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New health insurance “transparency data” looks suspiciously wrong
- logicallee 3y agoI've asked the author for a copy of a correct csv or xlsx file, I'll share it if the author responds. https://imgur.com/a/bTmfDEU https://imgur.com/a/bTmfDEU
- axutio 3y agoWhat does this mean? Having read the article, I don't understand what it is you're asking the author for.
- logicallee 3y agoArticle says "contracted rates that are wrong, mislabeled, or missing" so I want to see what a correct, properly labelled example looks like according to the author. I want to see what they think correct data looks like.
- axutio 3y agoBut that's entirely dependent on the data - if you read the article, you'll see that the author is pointing out how different datasets are reporting different values for the same healthcare service. A correct, properly labeled example is just that - a document where values are accurate rather than misreported. If you want to get a sense of what a correct, properly labeled example might look like, you should visit the CMS's guidance [1]. Health insurers should be providing documents that follow the format described there, and most importantly, reporting values that are accurate. [1] https://github.com/CMSgov/price-transparency-guide https://github.com/CMSgov/price-transparency-guide
- sl-dolt 3y agoI'm the author. Publishing my reply to you (as I understood your question): > No one can produce the corrected/missing rates but the insurance companies themselves. All we can do is point out when we’ve found rates/patterns that don’t make sense. E.g. https://github.com/CMSgov/price-transparency-guide/discussions/633 https://github.com/CMSgov/price-transparency-guide/discussio...
- deleted 3y ago[deleted]
- logicallee 3y agoThe author has replied to me, and shared these great examples of transparent prices: https://github.com/CMSgov/price-transparency-guide/tree/master/examples/in-network-rates https://github.com/CMSgov/price-transparency-guide/tree/mast... Along with this fantastic guide: https://github.com/CMSgov/price-transparency-guide https://github.com/CMSgov/price-transparency-guide I recommend them to anyone who wants to see good examples of price transparency.
- richwater 3y agoThe healthcare industry is actively hostile to the well-being of citizens.
- ktta 3y ago"Never come between a man and his meal" playing out right here
- jgeada 3y agoUnfortunate that the man in this analogy is Hannibal Lecter (Silence of the Lambs, Hannibal is a violent psychopathic cannibal in that movie), and should be stopped from getting his meal. Insurance companies are a problem, and they've grown fat skimming a fair fraction of this nation's GDP for no observable value provided. Our healthcare system is more expensive and has on average worse outcomes than other first world economies.
- daniel-cussen 3y ago[dead]
- emeril 3y agohaha - don't tell that "fact" to any republicans... none of my colleagues believe it (they also don't believe in human caused climate change or that ectopic pregnancies are unviable, all sorts of nonsense) I'm waiting until we meet that great filter in the sky
- SoftTalker 3y agoYes, I try to avoid it as much as I can.
- candiddevmike 3y agoEveryone assumed there would be malicious compliance here but it's definitely eye opening just how malicious they made it. Speaks volumes for the perceived risk releasing this data, IMO. Still waiting to hear about someone using this data to negotiate down a hospital bill, seems like it's just insurance companies that can weaponize this data for better rates.
- xmddmx 3y agoI wonder, does the law have any whistleblower provisions? Seems like a programmer who had been coerced to fudge the data, and kept receipts, could be in a good position...
- JPws_Prntr_Fngr 3y ago> seems like it's just insurance companies that can weaponize this data for better rates. That’s because their negotiating power is mainly due to the size of their buying power, not special knowledge or skills. Health “insurance” is basically the lamest, most economically perverted form of collective bargaining ever.
- maxwell 3y agoAnd why federal governments make the best health insurance carriers. Brokers, medical billing staff, and other middlemen serve no purpose other than increasing cost (in order for an inefficient, openly colluding private cabal to invest premiums, deny claims, and collect profit) because everybody needs access to medical treatment.
- xupybd 3y agoI live with free healthcare. The last three trips to the emergency department have been over eight hour waits. My father's cancer treatment was not covered so the last year of his life cost him everything. On the other side my child's healthcare is amazing and all free. We get instant access to great services.
