Mastodawn

stevenhubertron Oct 28

Using AI to negotiate a $195k hospital bill down to $33k

https://www.threads.com/@nthmonkey/post/DQVdAD1gHhw

Matt Rosenberg (@nthmonkey) on Threads

My brother in law died in June. Heart attack. Four hours in the hospital and gone. And then the bills came. He’d let his insurance lapse two months prior. Bills were a few thousand here for the cardiologist, another few there for the ER docs, a bit for the radiologist. I helped my sister-in-law negotiate these down but they weren’t back breakers. Then the hospital bill came: $195k. This is a story about that.

Threads

I fought insurance over this past summer after they declined covering a life saving surgery for my 6-year-old child at the last minute. We were in despair that my child's life was at risk each day we waited because of insurance incompetence.

ChatGPT literally guided me through the whole external appeal process, who to contact outside of normal channels to ask for help / apply pressure, researched questions I had, helped with wording on the appeals, and yes, helped keep me pushing forward at some of the darkest moments when I was grasping for anything, however small, to help keep the pressure up on the insurance company.

I didn't follow everything it suggested blindly. Definitely decided a few times to make decisions that differed from its advice partially or completely, and I sometimes ran suggested next steps by several close friends/family to make sure I wasn't missing something obvious. But the ideas/path ChatGPT suggested, the chasing down different scenarios to rule in/out them, and coaching me through this is what ultimately got movement on our case.

10 days post denial, I was able to get the procedure approved from these efforts.

21 days post denial and 7 days after the decision was reversed, we lucked into a surgery slot that opened up and my child got their life saving surgery. They have recovered and is in the best health of the past 18 months.

This maybe isn't leveling the playing field, at least not entirely. But it gave us a fighting chance on a short timeline and know where to best use our pressure. The hopeful part of me is that many others can use similar techniques to win.

egorfine Oct 28

Non-US person here.

Happy for your happy-end to that story!

Though why do you Americans put up with all this? I have heard the US is a democracy. So then insurance-based healthcare is what American people truly want?

georgeecollins Oct 28

I think the reason is that people know it is a problem but ideologically they really disagree about what to do about it. The impasse creates an opportunity for profit driven actors to fight reforms. Also, democracies do dumb things sometimes. See Brexit.

But also, sometimes people from other countries-- I am thinking parts of Europe-- underestimate how well paid people in the US often are. They compare the averages, like the US only makes 20% more per household, why do they put up with this or that. But that comparison is for the whole country, so imagine if you were comparing all of Europe or China.

I had a friend in Spain at a similar company as mine say, how can you put up with no safety net, etc. But I look at his company and every one at my company at any level gets paid 2-5x as much. So like these are less serious issues if you are paid an extra $1-200k/ year. It doesn't explain the inaction, but I believe it is why a lot of politically influential people don't care.

Yes, a challenge for major structural alterations to the American system is that the median American family is probably better off under this system than they would be under any of the European-style systems: the wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays.

So when you're talking about how bad the American system is, you're really talking about a minority of its users. That doesn't make everything OK, but does highlight the political difficulty of enacting seemingly-popular changes.

dragonwriter Oct 28

> Yes, a challenge for major structural alterations to the American system is that the median American family is probably better off under this system than they would be under any of the European-style systems: the wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays.

The US spends nearly as much in taxpayer funds as a share of GDP as other developed countries (and vastly more on a per capita basis), with even more in private costs on top of it. It is simply dishonest to say that the "wage premium enjoyed by many Americans and the lower tax level offsets the cost of insurance and copays", because neither the US wage premium nor any lower tax burden are attributable to differences in healthcare systems, but rather are in spite of the far greater burden of the US healthcare system.

OTOH, it is true that a major challenge is that people respond with this line to any proposed major structural changes to the US system.

Again, you can just do the math on this. You're making an argument about the macro costs of our system --- I think those costs are fucked, too. But I'm not talking about that; I'm talking about the actual experience of an ordinary middle-income family with private health insurance. That family would likely (in fact, almost certainly) be worse off in a single-payer system.

