Must-read op-ed in today’s Wall Street Journal: ‘Health Care and the $20,000 Bruise’

The Wall Street Journal has a stellar and informative (and slightly depressing) op-ed today by Dr. Eric Michael David, recounting his recent experience taking his son to the hospital after discovering a bruise on his head. Self-pay patients who have ever had to haggle with a hospital over charges will recognize the story easily:

Health Care and the $20,000 Bruise

As a doctor and a lawyer, I like to think I’m pretty good at navigating the health-care system. So when my wife and I found a large swollen bruise on our 3-year-old son’s head more than a week after he had fallen off his scooter, I was confident we could get him a CT scan at a reasonable cost.

We live near one of the top pediatric emergency rooms in the country. The care was spectacular. My son was diagnosed with a small, 11-day-old bleed inside his head, which was healing, and insignificant…

Then the bill arrived, and you know where this is going: $20,000. Our insurance had already paid $17,000, and we owed $3,000 out-of-pocket. What for? Among the items listed on the printout was a $10,000 charge for a “trauma team activation.” 

Dr. David offers some advice to patients negotiating hospital bills, based on his experience with the bill for his son’s visit to the ER. Unfortunately, and I suspect the good doctor wrote this somewhat tongue-in-cheek to make a point, most of the advice isn’t terribly helpful – most of us aren’t going to be able to follow through on #1, for example: Get yourself a job as a doctor or nurse. Other unlikely solutions include: Have the resources to pay huge bills up front while you wait the months it takes to correct billing errors (#3) and Have the combined medical and legal knowledge to understand the implications of the coders’ rules (#7).

There was one nugget in there that I thought might be exceptionally helpful to self-pay patients though. Apparently, there are online forums where hospital billing staff go to discuss how to squeeze insurance companies and self-pay patients for everything they can (I suspect that’s not the way they would characterize it). Here’s what Dr. David writes:

5. Know where the hospital billing managers go to decide what kind of upcoding they can get away with.

Most hospital billing guidelines, whether for Medicare or private insurers, are derived from a several-thousand-page manual published by the Centers for Medicare Services called the Medicare Claims Processing Manual. You can access it online at, although it is impenetrable. But here’s a secret: There are lots of blogs out there written by the hospital coders that do the billing, and they blog about how to ensure a hospital can make their bill stand up to the payers—i.e., insurers—whose job is to negotiate the bill down.

I went online to see if I could track down a few of these forums, and a quick Google search turned up the following:

I didn’t have much time this morning to look closely at each of the blogs, but they appear to be only moderately more penetrable than the Medicare Claims Processing Manual. I wouldn’t recommend trying to read these blogs without a good reason, but if you do have a good reason (like an unjustifiable $20,000 hospital bill) they might be worth turning to, particularly if you opt to try to handle the medical bill negotiation process yourself, instead of obtaining the services of a medical bill negotiation service (which typically charges around 20 to 30 percent of the amount saved).

Of course, the best option would be to go to a cash-friendly provider in the first place, one that doesn’t routinely charge inflated prices or bill for services that weren’t actually provided. I wouldn’t second-guess Dr. David in his decision to take his son to a pediatric ER, but for many injuries and ailments a visit to an urgent-care clinic and getting imaging at a stand-alone imaging center is probably going to be a better choice in terms of both the quality and appropriateness of care, as well as the cost.

Oh, and I highly recommend you read Dr. David’s full op-ed, I believe it’s available online to all, not just subscribers.

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28 Responses to Must-read op-ed in today’s Wall Street Journal: ‘Health Care and the $20,000 Bruise’

  1. I am practicing medicine now for just over 20 years. Your blog is going to cause me to go into some detail- here goes! This past year I have been watching the random ways in which CMS/Medicare uses the coding system to deny or lump services together thus lowering my office reimbursement.

    The corollary as your blog and the WJS article points is out is that providers and especially hospitals look to the coding system to “game” for maximal reimbursement.

    It is my conclusion presently that the coding system as developed (in collusion with the AMA, government and all other active participants) is touted as the way to avoid fraud. The irony is that it has become the tool by which fraud is committed. The government commits fraud each minute (claims are submitted continuously) by creating random unforeseen “rules” of not recognizing prior established coding rules (changing the rules on the fly) and thus reducing reimbursement by decree. The government further commits fraud by creating the laws that eliminated a free market for our services. Most people do not understand that Medicare providers (virtually 98% of doctors in this country presently) cannot collect any revenues above the prices fixed/set by decree each year. This price fixing is what is actually harming access so terribly. PPPACA/Obamacare is/will make this worse in spades.

