Happy New Year!
Do you have a dumb question that you're kind of embarrassed to ask in the main thread? Is there something you're just not sure about?
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Notes -
If you have your car repaired and drive off without paying you are going to get reported, and you certainly don't get to come back and demand the next issue be fixed. It's absurd. Even in outpatient land you can't fire a patient (even with just cause like total refusal to pay or blatantly abusive behavior) without jumping through a ton of hoops.
Rural hospitals and suburban/urban hospitals with poor payor mix (in a lot of areas/for a lot of types of care medicare and medicaid pay less than cost) are going under left and right, and other places are closing their EDs in an attempt to stem the bleeding associated with most of the people least likely to pay. It's not getting a terribly large amount of attention outside the field because it's mostly poor whites and the media/left feels awkward about leaving healthcare out to hang after so much superficial support during the pandemic.
This specific practice (this explanation is abbreviated)* is driven by insurance companies refusing to negotiate with physician groups and just say lol I'm going to underpay you, fuck you. When providers try and negotiate the insurance companies label this "surprise billing" and lobby jurisdictions to ban, knowing that the result is professionals have to just not get paid or accept the lowball offer. It's a negotiating tactic. In the last few years providers and low resource health symptoms have seen total crashes in economic health while high resource systems and insurance companies are doing fantastic, but they don't replace the resources that are closing and retiring.
About half of the psychiatrists in the country are able to retire and they are just fucking right off instead of staying and during a time of sky rocketing mental health crisis. We have limited ability to train replacements if we even wanted to (for a number of reasons) and the stopgap (Psych NPs) are uniformly terrible and create more work for the leftover physicians (psychopharmacology is a lot more complicated than most management, as in diagnosis).
*Their are other explanations, you have stroke and the one neurologist on call doesn't take your insurance. Either they let you die, or work for free/try and bill your insurance anyway.
Do you think billing for car repair is in the same zipcode as medical billing? When I ask for how much something is going to cost to a car mechanic, they tell me how much it's going to cost. I don't find out a month later that, actually, a ringer car repair guy which costs $10,000 flew in town overnight and did the work. This isn't an appropriate comparison and it's why your attempt at moralizing in this way falls flat. When a person is complaining about a specific reason why this practice makes nonpayment justifiable, your analogy need to address that specific aspect of the justification.
the healthcare sector at every level delivers more care at higher prices and higher pay than ever before
given that context, a claim that people refusing to pay bills in situations the OP described is going to result in no services being offered is a stretch
Are places which ban the above practice more likely to suffer the effects you're talking about? If not, I don't really understand the relevance beyond a general criticism for nonpayment.
when a patient criticizes a practice which is intentionally designed to extract more money in dishonest ways from patients, your response is to tell the patient they are morally obligated to either pay whatever bill is sent to them or not seek medical care at all and the real bad guys are those darn insurance companies
an easy response is for patients also not to pay, this is just "the system," tell you to whine into the wind at your congressperson, and blame those darn insurance companies
"we're getting screwed so we're going to screw someone else" doesn't magic some moral obligation on the part of the last screwed anyway
this justification is that you have more negotiating power over patients so you're going to use it to extract more money because you don't have that negotiating power against insurance companies; this aspect of the argument is even more true in the case of the individual patient vis-a-vis anything
okay, so what does this have to do with a physician's assistant in a non-emergency situation?
-Hospitals can't tell you how much things are going to cost because they don't know and insurances won't tell them they how much they'll reimburse. Insurance rules are complex, constantly changing, and do so with no notice, if a place says "it will be 500 dollars after insurance" they have no idea if that's accurate or enough, and that's when needs are static. And that's if you pretend cost of delivering care is static. It isn't. If a surgery costs on the median X a specific instance could be 0.8x (healthy thin young adult, 1.2x (obese 50 year old), or literally 100x (patient has a complication, crashes, ends up in the ICU). Is the hospital supposed to charge everyone 1.5x to cover for the one person who explodes? That's like involuntary insurance. Places will offer elective and simple procedures in a fixed price fashion but they are very very cautious with that.
-Healthcare in the U.S. is collapsing, many disciplines are moving out of public insurance (most OP specialties) or private insurance (psych, in a limited fashion). Hospitals and facilities are going under with enough frequency it is approaching a full blown crisis, but most of us live in big cities with a famous name brand academic hospital that just put up a 500 million dollar building and has a million billboards. Easy to miss the crisis.
-This process is not designed to extract money unnecessarily from patients, the insurance company is refusing to provide the paid for service and instead of refusing to pay the insurance company for sucking balls the patient is fucking a different victim who is also legally prohibited from retaliating. I don't understand how the hospital/practice management group (and keep in mind that no clinician at any point is involved with any of this) is the villain because the insurance company refuses to provide insurance.
