s been able to move incrementally to get to where it is today. If you look at other states, the politics and the interest groups are very different, and you wouldn’t necessarily be able to build that same consensus today.

your most memorable case you have covered?

Honestly, writing about hospital loans was one of my favorite stories – and I think it gets at the heart of why this is such a complex, interesting issue. I did actually find the story through Reddit: Laura Cameron’s husband posted about it on either r/health or r/healthcare, and they both kindly agreed to speak with me about it. It gets at what a crazy system this is for consumers and illustrates tangibly how much more we spend on health care in the United States than in peer countries. (Also, it’s always fun to talk with real health care consumers, and get out of the DC lobbyist / politician bubble!)

But it’s also a complicated story for hospitals. A lot of them are dealing with growing problems of bad debt, and many are on thinner and thinner margins. (One of the big health policy issues: rural hospitals have been shutting down in increasing numbers because they can’t afford to stay open.) So many need a way to collect money and stay solvent. There are a lot of parties here, and tradeoffs and negotiations involved in any policy debate.

I recently heard a story on NPR that was produced "in collaboration with Kaiser Health News" and I was shocked to say the least.

Kaiser is the name of a health insurance company. In case you haven't noticed, we all hate health insurance companies. Every last one of them is famous for denying coverage due to preexisting conditions in the pre-ACA era, weaseling out of paying health costs whenever possible, and victimizing customers when they're at their weakest and most vulnerable.

I am disgusted by your company's attempt to whitewash the name Kaiser by putting on a thin veneer of sympathy for people who get stuck with enormous medical bills.

Have you considered quitting Kaiser Health News and using your talent with words to advocate for socialized medicine, a system that actually works in other first world countries to make sure people don't get stuck with crippling medical debt?

Thanks so much for bringing this up – it’s a common question. We actually have no relationship to the insurance company. KHN is run by (but editorially independent from) the Kaiser Family Foundation, a prominent not-for-profit that researches health and health policy. Our staff is all professional journalists, and we report on Kaiser Permanente just as we do any other insurance company!

One of my colleague’s stories on KP is below:

https://khn.org/news/california-fines-kaiser-permanente-2-5-million-over-missing-medicaid-data/

And here’s our official tagline: “Kaiser Health News (KHN) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.”