    Evidenced by the “coding education industry”, providers, the pharmaceutical industry and as in the cases outlined in the article, hospitals commit fraud by pigeonholing services into a code that provides for maximal payment. The perpetrators feel entitled to this activity because of the “free rider” principle. By placing the service into a code, then asking a large, faceless pool (called Medicare or Health Insurance) to pay for it the myth of “someone else is paying”, the free rider principle thrives. The truth is the risk is all born by the collective (high costs of taxes for health and now mandated health insurance) and the profits go to the various participants in the market. I say to this “no thanks” and your website and terrific book The Self-Pay Patient is saying the same.

    To those concerned, it is my experience that your hospital bill is never accurate. Hospitals intentionally place their billing services off site -usually in another totally different geographic area. They only supply numeric codes for their initial bill and most insured people never make the significant effort to find out what the code is describing. If they do often they will have a bone to pick with the submitter. Certainly they will recognize inexplicable fees for the experience they encountered. Granted it is impossible to place a number on a life-saving service but doctors do this routinely and don’t charge inexplicable fees. Quick pointer: if you want to commit fraud, commit confusion. Going further into the model, the various cost centers (take the ER in this case) don’t actually have a collections department or billing department. By removing any incentive to collect or explain their services, the customer is again moved additional steps from the actual service experience, allowing the confusion factor to multiply. Now add the time element to this confusion recipe. You don’t get to see a bill when you leave, rather it shows up in the mail weeks to months after your care. I hope this is starting to place some light on the subject.

    In my office it is simple, Medicare patients get charged what Medicare allows, I have no say in the fee. My ability to participate in this market is waning fast due to insufficient revenues for the work demanded. Eventually a bad customer has to be asked to leave; the government is pushing beneficiaries into this category. Demanding balance billing to return will remedy this problem (AMA”s My Medicare policy for instance).

    Then I have the rest of the market/patient base. I post my basic services and prices/fees on my website. These are the fees I need to maintain a healthy and viable medical practice. My staff collect at the time of service. This means any billing errors are brought to light at the time of the exchange and corrected. Payment is settled and then my office will submit your claims history to your insurance if you have insurance. I have no time nor interest trying to satisfy the unreasonable administrative burdens and restrictions for the experience of delayed care and payment, fraudulent payment schemes constructed by the various health insurance options.

    Going forward we are experiencing the two tiered system. Bureaucracy vs private market. On the private side, I see the possibility of lowering my prices if I can harness technology to allow the removal of redundancy (paperwork for histories, billing, etc), and to enhance services (disease specific education, screening/monitoring options). By offering and providing enhanced services patients will have more efficient, comprehensive care at a lower, more affordable price. In order for that to happen, I need the rules and regulators to get out of the exam room and office. Continuing to go along with the various political and insurance based recommendations will only harm the situation further for the actual patient.

    The market participants need to have the opportunity to recognize their needs, wants and budgets and then maximal supply and demand efficiency can be delivered.

    • Mr. Good says:

      Sorry Mr. Kordonowy it’s not going to happen my friend. While I agree a free market would without question lower health care cost because people could not afford to pay the ridiculously bloated prices. It is your own profession that pushed itself into the corner and your profession cannot get its act together even through it is under threat of Socialism. I was recently quoted $10,638.00 for a simple straight forward Cataract Surgery no special lens or anything complicated. No I’m not Medicare eligible. The provides fix the prices and collude to prevent true competition. Its been going on for years and for years the profession has been given chance after chance to get their act together but they have stubbornly refused to do so. While there are good providers out there I wasted a lot of money until I found one. For every good provider that I have found there was a least 4 who ripped me off before I found the good one. I have had providers charge me $300 or $400 for nothing more but to talk to me for 5 minutes. Worse I have been charged in excess of $500 for a completely wrong diagnoses and than they wanted to charge me more to fix the mistake that they made.

      Take responsibility for your own mess medical profession and quite blaming the lawyers you did it to yourself.

  2. Jerome Bigge says:

    We should know that the entire medical profession (all parts of it) are organized upon the basis of collecting the maximum possible for their services. In effect the entire health care industry is “organized” just as the “Detroit Three” (US automakers) are “organized” by the United Auto Workers union. The major difference is that the US health care industry has such massive financial assets that it can very easily determine what the federal government is permitted to do and what it isn’t allowed to do.

    The best proof of this occurred in 1994 when the industry effectively “crushed” the Clinton Health Plan like a Tyrannosaur stepping on an ant. Because of this, both “Rommeycare” in Massachusetts and Obamacare do nothing to effectively reduce health care costs here in the US. All they do is take money from one group (the better off) and transfer it to the lower income people so that they can purchase health insurance from one of the insurance companies. Also, the insurance companies are allowed to collect a dollar’s worth of premiums while providing only 80 cents worth of benefits. In effect a 20% interest rate! Compare this to what my credit card company charges (12.99%) and you can see which group is really the most exploitive…

  3. Jerome Bigge says:

    US health care costs are far higher relative to the US standard of living when compared with all the rest of the world, including countries with standards of living close to that of the USA. Note that this is not just the drug companies who claim that they have to make up their cost of research here in the US since the rest of the world won’t pay the price that Americans are forced to pay. Physician office fees, hospitals, every part of the US health care system has prices far above those charged elsewhere. Countries such as France and Germany are certainly “developed” countries, and the Nordic countries of Denmark, Norway, Sweden have living standards comparable to that of the USA. However their health care costs are far less on a per capita basis than those of the US.

