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Chuck Schumer Eyes Glasses

Image by DonkeyHotey

Image by DonkeyHotey

Senator Chuck Schumer (D-NY) wants to change some regulation to “make eyeglasses cheaper.” Specifically, he wants to do three things:

  1. Require that optometrists give customers their prescriptions, so that they do not have to purchase their glasses from the optometrist.
  2. Require optometrists to verify prescriptions in a timely manner.
  3. Allow people to go more than one year without getting their eyesight checked.

I wrote about an experience with some of these issues a while back:

In other news, my optometrist’s office apparently refuses to send my prescription to the Redstone Walmart because the optometrist is on vacation. I cannot for the life of me figure out why that matters and why they don’t have my prescription on file so that they can send it out. Meanwhile, Redstone Walmart won’t let me place an order with a prescription to be named later, nor will they let me order over the phone even though they have my frame preference on file. This is going to set back my glasses order by a couple of weeks, most likely. My glasses are getting scratched up.

Two Weeks Later The situation with the optometrist has not been resolved and has in fact gotten worse. When they finally send the prescription to Walmart, they sent a contacts prescription. I don’t need contacts, I need glasses. I haven’t been able to check with them in order to see whether or not they even have a glasses prescription or whether they were under the impression that it was specifically for contacts. I’m never going to get my new glasses. If I have to get a glasses prescription, I’m just going to go to the Walmart eye center. The most frustrating thing about all of this is that my vision hasn’t changed. This was confirmed on my last visit.

The situation did get resolved at some point.

It seems rather weird to me that I apparently let the optometrist not give me the prescription. Maybe I lost it? Or maybe they would give it to me, but not in a form that Walmart could accept. Whatever the case, the inability to get it verified was certainly quite the hassle and #1 and/or #2 were to blame.

I’ve also long complained about #3, and of course did so in a post from long ago. I won’t blockquote it because my narrative is not especially clear, but to summarize I found myself in a position where an old glasses prescription was actually better than a new one and there was nothing I could really do about it because the only prescription I could get them to take was the new one.

So, three cheers for Chuck Schumer!

However!

This will actually do me no special good. I just got new glasses and contacts earlier this year. I had from the start intended to order them online, so I made darn sure that I had my prescription on paper (which they had no problem providing, despite imploring customers not to order glasses online). Now, because I did go to the doctor first, my prescription is no longer out of date. But as long as I can see, the online vendors don’t even look at the piece of paper nor do I have to refer them to the optometrist that wrote it, so… yeah, I can pretty much flout the regulation that Schumer rightly wants to relax.

Of course, I’m not supposed to do that, and I have to admit that a part of me worries that somebody, somewhere is going to make a big deal out of this regulatory hole. Someone like Chuck Schumer, come to think of it…


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Will Truman is a former professional gearhead who is presently a stay-at-home father in the Mountain East. He has moved around frequently, having lived in six places since 2003, ranging from rural outposts to major metropolitan areas. He also writes fiction, when he finds the time. ...more →

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142 thoughts on “Chuck Schumer Eyes Glasses

  1. Like Harry Browne used to say, government breaks your legs, gives you crutches, and says, “If it weren’t for me, you wouldn’t be able to walk!”

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  2. I’ve never had any of these problems, and I’ve gotten the written scrip once or twice.

    The company eye insurance, should I choose to select it, REQUIRES that I get my glasses from an optometrist’s office or a place where an optometrist can examine me and I can buy glasses. I cannot take a written script to a store in the mall and buy glasses separately if I want the insurance to cover it. I ran into this once or twice when my opto didn’t carry some named brand frames I wanted. I ended up waiting a year and they had them. Also, my insurance will only cover an exam one a year. New lenses once a year, and frames every other year.

    But I’m curious…Re 2, “verify”? Does that mean “confirm the prescription” is your current one or “conduct an exam to confirm that the prescription is what you need”? You can run a lot of room through that one word. Re 3: I am unaware of anyone optometrist that drags you into the exam room every year. Is there a “eye police” that make you go to the doctor to have your eyes checked?

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    • My understanding is that in at least some states there are laws that prevent opticians from selling you glasses for a prescription more than X months old. So no one’s forcing you to get your eyes examined, but if you don’t, you can’t get new glasses.

      We need these laws to catch glaucoma early and making sure people are getting glasses that allow them to drive safely, and they are not in any way motivated by the desire of ophthalmologists and optometrists to make more money.

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      • and they are not in any way motivated by the desire of ophthalmologists and optometrists to make more money.

        One of the deeper mysteries of how health-care delivery works is the nature of in-network contracts between carriers and providers which defines pretty much the entirety of the three party nexus, and a lot of that (not all) seems to me determined, more or less by default, by a culture of historical inertia. Prices aren’t determined by what a patient pays a provider, of course, but rather what the provider and the carrier “negotiate” under the terms of the contract, and those contracts can include all sorts of terms and conditions which the patient has no knowledge of but are bound to by signing a contract with the carrier. And for a long time, THAT model worked for everyone involved on the business end in a big way: providers and well-run carriers, engaging in some well established shenanigans along the way, made bank.

        Seems to me that Shumer, recognizing that neither insurance companies nor in-network providers have any incentive to break apart that closed loop, is passin a law to break it open to meet customer’s needs and desires. And make it a little more like an actual market.

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            • It’s coverage for a relatively predictable and routine expense that is rarely an emergency. For that, you often become limited in what your consumer options are (Zinni is unlikely to be in-network) and you’re throwing gum in the works of provider accounting (which is their problem, but a part of the overall problem).

