Today THCB is happy to publish a piece reflecting the learnings from Charles Silver and David Hyman’s forthcoming book Overcharged: Why Americans Pay Too Much For Health Care, shortly to be published by the libertarian leaning Cato Institute. In subsequent weeks we’ll feature commentary from the
right radical libertarian zone on the political game board (Michael Cannon) and from the left (Andy Slavitt) about the book and its proposals. For now please give your views in the comments–Matthew Holt
There are many reasons why the United States is “the most expensive place in the world to get sick.” In Part 1 of Overcharged: Why Americans Pay Too Much For Health Care, we show that the main reason is that we pay for medical treatments the wrong way. Instead of having consumers purchase these treatments directly, we route trillions of dollars through third-parties payers – both government and private insurers.
Relying on third party payers has many consequences — few of them good. To start with, this arrangement removes the budgetary constraint that would otherwise cap the amount consumers are willing to spend. By minimizing the direct cost of treatments at the point of sale, third party payment arrangements alter everyone’s incentives fundamentally. Consumers no longer need worry about balancing marginal costs against marginal benefits; instead, they have an incentive to use all treatments that have any potential to help, regardless of their prices. When millions of consumers act on these incentives, total spending skyrockets and consumers collectively wind up worse off, because their fixed costs spiral upward too. Heavy reliance on third party payers creates a classic failure of collective action.
It isn’t just consumers. Providers love third party payment as well. And why not? Once providers have access to the enormous bank accounts of third party payers, the sky is the limit, at least until third party payers start setting limits on the amounts they will pay and saying no to unproven and/or cost-ineffective treatments that doctors want to provide and patients want to receive.
Not surprisingly, it has turned out to be extraordinarily difficult and politically unpopular for third party payers to set such limits. Obamacare’s appeal derives largely from two requirements: health insurance plans must accept all comers, including applicants with preexisting conditions that require expensive medical treatments; and health plans must provide unlimited benefits (i.e., no annual or lifetime spending caps). From an individual consumer’s perspective, what could be better than having access to unlimited amounts of money to spend on medical needs? From society’s point of view, though, this combination is a recipe for disaster.
Medicare hasn’t been able to do much about this problem either. In Medicare Part B, the program simply pays whatever price the drug companies ask – even if the treatments offer only marginal benefits over existing (and far cheaper) treatments. Medicare Part D is better, since private plans can use formularies to create competition among drug manufacturers. But even here, there are limits, since plans are required to cover all drugs in six “protected” classes: immunosuppressants, antidepressants, antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics.
Why is Medicare such a patsy when it comes to drug prices? Politics. If CMS were to refuse to pay for an effective medication because of its price, cries of rationing—the third rail of health politics—would quickly fill the air. The AARP would pack the halls of Congress with seniors in wheelchairs, drug makers and the AMA would send in hundreds of lobbyists and doctors in white coats, and pandering politicians would inundate CMS with demands to pay for the drug. Knowing full well how this scenario would play out, no head of CMS who wanted to hold onto the job would risk incurring the backlash in the first place.
Private insurers haven’t done much better. In fact, there is an emerging consensus that private insurers don’t care about prices nearly as much as they should. “Widely perceived as fierce guardians of health care dollars, insurers, in many cases, aren’t. In fact, they often agree to pay high prices, then, one way or another, pass those high prices on to patients — all while raking in healthy profits.”
The main problem with our health care system is that the prices are too damned high. Consider the conclusion of a well-known study published in Health Affairs in 2003:
In 2000 the United States spent considerably more on health care than any other country, whether measured per capita or as a percentage of GDP. At the same time, most measures of aggregate utilization such as physician visits per capita and hospital days per capita were below the OECD median. Since spending is a product of both the goods and services used and their prices, this implies that much higher prices are paid in the United States than in other countries. But U.S. policymakers need to reflect on what Americans are getting for their greater health spending. They could conclude: It’s the prices, stupid.
In case anyone missed the point, the same authors published a follow-up paper in 2004, entitled “It’s The Prices, Stupid: Why The United States Is So Different From Other Countries.”
A decade later, little had changed. That’s when the late Uwe Reinhardt, one of the authors of the two studies already mentioned, wrote a column entitled “U.S. Health Care Prices Are the Elephant in the Room.” Additional confirmation arrived in 2018, when JAMA published a study finding that “Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries.” If third party payers had been doing a good job of controlling prices, none of these publications would have been written.