    The big question is “why are US costs so high”? Life expectancies in the US are lower than those of the rest of the majority of developed nations. And those countries that do not exceed the US are less “developed” than the rest of Europe.

    The claim will be made that these countries educate their medical professionals at taxpayer cost so they don’t graduate with six figure student loans to pay off. If this is true, then why doesn’t the US do it too? It is said that the US has far more high tech medical equipment than the rest of the developed world. Even if this is true, it does not appear that the American people benefit that much from having more high tech medical equipment available since if we did, our life spans would be longer than they are. In fact in some parts of the US, life spans are lower than those of some lesser developed countries (mainly due to lack of access because of economic issues).

    Part of the problem may be due to “inefficiency”. The rest of the developed world has developed health care systems that have far lower “overheads” than ours does. An American hospital will have perhaps as many non-medical (office, administrative) people working as those actually involved in providing services to patients. The rest of the developed world has solved this problem. Less “overhead” means lower health care costs. And there is evidence that a great deal of US health care costs are due to waste created by our malpractice policies. Ranging from unnecessary check ups to the overuse of expensive technology done solely because of the fear of lawsuits. Lawsuits that happen because of a great surplus of lawyers over and above those actually necessary.

    Additionally, one of the major drivers of high health care costs is due to the physician’s legal monopoly (enforced by the government) over access to medical drugs. Eliminate that and suddenly a considerable percentage of those people sitting in waiting rooms wouldn’t be there anymore. Going by my own personal experience, at least half of all visits to a primary care physicians are requested by the physician and/or the insurance company, not by the patient. Plus physicians often prescribe more expensive medications when a much cheaper generic would do just as well. I know of a woman who is paying several hundred dollars a month for a medicine to treat osteoarthritis when a generic that costs $4 a month at Wal Mart would do just as well. Giving patients the power to make these decisions for themselves would reduce US health care costs by hundreds of billions of dollars a year.

    As a libertarian, I want people to have all the all care they need, but the cost of that health care should be as low as possible. It is the actions of professional organizations along with the law enforcement powers of government that is the problem here. The AMA is no different than the UAW, or any other labor union. Labor unions organize against employers, professional organizations organize against the American people! The objectives of both are exactly the same. The only difference is that the professional organizations have much more power to influence government than do labor unions. This is one of the reasons why Americans have to pay so much for their health care.

    • A conundrum to your position about other country’s having lower overhead is that they do precisely because American has allowed a much more supply side policy legislatively. This has effectively put other countries into that “free rider” principle I discussed in my initial comments to Sean’s blog. Example- Canada gets to by government decree tell the medication industries what they are going to pay for medications. In many instances it was our pro-development price and patent protection incentives that resulted in the medications getting developed in the first place. This is effectively a price/tax placed upon Americans to get the drug to market at all. Then in come the free-loaders, demanding after the fact price reductions. To make it even more laughable, Americans then buy up the Canadian stock and the Canadian pharmacy companies run an arbitrage profit center off government contracts for cheaper drugs (we pay twice). Eventually after their supplies run out things get so out of control that they eventually sold us totally counterfeit chemotherapy. see my prior blog on that story:

      I agree that we should have as affordable of health care as possible. I don’t think we can point to other countries for lower cost examples due to the intricate economic relationships that are allowed to be missed or ignored due to the different country policies and politics. As a mutual pro-libertarian ideas person, if we really want a more free market based health care economy the other consumers (including other socialist countries) have to pony up their share. The socialist health care systems have the worse access. The best system allows the best match between supply and demand, meaning, no wait times, high quality providers and numerous levels of service based upon need, affordability and buyer/seller goals. Cheap alone is not the correct answer in my opinion. You get what you pay for when it is just cheap.

      • Jerome Bigge says:

        Problem of course is that many people here in the US cannot afford to pay for health care. It isn’t just the drug companies (who at least have some justification for their prices), but the rest of the system. However even the drug companies over price their products since the cost of advertising is higher than the cost of development. And a lot of the drugs out there are effectively “me too” versions of other drugs.

        This also raises the question of why the drug companies sell their product for far less in other countries than here? The other countries cannot produce the drug (even ignoring patents and copyrights) without going through considerable effort. So the claim that if the drug company doesn’t sell at a low price, the drug will simply be copied by the country concerned doesn’t really apply. No doubt some of the countries do have their own production facilities (Germany does), but they’d still have to do considerable work to produce the product. So the “threat” to produce the drug in question is likely more a bluff. This isn’t like copying some automobile design. Or a computer program or whatever.