I'd appreciate if you'd avoid using language like "simply dishonest" with me in the future. It's easy to tell me I'm wrong about something without accusing me of commenting in bad faith. This is in the guidelines. Thanks in advance!

dragonwriter Oct 28

> Again, you can just do the math on this. You're making an argument about the macro costs of our system --- I think those costs are fucked, too. But I'm not talking about that; I'm talking about the actual experience of an ordinary middle-income family with private health insurance.

Yes, you can just do the math, and changing nothing about the US except transition to a European style universal system, the median family would face lower aggregate tax, out-of-paycheck, and out-of-pocket costs than they do now, with less health insecurity around unexpected events (either health or employment), unless the tax increases necessary were deliberately and perversely targeted to avoid that.

That’s a direct consequence of the difference in the macro-level costs: they aren’t separate, orthogonal concerns. People just have a hard time accepting that the US health care system is structurally constructed right now to waste vast hordes of money preventing people from accessing health care, but that’s exactly what it does.

Provide numbers. Sanders, for instance, funded his proposed system by (among other things) taxing capital gains at the level of ordinary income.

I'm critical of the US system, but I have exactly the opposite diagnosis you do: my concern with the system is that, by the numbers, it appears to function by driving way too much spending on "actual" care.

dragonwriter Oct 28

> Provide numbers. Sanders, for instance, funded his proposed system by (among other things) taxing capital gains at the level of ordinary income.

Not tax penalizing non-capital income is sort of an essential reform in the era of increasing automation anyway; I'm not sure what point you are trying to make there. The average middle income family isn't making a substantial share of their income in forms taxed as long-term capital gains, so that seems...unrelated to the focus of your argument.

> I'm critical of the US system, but I have exactly the opposite diagnosis you do: my concern with the system is that, by the numbers, it appears to function by driving way too much spending on "actual" care.

It does both (particularly, in the “actual care” angle, as regards low-benefit, high-cost measures near the end of life.) We have a system based on denying and economically incentivizing younger people to avoid and defer care, but then doing much less of that with (most of) the elderly.

You're contradicting yourself. You took me to task earlier for factoring in the wage penalty for working in the UK market --- fair enough, though really I'm making the simple descriptive point that people in the US are accepting of a dysfunctional status quo in part because they would be worse off in Europe.

But taxing capital gains at the level of ordinary income would be an immense change our tax code. All sorts of things the broader economy would change as a result. If you accept Sanders plan, you're not holding to your original constraint of changing only the health financing system.

I want to be clear that I'm not stipulating that families would be better off under M4A if you didn't do this: I still think your argument has the fuzzy end of this lollipop. I think it's unlikely that you will come up with a set of numbers for any proposed single-payer health system that leaves the median family with private health insurance better off on a take-home basis. I'm making a strong claim, so you should be able to knock it down straightforwardly if I'm wrong, and I'm interested to see if you can.

As a non-american (from South America) who lived in both USA an Europe:

Yes, in USA you get much more money, like you said 2x~5x, but then:

University is expensive as fck.
Health care is expensive as fck.
You have 5 days of paid sick leave per year in most companies.
You have 10 days of paid holidays per year in most companies.

In contrast, in Europe:
University was cheap or free.
Healthcare is cheap and universal.
If you are sick you are sick, either the company or the health insurance pay.
You have between 20 and 30 days of paid holidays.

This is why quality of life in Europe, is so superior. And again, I am saying this as a non-European.

basisword Oct 28

>> University is expensive as fck.

While healthcare is brought up all the time this is usually ignored. The idea of parents saving a 'college fund' for their child is something I only know from movies. It's such a strange idea that access to education would be something you either need to be able to afford or need to get a 'scholarship' for (another strange concept).

Implicit in all these stories is that "education" means "access to highly selective universities". In-state tuition at Directional State University is much more manageable.

davidcbc Oct 28

Not really. I went to a public land grant university 20 years ago and paid about $12k a year in state. That same university is now $44k per year.

Both my kids went to UIUC and we paid about $15k/yr, and both my kids graduated within the last couple years. And UIUC isn't a Directional State University; it's the flagship of the UI system. You can just look this up: tuition numbers aren't secret.

davidcbc Oct 28

Ok I will. This claims the cost of attendance is $36,930-$42,310 per year:

https://www.admissions.illinois.edu/invest/tuition

This claims $21k per semester:

https://cost.illinois.edu/Home/Cost/R/U/10KP0112BS/15/120258...