Part 1 of Overcharged documents the real-world consequences of our third-party payment system. For example, Chapter 2, focuses on the prices drug makers charge for new medications. When the sky is the limit, pharma companies maximize their profits by developing new medications on which they hold monopolies and by charging absurd amounts. Often, these medications confer minimal benefits. “The 72 cancer therapies approved from 2002 through 2014 gave patients only 2.1 more months of life than older drugs,” but 11 of the 12 approved in 2012 were priced above $100,000 per course of treatment. The tally was even higher in 2016, when the approved drugs cost an average of $171,000 a year. “Although the high prices can lead patients to think they’re getting the Mercedes of cancer drugs, research shows that a medication’s price has no relationship to how well it works.” The situation is so bad that “[a] group of academic researchers has demanded an end to cancer medicines costing more than $100,000 a year.”
By comparison to the prices being demanded for the new CAR T-cell cancer treatments, $100,000 seems like a bargain. Novartis set Kymriah’s price at $475,000, a level that, in the words of Dr. Leonard Saltz, chief of gastrointestinal oncology at Memorial Sloan Kettering Cancer Center in New York, “shattered oncology drug pricing norms.” And that’s just the price of the drug. Kymriah requires lengthy hospital stays and can have serious side effects, including immune system reactions, stroke-like symptoms, and coma. Some patients who receive it need bone marrow transplants and other expensive procedures. The total cost per patient could reach $1.5 million. With 21 other CAR T-cell treatments currently under development, the cost of treating cancer patients seems bound to increase.
What’s true for cancer treatments is also true for other specialty drugs. “[S]pecialty drugs account for less than 2 percent of all prescriptions, [but] they make up roughly 30 percent of spending on all prescription drugs.” “That is projected to grow to 50% in 2017, according to Express Scripts, the pharmacy benefits manager.” The growing number of high-priced specialty drugs is a primary reason that total spending on prescription drugs is expected to exceed $590 billion by 2020, up from $337 billion in 2015.
The absence of a ceiling on prices is a serious problem, but it is far from the only pathology caused by our heavy reliance on third-party payers. There is also the gaming of payment rules, quality indifference, waste, and fraud. Part 1 delves into these consequences in nauseating detail. One reader, a well-known health economist, told us that, after finishing this part of the book, he felt like he needed a shower. Another health economist complained the book made him depressed about his career choice. When even practitioners of the dismal science find the stories and statistics overwhelming, it is clear that the problems we document are pervasive and severe.
Many knowledgeable observers believe that something on the order of one-third of dollars spent on health care are wasted. Donald Berwick and Andrew Hackbarth offered a mid-point estimate of the 2011 cost of waste to the U.S. health care system of $910 billion, with an upper bound of $1.263 trillion. Paul Keckley and coauthors reached a similar conclusion in 2015. And as health care spending continues to grow, the number of wasted dollars does too.
Why so much waste? Because our third-party-dominated payment system corrupts everyone’s incentives. As explained previously, consumers care about neither costs nor the ratio of marginal cost to marginal benefit. Providers gain by maximizing their billings, which they do using multiple schemes. Many are illegitimate and inappropriate. Some expose patients to unwarranted risks. Payers have neither the incentive to ferret out waste nor the resources that a serious undertaking would require.
Put simply, third-party payment creates an enormous need for monitoring because the incentive—always present in first-party arrangements—to demand value for the dollar is lost. This monitoring problem has never been solved, and never will be solved, because the health care sector is too large to be policed. It is easier for payers to recoup dollars lost to fraud, waste, and abuse by raising premiums and collecting higher tax revenues than it is to keep providers and patients honest.
The lack of a price ceiling and the extraordinary sums lost to waste are the problems that Obamacare should have tried to fix. Unfortunately, it didn’t address either. Instead, it made both problems considerably worse. The Medicaid expansion and the new insurance rules brought tens of millions of new people under the comprehensive third-party payment umbrella.
