I am having problems with my insurer at this very moment. I went to an in-network hospital for an ER visit, which turned into an 8-day stay (yes, it was serious). Evidently, none of the doctors at the hospital are in-network, however, (claims from various technicians are still "in processing", so I don't know how they will turn out) despite the fact that the hospital itself is definitely in-network. I had no choice as to what doctors came in, and, yes, I can now see them billing $600 for a 1-minute visit ($600 per visit, & they came every morning).
This is ludicrous! I have insurance, & still this will completely drain me financially. I'm at the point where I almost think it would be easier to declare bankruptcy and start over!
I had this same thing happen. My daughter was admitted via ER and it turned into a 6 day stay. At the end we received a bill for 40k for being out of network. Luckily I have friends in the industry and it turns out if they fail to inform you within 48 hours that you're not in network you don't have to pay the out of network cost. We ended up paying just our deductible after a letter was drafted. Do not take what the hospital/insurance Co say at face value. Call an attorney.
> Luckily I have friends in the industry and it turns out if they fail to inform you within 48 hours that you're not in network you don't have to pay the out of network cost.
Curious, can you perhaps provide evidence of this? Seems like a good thing to know.
> Call an attorney.
This is itself a cost, and maybe only makes sense if you owe ≥ $10k but for procedures billed as $1k when they should be $400 I don't think warrants the cost and time of an attorney; what other recourse is there except to pay?
Many attorneys will provide a free or very low cost initial consultation; you may have an unrealistic picture of what the actual cost of legal services for this particular scenario would be, and may benefit from actually finding out before assuming they are too expensive.
> you may have an unrealistic picture of what the actual cost of legal services for this particular scenario would be
I agree, I do, which is why I tried making my statement as much a question as possible. I am unaware that attorney's would fight for cases like this, if they are more common and do not lead to lawsuits.
I paid my last attorney around $250 per hour and was very satisfied. Something like this might only be a couple of hours. Have an initial meeting with the attorney (usually free). They'll develop a strategy with you, in this case it would probably be to document the situation and send a letter explaining that a lawyer is engaged. Then the whole thing might stop there.
Some attorneys will actually answer the phone and have a small conversation. Maybe it's rare or different for healthcare issues, but I've made that phone call before. I politely asked a few questions and that was it.
I have no evidence other than a person that works in claims for an insurance company looked at my claim, drafted a letter citing relevant statutes and the bill went away.
I agree that an attorney only makes sense if you're facing a significant bill. On a smaller bill I would go to the hospital billing department and negotiate.
If you have excellent credit you can simply not pay and make them do the work. I had a $1500 dispute. I was getting tired of wasting time. When it went to collections I drafted the standard leave me alone. The funny thing is now the collection company has screwed up twice on some things. It is their prerogative to sue. I doubt they will. If they do it, it will be annoying but I can respond in kind with a countersuit. Oh and the credit score? Dropped about 40 points into the upper 700s. Annoying, but not worth just rolling over and paying.
Agreed, this is just part of business for hospitals. We as honest people feel ashamed if we cannot pay bills. But I make an exception medical bills and other unpredictable broken industries (if any).
If someone bought a car or house, they knew their obligations exactly. If they declare bankruptcy, I would lay some fault with them, if not all.
But with medical billing, you cannot get a straight answer. If they cannot tell you what a simple procedure would cost you, then you don't owe them anything.
Also hopefully if enough people don't pay surprise bills, then medical industry would have motivation to simplify their systems.
You'd hope they would simplify their systems, but instead they just throw it into higher risk pools and raise prices for everyone to cover the non-payments.
I agree with dungle6, whose comment is now dead. I say screw them and don't pay. Ignore collections for a few years and don't be a wuss about your credit score. Problem solved.
I don't get this statement. Not protecting your credit score can cost you real money. Yeah, the whole thing is a racket, and I frickin' hate it, but, pretending like you can ignore your credit score without impact seems counterproductive.
I would really rather see this whole racket of a medical billing system held to account versus advocating that we allow them to punish us in any way for not playing their fraudulent game.
I agree with your second statement, but I have spent most of my 20s and a great portion of my 30s with crazy negative stuff on my credit report. I flatly refuse to pay outrageous collection fees, and there are at least three items on my credit report which are outright lies. For example, switching from Verizon to T-Mobile, and T-Mobile handed out gift Mastercards to pay the early termination fees for getting out of your Verizon contract. well, Verizon refused to accept my $350 gift Mastercard, so I mailed it to them certified mail. They received it. I have the receipt. But now I have a $400 item on my credit report that I refuse to pay. An administrative mistake the Army made, and now there's another $900 item on my credit report that I refuse to pay because it's a clerical error. That last one's interesting, because I have signed witness statements from a finance guy involved in making the mistake, yet they refuse to clear it, so I refuse to pay it.
Despite this, I have been able to get a car loan, I got a VA loan for a house, I have opened two credit cards (which I use responsibly) since then, and also was able to get a personal loan for an emergency six years ago. It is absolutely possible to do "normal" things. It's just been a matter of explaining the situation.
I hear you, and most of us probably have similar stories to tell. There are really two rackets here: credit reporting agencies and medical billing. Then, they have the audacity to add debt collectors to the mix, who primarily harrass you and threaten to blow up your credit score.
Clearing errors involves a byzantine maze and way too much time in an era when everything is digital. There should be stringent regulation around accuracy and we should all have free year-round, real-time access to our credit scores.
But, my point here is not that you can't live a normal life with a few credit dings. It's that those dings represent punishment that can impact you. For instance, you may not have gotten the best interest rate available on your subsequent credit. So, we should be advocating an end to these fraudulent medical billing practices vs accepting punishment from them, then trying to live with it.
BTW, I predict Verizon will soon be the target of some hefty class-action. They are very shady when it comes to contracts. They also have periods wherein substantial numbers of customers report mysterious, frequently dramatic data overages for a time [0] that suddenly disappear. But, they refuse to acknowledge any issues.
And they specialize in making it extremely difficult to achieve resolution, with multiple phone calls, etc.
This may cause a cascading effect on your credit score. Certain banks tend to trim credit lines or outright close it when collections are reported on credit reports, which in turn increases utilization of credit lines which in turn drops score, which in turn leads to new reviews.
That's bad advice for the HN crowd because as much as they all say they love the valley they all have their eyes on home ownership and GTFOing in about that timeline.
Can someone knowledgeable on the subject comment on whether the "Obamacare movement" has been up front in acknowledging this aspect of the problem with health care in the US?
My perception is that the problem is typically framed as a lack of insurance problem for financially challenged people, but the "abuse" on the billing side to me seems like at least as big of a problem. And if this is being conveniently ignored, it feeds my conspiracy thinking that the Democrats are actually largely indistinguishable from Republicans - they may wear a different mask, but their actions are only slightly different, in this case altering who is getting robbed.