Tuition, Undergraduate Admissions, University of Illinois Urbana-Champaign

Tuition, Undergraduate Admissions, University of Illinois Urbana-Champaign

You just cited the out-of-state cost of the flagship state university in Illinois as if it were the in-state cost of a Directional State University in Illinois. Again: you have an argument here that depends on people not Googling list prices (the prices that nobody actually pays) and seeing what they actually are.

davidcbc Oct 28

No I didn't, that is in state, it's right there on the page.

Directly from the page:

> Illinois Resident

> Tuition & Fees: $18,046-$23,426

> Food & Housing: $15,184

> Books & Supplies: $1,200

> Other Expenses: $2,500

> Total: $36,930-$42,310

I literally looked at the exact school you used in your example and you are just wrong

Couldn't have been clearer that I was referring to tuition, including the fact that I said that specifically upthread.

davidcbc Oct 28

Well then as long as the kids don't need housing or books or food or to pay the other fees they'll be set. Luckily those are all optional

They in fact differ wildly between students and between colleges! UIC and NIU are commuter universities where students generally don't live on campus. Students at UIUC live in campus-provided housing for their first year, but not generally for subsequent years. Everybody, whether they're in school or not, pays for housing. So no, the cost comparison you're offering here is not very useful.

Shortly later

I also think you might have to ask around to find a student paying full price for books.

epistasis Oct 28

Oddly enough the big rhetorical push against a universal system from prior decades was about "death panels" deciding what care somebody would get. And guess what's happened with insurance? Death panels!

The propaganda spin on the health care system in the US has been on overdrive ever since Hillary Clinton wanted to implement some reforms in the 1990s, leading to absolutely massive resistance to any change whatsoever. Even the changes implemented by Obama, which were a HUGE improvement in access, barely made it across the legislative line, and dismantling that access to the health care system has been a huge rallying cry for one of the major political parties. I won't say which one because mentioning that fact results in people turning off their brains and downvoting.

The US healthcare has optimized for availability and higher access to the most treatment options. This does not mean evenly distributed treatment options, but that people have the chance to get access to things more quickly.

And for most people, the healthcare system works fairly great. There are exceptions, like the denial described in this thread, and they usually get lots of attention because holy hell is that a messed up situation. But the everyday care that most people get is better than adequate.

nonfamous Oct 28

>>> And for most people, the healthcare system works fairly great. There are exceptions, like the denial described in this thread, and they usually get lots of attention because holy hell is that a messed up situation. But the everyday care that most people get is better than adequate.

As an individual who has lived in multiple countries in three continents, I dispute that “the care most people get is better than adequate”. Perhaps better than the world average, but certainly not better than in most first-world countries. And that’s not even counting the impact of delayed decisions and denied care, and the stress of dealing with the system overall.

And if you’re looking for more than anecdotes, there are plenty of studies that show that Americans have lower expected lifetimes than citizens of peer countries, despite much higher per-capita health care costs.

Life expectancy tells you basically nothing about the quality of health care in the US. It's dominated by car accidents, homicide, and then CVD --- but CVD varies dramatically across the United States (from states in the south with drastically worse CVD outcomes to states in the north with outcomes on par with the Nordics) despite the same health care structure across all those states.

nonfamous Oct 28

There are plenty of other countries with car accidents, homicide and cardiovascular disease. They also do worse than the US in life expectancy.

Do you need a cite to back up the analysis I just gave you? Because it will be easy to provide.

Like Ticketmaster, health insurance companies get paid to be the "bad guys". This is a reasonable function since Americans can't seem to understand that someone must decide where limited resources go. However, there's no reason their cut should be so large.

Their cut is in fact very small; it's around 6.5% of total US health care spending.

https://nationalhealthspending.org/

CMS National Health Expenditures

But for what? Why not something closer to credit cards, like 1%?

