Comment by vjvjvjvjghv
4 hours ago
"Rome said the companies seem to be maximizing prices while negotiating discounts behind the scenes with health and drug insurers and then setting yet another price for direct-to-consumer cash-pay sales."
This describes the biggest problem in US healthcare. No clear and consistent pricing. If we had a real market, you would get a prescription and then go to the seller with the lowest price. And everybody would get the same price. This whole business with PBMs that are owned by the insurance companies, discount cards and other shenanigans just invites corruption.
Last year I needed to get blood work done, some of which may or may not be covered.
It took me two weeks, dozens of phone calls, and multiple "escalations" to learn what would be covered and what the price would be if it wasn't
Totally insane. The kicker is that after all that, the price I was billed wasn't even the price I was given (thankfully it was less though).
I just had some bloodwork done, myself. My provider accidentally billed insurance, which had lapsed due to being laid off. I got my "Explanation of benefits" and it was $1000 billed to them, but I was given a $500 "discount." So I only owed $500... Cash cost was $50. Makes no goddamn sense.
Also I went in for a colonoscopy and an endoscopy. Insurance was billed for $14000. I got statements from 4 different doctors, and the facility where it was performed. None of the statements matched the explanation of benefits from the insurance company. And when I called each doctor, to pay them, they all told me that I didn't actually have to pay them what it said I owed. So I just ended up paying $2500 to the insurance company. It again, makes zero sense.
It makes perfect sense. The prices are inflated with a few extra zeroes to try to force people to get any job with insurance. The big numbers are just to scare people. You can also turn negotiating with the hospital into a full time job and get the real numbers. If you're too unhealthy to do either of these then you can just die I guess.
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I don't think the hospital expects to actually ever get paid what they bill out, or anything at all, if it's not paid onsite or by insurance.
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In practice, the whole system is set up in a way that discourages asking questions. Waste of time. It's truly the opposite of the transparent ideal market.
"And everybody would get the same price. This whole business with PBMs that are owned by the insurance companies, discount cards and other shenanigans just invites corruption."
It's hard to say that it isn't racketeering at this point.
"Specifically, a racket was defined by this coinage as being a service that calls forth its own demand, and would not have been needed otherwise."
There's demand for the meds, but the demand for discount cards, forcing people to use specific services/companies, and related programs is all invented by the companies themselves.
Health insurance in general is the problem; PBMs/discount cards are just a cherry on top. Insurance is fundamentally incompatible with clear and consistent pricing.
Germany has health insurances and they don’t do that nonsense. They fulfill their task which is to spread the risk over a wide range of people. That’s what insurance is for.
Pharmaceutical companies, hospitals, and doctors are free to charge by the medicine, by the night, and by the minute.
For example, this place does it:
https://surgerycenterok.com/surgery-prices/
Insurance companies do not force the sellers to use complex billing practices, they would benefit from more transparent pricing (since they are seeking to pay less).
The root cause is healthcare is inherently complicated and complex, it has a problem of supply being nowhere near demand, and since prices for things are so high (including liability), there is a lot of cover your ass and fraud prevention going on.
Insurance companies absolutely benefit from the higher and opaque prices, because they negotiate rebates with providers. This allows them to maximize patient copays and ensures they hit their deductible, i.e. paying as much as possible under their respective insurance plans. Contrast this with a no-rebate world with cheaper/more transparent pricing. Fewer patients would hit their out of pocket maximum.
They can use the rebates they get from the providers to subsidize the insured, allowing them to offer lower premiums and gain market share. This is what people mean when they say "In America, the sick people pay to subsidize the health care of the healthy people".
Of course, that above only applies if there is competitive pressure. If there is no competitive pressure (e.g. in states with only one or two insurers), they can keep premiums high and book as profit the difference between what the patient paid out and what the patient would have paid out in a lower-cost no-rebate world.
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Don’t do pro bono PR for those companies. Healthcare isn’t so complicated that every other country in the world hasn’t been able to solve it for significantly less money and far less stress for users, not to mention better health outcomes in most cases.
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Pharmaceutical companies, hospitals, and doctors are free to charge like that. But if I'm using insurance, it's irrelevant; that's the price to the insurer. It's the insurance company who determines the price I pay, using whatever arcane rituals they've chosen.
> "Rome said the companies seem to be maximizing prices while negotiating discounts behind the scenes with health and drug insurers and then setting yet another price for direct-to-consumer cash-pay sales."
This sounds like typical negotiating 101. You know you are going to be forced to lower from your starting position, so increase your starting position so when you do negotiate down you are closer to where you wanted to be.
As a european living in the US, the idea there is a market at all is laughable. I tried to get price quotes for treatments several time just to get a "well, it's hard to say" or "it's very complicated".
Here in Brazil, we have something called 'Genéricos.' These are essentially the same medications as the brand-name versions, produced with the same chemical ingredients, but they often cost half the price, sometimes even cheaper than that.
Insanely comical.
Interestingly, while on-patent medications in the US tend to be significantly more expensive than elsewhere, generics in the US tend to be less expensive than generics available elsewhere.
in the US, we call these 'generics'
Those are available in America too
But prices are going up. Look at the statements your insurance company provides about the reimbursed "cost" of covered generics:
Some experts report that PBMs overcharge for generics; The Wall Street Journal estimated that Cigna and CVS Health, both of which own PBM services, are able to charge prices for specialty generic drugs that are 24 times higher than what manufacturers charge.
https://www.americanprogress.org/article/5-things-to-know-ab...
So this must be worldwide. It seems like the patents held by big pharma are the root of the corruption. What is the guarantee here? That the chemicals are pure, or just that the companies are getting their cut?
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That's what he said. Brazil is in (South) America.
Huge caveats. The drug manufacturer gets over a decade of market exclusivity which bars the selling of generic versions of the medication, which they can then extend again if they find another distinct use case for the medication (3 more years). This is why the Vyvanse generic took so long.
Now look into the places that manufacture these generic versions. Not all factories are equal, and some are not of the best of reputations.