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- Brendinooo 3y agoSeems like really important work that gains more value as more people hear about it. I hope that what you're doing will lead to better data and greater transparency.
- axlee 3y agoWhoever is doing this due diligence is truly helping millions and millions of people. Good luck. There are very few among us here that could pretend the same, and I'm not one of them.
- hammock 3y agoCan GPT4 help process this data?
- csnover 3y agoGPT-4 readily hallucinates data[0], so that seems unlikely, though it also appears unlikely that it would make it any worse! [0] https://news.ycombinator.com/item?id=34775853 https://news.ycombinator.com/item?id=34775853
- chatmasta 3y agoGPT-4 can write queries if you give it a schema, but I definitely wouldn't rely on it to generate any actual data.
- nradov 3y agoThe government has a databases of synthetic medical insurance claims that developers can use for testing. https://www.ahrq.gov/data/innovations/syh-dr.html https://www.ahrq.gov/data/innovations/syh-dr.html
- ThePowerOfFuet 3y agoCome on.
- aintgonnatakeit 3y agoThere are two problems here: 1) Hanlon’s razor 2) The author doesn’t understand health insurance data. I’m not trying to excuse the other bad behavior, but within the data itself, he’s experiencing a combination of health insurers’ incompetence, the kludged up data models they’ve had to build to represent the output of the multiple generations of claims processing systems and other administrative processes, and the general mess that provider identifiers are. Every payor calculates values differently. Every payor uses different codes (beyond the standard CMS and CPTs). Every payor has different arrangements that are difficult to represent in standard schema, eg capitation in Florida, delegation in California, or the oddness that are Taft-Hartley plan. There is a link in the article to a discussion with CMS. Another participant in the discussion works for IQVIA, a long-time claims data aggregator (and CRO and a bunch of other things), and clearly understands what’s going on. It would be extremely difficult to do this work at all without significant experience working with multiple payors’ data, which requires time and access, and pays well once you do have that specialized experience.
- yunohn 3y agoBut the given examples are basic procedures like “wrist x-ray” or “endoscopy”. Surely they have simpler rate calculations than the potential special cases you mention?
- aintgonnatakeit 3y agoLet’s do wrist x-ray and keep it simple. I’m sure I’ll mess up the formatting here. When you get an x-ray, you would expect to see 3 claims (again, simplifying). —— One is the x-ray tech taking the picture. That gets a professional claim with a CPT code and is straightforward. —- One is the interpretation by a radiologist of the imaging. That is a professional claim with a CPT and a modifier. —- The last depends on the place of service. If it’s in a hospital, or at an outpatient facility, or at an ASC, then you get a facility claim to go with it. Next, under what circumstances did the x-ray occur? Was it during an inpatient stay? If so, the payor might pay based on a DRG, which is basically a bundle of all the services that occur during the stay. How do you decide how much of the cost to allocate to the various parts of the x-ray? There are more variations on this. Next, how are the providers contracted? Are they participating providers? Par vs non-par have different payment rates. Next, was the service in-network or out-of-network, defined by the patient’s insurance benefits? Does the patient’s PCP participate in a capitated arrangement (fixed fee to the PCP’s office per month)? If so, what is the allocated cost for the service based on the submitted encounter? What about fees for network rental? Sorry, this one is esoteric, but it’s another factor. And so forth and so on. It’s a mess.
- newjersey 3y agoWe should compel these companies to comply. There should be fine a 1% of annual revenue for every day these companies are in non compliance with prison for the ceo if they are non compliant for over thirty days.
- deleted 3y ago[deleted]
- sl-dolt 3y agoAuthor here. The problem is checking compliance. By publishing these files, they seem compliant, but really aren't. Since the payors are the guardians of the data, it's very difficult to check that what they're posting is correct. That was the main thrust of the article.
- westmeal 3y agoYeah these people are sketchy as hell, glorified middlemen trying to continue making billions for contributing nothing. Thanks for posting.
- SamoyedFurFluff 3y agoIf anyone is interested, the arm and a leg podcast covers how people leverage transparency data and other strategies to fight hospital bills. Most recently it was covered that so few people take hospitals to small claims court over their billing practices that hospitals can afford exorbitant teams of lawyers to establish more case law that their behavior is legal. https://armandalegshow.com/ https://armandalegshow.com/
- nradov 3y agoA win in small claims court doesn't create any case law.