              For which, somebody is making a profit and people are doing administrative jobs that should be entirely unnecessary.

              And when it’s something particularly expensive (Lasik or glaucoma analysis for example), it falls under health insurance or otherwise isn’t usually covered.

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                • At least with dental insurance, there *are* cases of immediate and unforeseen expenses. Whether we get a dental plan or not depends mostly on who is picking up the tab (whereas I wouldn’t get vision even if the employer is doing almost the whole thing). But teeth problems can be a pretty miserable thing, and expensive to address. And not always covered by health insurance when that happens.

                  So dental is sometimes going to be worth it.

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                  • I don’t quite understand your dislike of it. It’s just an employee benefit, like a company car. Or dental insurance. Or free legal advice. Or a Costco membership.

                    I understand you not needing it, or wishing for for it to be different in a way that works better, but I don’t quite get the level of dislike you have for it.

                    Is it just a semantics thing? If it didn’t use the word “insurance” but did exactly the same thing, would you still hate it?

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                    • It’s everything that’s wrong with everything!!!!111!!1!!!!

                      I would object to it almost as much if it called itself a Buyer’s Club, as Troublesome Frog suggests*. But it’s a bureaucracy with tax benefits. It’s one of those areas where the government and corporations have figured out a way to take something that is simple and make it needlessly complicated, obscuring costs, and incentivizing people buying more than they need. Value transference rather than creation, and if TF is to be believed right into the pockets of eyeglass makers. Pah-tooie.

                      It’s not as evil as Rent-2-Own in scope, but in kind it’s almost worse than R2O because of the preferential tax treatment. While R2O is capitalism non-fraudulent capitalism at its worst (or near its worst), the preferential tax treatment brings the government into the picture.

                      I spit on it. I spit on it with the fury of 1,000 suns. I am so revulsed by it I cannot keep my metaphor straight. Or express my thoughts coherently.

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            • My company offers VSP and I just looked up my benefits.

              In all honesty, it’s a buying club and not any sort of “insurance.”

              There are 4 categories of benefits (at least for our plan):
              1. WellVision (eye exam – 1 per year per family member).
              a. Prescription Glasses – $150 credit (plus discounts disguised and co-pays).
              2. [conditional] Retinal Exam – if you meet criteria
              3. LaserVision (5% – 15% discount)
              4. eyeconic.com buy glasses online at their new shoppe.

              The out-of-pocket cost to me is so low, that I’m sure we get our money back each year… but then, every time I buy glasses at a VSP provider, I end-up paying an additional $100-$300 for the lenses we want (vs. the generic)… so have I gotten a discount or just paid retail at a provider they own? I couldn’t really say, because I assume my “insurance” protects me from retail pricing.

              If something were to actually happen to my eye, like an eagle attack, that would be covered by my Health Insurance.

              So, as far as I can tell, I belong to a buying club with an annual membership fee that may or may not save me money when I buy glasses – but certainly covers the cost of WellVision visits for my family. I think it is confusing to call it insurance and we’d be better off calling it some sort of collective buying group.

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              • The best part of the whole thing is that if VSP is laying out $100 for you at any point for a very predictable expense, your employer has surely given them more than $100 or they’d be out of business. Vision plans are basically fruitcake. It’s a gift, but you’d be better off just handing over the cash (or even the raw ingredients). No value added.

                They take some valuable dollars that you’d appreciate and turn it into a gift certificate that it will cost you money to redeem. You’re better off than if they hadn’t given you the insurance, but you’re worse off than if they’d just given you the cash. And we do all of this because our tax system gives us an incentive to do it.

                It’s basically just the taxpayers cutting a check to the vision industry, just like the 401(k) is just a big gift of tax money to the investment industry.

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          • Will, you’re making the “catastrophic coverage” argument, and during the ACA discussions we learned that if you favor that insurance model it means you think that going to the doctor is EXACTLY like getting your car’s oil changed, and that you hate poor people and want them to die of diseases.

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      • Not sure about other states, but I’ve gone to my opti’s shop and said, “give me a new set of these” glasses or “make these prescription sunglasses” when converting a set from non to sunglasses mode. I don’t recall getting much of a push back, but if you’ve not noticed any change in your vision, why would you think you needed new glasses? And if you did, why couldn’t you go to one of those places in the mall that just makes glasses?

        “We need these laws to catch glaucoma early and making sure people are getting glasses that allow them to drive safely,..” We NEED laws to catch glaucoma? If folks aren’t driving safely, they won’t be insurable for long. Problem solved.

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    • I bet that if you look up the corporate structure of your insurance provider, it’s ultimately owned by Luxottica, the De Beers of eyeglasses. They make most of the expensive glasses you’ll see at any optometrist’s office. They also own a few eye insurance companies. And Pearle Vision, Lens Crafters, and a bunch of other providers. Basically, for a lot of people, going to get glasses using “insurance” is a big shell game with Luxottica making a big show of moving money from one pocket to another while they talk about “discounts” and how much insurance “allows.”

      I learned all this when I started to dig around after a colleague of mine and I were discussing the fact that the high precision multi-element lenses we were having custom built were a few dollars each and eyeglasses cost $300 a pair even though they have much simpler lenses and are built on a scale we’d ever come close to.

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      • I don’t know that company but I wear Paul Smith frames which were fairly expensive but I got on super-sale.