        In any case, this doesn’t apply to the rest of the health care industry. The concept of highly trained doctors doesn’t hold water when you consider that very few if any people actually retain for long every bit of knowledge they were once taught. I know from my own experience that I’ve forgotten most of what I learned in 14 years of education simply because most of it wasn’t all that applicable to what I did after graduation. Effectively the same thing applies to everyone: You retain only what you use… It is likely that eventually we will rely upon computer programs to diagnose and treat disease. This is because people forget what they learn, but a computer never does.

  4. I don’t disagree with your above comments with the exception of highly trained doctors not holding water. Is it your position that today’s physicians aren’t highly trained? If not then who in the health care field is more trained? The fact that we lose knowledge that isn’t applied has little to do with the level of training achieved by physicians. The quality of talent physicians to this generation has is exceptional. Nonetheless I was referencing how the ideal health economy should work.

    Regarding the fact that a computer never forgets, obviously if the data is there and it hasn’t been poisoned by a virus or some other method of tampering this is clearly true. As a physician in practice, remembering isn’t the key ingredient, rather the ability to synthesize and apply numerous data inputs and apply continuous and modifiable problem solving skills to what might be either mundane or life-threatening situations is the skill set folks are paying for and counting on.

    At this stage of our conversation related to this blog we are a bit off point. We do agree that the present system is not affordable, I am contending that a big part of the unaffordability is linked to past, present and worsening policies driven by false premises and a history of responding to meddling in the market by folks very far removed from the actual delivery of health care. By being passive victims I feel all/most of us are to blame either out of ignorance, complicity or active perpetration of the model. It is my opinion that the only way we can improve the situation is to come to terms with some of the key driving forces. As I pointed out initially, the fraudulent use of codes highlights many issues. A more direct point of purchase in a free market would eliminate a tremendous amount of currently inefficient waste of resources to the chagrin of many middle persons and politicians.

    • Jerome Bigge says:

      Increased government involvement in US health care seems to do little more than increase costs. The more “regulations” there are, the higher the cost of compliance. Which in turn drives up the cost of providing a service through increasing overhead costs. Then there are concerns over “fraud” which tend to add extra work in applying a claim for compensation for service rendered. As I’ve noted, a US hospital will have as many “office” people working as people actually performing patient care. It is adding quite a bit to the size of the bill that the patient (or insurance company) will eventually get. I should note that before all of this regulation and such took place, health care costs here in the US were not that far out of line with those of other countries. Which leaves little doubt that one of the major forces driving our high health care costs originates in Washington, D.C.

  5. Good evening,
    We all agree that our system is broken, we just disagree on why it is broken and how to fix it. Here is my simple answer, go backwards. That’s right, go back to the simplicity of direct pay care where a physician contracts with a patient for a specified service at a specified price (possibly in eggs or chickens or veggies). Get the insurance companies and government payers out of the office visit equation, especially primary care. Get rid of all the administrative costs and be a doctor not a medical coding specialist.
    That is what I am doing with Sanctuary Medical Care and Consulting in Tennessee and that is what others are doing across the nation.
    I look forward to more doctors waking up to this option of direct pay care.

    Eric Potter MD

  6. Sandy says:

    If an independent small business (e.g. a dry cleaning shop) were to charge customers outrageous sums for services not rendered, we would call it fraud, and the district attorney would be happy to pursue criminal charges once someone presented the evidence. If many people presented similar evidence, the D.A. might even add on racketeering charges and go for triple penalties and damages.

    It seems to me that heads should be rolling, people should be spending time in jail for this type of criminal activity. Knowingly charging thousands, or tens of thousands, of dollars for services which were never rendered just because hospitals assume that most people lack the knowledge to challenge the charges is the same as the confidence man bilking his marks out of their money because he was able to fool them. That’s fraud, and perpetrators who do this should face criminal charges and loss of their liberty. Administrators who put together their policies and training programs to cause the “upcoding” (i.e. fraud) should face racketeering and conspiracy charges. Insurance companies which knowingly go along woth the practice should face stiff penalties as accessories to the crime.

    I’m sick of white-collar criminals getting away with their fraud and theft just because they’re doing it for high stakes. Time to right those wrongs. Start local, with your local district attorneys. It’s beyond me how decent people can cause such anguish over financial matters for those who are already suffering from illness or death. Legitimate care actually provided is one thing; fraudulent charges for services never rendered is quite another. The entire conversation about controlling health care costs relates properly only to the former, and I am perplexed why people have not insisted that hospital con artists be properly prosecuted in the latter cases.

    • What you propose is out of my realm of knowledge. If in order to purchase a medication it is required by law to have a prescription by a licensed health professional (doctor usually by ARNP’s in some states) how does an individual (not licensed in medicine or with an advanced nursing degree) sign an agreement to accept a prescription medication?