- ecommerceguy 3y agoThere used to be, and I'm not in a position to find it, a forum that specialized in cash paying the least amount for all procedures, lab tests, imaging etc. It truely was impressive how these forum members unearthed massive savings and really, once you knew what to do, didn't seem all that invasive or difficult. We are writing more groups using Referenced Based Pricing. Good idea.
- ElijahLynn 3y agoThis paragraph is missing the link at the end: At DoltHub, where we build databases like codebases, we're running a data bounty, collecting rates for popular medical procedures for all US hospitals. Then we'll release the data under CC. Find out more here.
- sl-dolt 3y agoThanks. Will fix that.
- iamerroragent 3y agoImagine a world where one entity received all the peoples medical bills and was incentived to negotiate for the lowest possible rate from each provider. Imagine the savings alone from reducing a massively overly bureaucratic and complicated system down to just one entity negotiating and paying the health service providers. Just imagine in that world this article would have never needed to have been written.
- avidphantasm 3y agoBu…bu…but we can’t have “big government”!!! Imagine the horrors!
- firstlink 3y ago> was incentived to negotiate for the lowest possible rate from each provider So, not an entity which by its very nature spends other people's money and can never run out? I agree, sounds like a great idea, but someone will have to invent such an entity first. The ones we have would not meet the requirement.
- mlyle 3y agoOf course, the existing private entities are barred from doing something like this by antitrust law.
- yamtaddle 3y agoThank god no-one's tried, I'm sure the population of any such country would riot to reform to something free-market-based instead in short order, because expenses would rapidly grow out of control, vastly in excess of, say, what the US spends per-capita, and service would be completely terrible, leading to plainly-worse-in-every-way outcomes than in countries that retained more-enlightened systems. ... what's that? The entire OECD has more centralized government control of healthcare than the US, ranging from extensive price controls, to de-facto or de-jure monopsony, to outright direct control of the healthcare system, and nowhere is there a strong populist movement to ditch that for a heavily free-market-based solution? And literally all of them are way cheaper per-capita than our system? And outcomes remain between pretty-good and great? And instead of the bureaucratic billing mess we have, that's all nice & simple and takes up almost none of the time of sick people and their families? This makes no sense, I read several columns on mises.org proving from first principles that this is impossible!
- seventytwo 3y agoName any other industry where neither transparent pricing exists nor government socialization exists. The health insurance industry is quietly and uniquely one of the darkest markets in the world.
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- joseda-hg 3y agoThe world is a curious way to put it, this feels like a particularly American facet of the problem
- avidphantasm 3y agoSo not only shouldn’t healthcare be a market good (moral argument), but healthcare profiteers are actively distorting the market and are not taking seriously efforts to provide a modicum of information to participants in this so-called market.
- polygamous_bat 3y agoCan't really be a market with such obscure pricing and inelastic demand.
- brewdad 3y agoEven given inelastic demand, a market with open, easily available pricing would be freer and fairer than what we have today.
- klabb3 3y agoIt’s one of the most complicated and regulated markets on earth. Yet both the critics and supporters think it’s a free market. Would a free market be better? Probably overall, but the bar is very, very low. Instead of running another decades-long experiment, perhaps just use a model proven to work? There are many to choose from.
- wswope 3y agoJust to throw out a possible next step to put pressure on the payors: consider reaching out to the CMS technology ombudsman to ask if you can CC him on a round of follow-up inquiry emails. His nominal role is to assist with Medicare-related matters, but given that the ostensible goal here is to compare rates (and most payors define rates as a percent of Medicare), I think the request wouldn’t be too much of a stretch. Similarly, might be possible to get some congressional offices to lend their weight. Happy to personally lend a hand with the outreach if there’s interest.
- JumpCrisscross 3y agoHow catastrophic would requiring hospitals honor their transparency pricing be to the system?
- ecommerceguy 3y agoMost hospitals have provided flat files, phase 2, and now the current administration has decided not to enforce this through completion of phase 4 fully searchable due next year. Enforcement began with the previous administration fwiw.