-As is usual for legislation, surprise billing stuff has a tendency to be written by corporate interests that have a financial interest in making the stroke attending and the ED fast track PA the same situation on paper.
so how is this similar to the car mechanic bill situation?
besides, all sorts of other professions delivering all sorts of other services with non-fixed costs and complications manage to present agreed upon, known costs and estimates up front and don't send a surprise bill with an absurd amount attached
I've received healthcare at countries all over the world; there, despite the complications you describe w/re pricing, they're able to tell me an estimate which aligns with the bill I receive later. Even when there are complications. Even when a mechanic while looking at the drivetrain notices the transmission needs to be replaced. As far as I know, there is a single industry which does this and only in a single country in the world.
I am sure there are parts of the US which really struggle with medical services and have the problems you're describing, but on net no it is not or else it wouldn't be delivering more total healthcare, with higher salaries, and higher prices than ever.
Are places which ban the above practice more likely to suffer the effects you're talking about? If not, I don't really understand the relevance beyond a general criticism for nonpayment.
"Unnecessarily" doesn't have much explanatory weight, e.g., I promise to pay any bill I think is "reasonable," and I won't unnecessarily refuse to pay any bill I think it reasonable. This statement doesn't really mean anything.
Nothing about this is strictly "necessary" because if it was then it would be done in places which banned the practice except they don't and medical care is still delivered there. An accurate statement would be that they do it because they're trying to extract more money from the patient or their insurance, they don't have negotiating power with the insurance company, and so they're going to go after the weaker position patient.
no one has to be the villain here, but it also doesn't mean by default it's just the patient who has some moral obligation to get screwed and fork over whatever amount some derp bureaucrat decides to send them
I don't doubt that. Judging by the ACA, insurance company lobbying groups will find a way to make it even worse. If the legislation is similar to efforts in my field, it may help some random person like the OP accidentally in certain situations but will mostly be used by megacorps to put them in better negotiating positions.
Healthcare provision outside the U.S. is structurally different in a number of ways that fundamentally change the feasibility of what you describe like:
-Rates of nonpayment being orders of magnitude lower (a huge chunk of ED care is just not paid for by anybody, in most countries some combination of less recalcitrant insurance and single payor takes care of this).
-Our population is sicker and requires more care and more complicated care and more variable care (the number of patients with BMI over 70 in most countries is close to zero and that kind of stuff is more expensive to deal with and more variable than diseases of poverty).
-Other countries can ration and not engage in heroic care
-Related to that most countries don't have the legal environment. Malpractice related stuff is a huge driver of U.S. costs and complexity.
-You don't know what's going on under the hood with your bill, does the health system automatically write off most of the encounter for tourist patients because it's easier than trying to send a bill to another country? Is that care funded by something specific?
-The type of care where this likely to be relevant is stuff I'm doubting you are getting (how are you getting operated on in multiple countries????).
-Where are you getting this impression of U.S. healthcare? Costs are skyrocketing and health is plummeting but that's not a sign of health. Physician salaries have been decreasing relative to inflation for decades, not sure where you think higher salaries are coming from.
-Shockingly people are not willing to work at places which underpay or have a risk of not getting paid at all, this is doubly a problem because it's incredibly hard to get physicians and to a lesser extent midlevels to work outside of a major metropolitan area. Increase the risk of you not getting paid and nobody wants to work there. A hospital can't exist without providers. This is one of the causes of the death spirals leading to hospital closures recently.
-So is your claim that wanting to get paid for doing work "unnecessary?" That kind of attitude is why people are leaving medicine in droves. Not just doctors, nurses too.
-The villain is the health insurance company for not providing the agreed upon service, but if you say "no I'm just going to steal from someone else and demand the right to continue stealing" than the villain includes you. Again we aren't talking about a heart attack here, we are talking about care that shouldn't be initially triaged by an ED.
Yes, I agree healthcare provision is different in many ways, but that also sets the context for this entire discussion and criticism. Your argument is the end-user has a moral obligation to pay whatever $$ bill is sent to them (if you have some restricting condition, you have not yet mentioned it although I would assume you have some sort of "reasonableness" limit). You justify this by saying healthcare providers cannot refuse to provide services.
The main issue I have with this argument is you're using situations which do not account for the overwhelming vast majority of healthcare in order to justify practices and moral obligations. An example is your ringer neurologist to a patient having a stroke with other examples being almost entirely focused on ED care, but this is not representative of the majority of healthcare expenditures. Healthcare providers can and do refuse non-emergency care to people who they know will not pay for it. Perhaps in the context of megacorps and hospital systems, it is true individual doctors cannot de facto refuse care due to billing.
You set this context by essentially requiring the end user who is being screwed to think of it in situations which aren't representative and about individual doctors and other providers who have limited choice with pay structures likely irrelevant of whether or not each individual pays any bill sent to them.
But then, so what? This would be a systemic criticism, not a moral obligation on the final screwed person. The enduser can simply respond with your same moralizing back at you.
