An Arm And A Leg: This Health Economist Wants Your Medical Bills

Economist Vivian Ho has been researching nan U.S. wellness attraction strategy for 4 decades. These days, she's focused connected what she thinks are nan biggest burdens connected nan mean American: runaway infirmary prices and rising wellness security premiums.

She has developed a strategy for addressing precocious security premiums — 1 that's based connected giving patients reliable accusation astir really overmuch they, and their insurer, would person to salary for care. The strategy is already moving successful Massachusetts. Could it beryllium a exemplary for nan remainder of nan country?

Ho explains to Dan Weissmann, big of "An Arm and a Leg," why she thinks this attack could thief curb precocious prices and really listeners tin thief beryllium it by sharing their aesculapian bills.

Dan Weissmann @danweissmann Host and shaper of "An Arm and a Leg."

Previously, Dan was a unit newsman for Marketplace and Chicago's WBEZ. His activity besides appears connected "All Things Considered," Marketplace, nan BBC, "99 Percent Invisible," and "Reveal," from nan Center for Investigative Reporting.

Credits

• Emily Pisacreta Producer
• Claire Davenport Producer
• Adam Raymonda Audio wizard
• Ellen Weiss Editor

Note: "An Arm and a Leg" uses speech-recognition package to make transcripts, which whitethorn incorporate errors. Please usage nan transcript arsenic a instrumentality but cheque nan corresponding audio earlier quoting nan podcast.

Dan: Hey there-

Vivian Ho is simply a wellness economist astatine Rice University and nan Baylor College of Medicine successful Houston. And since early 2024, she's been giving talks at… HR conferences. Which is not a emblematic gig for an economist.

Vivian Ho: Um, yes. Economists don't usually do that. We emotion to spell talk astatine our ain conferences.

Dan: But she's been eager to dispersed a beautiful large message.

Vivian Ho: There's a imaginable to prevention workers, um, you know, and labor a batch of money.

Dan: And a fewer weeks ago, she sent maine an email asking for thief pinch what she's trying to do: 

She's wants folks to nonstop her infirmary bills for a study she thinks could beryllium portion of redeeming group a batch of moneys. She wondered if I'd promote group to transportation in.

And honestly, I wanted to opportunity yes earlier I moreover really knew thing circumstantial astir nan study.

I should say: Vivian Ho has been a philanthropist to this show. That's really really I met her and learned astir her work. And became benignant of a fan. 

Over nan past fewer years, she's been digging up and publishing grounds we need, to push backmost against nan measurement wellness attraction keeps getting much and much expensive.

This is worldly a batch of america suspected, to opportunity nan slightest — worldly reporters person documented examples of — but she's demonstrated they're existent trends, not one-offs. 

For instance: When nonprofit hospitals make large profits — and they often do - they telephone them surpluses- they don't mostly usage that money to thief patients, by giving much kindness attraction to trim people's bills. 

In 1 study, she compared infirmary finances successful nan early 2010s and adjacent nan extremity of nan decade. As nan decade was ending, she recovered nonprofit hospitals were a LOT much profitable than they'd been before. 

And they'd gotten a batch richer, pinch for illustration seventy percent much rate successful nan slope than they'd had earlier. 

But they were really giving retired less kindness care. 

 She told maine she ran that down aft she sewage thief knowing a large group of information that helped her spot what hospitals really do pinch their money- and started to flick astir successful it.

Vivian Ho: I say, well, I'm conscionable gonna spell person a look at, you know, 1 of nan section hospitals and spot what it says and past I propulsion it up and I go, ohio wow.

Dan: She took a peek astatine 1 hospital's "fund balance" — that's non-profit speak for an institution's savings, for illustration for a rainy day. 

Vivian Ho: The money equilibrium for 1 of nan hospitals crossed nan thoroughfare from Rice University is 5 and a half cardinal dollars. And so, you know, past it's like, well, I request to return a person look astatine this.