      • muskegonlibertarian says:

        Without prescription laws (came with the creation of the FDA during the Roosevelt administration) it wasn’t that difficult to obtain what you needed. Often your local druggist knew what medication would be the most effective. Or for a chronic condition, one you were taking medicine for, you simply purchased it from your local drugstore. Most people on Medicare for example have a number of chronic conditions that can treated to a certain extent, but not cured. Medications for blood pressure, cholesterol, arthritis, are all chronic conditions that can be treated, but not cured in most cases. Diabetics for example are either dependent upon “pills” or injectable insulins of one sort or another. It is true that in some of these cases if the individual was lose enough weight, they might not need these medications or as much as they are currently taking which would be more likely the case. People can measure their own blood pressure and their blood sugar. A simple blood test (sometimes given for free by a charitable organization will give them sufficient data to know that they should be treated for the condition under consideration. The cost of taking charge of your own health in a more libertarian society that allows you the freedom to do so will be considerably less than what we pay now.

    • Speaking to market efficiency I would like to see hospitals consider a totally new approach to pricing. A couple of ideas rapidly come to mind.

      I think they could look at the hotel model for direction. Let’s think about it. Why not advertise and charge day rates for hospital beds and services? The market could be not only patients but providers. Example- a new surgeon in town needs an OR room to perform surgeries. Her/his options hopefully include a competing hospital (nowadays it is becoming more common for all competition to have been merged, another example of how government is failing the market) and consideration for an outpatient surgical center. A hospital could offer a surgical package with a per case or per hour expense rate. This allows the surgeon to lease the time and services effectively brokering on her/his behalf in order to arrange and provide the best value service for patient cases. Average bed days can be advertised and the surgeon can explain to the patient that that the surgical OR services are not part of that. Now you don’t need to have “length of stay police” as the patient is paying for each day spent in the hospital weighing the cost/benefit of remaining in the facility and getting the additional services of the nursing, food and custodial staff versus heading home and back to the outpatient status. With other competing hospitals and surgical center facilities services would improve, efficiency would improve and patients and doctors can assess value based upon the normal and important issues: hygiene, infection rates, support staff, contemporary aspects of the facility, geography, ease of use and ease of settling accounts. Numerous products would emerge, you would have the equivalents of the Ritz and the Holiday Inn express come to the market. Also the indigent/government programs would find options and or become own and operated by the various charities and other subsidies that could be channeled into this paradigm.

      Another consideration would be to consider a public utility model for the public option. I am confident such a model could be run at less cost and more financial stability than the present fiasco. Why not allow for more charity run hospitals as well, let them monitor and police themselves for quality etc. There is plenty of competition in charity/philanthropy as well.

      • Jerome Bigge says:

        Sounds like a good idea to me. I’d also suggest that hospitals start charging on a basis of services actually rendered instead of having a flat fixed room rate. Just as motels charge according to number of guests, the difference between a room and a suite, hospitals could do the same thing. As it stands today, even if you don’t use very much in the way of services, you still pay a high price. Hospital “room rates” have risen far faster than people’s incomes, which raises the question “where” all this added money is now going?

        The only problem with patients making the decision when to leave the hospital is that as it stands today, if you decide to leave before your doctor wants you to, it is considered “against medical advice” and insurance companies (some companies) might refuse to pay the claim.

  7. Jerome Bigge says:

    To a great extent, hospitals get away with this sort of thing because they are “organized” and are able to prevent legislation that they don’t like from becoming law. In effect they have purchased “protection” that allows them to rip off consumers to the point they do.
    The same applies to the health care system in general. Over the decades they have now “purchased” legislation that favors them over the consumer. The same is true of all the professions to differing degrees. This also applies to “organized labor”. The workers organize a union which then collectively represents them before their employer. The minimum wage also does this same thing to a certain extent. The power of government is used to establish a minimum level of pay below which it is illegal to hire someone despite the fact that they may be willing to work for you at that low a wage.

    The only people whose incomes are determined by the laws of supply and demand are those who are not “organized”. Everyone else is able to set the level of their incomes or earning well above the level they would receive in a true free market where what you earn is determined by the economic laws of supply and demand. Or they possess a legal monopoly of some sort that prevents people from obtaining “something” without having to obtain it from someone authorized by the government to provide it. Prescription laws follow this pattern. In effect doctors have been given a legal monopoly over access to medical drugs which they exploit to gain a higher income than they could otherwise obtain. Hospitals effectively do pretty much the same thing. Otherwise people would likely in many cases seek out the services they need from from an institution that offers services at the level they need, but below the levels that hospitals offer today. In a true free market health care system no one holds any sort of “monopoly” power, so the consumer is the one who makes the decisions as what level of service is needed.

    I cover these issues in more detail on my blog at “”.

    • While it is true that doctors hold the special authority to monitor and prescribe medications, I don’t think this represents a “monopoly” in the normal sense. There are thousands of independent practices and for that very reason we are not a monopoly.