        As with most things, there seems to be an issue over how much people are willing to spend on frames.

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        • You’re wearing Luxottica glasses. If it’s a remotely well known name brand, Luxottica licenses it and stamps their brand on the glasses. $4 frames become $1100 frames. Then they add $6 worth of lenses and $1 worth of coatings, which brings the total price to $300.

          Fortunately, your Luxottica eye insurance “covers” $150 of that (meaning, for people with a company vision plan, your employer already paid the $150, plus the extra money required to do pay the staff to do the accounting shell game).

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          • Fair enough. TBH, they might be cheap to make but I do get compliments on them and I think they do look better than anything I have seen at Warby Parker, LensCrafters, Wal-Mart and other places that boosts cheapness as a virtue. They might stamp a brand on them but they still pay attention to design.

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            • Of the “cheap” vendors, I think Luxottica only owns Sears Optical and Target Optical. :)

              They do make some nice looking glasses, but that’s more a function of the fact that they make 80% of the world’s glasses and have all sorts of styles. The designer brands approve the glasses that carry their branding, but they don’t design them. Luxottica does it end-to-end.

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  3. Require that optometrists give customers their prescriptions, so that they do not have to purchase their glasses from the optometrist.

    Isn’t that already covered? From the Electronic Code of Federal Regulations (Title 16, Chapter I, Subchapter D, Part 456), noted to be accurate as of Oct 22, 2015:

    It is an unfair act or practice for an ophthalmologist or optometrist to:

    (a) Fail to provide to the patient one copy of the patient’s prescription immediately after the eye examination is completed. Provided: An ophthalmologist or optometrist may refuse to give the patient a copy of the patient’s prescription until the patient has paid for the eye examination, but only if that ophthalmologist or optometrist would have required immediate payment from that patient had the examination revealed that no ophthalmic goods were required;

    (b) Condition the availability of an eye examination to any person on a requirement that the patient agree to purchase any ophthalmic goods from the ophthalmologist or optometrist;

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      • It’s been a while since I had my eyes measured for my reading glasses. I do recall that before I was out of the exam chair the optometrist was handing me the prescription form with the information. As I read the regulation, that would be the end of his obligation under this part of the code. Technically, it would appear that if I lost the prescription, I’d be out of luck.

        My recollection of the fine print at the big chain glasses places is that the optometrists are individuals in private practice, renting the office space and test gear from the chain. I assume that if they get a better gig a couple of months down the road, they just “disappear” without any forwarding address. My wife’s eyes are both worse and more volatile than mine; she sees an optometrist with an established practice so that she has a longer-term relationship.

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        • Michael,

          Sorry, I was expressing puzzlement about some of the provisions Schumer is introducing given the reg. you quoted above. Seems redundant or maybe there’s some subtlety we aren’t catching.

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          • It’s plausible that “unfair” doesn’t quite mean “illegal”, or whatever the appropriate thing would be. These paragraphs pretty clearly define something mentioned elsewhere; any chance you could find that, ?

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  4. Semi-related.

    Health economists believed that high-deductible health insurance plans would cause people to shop around for procedures and do price comparison. What happens is people just use less health care including preventive care:

    http://www.vox.com/2015/10/19/9567991/health-care-shopping-mri

    I don’t understand why experts believed there would be shopping around:

    1. It is almost impossible to get a price on a procedure and this can be any procedure. Most of this prices are negotiated between the insurance company and the provider anyway.

    2. If you need an emergency something or other, you are going to get it done as quickly as possible. You (general you) are not going to wait around and make calls and price shop.

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    • One mile away, the procedure costs half as much as it does at the other hospital.
      Same Health system. Including the Insurance negotiations — still one MRI costs double as much as the other.

      Why wouldn’t you want to go to the place that has newer equipment and is cheaper??

      Price shopping ought to be mandatory, and provided by the health system.
      (and I’m certain it will be, sooner or later).

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      • Newer does not always equal better. The author said she went on got a 400 dollar vs. 800 dollar MRI but the imaging on the 400 dollar one came out more fuzzy. There were also admin delays and snafus between getting the MRI and getting the results to her doctor.

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      • There is a very ugly question:

        Would I rather spend this money and get a certain percent chance to live X more years or would I rather have a lower percent chance to live X more years and leave this money to a group of people of my choice (minus a certain chunk of it that was devoted to bucket list)?

        This question is so ugly that we don’t want people to ask it in the first place.

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      • The culture surrounding price is actually changing, tho. Not too long ago, people couldn’t get an actual price from any provider or front-end person cuz there literally was no price to know. Performing the same procedure for three different people with three different carriers paid three different prices. (I know the bill rates for a business here in town where the lowest end for in-network patients is less than half the high end in-network price for the same service.) On top of that, there’s another layer of obscurity in price discovery: it’s illegal (or at least violates the terms of the contract) for in-network providers to reveal their negotiated rates to other providers. So not only do individual providers not know “the” price of a service, they don’t know what the “market” price of the service is.

        Now, if enough people actually were to shop around, I’m sure that price discovery would do its thing and people would make informed choices based in part on price and providers would compete with each other in part on that metric. But I just don’t think people actually do that (very much, anyway) nor do current practices make it very easy to do.

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        • While there is more wrong than right in the current state of affairs with regard to price transparency, my experience is that the opacity is pretty consistently overstated when we talk about it. For non-emergency care, you can get prices and shop around if you are really inclined to do so.

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          • “opacity is pretty consistently overstated….you can get prices and shop around if you are really inclined to do so.”