Dan: Here's a mates things she found: That money equilibrium — nan "rainy time fund" — was capable to tally nan infirmary for much than 2 years. And it runs a patient profit margin. 

And her study showed erstwhile she zoomed out: This is not a one-off. Among hospitals that do well, it's nan norm.

And this benignant of information — this benignant of EVIDENCE of really things work, of who benefits, and really much, from nan wholly unfair and unaffordable prices we're each up against — it's ammunition. 

Vivian Ho is looking for group to stock their infirmary bills pinch her, successful bid to build up her arsenal of accusation . 

She's sewage a strategy successful mind for really to deploy that accusation to prevention a batch of group a ton of money. It's interesting.

And: I person nary thought if this circumstantial strategy will salary off.

But here's what I do think: ?If we're going to conflict against nan greed and exploitation that make our wellness attraction strategy truthful unhealthy — truthful deadly — we're gonna request each nan fighting powerfulness we tin get.

So, I've sent Vivian Ho a infirmary bill. And astatine nan extremity of this section I'll promote you to do nan same. 

This is An Arm and a Leg — a show astir why wellness attraction costs truthful freaking much, and what we tin possibly do astir it. I'm Dan Weissmann. I'm a reporter, and I for illustration a challenge. So nan occupation we've chosen present is to return 1 of nan astir enraging, terrifying, depressing parts of American life, and bring you a show that's entertaining, empowering and useful.

Dan: Vivian Ho has been a wellness economist for for illustration 40 years. And you could opportunity she has mixed feelings.

Vivian Ho: Health economists, they activity connected truthful galore different things and they are each important and interesting. But I do deliberation nan rumor of nan costs of healthcare and nan costs of wellness security premiums is nan biggest problem putting a load connected nan mean American citizen. And I don't deliberation arsenic a occupation that we walk capable clip connected that basal issue. I consciousness benignant of - well, it does make maine rather sad because present I am, I've worked successful this profession for this full time, and things aren't getting better. They're really getting overmuch worse.

Dan: And that, she says, is why she does things for illustration spell to HR conferences these days. She's sewage nan information and she's sewage nan state to do it. 

Vivian Ho: So I'm ace lucky. I've sewage tenure astatine Rice and you know, I'm a personnel of National Academy of Medicine. I've benignant of achieved everything that I wanted to achieve, and now it's, it's each about, well, what tin we do?

Dan: She's decided to spell aft what she now sees arsenic nan biggest problem. Not nan ONLY problem, but nan biggest driver successful prices that only look to spell up much each year.

Hospital systems are consolidating — gobbling each different up. So they get much bargaining powerfulness pinch insurers. They get higher prices without needfully delivering much value.

Which isn't what economists ever expect. Bigger tin mean better, much efficient. That's what Vivian Ho utilized to expect.

Vivian Ho: I started this full investigation schedule benignant of 10-15 years ago, and I thought bigger was going to beryllium better. I thought because of economies of standard and that if you allowed hospitals to get expert practices, location would beryllium little plagiarism of services, you'd prevention money. But past nan problem is there's nary system that forces a supplier to walk immoderate savings onto nan consumer. So location whitethorn beryllium economies of scale, it's conscionable you and I arsenic consumers aren't capable to bask immoderate of those benefits.

Dan: That's thing we've talked astir connected this show. Like a lot. But what Vivian Ho has been capable to show is: At this point, nan mean profit margins for hospitals — including "non-profit" hospitals — are really higher than mean profit margins for security companies.

Vivian Ho: There's plentifulness of agrarian hospitals and smaller hospitals that suffer money, but net, erstwhile you mean connected conscionable really overmuch profits nan consolidated systems are making and you adhd them up each complete nan country, it's overmuch higher than what you get for nan full profits of insurers.

Dan: Which isn't to opportunity that security companies don't person a BIG domiciled to play successful our suffering. 