      There are many reasons we hold that authority and one of them is patient safety. With that authority comes lots of liability as well. This situation certainly is an example of barrier to entry but in terms of satisfying the market I simply say- those interested are welcome to go to medical school. After that slog, you have crossed the barrier and are welcome to open up for business. We as a profession will salute and support you whole heartedly. The insurance companies and the Federal health care payment programs known as Medicaid and Medicare will try to screw you out of your revenue stream and enslave you to their added work list, created to slow your productivity and efficiency down as much as possible. Patients will try desperately to see you but given all the massive confusion will actually believe unless you are on their insurance it is physically and legally impossible to see you (I have heard people in crowds make such insightful statements, trust me). This ignorance about their own rights to access health care illustrates how much more successful the third party payers have been in this process.

      I remain with the position that the complexity that has been legislated over the decades to interfere with the process of satisfying a simple payment claim is a very strange phenomenon and it has been growing to this god-awful state of circumstances because all the parties at the dance are trying to extort and protect the money flows. I stated earlier that my practice style and preferred approach is very straightforward. Service is sought, rendered and payment is due, what is so difficult about that? Do you need a third party to charge you to interrupt the simple exchange of paying for the service? Is the average patient customer too unintelligent to understand they just saw the doctor and need to pay for his/her time, expertise and assumed overhead to be made available for their health care consumption? The codes, third party interruptions etc are the map for which each party involved tries to create a “gotcha moment”. Sadly this is such wasted energy and resources for any market to bear.

      I will be commenting in a moment to one or two of the prior comments as I have been traveling these past 2 days. I have signed up for your blogs, BTW, good stuff on your site.

  8. Jerome Bigge says:

    Some of us “patients” would be quite content to accept the “supposed” risk of obtaining medical drugs upon a “signature required” basis. Which would also state that we were in fact accepting the risk of adverse reactions and so forth. The only problem here is that the legal profession frowns upon people who make “agreements” of this sort as it cuts off any hope they might have of filing a future lawsuit and perhaps “winning” a great deal of money. I’ve read of cases where the lawyer got about 1/2 of the reward, so the legal profession does have a monetary interest in seeing to it that people are not allowed to sign such contracts.

  9. Tia says:

    To the poster who demanded that “we lock ’em up” for theft and rackeetering – once again we are losing sight of how this perverse situation came about.

    Due to government regulations and mandates, the reimbursement for Medicare and Medicaid are so small that it drives this behavior. In addition, the private insurance companies have also jumped on this bandwagon of providing such small reimbursement for services rendered, it makes it unprofitable for the providers to give care to patients.

    The providers [hospitals, doctors, etc] have a couple options – drop their Medicare and Medicaid patients, do not accept any new Medicare or Medicaid patients, drop patients from those insurance companies who refuse to pay a reasonable charge.

    This is currently happening. In many cities and towns, you cannot find a doctor for miles, who will accept Medicaid.

    The patient/consumer loses – far less access to health care.

    The other option is – accept the low payments, and charge other patients to make up the difference, or go out of business.

    Or, they then engage in the behavior of trying to find ways to inflate the costs of certain procedures to Medicare, Medicaid, insurance companies to recover lost revenue on other services which they are no adequately paid for. Do I agree with this practice? Hell no!

    Can I follow along to see how government regulations in the health care market is driving this activity? Hell yes!

    We can lock up all those who engage in this practice. But, it won’t solve the original problem of government involvement in the market breeds perverse behavior. Most of these providers are trying to survive perverse government regulations.

    Medicine is a business like anything else. The providers must be able to cover their expenses. Any business which cannot cover its expenses will inevitably close. Again, the consumer loses another access to medical services.

    Those medical practices which have dropped/reduced accepting private insurance, Medicare, Medicaid; and require payment directly from their patients, are able to stay open because they do not have the government, insurance companies, and lawyers sitting with them in the treatment when delivering care to the patient.

    They are able to keep their charges reasonable, and deliver quality care, because their do not need to employ an army of personnel to ensure they are complying with every government mandate, and insurance company demand. And, the the worry of having to pay hefty fines for failing to comply with a government mandate is reduced.

    We love the saying “there ought to be a law…”, because our magical thinking says “laws solve all problems.” Although it does not, and the evidence is before our eyes, we just cannot see it. We love to “lock ’em up,” because we cannot see how the mountains of onerous laws and regulations drive businesses to act in a perverse manner to try and survive.

    Everything that is wrong with the “death care” system in the US, can be traced directly and indirectly to government interference in the health care system. This is Economics 101. There is noting inscrutable about it.

    There is no “right to health care.” In the same way there is no “right to auto repair services,” or “right to hair styling services,” or anything else. Someone had invest time, energy, money into gaining the skills to provide the services. We should expect to pay him for his services. And, we should take responsibility for our health by not engaging in practices which degrade our health, then demand that we “have a right to health care.” “Someone” has to provide that care. Is he supposed to work for free?