            But should you have to be “really inclined”? I’ve asked, more than once in recent years, for ballpark estimates of various medical procedures – not for the exact number, but you know, “somewhere around 500-800 dollars” would be fine, and the person seemingly never has any idea at all (or if they do, they won’t tell me).

            It’s possible that if I pressed the issue they could research and call me back with a number, but seriously, the opacity is not really that overstated; and decades of that opacity have allowed everyone to ignore the fact that (IMO) the markets have gotten royally effed-up over time, with (to my layman’s eye) the prices ultimately paid bearing little apparent relation to a procedure’s actual cost or value.

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            • I mean that I have for stretches been uninsured or underinsured , and when I have I’ve always asked the price, and when I have I’ve always gotten at least a ballpark figure. Not just for checkups and tests, but skin surgery.

              Some haven’t been able to give me one, or haven’t wanted to, but that’s when I move on to the next one (or threaten to).

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              • Huh. Maybe they treated you differently because they knew you were uninsured? I’ve asked for the price, been told they didn’t know it, so I said “just give me a ballpark then, is it closer to $500 or $2000?” and they can’t/won’t tell me. It’s lunacy.

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                • “I’m not insured” may be the magic phrase. When I had my sham “ever use it you lose it” plan with Fortis, I would just say that I was uninsured.

                  If you’re uninsured, they need to know if you will actually be able to pay them. Added motivation, perhaps.

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                    • That’s not true across the board. Part of the language of an in-network contract is that the provider will not (WILL NOT!) charge the patient more than the negotiated rate. Not a penny more. So if a person has insurance and the provider they go to is in-network, the contract requires that person to pay no more than the negotiated rate. (The logic works backwards, actually, in that the agreement is that the provider only receives $X for a service, and cannot receive more than that from billing either or both the carrier or the patient.

                      CO actually passed a law protecting patients from over-billing (it’s commonly called the “balance billing bill”) and one of the provisions makes it illegal for providers to overcharge in-network folks, or even outa-network folks who have insurance when that situation arises.

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                      • Oh, no, I don’t mean to imply they are charging ME, directly, more than procedure X is worth. I am sure that happens to many people but at least so far, I’ve been lucky to not get hit too hard with additional unexpected costs (there have been times when we’ve had to pay some additional cost, but it hasn’t been too exorbitant). Not sure whether I just have good insurance, or have been protected by law, or both.

                        I mean that providers are routinely billing the insurance company rates that, to my mind, have little relation to the actual services performed. On occasion we get some piece of mail that shines a little light into the payment negotiation back-and-forth between provider and insurance company, and some of the minor-procedure prices on there are simply…bonkers, to my mind.

                        On occasion I’ve considered getting on the horn with the insurance company to make sure they realize they are getting fleeced, but who has that kind of time? The point of insurance is, in part, to let them handle this stuff.

                        Of course, them handling it has a cost (which I/my employer will ultimately pay in premiums) and if they don’t fight it and just pay it, that also ultimately raises premiums.

                        In short, I had/have my misgivings about the Obamacare solution; but the Republicans denying that things had gotten way, way out of hand and that price opacity was a huge part of why and how that had occurred, was delusional IMO, and gave them no standing to complain about someone at least attempting a fix since they obviously weren’t going to.

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                        • Glyph,

                          Yeah, agreed. That’s the problem I was talking about upthread: the institutional culture of healthcare delivery takes it as a given that providers (and large hospitals, which have the most leverage, tend to set the bar height by stipulation to some extent) negotiate price with carriers without any considerations of retail pricing (since there is no retail market) or overall cost (since the only “price” an insurance company NEEDS to care about is the price of the policy, which is predominantly passed thru employers to employees, neither of which – well, until recently – have cared about price).

                          Via my wife’s business, I’m intimately aware of how in-network contracts are negotiated and the (lack of) decision-making that goes into it. If people only knew!!!

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                        • What the hospital initially bills you has as much relation to what you actually pay as the sticker price on a car has to how much money the dealer actually gets.

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                          • What the hospital initially bills you has as much relation to what you actually pay as the sticker price on a car has to how much money the dealer actually gets.

                            Only more so. My friend who works in a hospital business office says that the proper procedure, if you can manage it, is to take the bill to the hospital and speak to the office manager (not anyone lower). Offer to pay one third the amount on the bill in cash or equivalent. She says in almost all cases, the hospital will take the cash and stamp the bill “Paid in Full”. She says that what they want is not the amount on the bill, but rather what a bill collector will pay them for the debt.

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                  • There’s that, and I believe that if they’re dealing with insurance, a lot of providers outsource all of their billing to third party companies that specialize in it. The doctor’s office just gives them the codes for what they did and the billing company figures out how to game that into the maximum insurance payment. The doctor’s office literally doesn’t know what they get for any particular thing in advance unless they go through the records of what they got for previous procedures. On top of that, they’d only really know what they got out of it, not necessarily what you’d pay.

                    I assume that if you don’t have insurance, they’ll have to figure out what to charge you since it’s a transaction between you and them.

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                  • Yeah, same experience here. When I was uninsured, I could find out how much things would cost in advance. But only if I asked. (I actually walked out of a hospital because I was quoted $5000 for a simple pyogenic granuloma removal from my hand. I went back to the doctor’s office and said ‘We’re doing it here’, and it cost something like $400.)

                    Now that I’m insured, I can’t find prices.