The fact that the problems addressed by the Democratic health care bill are orthogonal to some other problem you care deeply about is not, logically, evidence that the Republicans and Democrats are "indistinguishable" when it comes to health care. The status quo ante of the ACA was a system in which millions of people were locked out of insurance by fiat due to pre-existing condition bans. For those people, all providers were "out-of-network".
The kind of problem described in the OP doesn't seem orthogonal to ACA. It looks to me like the problem is part of the adjustments that the market has made in response to the regulation. One of the biggest tools used in differentiating between the various levels of ACA marketplace plans is the breadth of the network they allow access to: getting more providers to accept your plan will cost you additional money.
It only makes sense to at least postulate that the converse is true as well: if you find yourself stuck out-of-network, it's because these regulations created an environment where the insurance companies could do better by eliminating the providers it partners with. So it's reasonable, at a first approximation, to guess that this problem is the result of ACA.
Right, which increases revenue for the medical establishment, while also helping some people (and harming others) in the process. For me to consider the Democrats as the true party of the people rather than a tool of corporations, I'd want to see the cost side of health care addressed as well. My question is: was it?
I don't think you're going to get anywhere productive with analyses that connect all commercial health care spending with top-to-bottom regulatory capture by the health care industry. Essentially what you'd be saying is that any system short of federally-run single-payer was a sign of corruption.
Also: this idea that the "Democrats are the party of the people" and the "Republicans are the party of corporations" is pretty silly.
The Republicans are a conservative political party. The Democrats are a coalition of blacks (~25%), latinos (~10%), women (+10% share), labor unions, and urban (but not suburban) college-educated whites. Liberals are an important component of the Democratic party (and have no home whatsoever in the GOP), but they don't run the table.
Democrats are a big tent party and idealology doesn't rule as a result. When they get ideological they pay dearly, as gay marriage demonstrated. (Lots of older white and black voters stayed home or voted GOP)
Republicans can't win the numbers game so they hammer home on right wing populism. Unfortunately, the last 30-40 years hasn't been kind to the "Main Street" centrist republicans of the past.
My impression is that the tent-restricting social issue that has held the Democrats back in recent years is abortion, not gay rights. I'd be interested to hear if you have studies or polls showing otherwise.
On one hand, the Democrats did not have control of congress to pass whatever they wanted when the ACA was passed. On the other hand, the Democratic party of the US has never fought with any fervor against Republicans on pretty much anything. The closest I have seen in my lifetime to democratic resistance was to the most blatantly and obviously stupid and racist decisions Trump has made like travel bans and appointing fossil fuel and wall street banker execs and investors to every cabinet position. In the Bush years, there was practically no resistance at all. Bipartisan support for the evil Patriot Act and disastrous No Child Left Behind. No adherence to any ideology or conviction.
Probably the most important realization for the average American in the current political climate is how no party establishment represents you. Both have their sponsors, and none of them are the American people. Individual politicians might have more empathy than others and some might try to help the common man more than another, but they all still have their bosses and despite whatever rhetoric we throw around in almost every election (aside the scant few in contested states and counties) the people are not holding their leash, so they don't work for you.
It is like climate change. It doesn't matter how you want to argue about solving it, it is simply acknowledging the reality that has to happen first and moving on from there on a unified foundation of fact.
Even if we just stay on the subject we're talking about here it's easy to rebut this notion that the Democrats don't fight the Republicans.
A lot of people forget that the GOP does not, as a political party, believe in universal coverage. Moving the country closer to universal coverage is not a GOP political objective. What is a GOP objective is minimizing federal interference and involvement with business. Health care is something like 15-20% of the entire economy, so the GOP's stated objectives run directly counter to universal coverage.
And yet, repeated efforts to eliminate the ACA have all retained policies built around universal coverage, including a massive federal expenditure in Medicaid (block granted or otherwise) and an extremely intrusive regulatory requirement for guaranteed issue insurance, something that only Ted Cruz has tried to push back on.
If that's not a win for the Democrats it's hard to imagine what plausible outcome would be. Nothing that involves 15-20% of the American economy will be simple, or will happen in one legislative session.
Is that the Democratic party fighting the GOP, or just the GOP realizing that if they start throwing people off healthcare, especially those that both need it most and represent their most substantial voting block (middle aged, white, poor midwesterners and southerners) no amount of campaign dollars will keep them in office. They would probably never turn blue, but the GOP establishment would primary them out of their own reelections for how unpopular they would be.
Obamacare only reduced the growth of healthcare costs, it did not stop the growth. The approach that most democrats believe would reduce cost is single payer or Medicaid for all.
As far as I can tell by looking at my premiums, it actually significantly sped up the growth of costs. I don't know how anyone could argue otherwise with a straight face.
That's not the cost we're measuring! We're measuring cost on the macro scale, in terms of the percentage of the economy spent on health care and, in particular, the percentage of the federal budget spent on health care entitlements. That's the cost curve we're talking about bending, because the pre-ACA projections were literally prima facie untenable.
Any number of effective cost-saving measures could be passed that would have the effect of increasing your premiums.
You can measure whatever you like, but my costs have gone up nearly threefold and my plan is worse now than it used to be. I'm not interested in solving world peace here. I just want to understand why insuring a relatively healthy family of three under a very high deductible plan costs $1700/mo, and why is it now illegal to not go along with this ridiculous rip off.
Your plan was already going up before the ACA was proposed, even if you were in medium or large group markets. (My firm offered health insurance to employees in California, New York, and Illinois from ~2006-2012.) Family health insurance on the group market was something like 1100-1200 pre-ACA.
If you're paying for your own insurance, you're in the individual market, which is significantly more expensive, and what you're seeing is, in part, the market absorbing the cost of guaranteed issue, something we decisively did not have before the ACA, when health insurers could lock people out of coverage on suspicion of a medical condition, and later rescind care. Pre-ACA and post-ACA insurance is for that reason also not an apples-apples comparison.
Is the actuarial and outcomes data corpus of the health insurance industry so bad that it makes actuarial sense to segment the markets to individual, medium group, large group, etc.? I've always wondered what the explanation is for so many cohorts.
Are state insurance regulations preventing medical insurance providers using more sophisticated risk modeling to create larger pools, or co-marketing with life insurance companies that gather pretty detailed data on individuals before underwriting?
> Are state insurance regulations preventing medical insurance providers using more sophisticated risk modeling to create larger pools
Especially post-ACA, there are very strict limits on what factors can be used to set premiums. Risk-based assessments are basically outlawed except for a few defined variables like age and smoking habits.