Vivian Ho: Insurers are, successful galore ways, not doing what they should beryllium for customers. Certainly nan show demonstrates that successful galore ways and that they are earning precocious profits. I've conscionable looked astatine nan information and concluded that nan hospitals are earning overmuch higher profits than nan insurers are, and that's wherever we've gotta attraction our attention. 

Dan: I mean, there's truthful overmuch to unpack there, right? One is, wow, nan hospitals are earning higher profits than security companies, and nan security companies, by and large, are publically traded entities that reply to shareholders. And nan mostly of hospitals successful nan United States are, arsenic acold arsenic nan IRS is concerned not-for-profit entities.

Vivian Ho: Exactly. We've been doing investigation lately that unluckily shows that our not-for-profit hospitals behave a batch for illustration for-profit companies.

Dan: So, okay, really do we get astatine that? 

Vivian Ho: Oh, uh, really do we alteration nan behaviour of what's going on? 

Dan: Yeah.

Vivian Ho: Yeah. So…

Dan: Here's Vivian Ho's crippled plan. It's complicated, and I'm not successful a position to say, "this'll wholly work" — but there's a batch that's worthy knowing here.

Especially this:

When Vivian Ho talks to business executives aliases HR managers, she brings retired different group of data. And this is information that's only go disposable successful nan past fewer years. 

Insurers now person to show what they salary hospitals. Not nan sticker price, nan negotiated price.

So, Vivian Ho's talk includes a descent showing immoderate specifications from 3 Houston hospitals. Blue Cross pays 1 of them astir 22 1000 dollars for spinal fusion surgery. Another 1 gets 66 1000 — 3 times arsenic much.. 

And nan descent shows: That mathematics is akin for different procedures. 

Vivian Ho: Employers didn't recognize really different nan prices could beryllium astatine their section hospitals. They thought, you know, anyone would think, oh, nan prices couldn't beryllium that different. And now that immoderate of nan information is starting to make it retired there, it's becoming clear you really could prevention a batch of money.

Dan: I mean, you MAYBE could — if you could springiness your workers a bully logic to spell to nan infirmary that charges less.

Vivian Ho has a exemplary for really that could work. It's — based successful portion connected a communicative I telephone Once Upon a Time successful Massachusetts. 

That's next.

This section of An Arm and a Leg is produced successful business pinch KFF Health News. They're a nonprofit newsroom covering wellness issues successful America. Their reporters do astonishing work. They triumph each kinds of awards each year. We're honored to activity pinch them. 

So, here's our communicative — Once Upon a Time successful Massachusetts — consecutive from nan story's author.

Elena Prager: I americium Elena Prager. I'm an adjunct professor of economics astatine nan Simon Business School astatine nan University of Rochester.

Dan: And while doing her dissertation, she came crossed a very different group of data. 

Elena Prager: I was like, wow, goldmine.

Dan: Here's nan story: Massachusetts has an agency that fundamentally runs worker wellness benefits for each authorities employees, and a batch of local-government workers too.

And erstwhile upon a clip — starting successful 2010- they tried thing unusual. 

Elena Prager: Possibly because they were lucky, perchance because they were smart, they designed their wellness security plans - astatine slightest erstwhile it came to infirmary attraction - based everything connected copays. And what that intends is that you are fixed a dollar number. Let's opportunity $250 aliases $500 and for illustration that's it. That's nan number. If you spell to infirmary A, you salary 250, you spell to infirmary B, you salary 500. The end.

Dan: Which is wholly different from really we're utilized to looking astatine hospitals, right? I mean, regular security plans typically say, "You'll salary for illustration 10 percent, aliases 20 percent aliases 30 percent of immoderate nan full measure turns retired to be." 