    I do not have health insurance. I managed my healthcare needs, and raised five healthy children without health insurance. I engaged in preventative health practices, and paid for care at the time we needed it, when we needed it. And, I am low income.

    I do not have Obamacare. I do not want it. However, the Obamacare law is now driving the perverse behavior of me trying to find some way to comply with the mandate, so I will not have to pay the fines. This is how “feel good” legislation forces people to engage in behavior which is different from what was intended, or what the consumer wants.

    It is the law of “unintended consequences.”

    Government regulation is the root cause of the medical care problems. Not insurance companies. Not hospitals. Not doctors. They do all take advantage of a system put in place because of government regulation. Don’t lose sight of that.

    We have demanded whole hog that government essentially take over health care, and are moaning that it’s not working. Then, we demand to lock people up, because they try to survive the imposed system. Sigh.

    It’s like inviting the fox directly into the hen house, then railing about all the dead chickens.

  10. Tia says:

    Dear Dr. Raymond,

    I’m sure your suggestion was sincerely meant. However, I would not even bother trying to talk with a wider audience about the issue of government intervention. It would be pointless. I know that sounds defeatist, and it is. I will give you a few reasons why…

    There is no way to undo 12 years of government education. Add another 4/more years of college, for those who pursue higher education. It’s just about impossible. I have found that very often, the most “serf like” thinking person I meet, are usually those with a college degree. It seems the more schooling the person has, the more “serf like” he is. You would think it would be mostly so for the less educated. I have found the opposite.

    But, the astounding thing I realized is that these highly educated people vigorously deny that their views, and value system are “serf like.” That is quite a feat for a system of education to achieve! And, impossible to overcome.

    We do not have to go back to the Middle Ages to learn about the feudal system. In the US we have a system of feudalism, and the American people individually – and collectively – have the mentality of serfs. It is so systemized, that the average person just cannot see it. Every ares of life is so legislated, that it’s estimated that each person commits about 3 felonies a day, without even knowing it. The serfs vigorously defend the system, and call it “freedom.”

    When you point out, this is not what “freedom” should look like, then you get the canard that “I” don’t want ANY laws, and I just want anarchy [As if government doing what it wants, when it wants, to whom it wants, with nothing/no one to restrain it, is not anarchy.] This demonstrates such poor intellect and lazy thinking, that I don’t have the energy to attempt to overcome it. Strip away the veneer of “modernity” and the hypnotic array of technology, and you can see the system of feudalism. Meet the new boss. Same as the old boss. Yet, those most harmed by it, are its most ardent defenders.

    Like Harry Browne used to say, just like a battered spouse, Americans suffer from Battered Citizen Syndrome. They cannot see that the batterer – their government – is the source of their misery. They cannot see that their government abuses them daily. Instead they defend the batterer. How do you overcome that?

    Americans do not have control of their government. The “We are the government” myth is ingrained from babyhood, yet repeatedly revealed as a farce when you note that when the people object to something, the government goes right along and does what it wants anyway, and the people can’t do anything about it. But, the people continue to believe in fairy tales.

    Oh, this is the part where I expect everyone to pile on to tell me how wrong I am. That I am unpatriotic, Communist, Muslin, and other derogatory name calls; and if I don’t like it I should move to N. Korea, or China. No one sees the irony that I don’t “need” to move to N. Korea/China to experience that brand of government, since the American government is imposing N. Korea/China’s policies right here. We are told it is “freedom.”

    Obamacare, and just about every government program, is the result of a “serf” mindset. The idea that if we want to help others, we should use the might and power of government to achieve that goal. And, although it hurts many of the very people it is intended to help, people will still call for “more,” and really do expect it to “by magic” fix things. Then, there is the idea that we have a right to use the might and power of government to reach into our neighbors wallet to fund our “good deeds” which is powered by government schooling.

    For some people, it is a desire to get themselves “free” goods/services. Oh, they would never put it that way. No! No! No! It is always framed as some sort of “right.” And, they believe the rest of us “owe” them something, everyone else must work hard to provide it, and they want the government to take from others and give to them. Because, we are serfs…

    Our masters decide how much of what we earn belongs to them, they get paid before we do, and they decide how the money is used – regardless of whether we agree or not. Of course, if we “disagree,” we can always vote. How’s that working for you? But, if we refuse to give up any part of what each of us have worked for all by ourselves [I don’t see any politician working alongside me to earn the money, do you?], you will find yourself in prison. If that isn’t a system of serfdom, I don’t know what is.

    No one ever talks about the “right” to take responsibility for themselves, their health choices, their eating choices, drugs – prescription and recreational, smoking, drinking, etc. Which is what free, independent people do. However, once health issues start surfacing, they have a “right” to health services, providers have a responsibility to provide health services, and the rest of us have the “responsibility” to work and pay for it. Of course, the payment is laundered through government mechanism, so there is a disconnect between problems in the “sick care” system, and the intervention of government. Create a problem. Offer the solution. The serfs will be none the wiser.