                    I actually find it a bit baffling how failing to list prices for services *in advance* is even legal. Really seems like there should be some sort of law about that. If I walked into a quick oil change place, got an oil change, and then was charged $800 because that was what they charged for an oil change and just don’t bother to tell anyone, seems to me that no one would allow that place to continue to operate. We require *printed prices* in stores, too, and stores can get into legal trouble if they’re wrong.

                    But somehow this all goes away with the hospital. I mean, yes, sometimes there are complications and whatnot, and each patient is going to be different…but surely they should be required to give some sort of quote in advance.

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                    • My wife had minor surgery awhile back. The surgeon in question’s specialty was reproductive medicine, so it was half “fertility” (not covered by insurance) work and half “medical problems” that were.

                      It was our first year in a HDHP, and they quoted us 3k. Total. EVERYTHING. I had more than 3k left to meet my deductible, so I scraped together the cash, paid up front, surgery went fine.

                      They bill by insurance for 24,000 dollars. My insurance laughs, adjusts it to 16,000 dollars and tells me it was out of network. (That was my fault). I immediately panic and appeal.

                      Meanwhile, the surgeon assures me 3k covers the whole thing. (And it did. My appeal was denied, my insurance to this day thinks I forked over 16,000 dollars apparently).

                      I don’t even know how to process that. 3000 paid for everything, because that was the cash price. But they tried to bill a major insurance company for 24,000, and said company agreed 16,000 was reasonable. But if you shop the procedure on their site, it says…2 to 3k is reasonable.

                      WTF?

                      I literally don’t even know who to consider the bigger scammer here.

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          • One of the interesting things I’ve noticed over the last few years, as urgent care clinics and even the detached ERs have popped up all over the place, is the contrast between the model that seems to be used by most old school general medicine practices and that of the new UC and ER clinics. Pricing in the former is still mostly opaque, and if you look at a bill you’ll see pretty clearly that they’re billing your insurance for anything they can get away with billing them, while the UCs are up front about their prices, and in some cases have you sign off on a procedure with pricing information before they’ll perform it, so there’s little if any unexpected or inexplicable billing.

            The upshot for me is that if I have to go to the doctor for anything that’s not long-term or preventative, I’m going to go to a UC clinic, since despite the higher copay, the end bill will be both more predictable and in almost every case, significantly less. I would assume that UCs are taking a significant amount of business from traditional general medicine practices, but maybe they make most of their money in long-term and preventative care?

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            • I’ve taken to going to a nearby UC for minor stuff, even though it has a higher copay, because it’s also mostly a better experience. Lesser wait time, lesser total time spent there – which makes no sense, since the whole point of making an appointment ahead of time is to, you know, insure that doctor and patient are ready to see each other at the scheduled time. So why the hell am I there for two hours every time?

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              • Right. I had to go to one last week. I walked in, was there for under 30 minutes, and walked out. They were so fast that while I was walking to the bus stop across the street I got a text message from the pharmacy telling me that my prescriptions were ready.

                Had I gone to my PCP, I might still be in the waiting room today. And they’d have billed me for use of the waiting room chair.

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              • So why the hell am I there for two hours every time?

                One very well established, highly regarded clinic here in town – and to a certain extent is the ONLY game in town – paid some smart-guy MBA-types a whole lotta money to evaluate their business practices for leaks and such. Their total recommendation for the firm was pretty much a single sentence: reduce clinic appointment times from 15 minutes per patient to 7.5. Genius stuff, right? (That’s the kind of penetrating analysis 30k gets you from MBAs, I guess.) Patient care went way down and wait times went way WAY up. But the bump to the bottom line was too much to pass up.

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            • One of the interesting things I’ve noticed over the last few years, as urgent care clinics and even the detached ERs have popped up all over the place, is the contrast between the model that seems to be used by most old school general medicine practices and that of the new UC and ER clinics…

              …I would assume that UCs are taking a significant amount of business from traditional general medicine practices, but maybe they make most of their money in long-term and preventative care?

              The contrast in the differences in business models between the new UC and ER clinics and the old general practices is that the latter facilities are being built either by the hospitals and health systems as part of a general hub-and-spoke outpatient strategy, arguably the best result to come out of the ACA, or by entities 100% affiliated with them.

              Unless you’re talking about the very large multi-specialty practices, the trend with general medical practices is for them to get acquired by the hospitals that they affiliate with. It’s much more difficult to operate independently in the current environment.

              One of the advantages of UC clinics is that they cost significantly less compared to ER visits, and that applies both to patients and hospitals. It’s a necessary win-win for both.

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              • Whatever the cause, the fact that I pay less in the long run, and get faster (and perhaps better, certainly nicer) service, is awesome. I assume, however, that the general dysfunction of the health care industry will make its way into these clinics as well sooner or later (probably sooner), and before long they’ll be filled with rude clinicians who would rather be anywhere else but there, who’ll treat me at a pace that can only be described as glacial, and they’ll charge me an arm and a leg for the privilege.

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                • I don’t share your cynicism. When you find me a clinic that’s operated that way, I’ll show you a clinic that will either be out of business or acquired by a local hospital.

                  The old model is very bad for business in the post-ACA environment.

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                • Not every primary care provider is created equal. I have a good one. I can get in the same day if I call early, or the next day if I call late. I will almost always get into the examining room in a timely manner. I can usually swing seeing the same person I and my family have been seeing for years.

                  It also helps that I have excellent health insurance. This is the one big benefit of my wife being a public school teacher. I will pay ten bucks for the visit.