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- eftychis 3y agoMonopsonies require a single buyer with a stick to work. Economics teaches that to us since inception. I am not sure why this is even a divisive topic. Sure discuss how a doctor decorates their office. Who cares. When you are dying or are in pain, nothing but treatment at any cost matters.
- sclarisse 3y agoWhile there are arguments for and against a variety of systems, this one is weak and specious. Oh, sure, in a crisis you need care immediately. What about all the other circumstances? What about the possibility of making pre-arrangements in event of crisis, some sort of “insurance” even? Not to be confused with the comprehensive health care delivery product called “insurance” in the US (which, hey, also exists as a model and could persist in a market.) Maybe some markets are still monopsonies, but surely not all. I can surely find a variety of GPs, allergists, physical therapists, … A sound argument for or against a market health system recognizes that emergency care is only one circumstance of many, a minority of health care costs, and it’s possible we might be better off if it does not drive the overall design of healthcare.
- russellpekala 3y agoIf you want to be a part of this battle while also not being a part of the "middleman" (e.g. price transparency venders), come join us at Yuzu Health. We are hiring for a senior engineer to help us build a modern health plan tailored to the needs of startups and their employees. https://yuzu.health/careers https://yuzu.health/careers
- Spivak 3y agoThis could have been much much easier if they just required the medical equivalent of certificate transparency. Every insurance company is required to post publicly every single claim they receive, the full information of the provider(s), the name/code of the plan, the billing codes, whether it was approved or denied, how much the insurance was billed, and how much insurance actually paid (where paid doesn't mean discount, it means the literal dollars that left the insurance company's bank account), and the "patient responsibility" along with where the patient was with regards to their deductible and oopm. Every medical provider is required to do the same every time they create a bill. Fine, "you don't know" how much things will cost. We can figure it out for you. No thoughts, head empty, just post and sign every bill you generate as it comes.
- sl-dolt 3y agoCompletely agree. There are databases like this out there (All-Payer-Claims database) but they're extremely expensive (it would cost millions to get data for the entire US) and I have no idea why.
- emeril 3y agotoo bad that data hasn't been leaked which would actually be helpful for the US
- johngladtj 3y agoThe big problem with health insurance is that the people who buy it think that they are buying a health subscription. The second big problem is that they are being forced to buy it. So you have something that isn't what people want, but that they are legally obligated to "purchase"... Is it any wonder most people are dissatisfied with it?
- chaxor 3y agoThe reasonable solution that people in the US arrive at is to avoid going to physicians at all costs. I recently found out that a simple blood test at the physicians office costs ~$600 (with insurance), along with all of the annoyance of dealing with setting up the appointments waiting for several months, waiting on insurance, the trouble and time off work to get there - all for a material that takes a few minutes to extract and few moments to run. Due to the cost I was curious, and found out that I could literally purchase all of the FDA-approved* lab equipment for my house and run tests on myself for less cost than it was to go to a physicians office. The physician (i.e. expertise) is irrelevant here (almost always are) as the most input I've ever seen provided by one amounts to 'take an Aleve if you're hurting'. Home labs are likely where the future is headed, and it's the fault of the medical industry being so utterly useless. I've been through most medschool (neurology-focused) courses, and most physicians or any medical professional uses essentially zero of that knowledge.
- gameman144 3y agoMy expectation is that costs for these simple tests will become competitive as physicians become more and more scarce -- if the person doing your blood test is no longer an expert, and is just feeding it into an off-the-shelf machine, then there's a lot more flexibility in cost-cutting. (In fact, my local hospital has pretty great lab prices for this exact reason, so I'd assume this kind of price competition for simple tasks might already be a thing in some urban areas.)
- BizarroLand 3y agoI know it's even stupid for me to say this, but capitalism should have no place in hospital health care. It's lives on the line. In a somewhat realistic ideal world, any monies that exchange hands at that level should be to cover costs plus a moderated profit. The lack of moderation and accountable oversight on the profit centers of healthcare is a real issue that we could solve, but too many people would rather have a 0.00000001% greater chance of becoming a millionaire in their lifetimes rather than put checks on unchecked capitalism.