Yep, prices were rising before ACA and continued to rise thereafter. I'm not sure on the rate of increase, but the absolute levels are getting to the impossible.
Regardless of the cause, it's extremely frustrating to be hit with such a large monthly bill for rather poor coverage. I'm not quite as bad off as 0xbear, but we're at $1550/mo for a family of three for much crappier coverage than we had a few years back.
Here in Phoenix we've seen double digit increases every year for years, and are down to a single provider on the individual market.
Paying $18k/yr before you even use a plan is insane. Use it at all and you're looking at $20 or 25k total, with coverage limits not really kicking in to stop the bleeding until you've shelled out 30k or so.
Somebody making $80k/yr just hits the subsidy payout and is spending 20-40% of income on health care. Unsustainable.
Argue the whys all you want, these sky high rates have to change.
> Argue the whys all you want, these sky high rates have to change.
If you don't argue the whys, you're mostly providing a lot of noise that is convenient cover for the next attempt to bilk insured people.
Yes, premiums are way too high. They are not high "because ACA", though. In fact, they'll rise at a much faster rate if we get rid of ACA. (The latest bill had an annual rise of $11.4K for a single male adult >62 years, with an annual income of $12K.)
There's no question ACA is broken, and we need to fix it. But we need to know and understand what is broken to fix it. A repeal won't do that.
There's a good argument to be made that e.g. enforcing cost transparency would do that. (Right now, you have no idea what insane cost your provider will charge you - they make shit up as they go). Single payer is one possible way to do that. Not the only one.
There's another good argument to be made that we need to talk about the right to die. Numerous patients are kept alive at insane costs, even though they would rather live out the last few quiet moments at home, with their family.
There's another good argument that for a decent risk pool, everybody needs to be insured. (This is an argument that stands little chance until being insured is actually somewhat affordable)
There's a good argument to be made that Medicare should be allowed to actually get competitive bids. (Right now it's rejected to "pilot projects" and "test markets").
There's a good argument to be made we need to focus much harder on preventative care. Follow-up costs from acute episodes are much higher than a decent investment in preventative care.
There's a good argument to be made we should talk about our test and prescription obsession. The amount of stuff unnecessarily prescribed "just in case" is ludicrous.
None of these will immediately lower rates. But each day we spend wasting on the theatre that is the junk the current GOP tries to ram down everybody's throats is a day they rise. And should this pass, they'll rise tremendously.
If we don't all inform ourselves as to the why's and then hold our representatives feet to the fire using well-formed arguments, so they can't weasel out, we're stuck with a shitshow. So, while I understand the frustration - I've got health care bills too, after all - an attitude of demanding change without informing ourselves what change to ask for leads to an even worse disaster.
And that feet-to-the-fire thing applies to all parties, in case you were thinking I have a particular partisan view. But it needs to be an informed roasting, or we'll merely end up with the loudest guy making the good sounding promises.
Certainly, and I am in full agreement with you on pretty much everything you said.
I'm ranting against those who continually tell me "it's not that bad", "suck it up", "you're lucky you have insurance" or some variation of the above.
The first step in fixing the problem is to recognize the problem, and there's many I've talked with that reflexively reject the premise that there is a problem in the first place because of what that means for the ACA.
The foundational issue is that we're stuck in an uncanny valley between single payer and private insurance. Either single payer or private could be viable, but not the unholy menagerie we have now.
The high costs, over prescription and under prevention that are bloating the system all driven by that issue and could be solved with a single arbiter that gets the bill, whether that be the government or the citizen.
The best proposal I've seen is a two-tier system like Germany has, with public healthcare for all and private healthcare available for the rich. That tends to rub Americans the wrong way because fairness, but really solves most of the problems because it gets universal coverage to spread the risk pool while accepting the natural impulse to want to pay for better care if you can rather than rejecting that option out of hand like some single payer systems do.
> with public healthcare for all and private healthcare available for the rich. That tends to rub Americans the wrong way because fairness,
I lol'ed. Because... we already have private healthcare for the rich, we just don't have public healthcare for all. Because fairness ;)
And I'm very much enamored with the German system as well, but then, I'm biased. I'm from there. (And currently pondering going back there, because as much as I love what the US could be, I hate what it currently is)
This is why Switzerland doesn't have a group market. Everyone is forced into the individual market, which makes individual polices cheaper (I.e. You can't get health insurance from your job).
The costs don't end there, though. Other than preventative care, you're also covering the first $6k or so in costs, though the insurance company will negotiate them down for you from the initial insane levels to something merely causing headaches and indigestion. I've yet to pay more than $6k per year, so essentially I'm paying the remaining 20k for the benefit of others. Not even when I broke my ankle a few years ago did the (negotiated) bills total up to more than $10k or so.
Unfortunately for the DNC, the costs many voters were measuring last November wasn't healthcare spending compared to GDP it was actual out of pocket costs that have risen dramatically for many working class Americans.
You need a source for "people care more about their family budgets than percentages of GDP spent on healthcare"? Take a look on how the middle class voted last election.
As for the increase premiums are up 25% in 2017 alone. At the same time deductibles are also rising, its much more money for much less coverage if you are unlucky enough to make over 50k a year or so.
"enrollment-weighted premiums in the individual health insurance market increased by 24.4 percent beyond what they would have had they simply followed trends"
The very next two sentences: "The observed premium increase reflects unsubsidized premiums. Insurers receive the full premiums each month, regardless of whether they are paid by the individual or the federal government (IRS 2014). Thus, although the data reflect premiums received by insurers, individuals likely faced smaller changes in premiums after taking the subsidy into account."
It's remarkable that premiums didn't rise more under the ACA, despite how many new previously-uninsurable people were covered.
... and this underplays the effect, because the plans being sold under the ACA have a higher cost basis for insurers than pre-ACA plans do. You can easily observe this for yourself if you're in a major insurance market by calling up an insurer and asking for prices on non-ACA-compliant plans, which are still sold.
> If the RNC wanted to show what has happened to employer-sponsored premiums under the Affordable Care Act, it should have started the clock in 2010, the year the law was passed. But that makes Obama look better. The rate of growth in average premiums from 2010 to 2014 is 22 percent.
That's why factcheck should not be used to check... facts. Just as they claim the RNC have twisted this and that to make themselves looks better factcheck is twisting things here as well, to make someone else look better. Health insurance providers had raised premiums in anticipation of the vote and the legislation passing. So it's specifically important to look not at 2010 when it was signed into law but a few years below when there was this uncertainty about it. One way market deal with uncertainty is to hedge their bets. "Not sure what will happen, but this might pass, and why don't we just raise the rate now" kind of idea.