Elena Prager: And nan diligent is near scratching their caput being like, well, really do I cognize what nan full measure is gonna be? Even if nan infirmary tells maine something. Like, what if thing goes incorrect pinch nan anesthesia? They person to telephone successful an other specialist. There's a complication. More worldly gets done. Like it's very, very difficult to, for a diligent and moreover really a provider, to foretell successful beforehand what's gonna beryllium done to them and truthful what nan value is going to be.

Dan: So there's nary measurement for maine to return value into relationship if I request to spell to nan hospital.

But Once Upon a Time successful Massachusetts, location was. It was a co-pay. Whatever security scheme you were on, it worked nan aforesaid way:

Go to infirmary A — wherever prices are mostly higher — your copay mightiness beryllium 5 100 dollars.

Go to infirmary B — that charges nan security scheme little for worldly — you'd salary two-fifty.

And Elena Prager recovered nan information that showed what happened next.

Long communicative short, she recovered that complete 3 years, patients started utilizing lower-priced hospitals much often. Patients saved money, and truthful did nan wellness plan. 

And actually, Massachusetts still runs its wellness plans this way, but- 

 Vivian Ho doesn't deliberation different employers tin conscionable get their security companies to adopt this aforesaid model. 

VIVIAN HO: It's really a adjacent magnitude of work.

DAN: Work for nan security company. Doing nan mathematics to fig retired which tier is which, and what nan copays would be.

Vivian Ho: and of people it gets nan hospitals really upset.

Dan: The folks successful Massachusetts had a ton of leverage that astir employers don't have: 

Elena Prager says they represented a immense chunk of nan security marketplace for illustration a twelfth of it. Enough business that it was worthy security companies' while to put successful nan work.

But now, Vivian Ho has her oculus connected a mates of caller services that are promising to do thing similar.

One is really a subsidiary of everybody's favourite security company: United Healthcare. They make an app called Surest.

Surest Ad: It's easy to shop for a picnic rental aliases your adjacent flight, but erstwhile it comes to thing for illustration healthcare, not truthful easy. That's why Surest is simply a wellness plan, designed to beryllium elemental pinch clear upfront costs.

Dan: Here's really Vivian Ho describes nan mechanics of this benignant of app.

Vivian Ho: Doctor tells you you request to spell get an MRI, you punch an MRI, nan app knows wherever you live, and it says, here's a database of providers wherever you tin spell get an MRI. And past if you spell to this peculiar place, there's nary copay and there's really nary deductible, and past if you spell to this MRI place, well, you know, there's gonna beryllium a $25 copay aliases a $50 copay. Yeah. Isn't that benignant of mind blowing?

Dan: I show her: That sounds for illustration I would want that if I trusted that nan spot that costs my employer little is, you know, gonna return bully attraction of me.

Vivian Ho: Right. Well that's why I'm trying to get backing to do an study to look astatine nan spending and value implications of utilizing 1 of these apps.

Dan: That is: Do group utilizing these apps extremity up choosing lower-cost providers? AND: Do they get bully attraction erstwhile they do?

Vivian Ho wants to study that. But first she needs to study thing else. 

Vivian Ho: All of these apps and value shopping applications, they each dangle connected having nan correct data. Now, nan insurers are required to disclose this accusation by national rules. It is slow coming out. It's not each location yet, but nary one's really looked to spot whether it's accurate.

Dan: Oh.

Vivian Ho: So there's been a batch of attraction on, is nan value location aliases is it not there, but not is it nan value that nan diligent is really getting billed.

Dan: And this is why Vivian Ho wants our infirmary bills. 

Because: Whether aliases not 1 peculiar strategy is gonna cookware out, nan information itself contains ammunition. One infirmary gets paid doubly arsenic overmuch arsenic nan ones crossed nan street? 

I mean, that's accusation I want retired successful nan open, and getting put to use. 

But that accusation tin only beryllium useful if we cognize nan information is accurate. And correct now, there's nary measurement to know. 