Therein lies the problem. Most mainstream health policy analysts believe that the biggest problem in health care today is that millions of people are uninsured. A large fraction of the population, especially voters who identify as Democrats, feels the same way. For both groups, the preferred solution is more and more comprehensive insurance. The large and growing base of support for Senator Bernie Sanders’ Medicare-for-All proposal reflects this belief. But it should be obvious that our heavy reliance on third-party payment arrangements is the major driver of our health care cost crisis.
Third-party payment is the disease, not the cure. This will be no prospect of reducing health care spending until this point is understood.
Charlie Silver holds a Chair in Civil Procedure at the School of Law, University of Texas at Austin. David A. Hyman is Professor of Law at the Georgetown Law Center. They are both Adjunct Scholars at the Cato Institute.
I’m tempted to say there’s nothing new here; these components of the price-cost and “waste” problem has been identified for many years, as the authors acknowledge, citing good examples and research.
But then I also know that the more we discuss this (even from the libertarian perspective), the closer we get (albeit in tiny steps) to doing something serious about it. Atul Gawande–now to head up the Amazon-Buffet-JPM initiative–may have a high-profile opportunity up this alley. Let’s hope he takes the bull by the horns. The CVS-Aetna merger may also bring fresh ideas. And Lord knows there are hundreds of other efforts, including, of course, the advent and too-slow creep of value based purchasing.
YES—third party payment leads to significant and unsustainable distortions. But I agree with the comments below: getting rid of it ain’t so easy. Nor are price controls. Or price transparency. And offloading this responsibility on to consumer direct pay is a non-starter.
Also, the shift to high deductibles and more cost-sharing shift has gone way too far and is now creating barriers to care and significantly financial burden on lower and middle-income families.
Medicare must lead by creating more “pure” forms of price competition-income in that program. Alex Azar seems to understand this. Payment reform needs to be accelerated under MACRA and in private sector efforts. Large employers need to turn the screws much harder; with the exception of the large-scale switch to managed care in the 1990s they have been AWOL on taking aggressive steps to restrain price inflation and address waste and poor value. I’d go so far to say they have been complicit. The authors are correct that insurers, too, have been actively complicit. The providers and manufacturers have been allowed to price at will, and you can hardly blame them in our lassez-faire system. If we keep paying the ever-rising tab, they’ll keep hiking the price. And in that time honored cliche: laughing all the way to the bank.
All health care costs are ultimately paid by the people–us, consumers, the patients…in the form of higher premiums, stagnant wages and fewer raises, higher taxes, higher deductibles, higher co-pays, higher OOP costs for uncovered services and goods. Not to mention the “price we pay” in unnecessary and inappropriate care and poor outcomes incentivized by extortion-level, fee-for-service prices.
I’ll offer a few thoughts on this.
First, regarding third party payer, a very significant percentage of the U.S. population has dental insurance albeit not as high a percentage as those who have health insurance. It’s usually pretty easy to find out what a dental procedure will cost before services are rendered, whether or not you have dental insurance. The same is true for the daily or monthly cost of long term custodial care in a nursing home or the hourly rate for a home health aide. Yet Medicaid pays for most nursing home beds and Medicare pays for some on a limited basis for up to 100 days if the patient was discharged from a hospital after an inpatient stay of at least three days. Long term care insurance pays for a small amount on an indemnity (daily rate) basis.
For dental procedures, the rate the uninsured patient pays is somewhat higher than the average insurer allowed rate but not egregiously so. The same is true for daily and monthly nursing home rates. I don’t think the problem is third party payer per se. Rather, I think it’s the huge difference between the list price and the contract rate for hospital based care and for some physician specialties including surgeons and anesthesiologists. Price transparency around insurer contract rates could go a long way toward addressing this issue. Special rules governing how much can be charged for care that must be delivered under emergency conditions would also be helpful in my opinion.
With respect to price comparisons between the U.S. and overseas, I’m skeptical about the size of the difference between Medicare rates and rates charged abroad. Medicaid rates are also significantly lower than Medicare’s rates. Specialty drug prices are a separate issue because drug companies tend to charge based on ability to pay with per capita GDP used as a proxy for affordability in each developed country.
I also think there are several cultural issues that drive up healthcare costs in the U.S. which won’t be easy to change. The first is our litigious society. When the medical specialty societies develop recommended physician practice patterns for various diseases and conditions, they are often more testing intensive than similar practice patterns in other countries. The U.S. hospital average length of stay may be comparatively short but a lot more happens to patients while they are in the hospital and all that extra care drives up costs. Litigation risk drives defensive medicine.