One, not a tourist. Two, your claim is that the healthcare system may automatically writes off tourist patients (I wasn't a tourist) and don't even bother at point of contact to tell them the cost and ask for payment? not that they give a bill they don't think will be paid
this criticism doesn't even stand on the face of it, it's little more than handwaving
knocks, stitches, broken bones, nose bleeds, etc., the kind of care which is being discussed as the example in the OP
again, you're using specific situations not described in the OP to justify obligations in other different situations
summaries of total delivered services, avg pay, total cost, number of ppl employed in industry, etc.
more money being spent and more people being employed to deliver healthcare to a populace which gets sicker and sicker every year isn't exactly a ringing endorsement of the healthcare being delivered let alone the healthcare system
no, my claim is that the practice described in the op isn't "necessary" and that the word "necessary" has little meaning in your sentence
I cannot find any support that "people" are leaving medicine in drones: more people work in "healthcare" now as doctors, nurses, etc., than ever before
yeah, well no one is saying that
Nurses are leaving bedside nursing in droves and while some specialties are keeping up with retirement rates we are slipping behind our overall healthcare needs.
My problem is not that OP has a moral requirement to pay a bill no matter how stupid it is, it's that he doesn't know if it's stupid or not in this case, he (and everyone else) is blaming the wrong parties (the PA has no idea what's being charged and has no control over it, blame the insurance company or the hospital/practice management group that owns the PA). He also went to an inappropriate level of care and was surprised that costs were excessive. If you get admitted and demand to be in the ICU instead of on the floor it'll be your fault when the bill is an order of magnitude higher.
if you're going to design a system for the purpose of extracting more money by surprise fucking over patients, don't be surprised when they're angry or refuse to pay
Again, the entity extracting more money and surprise fucking over the patient isn't the hospital or the healthcare provider it's the insurance company.
OP paid the insurance company for a service (covering healthcare needs) and then the insurance company was like lol nah we aren't going to do that, and instead of refusing to pay the insurance company or complaining about the insurance company they take it out on essentially a third party with no control.
If I wire transfer some money to 419 scammers and then walk into a bank and punch an employee in the face for allowing me to get scammed then I'm the asshole.
The ED is literally required by law to provide care regardless of insurance status, ability to pay, or appropriateness of that level of care. There's literally nothing the ED can do to stop this, it's OP's job to go to an appropriate level of care, think critically about whether an ED visit is required, investigate his insurance, or get new insurance.
OP and the Hospital are both victims of the insurance company being an asshole.
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Fundamentally, it sounds like you perceive that the problem is that people don’t pay enough for health care (whether that is through private insurance or through Medicaid).
This means that the hospital/physician is trying to take advantage of me because I am easier to negotiate with than my insurance company or the government. In the recent past where they could fuck my credit score they had most of the leverage and this would have worked and people like me would have been responsible for propping up a broken payment system. How is this not absurdly predatory?
Now that this is more difficult perhaps the AMA or the hospital lobby or any number of absurdly powerful interest groups which exist to guarantee the welfare of the healthcare industry, can take action on this instead?
I suppose they might also just increase bills so they always meet the 500$ credit reporting threshold but this will probably take them a few years since it will need to at least look somewhat what organic to avoid being sued by some ambitious attorney general somewhere.
The hospital and provider/provider group are definitely not making decisions based off of some credit reporting threshold, they don't have the time or energy for it and charges and costs are too often pegged to other things. The insurance company might be, can't speak to that.
I also make no claims as to if people aren't paying enough, I just want people to actually pay like they said they would (especially in the case of the ED where 9/10 visits are inappropriate and make things more expensive for the people who actually need the ED resources).
Now is the government or insurance paying enough, that's a separate question. No for some aspects of healthcare, in a very demonstrable sense (that is, if your hospital is being paid mostly by medicaid it WILL go out of business without another funding source like being directly propped up by the state government).
Another different discussion is "are providers overpaid" and while that's a much more nuanced question, in a very practical sense the answer is no - if you want to see a specialist outpatient (especially in something like neurology) you are going to wait two months or have private insurance. The healthcare sector of the economy has been trying to slowly boil docs with decreasing salary for decades and it's starting to boil over and you just wont get good care (or care at all in some fields like psychiatry) if you aren't rich. I'd not be shocked if life saving surgery is simply not available within the next 10-15 years because surgeons will just refuse.
But in this case the issue is that you have a problem with the customer service and overall service offered to you by your insurance company, and you are taking it out on the health system. The problem is the health insurance product you purchased not giving you what you want (because of blah blah negotiating with what's probably a private equity owned practice management group with no clinicians in the leadership structure at all). At no point was anyone directly in healthcare involved in what fucked you except for the person who actually helped with the epistaxis.
Generally speaking health systems are very willing to negate with patients paying out of pocket because the charges are made up as part of some bullshit voodoo dance with insurance and the government. The unwillingness to negotiate def increases the likelihood of that professional fee going to a private equity group (the PA probably got paid like 50 bucks for 30-45 minutes of work that was mostly invisible to you).
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