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            • This is one of the reasons that I am outraged by how medical records are handled. Even with the ACA’s push to electronic records, the intent is to facilitate transfer from one practice to another. No provider is as interested as I am in maintaining my history of test results and treatments. But getting such is difficult and/or expensive.

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              • If only we had a system of interconnected tubes or wires through which information could be transferred from one site to another, so long as both are connected to each other or a central clearing house via the tubes/wires.

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    • 1) The reason it’s impossible to get a price on anything is that providers aren’t used to the customers actually paying the price at the time of service.

      2) If you need an emergency something-or-other that’s what catastrophic coverage is for, but see my earlier post re: hating poor people.

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      • 1) The reason it’s impossible to get a price on anything is that providers aren’t used to the customers actually paying the price at the time of service.

        I disagree. I think problems with price (discovery, opacity, etc) is a product of the carrier-centered network model.

        2) If you need an emergency something-or-other that’s what catastrophic coverage is for, but see my earlier post re: hating poor people.

        I disagree with this too. Catastrophic isn’t intended to cover emergency care, it’s intended to cover statistically rare expensive care.

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        • “I think problems with price (discovery, opacity, etc) is a product of the carrier-centered network model…”

          That’s…what I said, actually. “Providers aren’t used to customers actually paying the price at the time of service” because of the carrier-centered network model.

          “Catastrophic isn’t intended to cover emergency care, it’s intended to cover statistically rare expensive care.”

          Emergency care is statistically rare (because, duh, emergency) and it’s expensive because, as you point out, you don’t have the option to shop around.

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          • Emergency care is statistically rare (because, duh, emergency) and it’s expensive because, as you point out, you don’t have the option to shop around.

            They’re also expensive because they’re expensive to run. Unlike an urgent care center, they have to be prepared to treat a whole lot of different problems. That creates enormous overhead that has to be paid for.

            People can get the impression that ER’s are profit-centers. They’re really not. Back in Arapaho, the clinic was subsidizing the hospital and its ER.

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    • ” It is almost impossible to get a price on a procedure and this can be any procedure. Most of this prices are negotiated between the insurance company and the provider anyway.”

      Really? Have you ever gone to the dentist and asked how much a crown would be, gotten the price, and asked “how much if I roll off 100 dollar bills and pay now?” I’ve know people who’ve gotten a 40% off doing that. Now, getting a reduction via insurance? Nope.

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  5. Chris: What makes these and your question so ugly is that there is no inherent reason why they should be asked.

    Except for the reality of scarcity of resources. We as a society don’t have the resources to give everyone as much heathcare as they might want or need.

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    • Suppose you woke up tomorrow, and all non-cosmetic healthcare was free, totally free of any charge whatsoever.

      What medical procedure or drug would you rush out to consume, or do you think others would rush out to consume?

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      • I would head out and see what a doc would recommend if it was free. Maybe a little liposuction and botox , who knows b/c I’m not getting younger. I’m in good health but if it’s free why not use it? There isn’t any point in not consuming things if they are free.

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        • Those are cosmetic.
          What non-cosmetic procedure do you think people would use frivolously, if they weren’t concerned with cost?

          My point here is that health care is the product that no one wants, unless they are forced to consume it.

          Forcing people to “be more selective” in their choice of medical care is a solution to a problem that doesn’t exist.

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          • Nobody wants it for spit and giggles, but there is a degree of triage involved.

            “Do I go to the doctor about this now or do I give it another day?”

            “Do I fill the antibiotic prescription, or do I let nature take its course?”

            “The doctor mentions this test. Should I have it run or not?”

            “This mole seems fine now, but it could turn bad and I can have it removed for peace of mind. Should I do so?”

            These are the ways that being insured, or not being insured, have affected my decision-making.

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                • NPR has been running a lot of stories recently about how maybe we don’t need quite as many mammograms as we’ve been getting.

                  Indeed, we’ve made distinctions between “cosmetic” and “required” surgeries so far in this thread.

                  AS IF I DO NOT DESERVE HAIR PLUGS.

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                • I honestly don’t grasp your answer.

                  On an individual level I suppose someone could assert that not being tested, not following up, not getting a procedure was a superior outcome because they saved forty bucks or something. I just fail to see how this scales up.

                  I mean, no one is saying that making health care free of cost is the same as forcing people to take it.

                  If it was free, you could still make decisions about letting it wait, or letting nature take its course.
                  Whereas, introducing price into it makes those decisions less free, more coerced.

                  I don’t grasp how that’s a superior outcome for anyone.

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                  • They save forty bucks for their own discretion, and also save money by the discretion of others. They allow providers to look after those who need care the most. They allow the resources being spent on an unnecessary to be spent elsewhere.

                    The ability to go to the hospital free of cost maximize freedom for the individual making the decision, but at a cost to others. And vice-versa.

                    This may not be what we, as a society, want. There are costs involved (financial, well-being, psychic) either way.

                    But to get back to the original thread, making health care cost less or more to the consumer will result in more health care being utilized or less. Both necessary and unnecessary. The latter isn’t some fictitious invention, nor so rare as to be completely irrelevant (depending on one’s threshold of relevancy, I suppose).

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            • “My Achilles hurts really bad the day after a game. It’s almost certainly just inflammation, but determining if it is or not will likely require an MRI, which they don’t have in-house and will cost $800+”.

              Note: this is not a hypothetical.

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              • Who should make this determination, the triaging of priorities of cost and probability, weighing all the pertinent factors?