I've heard this directly from the health insurance representative who came and told us told us, "sorry but rates are going up sharply because we anticipate this new legislation".
But they did during 2009. By July, a number of bills were already approved by committees in the House. And the Fall is usually when the companies get prices for the next year. So it went up sharply then. Then in again in 2010. Price is not always comparable because the level of coverage had also changed. We had to get new plans and while they covered some mandatory free procedures and didn't have lifetime maximum, they had also bigger deductibles and a reduction in options and procedures covered.
That doesn't mean we'll find a larger jump there, I found it for my self, but the KFF study shows there wasn't in general. However discarding date legislation has passed is also dishonest as factcheck did. Companies which are affected by regulations monitor them closely and adjust to them correspondingly.
Even then, the ACA came up pretty quickly after Obama got elected, they had one or two years to back up premiums, and premium increases seem to have remained steady during that time. What the ACA did do is outlaw junk insurance policies that were cheaper but not useful as health insurance.
Deductibles haven't 5x'd (let alone 10x'd) under the ACA, which, for what it's worth, caps deductibles. Before Blue Cross made it annoying to do this, we did the standard HSA+HDHP plan (most young families should HSA+HDHP), and it was a little annoying getting a bronze plan from BCBS with a deductible high enough to qualify as an HDHP for our HSA.
For some context, the Kaiser family foundation's 2016 Employer health benefits survey available at http://www.kff.org/report-section/ehbs-2016-summary-of-findi... suggests that the average in-network deductible for a single worker has increased from $917/year in 2010 (when the ACA was passed) to $1,478/year in 2016 -- not adjusted for inflation. While more people are using high-deductible plans, the growth in any specific plan type (eg, HMO) is about the same.
Without adjusting for inflation, this growth is ~60% growth in 6 years, or a doubling time of ~9 years. After adjusting, it's more like 40% over the same 6 years or a doubling time of ~12 years.
The article I linked to includes links to peer-reviewed research by the Kaiser Family Foundation. They look at the actuarial value (how much of your health costs the plan actually covers) to compare apples-to-apples. If you care about these subjects, I really encourage you to dive in and learn about them, rather than throwing out unsubstantiated anecdotes.
There are a couple of forces at work: 1. Medical folks charge more over time, for...reasons. 2. Previously insurance could be sold tailored to the customer's ability to pay; but that insurance didn't actually cover many useful things and had a low cap (hence was almost worthless). ACA disallowed that and made insurance industry offer policies that cover the stuff a regular person needs covered.
So you could have the impression that you had "cheap insurance" as long as you never need to have significant healthcare paid for.
I made significant use of my healthcare pre-ACA ($30k-$50k charges before insurance). All of it was in-network, covered, and a small annual premium.
The very year ACA took effect my health plan was canceled, my doctor went off-network, my new plan had 3x the annual premium and has grown 30% year over year, as have deductibles, and I fight tooth and nail every single charge to make sure it is in network and covered.
Yes, one anecdote is not data. But there is no more validity to the politician's lie that I can "keep my health plan, keep my doctor, and health care costs will go down."
In Florida, Blue Cross Blue Sheild had a plan called Go Blue pre ACA/Obamacare, it was a kind of bare minimum coverage but monthly premiums were like $80 and BCBS of Florida carries one of the best reputations and has one of the largest networks of providers.
Something like 80,000 Floridans lost that policy because it didn't carry the minimum services under ACA/Obamacare. But it wasn't just losing the policy, they were never able to afford the new blue cross blue sheild policies, having to purchase from a new insurer most of whom had reputations as fly by night operations (many not existing before ACA and shutting down 1 and 2 years in), and finally losing the good BCBS network.
"The very year ACA took effect my health plan was canceled, my doctor went off-network, my new plan had 3x the annual premium and has grown 30% year over year, and I fight tooth and nail every single charge to make sure it is in network and covered."
Same here, and I hear the same exact story from most people I talk to. Plans dropped, premiums skyrocketing. Here in Phoenix we've got a single insurer left, and we'll see if we have anybody next year.
What I haven't seen is stories of average joes who were substantially helped by ACA. Sure, if you didn't have coverage before by cost or pre-existing condition, or get subsidies now, maybe you're happier. But the vast middle class, not so much.
Post ACA I'm able to get my wife insured (congenital heart issue fixed forever at 14, still used to deny her coverage at 27), and my premiums dropped. We're rather firmly middle class, pretty sure I didn't qualify for any health subsidies, I think student loan deduction and mortgage were it.
So there's a face for you, 32 year old, healthy, middle class, white woman who likes cats, rides horses, and has a pet bearded dragon who she talks to in a baby voice can get regular cancer screenings because of ACA.
Average joe here: pre-ACA, I was uninsurable. My pre-existing condition was having had an organ removed in my 20s. No one would insure me when I went to buy it.
Post-ACA, I could once again buy health insurance.
I consider no longer being locked out of the US medical system a substantial help.
My partner is middle-class and was able to pursue education and a career more freely because she could remain on parent's isurance until age 26. By the time she hit 26, she was on her employer's insurance.
Consider also the not middle-class recipients of medicaid expansion.
If you're curious, the non-partisan KFF has pretty comprehensive data on how average premiums for single and family coveraged have changed from 1999-2016. The increase is pretty darn linear: http://www.kff.org/report-section/ehbs-2016-section-one-cost...
I recently read that while 80% of Democratic voters support single payer, their members of Congress prefer something that keeps insurance companies in the loop snd profits high for the medical industry. Presumably because of donations.
If that's the case, then the difference between Democrats and Republicans is that the Dems want to insure the poor while still ensuring high profits for the industry, while the Republicans want to screw the poor while ensuring high profits for the industry. They differ on one very important issue, but are still mostly the same.
Actually reducing medical costs requires a far more thorough overhaul of the system.
The problem isn't abuse on the billing side per se. The problem is that insurance is about risk management. In laymen's terms, it amounts to taking a bet. When you insist that private insurers cover people with pre-existing, incurable, chronic conditions, there is no "bet" to take there. It is all downside for the insurer. It amounts to charity. This fact then seriously distorts the business model, driving up costs for everyone in a big way. It has to be covered somehow.
We need a single payer system because, at the societal level, it makes sense for government to make sure people get their healthcare needs met for the same reason it makes sense for government to provide police and fire protection. But forcing all Americans to get private health insurance makes no sense and indicates a fundamental misunderstanding of what the insurance industry does.
Direct Primary Care, single payer and wellness programs all have a good track record of genuinely getting people healthier while bringing down costs. Obamacare cannot do any of those things and just runs expenses up.
Source/qualifications: Among other things, I worked in insurance for over five years. I have a certificate from a technical college in life and health insurance, paid for by my former employer.