The second difference is our attitude toward end of life care. We still have large numbers of patients and families who want the full court press even when the prognosis is between dire and hopeless. In other countries, people are more accepting of death when the time comes, in part, because part of the solidarity culture calls for them to not impose unreasonable costs and expectations on their fellow citizens.
The third is fraud. CMS tells us that there are 11 hotspots in the U.S. where fraud is a significant problem. These include New York City, Chicago, Detroit, Miami-Dade and Tampa, FL, Southern Louisiana, South Texas, Los Angeles and a few others. Better data analytics could help to address this problem.
I did read Overcharged, and, while frankly horrified, as most readers will be, by the litany of financial abuse they discuss, I think the authors’ core claim that $1.1-5 trillion of our health spend is fraud and waste is both poorly documented and wildly irresponsible.
There is an unacceptable amount of fraud out there, but it is highly concentrated in a few places. Your colleagues do make the case that the feds dramatically underspend in policing it. Patients are hopelessly overmatched in the places (Florida, Southern Calif, etc) where it has flourished.
The rent seeking physician behavior discussed in the book is also both grossly exaggerated and highly concentrated. I spent thirty years of my career traversing the US and being amazed at how much selfless behavior I saw among physicians and nurses. There are a lot of places in the US where there is simply no place for the fraudsters to park their Ferraris.
As a patient, I found their caricature of our motivations in using the health system to be insulting and demeaning and have blogged about this in THCB. I spent two years being a patient, not trying to maximize my access to other peoples money, but mostly drowning and trying to save my own life. Most of the people who took care of me were thoughtful, intelligent people who frankly could have cared less about the money. They were all about helping me get my life and get back to work paying taxes.
There is a LOT of work to do here, and frankly a lot harder work than the authors suggest. Simply shifting risk to patients is not enough. Incomes are grossly excessive and need to be reduced, and I can tell you as a patient, even a wealthy and well informed patient, I am not the man to do it. You are not going to offload the federal government’s fundamental challenge of not wasting our tax dollars and separating strong from weak claims onto a bunch of sick people.
Though I didn’t read the book earlier I did read the authors comments on THCB where I disputed the author’s contentions especially having to do with “The rent seeking physician behavior discussed in the book is also both grossly exaggerated and highly concentrated.” along with other things. Though I agree with some of his libertarian perspective and his dislike of third-party payer I think the author on this blog spreads too much blame the wrong way without having adequate proof and when he did have some proof he didn’t adequately investigate all the known variables.
Even if we got the prices down to what are paid elsewhere, care is still expensive. I don’t see how you do it w/o third party involvement. Premie twins? How many 21 y/os can pay for that? In every other first world country they have cheaper care, and they use third party payment systems for the most part. Show me a functioning model for health care that does not involve third parties. (Please, please don’t reveal yourself to be an idiot by citing Lasik or plastic surgery.)
Price ceilings? Sounds like socialism.
The lack of third-party payment under discussion does mean a lack of insurance.
That should have been: doesN’T mean a lack of insurance
Ways to get rid of third parties or their effects.
1.We could be as kind and altruistic as we wanted using refundable vouchers (Medi-bucks, etc.)
2.Go back to Indemnity payments of claims; these go through the patients’ hands first; don’t pay the provider directly–which would convert third party back into two parties….sort of.
3.We could stay with third party payers and get the courage to allow them to be monopsonic purchasers and demand that they negotiate prices. All other industrialized countries do this. We are terrified of this for political reasons.
4. We could allow large Health Savings Accounts, starting early in life, enough to do much of the job.
5. We could subsidize everyone at birth (or conception) with enough money to buy CAT policies for life. Bob Blandfold’s early idea.
6. Make the third party “us”, and turn non-ambulatory hospital care into a public good, run by hospital districts or counties,..so that there are no monetary transactions at all. Leave outpatient care untouched and let people take care of this sector any way they want. This means that the feds have to send some money to the local managing agency.
Some of these are not politically possible. How large does that HSA anyhow early do you start in life? Who put money in? Just don’t see it, and HSAs haven’t really shown themselves to be cost saving. So…
1) Puts no real limitation on incentive to spend. Same problem.