                The patient?
                The doctor?
                The insurance company?
                Someone else?

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              • I sympathize. Earlier this year I spent $800 or so that I had saved up on a specialist. I have low bone density, and every GP on Earth thinks they’re the one who can figure out why. All of the evidence across 15+ years is that it’s just the way I am, it’s not progressive, and absent some other change in my health, not something that anyone should worry about. The world-class research specialist and the tests he wanted resulted in a letter that said “It’s just the way he is, it’s not progressive, it’s not anything to worry about.”

                Since I have to go through at least one more change in health insurance in the next few years — I’ll reach Medicare age — which may mean a change in care provider, I wanted something I could hold up and say, “No. No more exotic blood tests. No more upper or lower GI examinations. No more pressure to try bizarre drug combinations. Smarter people than you say that those are a waste of time and money.”

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        • I love how when he specified ‘non-cosmetic’ your two examples were…cosmetic surgery.

          Couldn’t think of any actual medical procedures you’re undergo, just because they were free, that weren’t cosmetic?

          As someone with a HDHP, I put off as much as possible until I hit my deductible — and then I still only did what was medically necessary. I wasn’t out agitating for a colonoscopy or MRI just because it was ‘free’.

          The closest I got to an ‘elective’ procedure is I’m having an allergy test done later this week. And my insurance company actually considers that preventative medicine, as even with a HDHP they’ll pay for the allergen formulation even if I haven’t hit my deductible.

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          • I just don’t need anything right now, but who knows maybe tomorrow I’ll break a leg. I’ve already had LASIK and surgery to fix a deviated septum. I take care of myself and I’m in pretty good health. Upon further thought, I would get an x-ray/MRI of my shoulder where I broke my collar bone. Maybe another colonoscopy and a MRI of my back.

            The real point of this was question as to whether we have the resources as a society to give everyone all the healthcare they want or think that they deserve. Most resources are used at the start and end of life but folks waste the resources all the time. My wife used to work for the GA PeachCare for kids and she said all these low income moms that would bring their kids in all the time for the most trivial of reasons wasting appointment slots when they could have called in and had a nurse answer the questions over the phone.

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            • I’m pretty sure you’re not after the colonoscopy because it’s “free” unless you just enjoy unpleasant medical tests.

              Even MRI’s aren’t pleasant. The plain fact of the matter is: People, by and large, suffer through the tests their doctor orders. Few people actively seek out such things if they can avoid it.

              Because doctor’s visits are general unpleasant (all those sick people) and medical tests are invasive and unpleasant at best.

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            • Praising by faint damns…

              all these low income moms that would bring their kids in all the time for the most trivial of reasons

              You know that those greedy health insurance corporations, capitalists to their very marrow, practically give away routine office visits? They almost beg us to visit often, to get our blood pressure checked and flu shots updated and teeth cleaned?

              If your evidence against free health care is moms bringing their kids in for sniffles and owwies, the very services that health care robberbarons want to provide for free, then you have implicitly accepted that no one is running in to fraudulently take advantage of free chemotherapy or kidney dialysis.

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            • The real point of this was question as to whether we have the resources as a society to give everyone all the healthcare they want or think that they deserve.

              The pre-ACA numbers placed the US at the top in percapita healthcare spending across the big wide world – about $9000/person, about 1.5 times higher than the next closest country, and over twice as expensive as England – to provide healthcare ranked 39th (England, by comparison, ranks in the mid teens). There’s lots of things to worry about wrt our healthcare system, but having the “resources” to do better isn’t one of em.

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      • “What medical procedure or drug would you rush out to consume, or do you think others would rush out to consume?”

        A diabetic who’d been getting by on four-times-daily injections would probably be happier with an insulin pump. Which is a significant quality of life improvement over injections, but it’s also an order of magnitude more expensive(*). And I can quite easily say “he’s controlling his blood sugar just fine with the injections, an insulin pump is entirely elective and if he wants one he should pay for it himself”.

        Someone who can’t afford bypass surgery might have been making do with simvastatin and avoiding bacon. But hey, shouldn’ta had so much bacon in the first place, fatty, lose some weight and you won’t have a problem, right? Bypasses are elective surgery too!

        The purpose of this is not Let’s Be A Dick. The purpose of this is to show that snotting about how this or that is “elective” or “cosmetic” implies a utilitarian calculus which can turn against you very quickly.

        (*) although less so than it used to be. Insulin pumps are now so cheap that you can throw them away when they’re empty — see the Omnipod.

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        • Let’s Not Be A Dick is in all seriousness, a fine principle upon which to base our decisions.

          It implies a negotiation, a meeting of interests and needs and ability to treat all interests on a level ground of respect.

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      • RAND corporation actually studied this question back in the ’70s. They discovered that a group receiving a cash equivalent to free health insurance resulted in a significant reduction in healthcare services consumed, but no real reduction in health outcomes.

        I have a catastrophic-only insurance policy and the thing I skip is GP visits. I only visit the doctor is there’s something really wrong with me, and only then if I don’t think it will go away on its own.

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        • There are significant differences between the HC that is provided now and the 70’s. Most young people don’t need much HC. Once you get older you almost certainly will and when you are old unless you are very lucky you definitely will. Catastrophic plans can work for young and lucky people. That doesn’t really answer the question for older and unlucky people.

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          • HC provided now is also a lot better than the HC provided in the 70’s.

            We have pills for things that we used to require surgery for.