The insurance model is at the heart of the medical system's issues; it distorts the market by disconnecting prices from providers and consumers and severely disaligns their interests.
The provider must set a high sticker price so that they can give the insurer the expected 60-80% discount to get in-network (and still tolerate underpayment and other shenanigans). The consumer is either intentionally misled or confused (usually both) about basically everything cost-related, and often won't learn the true out-of-pocket cost of a service until ~1 year after receiving it, when the billing process has (mostly) finished.
Example: just yesterday I got a new bill for a routine lab test I received in December. It says that the insurance discount applied, but they never sent a payment, and thus I owe a balance of over $200 to the lab company. Now I have to call the insurer to figure out why they denied payment, which is sometimes due to an administrative error, sometimes a paperwork thing like signing a document that verifies there is no other possible insurance carrier whom may have been responsible for the bill, etc.
Obamacare is thus anything but up front, because honestly working to fix the American medical system would involve excising market-breaking, paper-pushing leeches from the marketplace, but Obamacare props up this destructive apparatus by forcing every American to pay in or get fined.
Not only the insurance model, but the encouragement of health insurance as an employer benefit. It adds one more aspect of indirection to an already complex health system.
> Almost any politician will tell you that taxing employer-sponsored health insurance is a "3rd rail".
Every employer outside of the health insurance and drug industries should be furious at the price they pay to pay their employees health benefits. Besides having a distraction that operating businesses in other nations don't have, they're likely paying more than double than what they need to in this area to maintain competitiveness against other nations. It's even worse for startups.
The ACA should have relaxed employer requirements and pushed people to exchanges; instead, it increased employer requirements.
It also probably should have used subsidies instead of Medicaid expansion. Expensive, but a bunch of healthy people would have been good for the exchanges (Medicaid expansion almost by definition was for healthy working people).
> it feeds my conspiracy thinking that the Democrats are actually largely indistinguishable from Republicans
Have you been watching anything that's been happening with the healthcare debate over the past, oh, 25 years? The Democrats have been trying with varying degrees of success to inch this country in the direction of a more sensible healthcare system and the Republicans have pitched a generation-long hissy fit about it.
From my observations, neither side has done much to reign in the cost of the cost of hospital services and doctor/nurse compensation, which are out of line with our developed world peers.
On the coverage side, the two parties have contrasting stances.
Healthcare and Health Insurance are related but distinct topics.
Obamacare does include a bunch of tools to help keep overall healthcare spending down. As far as I'm aware, they have helped. But there's a long way to go.
I'm actually not sure the BHCA or AHCA or whatever it's called now has much in it besides slogans and major spending cuts which aren't aimed at making care less expensive -- they're aimed and reducing the overall amount of care provided by shifting costs to those less capable of bearing them.
Correct, the GOP plan only seeks to "correct" (in their minds) the extent to which a wealth transfer occurs through the health insurance vehicle, via federal programs, direct aid to states, subsidies, etc.
Cost of healthcare, other than the occasional conversation about drug prices and definitions of necessary care (which continues to be abused by practitioners), continues to take a back seat.
For what it is worth, my personal opinion is that the medical professional lobby is a single issue voting constituency that is just as powerful as the NRA and the teachers unions.
I'd challenge anyone to present a link to a substantial article or video where a noteworthy democratic politician actually addresses in detail some of the very big problems in the current system, rather than just speak in feel-good generalities that if implemented could easily allow corporations to continue charging at current levels for delivery even under a single-payer system.
Until then, I will continue to believe democrats and republicans serve the same master and only differ in language to provide an illusion of choice.
That's more of a history lesson than a political one. Democrats and Republicans have wildly different perspectives on healthcare. Democrats tend to believe it's a universal human right. Republicans seem to think whatever solution the free market decides is the right solution, even if it means not everyone gets access to healthcare.
Well the progressives including President Obama pushed for single payer (or a public option) which would eliminate abuse on the billing side, at least to the insured.
If the democrats were serious, they could have deployed the "nuclear option" on this (suspend Senate rules). But of course there was more than one person's objection going on.
Ipso facto there weren't enough votes to suspend the 60-vote in the health care case.
But that's not always the case - Neil Gorsuch was confirmed by a vote to suspend the 60 vote rule. So the rule is available for things that a strong party consensus.
I think that's quibbling. If votes to abolish the rule for a case are available, it's reasonable for a single suspension vote to be possible to.
Both sorts of actions decrease the power of individual senators. If anything, abolishing for a whole category reduces senator's power more - if you also read the article, the basic point is the action indeed altered the power dynamic, what those considering individual senator power are worried about.
It's a perfectly reasonable question to ask whether the 60 vote threshold can survive for any kind of legislation in the future. In particular, here is an argument that American democracy is doomed because of the way partisanship ratchets towards more extreme mechanics over time: https://www.vox.com/2015/3/2/8120063/american-democracy-doom...
However, it remains the case that in 2009, 59 senators were ready to vote for a public option, but there was no 60th. By contrast, there were nowhere close to even 50 votes for removing the filibuster and changing to a 50 vote threshold.
Please do not miss the fact that Lieberman had no rational justification for opposing the public option and that one of the keenest observers at the time accused him of being "driven more by a pathological dislike of the liberals who dogged him in 2006 than by any remotely rational policy judgment."
http://voices.washingtonpost.com/ezra-klein/2009/12/lieberma...
Sure, 59 People were ready to vote but not so ready they'd take the action to remove the limit.
Those are the facts. You are laying emphasis on the one person who wouldn't vote and I'm laying emphasis on the 51+ wouldn't take take stronger action.
I think it's reasonable to give my emphasis given the way the Democratic Party has behaved over time.
On the other hand, if they had removed the limit, (a) there would have been an even bigger Republican backlash against "Obamacare" (if that's possible), and (b) the precedent would have emboldened Republicans to suspend the filibuster for their priorities as well. Result? In 2017, the Senate would have more motivation to repeal Obamacare and fewer limitations: they wouldn't have to shoehorn the repeal bill into the reconciliation process to avoid the filibuster, as they're currently trying, which (among other effects) limits the provisions they can include. And so they'd probably have passed their bill, and the public option would have died in 2017, just a few years after its creation.
I suppose that voters could have hypothetically had a positive reaction to the public option once actually set up, and rewarded Democrats for it in subsequent elections. But I doubt it. Although Medicare already exists, the public option would represent a significant expansion which would probably come with serious growing pains - plenty of material for Republicans to make horror stories out of. Probably fewer actual cases of huge premiums (which are already not that common), but it's not like statistics have ever been much barrier to politicians and their preconceived narratives. I guess the GOP wouldn't have been able to weaken the law through a constitutional challenge, as they did with Medicaid expansion - after all, the public option can't be unconstitutional unless Medicare is. But the Supreme Court is highly political, and I wouldn't be surprised if the law ended up being weakened some other way by a 5-4 majority...