2) Just means that the pt keeps the money sometimes.
3) Like that would ever pass with this Congress.
4) HSAs not shown to slow costs as Mark Pauly noted. Besides, it would take a lot of funding. Remember that most spending is on large acute care bills or chronic illness.
5) And we have seen that people complain about the large deductibles in the ACA. A large deductible (CAT) plan is about the same as no insurance for a very large segment of the population.
6) Again, just don’t see that as politically feasible. Socialism and all that. It might actually work, but not sure. Most of our growth in spending has actually been on the outpatient side, so that really does need to be addressed.
Mostly, I think it telling that almost everyone else uses what amounts to third party coverage. There just isnt a working model anywhere we can point to where someone else had made it work. NHS comes close maybe, but chances of that being accepted in US about zero.
Re HS A
If I recall Pauly did not say they don’t work…he just recounted his anecdotal issues with a single plan or lack thereof.
The Rand Corporation has conducted well designed large sample studies of employer adopted high deductible plans linked to Health Savings Accounts and the results are impressive. Their big study was 2008 (n=800,000) nationwide. Here is a quote from a Health Affairs article in 2012 “If consumer-directed health plans (CDHPs) grew to account for half of employer-sponsored insurance in the U.S., health costs could drop by $57 billion annually—about 4 percent of health care spending for the nonelderly, according to a Rand Corp. study, published in the May 2012 issue of the journal
“Re HS A
If I recall Pauly did not say they don’t work…he just recounted his anecdotal issues with a single plan or lack thereof.”
I agree with you. I went back to some of the THCB blogs with his interview and some of the other things Pauly said elsewhere and I don’t think Steve’s comment was accurate at all. Other studies such as the Rand Study you discuss have shown the effectiveness of HSA’s, but they are not the ultimate cure-all for the problems we face.
William, thanks for providing a number of ways to get rid of third-party. Some are unwilling to accept anything but government control and for some reason can’t see how government-controlled sectors of the economy lead to greater costs while the marketplace leads to lower costs and better quality.
We see this in various sectors of the economy and all over the world. If we moved to a truer marketplace one could expect total costs to fall substantially and that fall would help lower income folk buy insurance policies where they have more control over the dollar. Steve doesn’t want to look at Lasik and plastic surgery because it doesn’t support his case. Though these examples are not perfect examples of all of healthcare they do point in the right direction. Calling people idiots when they cite these examples only indicates a closed mind.
“can’t see how government-controlled sectors of the economy lead to greater costs while the marketplace leads to lower costs and better quality.
We see this in various sectors of the economy and all over the world.”
We are talking about health care. Show me where, in health care, that, “all over the world”, countries, using government, spend more than the U.S. on health care.
Peter, when it comes to outcomes the US leads the pack. Yes, things cost too much here but that is not due to a free marketplace rather third-party payer and other non free market ideas that have been pushed on the system.
Many countries spend less on healthcare and that is true and is a problem. However, Americans spend more on cars, TV’s refrigerators and many other things so higher healthcare bills go along with American spending habits.
We do need to cut costs and one way of doing it is to end third-party payer and provide all citizens the same tax break. Then they can choose if they want the employers healthcare or not and they can try and choose more cost effective insurance and care. We need to cut out regulations that make health insurance so expensive and we need to do a whole host of other things mentioned over and over again on this blog.
You can follow the Pied Piper if you wish but if you remember that eventually leads to a watery grave.
“when it comes to outcomes the US leads the pack.”
“Americans spend more on cars, TV’s refrigerators and many other things so higher healthcare bills go along with American spending habits.”
Really, you want to equate health care spending to cars and TVs to justify health care spending? Exactly how would that work?
Peter, in probably the best and most well accepted comparison of outcomes the US came out #1 or #2 on 8 common cancers with all the other countries having to share those positions. This is not to say that other countries don’t perform well rather this is just a response to your “Prove it” remark. Check out the CONCORD study. I think its full name is Cancer survival over five continents a population based study or something like that.
I am not equating healthcare with cars and refrigerators rather I am merely pointing out that Americans spend a lot on almost everything and even have more of many amenities than our western friends. I am not placing a value judgement on this. I am just showing why it isn’t surprising that Americans spend more on healthcare since they spend more on most things.
You mean this?