Insurers are publishing large information sets, but really do we *know* personification astatine nan security institution didn't conscionable spell to Chat GPT and say, "Make maine a elephantine spreadsheet pinch these fields connected it?"

Vivian Ho says if she has capable ACTUAL bills — a 1000 would beryllium good, 3 1000 would beryllium awesome — she tin check. 

Actually, moreover better: She wants your itemized measure and, if she tin get it, nan paperwork you get from your security institution astir what they paid. The point that says "This is not a bill." It's an "explanation of benefits" — aliases EOB for short.

And, she recognizes, this isn't a TINY ask.

Vivian Ho: I recognize it's clip consuming. It does, you know, because you gotta beryllium down. It's like, what's my password and log in, and past you've gotta, you know, find 1 of these EOBs.

Dan: Oh, and you've gotta screen up each your personally identifying information.

Vivian Ho: We don't wanna spot your your sanction and reside and so, you know, it takes clip to you, you tin benignant of people these retired and usage a Sharpie and transverse them out.

Dan: It does sound for illustration a immense drag, but I'm present to show you: I did it. And it took maine possibly 5 minutes.

I don't cognize really Vivian Ho's circumstantial strategy will play out, and honestly, neither does she.

Vivian Ho: You know, I americium going astatine this astatine benignant of for illustration galore different angles.

Dan: Yeah.

Vivian Ho: So conscionable trying to raise people's consciousness of location are immense value differences. This is, this is what it takes to reside nan issue. 

Dan: If you've gotten a infirmary measure successful nan past twelvemonth aliases so, and you've sewage 5 minutes — possibly group a statement connected your almanac for erstwhile you DO person 5 minutes? — I'd emotion it if you gave this a shot. 

Grab a sharpie, occurrence up your printer, excavation up your login. Print retired a measure and an EOB, scratch retired your identifying information, return a image connected your telephone — wow, this is sounding long, but honestly, it took maine 5 minutes — truthful do those things, and nonstop nan images to [email protected]. 

Vivian Ho's sewage researchers opinionated by.

Coming up connected this show: We're gonna return immoderate clip arsenic nan twelvemonth ends, to look astatine immoderate things that DIDN'T suck successful 2025. 

Which fundamentally means: Places wherever authorities governments stepped successful to protect america from ripoff prices. Which, it turns out, happened! 

News archive 1: Oregonians burdened by aesculapian bills whitethorn soon get a break connected their in installments scores.

News archive 2: New rule aimed astatine protecting Maine consumers from nan impacts of aesculapian indebtedness goes into effect.

News archive 3: Tonight Indiana politician Mike Braun signs 10 wellness care-related bills into law.

Dan: Happened capable that it'll return much than conscionable 1 section to springiness you a bully sample.

That's adjacent clip connected An Arm and a Leg.

Till then, return attraction of yourself. 

This section of An Arm and a Leg was produced by me, Dan Weissmann, pinch thief from Emily Pisacreta — and edited by Ellen Weiss. Adam Raymonda is our audio wizard.

Our euphony is by Dave Weiner and Blue Dot Sessions. Bea Bosco is our consulting head of operations. 

An Arm and a Leg is produced successful business pinch KFF Health News. That's a nationalist newsroom producing in-depth publicity astir wellness issues successful America and a halfway programme astatine KFF, an independent root of wellness argumentation research, polling, and journalism.

 Zach Dyer is elder audio shaper astatine KFF Health News. He's editorial liaison to this show.

An Arm and a Leg is distributed by KUOW, Seattle's NPR news station.

And acknowledgment to nan Institute for Nonprofit News for serving arsenic our fiscal sponsor.

They let america to judge tax-exempt donations. You tin study much astir INN astatine INN.org.

Finally, convey you to everybody who supports this show financially.

You tin subordinate successful immoderate clip astatine limb and a limb show, dot com, slash: support.

"An Arm and a Leg" is simply a co-production of KFF Health News and Public Road Productions.