I don't know how to answer that. I think the system is pretty inefficient in a variety of ways. If you universalized Medicare, eliminating insurance entirely, you'd get costs somewhere in between Medicare's current admin overhead and the overhead of private insurance (you mechanically would not get Medicare's current overhead, because the majority of your customers would have much lower claims than Medicare's all-seniors patients do, and overhead is a ratio).

But the largest inefficiencies are all on the providers side. We simply pay practitioners too much, enforce artificial scarcity of practitioners, and prescribe too many services.

So if we're talking about "The American System" as a whole --- which is what the thread is about --- it behooves us first to consider the question "how much better would things be if we simply zeroed this category of expense out". The answer is, to a first approximation, we would get a 6.5% price break. I would not drive even a couple blocks out of my way to get a 6.5% price break on a pack of chicken breasts.

> But the largest inefficiencies are all on the providers side. We simply pay practitioners too much

I agree. The complex insurance billing system enables his by obfuscating prices and limiting ability to comparison shop.

That's true, but it's a problem single-payer doesn't fix; that's my big issue with it (it locks in rapacious rates and preferences for the health provider industry, making them palatable to consumers by hiding the payer).

Scarcity is a fact of every country's health system and you'll quickly find stories with similar fact patterns with e.g. the NHS. There's not a lot to recommend the US system as implemented today, but the problem isn't "insurance-based health care"; lots of countries have insurance-based health care.

tracker1 Oct 28

It's largely a side effect of a couple things... first the ACA (ObamaCare) limited the percentage of profit that insurance and medical providers can make... so they instead just grow the pie larger by inflating everything. Second is that they are allowed to have effectively vertical monopoly investments controlling multiple layers of healthcare as a whole from insurance, providers, pharma and pharmacies.

Trust busting and multiple supply lines really need to be established in order to have a chance at restoring normalcy. Which is all but impossible as Pharma alone is the single biggest spender of advertising alone, let alone policy influence over politicians.

lotsofpulp Oct 28

> so they instead just grow the pie larger by inflating everything

So why would they deny coverage? All they have to do to earn more money is keep paying for more and more healthcare.

tracker1 Oct 28

Because they make more by not paying than by paying... When the payouts are larger, they raise premiums, make money on both sides.

Not to mention, if they can delay payment for a month, that's a month worth of interest on the money in an interest bearing account.

How exactly do they make more money by not paying? They're required to spend 80% of their funds on provider expenses. The only obvious way to sustain the narrative that insurers are distorting the system for profit is the preceding comment's hypo that they'd be over-paying (and then driving rates up as their expenses increased). You propose the opposite fact pattern here.

(Net cost of health insurance, all expenses, is around 6.5% of total US spending, as against 51.5% of direct provider costs for doctors, nurses, and procedures, not counting prescriptions.)

tracker1 Oct 28

They keep the 20% that they don't pay out... what they do pay out, they get the invested fraction of, which is less than than what they paid out.

Even if they only get to keep up to 20%, doesn't mean they will pay a dime of what they can get away with not paying.

"What they do pay out they get the invested fraction of"?

spacechild1 Oct 28

The problem is that the insurance is provided by private companies whose incentive is to earn as much money as possible, at cost of the people in need of medical care. In my country, I never heard of anyone going bancrupt over a hospital bill. It just isn't a thing.

Here's a fun story: my sister was living with an exchange student from the US. Some day the student was complaining about intense intestinal pain she's had for the past few days. My sister told her to go the hospital. The student asked her if she was crazy. My sister then had to explain her that hospitals are free and won't bancrupt her...

In fact many of the largest insurers are nonprofits, and insurance itself is a small faction of our total expenditure. People believe a lot of weird things about US health care economics.

https://nationalhealthspending.org/

CMS National Health Expenditures

spacechild1 Oct 28

There's another aspect: In my country, hospitals and (public) health insurance are both operated by the state and work together. If I break my arm, I go to the hospital, show my e-card and that's it. All the financials are directly handled between hospital and the (public) insurance provider. I don't have to worry about cost of treatment because I know it will be fully covered.

Right. The mainstream progressive proposal for comprehensive health care reform in the US is single payer, so-named because it does not nationalize the providers. But the providers are where all the cost is!