But politically, Republicans would have a stronger alternative to offer: ACA without the public option. Y'know, the thing they currently portray as the root of all evil; I think they'd have ended up seeing it as a good conservative compromise, that preserved universal coverage availability without requiring the government to be involved directly. Arch-conservatives might not like that outcome (then again, they might) - but they'd likely accept it as an intermediate step, that still accomplished the substantive change of repealing a huge government program (the public option). It would be much easier to get consensus on than the repeal-in-name-only bills they're tossing around in the real world.
I suppose I'm getting way too speculative; the last two paragraphs aren't even directly related to the nuclear option, although they're meant to question the upside of Democrats hypothetically having deployed it. There would've been serious downsides, not just in health care; it's quite possible the 60 vote rule would end up being killed entirely rather than only for 'special' bills, so Republicans in the current Congress would've been able to pass a wide variety of their priorities, and repeal a wide variety of Democrats'. (For all I know you might support the Republicans on their other priorities, but the Democrats whose votes we're talking about certainly didn't.)
> I think that's quibbling. If votes to abolish the rule for a case are available, it's reasonable for a single suspension vote to be possible to.
A suspension is both procedurally (or textually) more complicated (it either requires changing the rules twice, changing the rules to add a suspension provision and then acting separately to exercise it, or changing the rules to include a tailored exception that applied only to the case at issue) and more politically fraught (rather than publicly defending the case that the general rule is outdated, it requires legislators to defend that the rule is generally valid but should not be applied to the immediate case.) It's very much not the same thing as abolishing the filibuster for a well-defined class of cases.
This is particularly true in the Gorsuch case where the recent Democratic action to remove the filibuster from other Presidential appointees made applying the “nuclear option” to Supreme Court justices much less “nuclear” than it had seemed previously when it been considered.
It was dropped because it was politically impossible and it wasn't worth burning political capital on it. Even just the public option wasn't able to gain traction; single payer was never going to happen in 2009.
I would just note that "...it was politically impossible" and "the Democrats were never serious in saying they wanted it" are two ways to frame the same reality. Both are true. Take your pick.
I'm not saying any democrats at the time were willing to go all in on it, but the two statements would only be two ways to frame the same reality if democrats had the ability to make unilateral decisions in the senate. They never did.
The nuclear option - changing the rules to allow majority votes to override a filibuster - has existed in potentia for a long time. The republicans have used it lately for things they consider crucial to their agenda. If the democrats wanted single payer and considered it crucial to their agenda, they could have done that. Of course neither of those "ifs" are true and we can use the lack of action to judge this.
> If the democrats wanted single payer and considered it crucial to their agenda, they could have done that.
And then watched it get blown away by next congress as soon as the GOP gained 51 seats to do whatever they want. Blowing away the fillibuster is an awful, terrible, no good idea and there is almost no legislative agenda which would validate it.
And to be clear, the GOP senators were and still are slimey bastards for basically everything they did leading up to Gorsuch. It should have never been done. They will almost certainly regret it as soon as they lose the senate.
As I recall, the rough idea was to adopt a Republican plan (RomneyCare) in order to achieve bipartisan support (and "stake holder" support). And then it became the evil spawn of the Democrats...
And that is counting Lieberman as a D; a person who backed McCain for president and who later personally killed the public option.
I do think we will get to the public option at some point. It just makes too much sense not to and would strengthen the healthcare as a whole while allowing people more choice.
Public option is unlikely to happen in the near future. Too many people start frothing at the mouth and yelling "socialism!" every time it is proposed.
Well, if it works anything like IHS[1], then the system would run out of money before the end of the fiscal year and then you end up paying for it anyway or not getting the treatment. I find people who say "but it will be different for us" to need some proof from the US and not other countries.
> which would eliminate abuse on the billing side, at least to the insured
How does single payer fix that? If the hospital gives you a bill and won't negotiate down, how does the government "fix" this? Which is kind of what my question is: were specifics given in the ACA on how that problem will be fixed?
Well since single payer typically refers to the government being the single payer, the bill goes to the government because you the insured are not the payer of the bill.
At the end of the day their revenue is dependent on throughput of people for their facility. If they gain a poor reputation relative to other providers they will lose. Quality of care would be the only thing they could compete on.
See: Japan where the government decides the price of procedures.
On national health insurance (monthly cost depends on your salary but for an average person it is a few hundred bucks per month) the hospital pays 70% and patient pays 30%.
It means basic visits to the doctor or dentist are very cheap here. Like $20 for consultation + medicine. ER+X-rays and MRI (appendicitis, sigh) was a little bit over $100.
Yes there were attempts made in the ACA to control costs (hence the first 'A'). However 1. the clock ran out on the bill drafting due to people voting for republicans in mid-terms and 2. Corruption.
Were there attempts very early on because I remember them drafting a bill no one even had time to read. Republicans were going to vote anything down and it seemed like Dems waited out the clock so it would be forced in at the last second, either way.
> My perception is that the problem is typically framed as a lack of insurance problem for financially challenged people, but the "abuse" on the billing side to me seems like at least as big of a problem.
If anything, the billing abuse is a much, much larger problem than lack of insurance. At least, that has generally been true since the ACA/"Obamacare" changes passed.
Billing abuse (care provider) and billing fraud (bad agents) are two aspects of the system that need some serious time devoted to them.
My thought experiment for some of this. Suppose the US government had a rider on every insurance policy in the US that said the government would pick up the tab for any amount over say $100,000 (think catastrophe insurance). Now, you would make the assumption that looking at the actuarial tables this would reduce the cost of health insurance because no insurance company is on the hook over $100,000 (thus no need to worry about the million $ payout).
I am more and more convinced that hospitals would screw this up with over billing for every damn thing and every visit requiring a stay would get jacked to > $100,000.
> Billing abuse (care provider) and billing fraud (bad agents) are two aspects of the system that need some serious time devoted to them.
We have a solution. It is called "make it a personal criminal liability". Go after individuals. No matter how low they are on a totem pole and no matter how high they are on a totem pole. Committing such fraud should lead to bankruptcy ( all assets wiped out ) and jail time.
You would be amazed how quick those "accidents" and "mistakes" stop happening.
Unfortunately, as the society we do not want to throw Suzi the billing clerk into the slammer, which means that Mike, the Billing Manager, does not get a slap on the wrist, which in turn means that Jack, the VP of Billing Revenue Optimization, does not get Jackie his wife go bananas on him when their bank accounts, house and kids college fund is seized which means that Jack is represented by the public defender and ends up in a slammer together with Suzi, who actually pushed the buttons, Mike, who told Suzi to do it, and Jack, who came up with this wonderful idea.