You prove nothing, especially trying to prove our highest prices in the world are producing the best outcomes percentage wise to match the cost.
“You can follow the Pied Piper if you wish but if you remember that eventually leads to a watery grave.’
How’s your medicare coverage working for you Allan?
Go to the actual study this article is referencing from. You will see that the US was either #1 or number 2 in those cancers. When you look at the other nations that were #1 they vary widely for the other diseases.
If you can’t find the original study that was on Lancet that contained the data let me know, but in that study, the US clearly came out on top.
Peter, I think this should lead you to the PDF of the complete study. Look at the tables and the comparisons for yourself. If you can’t do it and tell me how I can copy the tables I will do so.
You mean this?
Not first in all cancers, and all countries marginally close to the numbers except for Japan on lung cancer, it blows the U.S. out of the water.
It’s interesting that all compared countries have some form of government controlled single-pay. But I guess you’d justify our close to double health care spending on marginal success in cancer.
Got any more diseases you’s like to compare.
“indicates a closed mind.”
Or maybe a lazy one. Much better to articulate why or at least cite a source that supports his assertion.
Managing market share is the great “montra” for payers and providers. The payers need the large institutional providers as a preferred provider and the providers leverage this niche to demand higher reimbursement. The resultant co-dependent interaction interferes with the autonomy of both institutions to manage cost and quality, as augmented by the “Parkinson Law” presence of Medicare/Medicaid/ACA 2010. As adjusted by inflation and economic growth, the portion of our nation’s GDP being allocated to health spending grew by 5.0% compounded annually between 1960 and 2016. There is no evidence that our current strategies for healthcare reform will accomplish anything. See The Milbank Quarterly, March 2018, analysis by two economists at The Wharton School, Pennsylvania: Lawton R. Burns and Mark V. Pauly. TITLE: “Transformation of the Health Care Industry: Curb Your Enthusiasm?”
I cite their “Findings: Data suggest a low prevalence of provider risk payment models and slow movement toward new payment and organizational models. Evidence suggests the impact of both on cost and quality is weak.”
Likely worse than just weak impact. Most data concerning cost and quality do not account for the negative impacts of bureaucratic growth, impaired production, and absurd amounts of waste provoked by following mindless protocols masquerading as “quality”.
Greg Scandlen in his book Mythbusters…. has been correctly blaming third party payers for years.
It fits the legal logic of “proximate” cause: 1. If, but for third party payers, we would not have had runaway prices. 2. Given third party payers in this sector, one can predict runaway prices.
“In fact, there is an emerging consensus that private insurers don’t care about prices nearly as much as they should.”
Thanks to the 8/20 rule, they are now completely invested in high prices and overutilization. Their profits and growth depend on it. That is the Unaffordable Care Act for you.
I don’t think anyone would argue that our cost-unconscious monopoly-driven & politically captured system works to control prices. In fact it works to inflate them as this book and Libby Rosenthal’s and Steve Brill’s show in excruciating detail.
But there are two problems that direct consumer pay cannot deal with.
1) In every other country third party payment + government price controls keeps health care prices and costs way lower than in the US. You can’t argue with the facts (Unless you’re part of the Trump administration)
2) Even if the cost of care was 1/5th what it is, the majority of health spending is on a small number of people. We need some third party mechanism to fund that spending. I think that mechanism should be called “taxes” but the libertarian right tends to create policy solution somersaults to avoid that simple solution
“Third-party payment is the disease, not the cure. This will be no prospect of reducing health care spending until this point is understood.”
Not sure I understand the, “conclusion” of this piece? If third party payer is the disease, what’s the cure – single-pay, direct patient pay?
I think they’d argue single payer is a third party too!
Are they arguing we should all just pay cash, or maybe in chickens? Yes, that may bring down prices, but would providers be able to earn a decent living and what would their collections ledgers look like?
Single-pay is not technically third party, more like second party with huge negotiating power to regulate prices. That’s why every other industrialized country does not do it our way.
Look, if we just entrusted everything to the (mythical) beneficent “free market,” my upcoming chest CT in advance of my aortic valve job (SAVR) would be $39.95 at JiffyScan in the strip mall. The K40.90 I just had yesterday would have been a couple hundred bucks at Walmart Ambulatory QuickScope, rather than the ~$10k Healthcare Bluebook suggests.