    Obamacare is just a symptom of the disease of the serf mindset. Nothing can change that.

    The US is imploding economically. It’s inevitable. Our way of life is disintegrating. And, we don’t have to do a thing, because the government is doing all the heavy lifting for us. Because that is exactly what government does. In every era, all the time.

    The right to life, liberty, and pursuit of happiness has been bastardized into meaning the right to use government to provide you with whatever your little heart desires, at other people’s expense.

    I cannot even persuade my own family and friends to see through the smoke and mirrors of government intervention, so how can I possibly hope to widen the thinking of total strangers?

    In the end, I value my friendships, so in order to maintain them, I refrain from discussing politics. I see it gets nowhere, and causes tension, anger, and hurt feelings. In the end, if something happens and I need help, my friends will be there. Government will do what government does best – muck things up.

    Yes, I feel resigned. I hear some of the most “serf like mentality” things being said by young people, thinking that represents “freedom.” There is no hope for a turnaround. I’m being dragged along in a current which I cannot hope to redirect.

    It was Freud who said, “Most people do not really want freedom, because freedom involves responsibility, and most people are frightened of responsibility.”

    I believe that to be true.

    • Tia,

      That was quite a lot of feedback- thanks. You mentioned my suggestion but I am not quite sure which one you were addressing. I had commented several times on this particular blog topic and my last comment had no criticism regarding your prior feedback ( I wouldn’t change a thing).

      If you were commenting on the hospital market recommendations “thought experiments” the first did not involve government at all- it was a market based recommendation. The second did open up the conversation of a utility model and hence definitely a government regulated consideration based upon a “cost plus” with independent audits and “voted” rate hikes etc, clearly not my preferred consideration.

      If I may I would like to comment on my trying to educate folks about how insidious the “there oughta be a law… for me” is in destroying our freedom. Intellectually you are right, I should just give up. Unfortunately at this point in my life and career I am instead like the Ancient Mariner with the albatross on my neck, forced to tell the tale to anyone who will listen.

      At the local level in our community and county, I am trying to convince providers to consider a more direct market approach. Obviously society has concluded the need for the rule of law. You understand ideally government should very limited and individual liberty premised. I have been involved with organized medicine (FMA delegate, IPALC president) and I can assure you I stand at the podium asking the collective to refrain from seeking legislated solutions to our issues, rather I advocate professional responsibility, decor, self regulation in the interest of optimizing our professional and personal freedoms and market based solutions to the topics that arise.

      My above actions and communications are my attempt at making my personal responsibility commitments. My voice and involvement in the health care space are my commitments to my profession and patients. Thanks again for your advice.

  11. Tia says:

    Dr. Raymond, please accept my apologies for my poor communication skills. My comments were not directed at you on a personal level, nor was it being critical of you at all.

    When you said I should take my comments on the road, I interpreted that to mean, I should share it with a wider audience.

    So, I was trying to explain my feeling about the general mentality of the population, and why any attempts on my part to illustrate to others how government intervention can be traced as the source of what ails the country, would be all for naught.

    My opinion is based on personal interactions and experiences at the local level with family, friends, acquaintances, strangers; and of course observations of things on a wider level.

    The tide of collectivism has swelled to a tsunami. There is no turning it back at this point. History will play itself out.

    I do not take issue with anyone who try to educate others at all. And, I am not saying you should give up. I’m simply saying I find it to be personally exhausting. Was I as clear as mud? LOL.

  12. Denver Todd says:

    I would like to take a little bit of contrarian point of view about this post: If a person has a $3k out of pocket on his insurance plan, then whether or not the bill is correct, if it is high enough, the patient will still pay $3k no matter what. The only way it benefits him to question the bill is if it will actually lower the bill to a point where the amount he pays will be below his deductible and out of pocket amounts. I suspect that even if the bruise bill was dropped to $10k, the doctor’s portion would still be $3k, so this is a poor example of why a person should dispute a bill.

    In Colorado, where a common deductible and out of pocket is $6350, whether the bill was $10k or $200k, I would have still paid $6350. These are 2014 numbers, and I suspect this will change for 2015.

    On the other hand, if you don’t have insurance, that changes everything, and it pays to question every line item on a bill.

    • says:

      This is a pretty good point. Many of the people who consider themselves self-pay are either completely uninsured or have some alternative form of coverage, but for those with high-deductibles at a certain point it doesn’t really matter if a bill is correct or not. One of the many reasons, in my opinion, that self-pay needs to expand if our nation is ever going to really get health care costs under control.

  13. Pingback: How The Health Care Billing Coding System Gets Gamed | The Doctor's Report

  14. Mary says:

    It really is painful, as a patient or loved one, to deal with the massive bills after the treatment. Haggling makes it more stressful.

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