This is my uninformed impression of the matter as well, and if true (please, anyone with a rebuttal please weigh in), to me it is further proof that the true motive of the ACA is to line the pockets of health care provider donors, by spreading the costs over the entire population and get rid of the politically damaging stories of overcharges causing individual bankruptcy.
Socializing this theft turns it into Just Another Crisis among the hundreds of others the US has.
Having an expansive definition of theft merely serves to raise the noise floor.
The "true" purpose of the ACA was to do something about spiraling health care costs. What was passed was a "compromise" where the people pushing for a public option got nothing and the most onerous restrictions on the monied interests were rolled back. This has not been an effective solution in many senses. I decline to further characterize the issue, however; this is extremely close to a political discussion, and those are ban-worthy here.
There were provisions that addressed cost containment (ACOs, Quality-Based reimbursement models for Medicare). In fact, medical cost inflation has come more in line with general inflation since about 2009/2010. But, you're right, the market based reforms like cost and quality transparency were left to fight another day. The ACA focused more on access to coverage than it did cost.
I would not put too much weight on conspiracy theories though. The healthcare system is massively complex. It will take multiple reforms to eat this elephant.
The previous administration was working to move to different payment models to try to address it (it's not clear that the different models will have much long term impact):
That applies to any and all insurance - especially mandated insurance policies. The main job of the insurance company is to collect your premiums and the find any way to deny your claims.
As cynical as it sounds, I think I agree with this sentiment even though it's being downvoted.
The employees at an insurance company have an ethical responsibility to the company to deny any claims that do not perfectly align with the policy they sold. I don't think every insurance company is the antagonist in The Rainmaker or the car company in Fight Club, but insurance companies will try to reject as many claims as they can, straddling the line of losing reputation with consumers.
And heaven forbid you have to take an ambulance to the hospital - ambulances might not be in network, in which case you're looking at a $800 charge for a ten minute drive (that you can't make yourself due to a variety of reasons). I wasn't even in bad enough health that they would turn on the lights, so I didn't even get that small silver lining.
Then you get to sit in an "emergency room" for hours, when you're physically unable to move, and with your phone dead so you can't even let anyone know where you are. When you're finally wheeled to where you need to be, you're basically dumped in a hallway facing a wall for half an hour, and you're in a wheelchair and so weak that you can't even turn to face anything interesting. I paid about $1000 for that luxury. At that price I'd expect a decent waiting room...
Yes I just needed to vent about that situation. It sucked, especially for a college student. I was hounded for months afterward to pay those bills, because of course when you're throwing up you can pick which ambulance gives you a ride.
We had a similar experience about 8 months ago, but only one night in the hospital. Raise hell with everyone.
The out of network doctors were resolved the fastest for us, and the longest was the hospital stay itself, which our insurance didn't agree to pay until 8 months after the stay. It was a seriously draining experience, and luckily my wife doesn't work so I didn't have to take time off for all the phone calls and following up that was required.
I don't fault our insurer. The hospital charged more for our one night stay than another slightly further hospital recently charged us for three nights stay. It was completely ridiculous. But completely out of our hands.
I've had to deal with that and more in the last couple years. In my experience there are no "good" or "bad" guys in this fight. It's a bunch of individually rational entities that when taken as a whole are completely fucking over the rest of us.
I think there are "bad" guys. I've pointed out to a doctor that their agreement said that I would agree to pay any charge they decided to bill me for. I pointed out that I was in their office because they were in network for my insurance and that I couldn't agree to pay literally anything they decided to bill. So, I asked them to tell me what the maximum they might bill would be. And, they kicked me out of the office.
So, yes, if you refuse to be transparent in your billing and you extort money from your patients by refusing them treatment unless they agree to pay literally anything for service, you are a "bad" person.
The funny thing is that dental care in the US is the exact opposite. If you ask $RANDOM_DENTAI_CLINIC what the cost for $RANDOM_PROCEDURE will be, they can quote you a price that will generally be pretty accurate.
I'm told this came about because historically more people had to pay for dental services out of pocket, so dental offices were used to having standard fees that they could just look up.
Also most dental insurance will only pay up to $10-5k total per year, so its not some unlimited spout of money you can abuse like medical insurance in the USA. Some dentists offer a direct subscription plan that costs around the same amount of costs as a dental plan directly as a result.
>>So, I asked them to tell me what the maximum they might bill would be. And, they kicked me out of the office.
There are of course shitty doctors, but playing devil's advocate for a minute: you were arguing about theoretical billing scenarios while there were other patients in line waiting to be seen. So it's not exactly surprising that he got fed up and kicked you out.
wrong. I was asking about a specific procedure that I made an appointment for. They gave me a form -- after I got to the office -- which said I agreed to pay any amount they decided to charge. When I asked for clarification, they refused to quote me a price.
> luckily my wife doesn't work so I didn't have to take time off for all the phone calls and following up that was required
This.
This is so horrifically true, it takes call after call after call (and emails, and faxes, and snail-mail claims forms that take "30 days" to "process") to get anything changed, and by then you have collections companies harassing you and your credit goes down the drain. Meanwhile you must keep working and taking care of family and dealing with the actual illness/issue that led to the medical visit in the first place. It is insane.
A friend of mine was in a sports accident almost two years ago. He had a good medical insurance plan for exactly this possibility.
He fractures his pelvis into 14 pieces, and broke another dozen major bones including both femurs.
The surgeries are still ongoing although he is mostly himself again. But even two years later, he is facing a daily barrage of calls, being put on hold, no callbacks, paper shuffling, records from hospital to hospital, faxing permission sheets, fighting with the insurance company (who has threatened to drop his insurance multiple times) and on top of it all, his landlord is trying to evict him.
It's been horrible to watch. It's like the insurance company is trying to kill him with stress.
These stories have me at 'WTF USA'. Like seriously, how does the US society think this is ok? Can anyone explain this to me?
Is it a 'won't happen to me' sentiment? Preferring the freedom of literally landing on the streets with one accident since you're presumably fully in charge? I do not understand, though there must be an understandable reason.
I think the only reason anyone can think it's OK is (1) they haven't had a major medical expense yet and (2) their political tribe tells them capitalism is the answer for everything.
Honestly, healthcare in the US is so broken I don't see how we avoid a crisis in the next few years because of it. Maybe it will somehow pop like a real estate bubble (sad when that's the most optimistic thing you can hope for).
It's becoming increasingly obvious that the political tribalism is insanely strong. Enough to prop up things that might've seemed outrageous a year or two ago.
Also, don't forget that you'll frequently need to deal with multiple bills, each potentially requiring separate work to resolve.