            We also have average life expectancies of 20 year old that are more than 15 years longer than a couple of generations ago.

            For what it’s worth, I have no problem with giving away the medical care available in the 70’s to all for a 100% subsidized cost to any who need it, citizen or not, taxpayer or not. Anybody.

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            • “We have pills for things that we used to require surgery for.”

              And, conversely, we have surgeries for things that there used to be pills for. Like, we now can fix things instead of writing a prescription for Vicodin and advising the patient to avoid fatty foods.

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  6. I’m very happily wearing a $15 pair of glasses from Zenni Optical. I’m never going back to buying through my provider. Even a pricey pair of feature-rich glasses usually costs less than the copay at an optometrist (or even the fee to have new lenses put into old frames).

    If more people saw the actual price of glasses, they’d freak out at what they’ve been paying. In fact, I’m starting to think it would be a good practice to have school districts bring in a optician and give glasses away to kids as part of the public school budget. At $7 a pair, it’s down in the noise.

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      • military glasses have got a lot better in the past few years. Thanks Obama(?) (Maybe thanks, Bush, not sure when exactly they gave more choices than the BCD frames?)

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        • And, oddly enough, the old BCG look is currently trendy. I have no explanation for this. Neither did my optometrist when I asked him. We shook our heads in wonder.

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      • The current state of affairs is that a lot of them keep their awesome glasses-free looks and just can’t see. My wife’s vision was terrible in elementary school and she struggled for years before finally getting glasses. I think it was a combination of being from a poor immigrant family (that couldn’t afford glasses and assumed that kids don’t need glasses anyway) and teachers who chalked up difficulty reading to her learning English.

        An annual eye test and $6.95 and the problem is solved. Way cheaper than just about anything else you could to to improve outcomes in a pretty good subset of young kids.

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        • My kid is getting glasses now, and one thing the eye doc told us is that if a kid needs glasses at a young age and does not get them, then even when they DO get them at age twenty, their vision will not be as improved by those glasses as it otherwise would have been – because their young brain never had the opportunity to “learn” what correct, non-fuzzy imagery is supposed to look like.

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          • That’s a really interesting point. I hadn’t thought about it (which is weird, because I’ve written more than one autofocus algorithm in my career), but focus assessment is a surprisingly complicated problem, so I could definitely see that happening.

            My wife talks about being late on in elementary school and saying, “Oh, that’s what letters look like!” I can only imagine how many kids don’t get there until they’re well beyond critical learning milestones and how hard it would be for them to catch up. I remember taking hearing tests in elementary school. Seems like a few bucks for vision would be a no brainer given a budget of $10K+ per pupil.

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    • school districts bring in a optician and give glasses away to kids as part of the public school budget

      My kid’s school is doing this, kind of, it’s actually bankrolled by the local pro football team (probably some sort of tax writeoff for them, as well as good PR).

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  7. I’m in NY and sometimes had to be a bit of a pest to get written prescription from the doctor. Especially for contacts. Sometimes I’d go to check out after a visit and they’d say, “And here are your contacts and you owe us $150.” “But I didn’t want contacts. I just needed an exam. I’m going to order my own.” “Oh. But we have these right here for you. We ordered them for you. Why do you want to go somewhere else?” “Just give me my prescription please.”

    One time I called up requesting a paper copy of my prescription as online contact sites (I don’t know about glasses) require an updated prescription be faxed or scanned. When I arrived, they again had a box of contacts for me. “No! I just want the prescription.” Sigh.

    I don’t even understand why we so tightly control eyewear. I mean, I understand the problems that can arise from someone not having an accurate prescription. But, seriously, can’t we just trust people? Really? Not even on this? Glasses and contacts need to be a controlled substance? Are teenagers OD’ing on fine print?

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    • Contacts are pretty serious business. I’m sympathetic on those. Not on prescription recency, though. I was part of a study in college and one brand on contacts turned my whites yellowish. I didn’t even know it was happening and at the end of it they asked me which brand I preferred. I thought the ones my eyes were reacting to were more comfortable. They told me to never get that brand.

      I’m a little disconcerted that they didn’t intervene,but I assume they knew what they were doing.

      For glasses, though, people end up going without any corrective lenses for longer than they should have to for want of a new prescription when their old prescription was certainly better than nothing.

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    • Kazzy: I don’t even understand why we so tightly control eyewear. I mean, I understand the problems that can arise from someone not having an accurate prescription. But, seriously, can’t we just trust people? Really? Not even on this? Glasses and contacts need to be a controlled substance? Are teenagers OD’ing on fine print?

      It is two simple words, doctors and monopoly

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    • “I don’t even understand why we so tightly control eyewear. ”

      The official reason is that vision is utterly critical to driving and so there needs to be a tighter relationship between exam and provider to ensure the best quality of vision-correction prosthetics. If they just let people handle it themselves they’d go to shoddy producers (or just not bother to maintain their prescription’s currency) and end up not being able to see.

      The true reason is probably just that, as with everything else involving American healthcare, we’ve gotten used to it working like that and the insurance pays for it anyway so who the hell cares?

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      • The driving thing is such transparent nonsense. If it were true, you’d have to submit evidence of periodic eye exams and updated prescriptions to keep your license current.

        What they actually do is put an eye chart in front of you and say, “Read the chart.” Can’t pass the test? Get some glasses and do it with glasses. You could get those glasses from an illiterate guy with no medical training who grinds lenses from old Coke bottles for all they care as long as you can read the letters on the chart.

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