If you take an ambulance to the emergency department, see a doctor, they order a scan, the scan shows appendicitis, and your appendix is subsequently removed, this can easily lead to six different bills:
- Ambulance
- Facility
- ED doctor
- Radiologist
- Surgeon
- Anesthesiologist
And that's assuming that the ED and hospital are under the same company (not always), and that no off-site labs are used. You may not have ever heard of the radiologist or anesthesiologist. I once had bill collectors calling me re: a radiologist I'd never heard of, who managed to ruin my credit for a good six months until I figured out what the bill was actually for.
Hospitals, doctors, and Insurance companies know exactly what's going on. They are paracites--plain, and simple. I won't get started on over billing at hospitals. It's been going on forever. Know-one stops them.
I don't buy for a minute they are just cogs in the machine. I really used to respect anyone in the industry. That respect is almost completely gone.
I am now furious thinking about our lovely medical system, along with the FDA.
This is ludicrous! I have insurance, & still this will completely drain me financially. I'm at the point where I almost think it would be easier to declare bankruptcy and start over!
I worked in insurance for over five years. Not this kind of insurance, but it was a kind of health insurance.
a) Get a letter of "medical necessity" drafted by your primary care physician.
b) Call the insurance company and ask about the policies concerning emergency treatment. Don't accuse them of anything. They get cussed out all the time and it will not help you. Be nice and start from the assumption that there must be some mistake.
c) If you make no progress with that, have a lawyer send the insurance company a letter requesting a copy of your records. This sometimes makes them look very carefully at the bill and sometimes is enough to get you whatever benefits you are legally due. Which may not be your wildest dreams of avarice, but may stave off your desire to declare bankruptcy.
If you do have a lawyer request your medical records, expect the insurance company to come back with a form letter stating they need a third party auth. Yes, a lawyer will need a third party authorization to get your medical records, but I wouldn't bother supplying them with one at the start. Just make the request without it and supply it if you really need to. If you get your bill paid because a lawyer wrote them, your lawyer doesn't really need your records. The initial inquiry sometimes gets the claim looked over more thoroughly. I am basically recommending this as a scare tactic.
There are actually a lot of errors made in paying complex medical bills at insurance companies for the simple reason that the claims processor may not see an 8 day hospital stay all that often and may have about 10 minutes in which to look your bill over and decide what is payable before moving on. I had to process 60 claims a day to keep my job. This meant I had minutes to decide what the benefits were and people who were very fast were actively rewarded for it. I often cleaned up their messes and, no, this did not get me promoted or anything, even though it sometimes kept the company out of court because the people were threatening to lawyer up.
Insurance companies and hospitals "accidentally" bill you for the wrong thing all the time, even for the little stuff.
I went to the ER for a broken hand a couple years ago, got a $450 bill in the mail when I should have just had a co-pay. Called the hospital, they said I had to pay. Called my insurance, insurance company said I didn't have to pay. Got in a three way call with the insurance company and the hospital... The billing specialist at the hospital literally said "Sorry, that's a known billing error!"
I'm generally not a conspiracy theorist, but I've never heard of a medical billing error that was in favor of the patient... If you see something alarmingly high or out of whack (especially if you've done your due diligence, read and understood your policy, and researched covered hospitals) you'd be silly not to fight it.
Fixed takes a percentage of the dollar value of tickets that get dismissed and you pay nothing for the service if it is not fixed.
Trying to get money out of an insurance company is sort of the opposite problem, though it gets monetized essentially the same way. Independent adjusters monetize by taking a cut of claims paid. This is basically the same monetization scheme that lawyers use for things like suing someone over an accident: They take a cut of cases they win, and you pay nothing if they lose. As far as I know, independent adjusters only work on real estate related claims, not health claims.
Last I checked, the only people legally entitled to talk to the insurance company on your behalf are your insurance agent of record, a lawyer or an independent adjuster. So, in practice, you would be talking about independent adjusters for the health insurance space. I am not clear that would even fly, legally.
Health insurance is a pain in part because it is very highly regulated. It has to comply with both federal and state laws in all jurisdictions in which it operates and laws for both health companies and financial services companies. Thus, it is subject to both HIPAA (Health Insurance Portability and Accountability Act) and The Gramm–Leach–Bliley Act (GLBA), also known as the Financial Services Modernization Act of 1999. I got annual training in Gramm-Leach-Bliley when I had an insurance job. Furthermore, claims must be reviewed and paid in accordance with various state laws. The company where I worked kept a database of "state exceptions." If you don't know those state exceptions yourself, good luck arguing the matter with an insurance company.
You are talking about a very challenging problem space.
I have had it cross my mind to offer a service helping people file claims with the company I once worked for. Although I haven't worked there in a while and some things have no doubt changed, I probably could help some people get more money out of their policy. But I have never gotten past the idle thought stage in part because insurance is such a pain of an industry, and in part for other reasons.
When I had back surgery, there were all these therapists coming in the moment I got out of surgery trying to get their 1 minute in. It was throughly ridiculous. One of them was attempting to do physical therapy and pulled on my leg a little and put me into so much pain I went into shock. She probably got her $600 bucks.
I am with Kaiser now and it is the most BS free medical experience I have ever had. To fix healthcare without single payer the government should just make a law that medical insurance can only be offered by hospital chains and the doctors and specialists cannot bill insurance separately, but must be paid by the hospitals. This is how Kaiser works.
That way the hospitals can pay a fair market rate to doctors and not have them demanding a surprise emergency room rate from distressed patients.
Everyone in the Bay Area loves talking down on Kaiser, but financially they've been the most worry-free experience. Had ringing in my ear for a week, went to the doctor, and she referred me to both an audiologist and MRI. Paid $20 for both of those other visits.
If I had been on Blue Cross Blue Shield, I probably would've sucked it up given my super high deductible and navigating the in-network maze.
BCBS IL is super straightforward. Every doctor is $20, unless it's a specialist, then it is $40. I've never actually been billed $40, despite seeing many specialists, so I'm not sure what actually qualifies. I've been hospitalized and paid <$1000 for an overnight stay, with visits from specialists, etc, so I'm pretty happy altogether.
My biggest complaint about the medical industry is the cost of prescription drugs. It's ridiculous how much we pay for drugs in this country.
Is your BCBS IL plan an HMO? That could explain the simplicity. I used to be on an HMO, but now it's a PPO with BCBS. The flexibility of choosing my provider hasn't been needed for my case.
Naw, I have a PPO. It's definitely one of the better plans I've seen offered anywhere though. My out of pocket cost is $1000 a year too, so that's pretty sweet.
It's not terribly expensive either. I just started COBRA and it is $750 a month or so.
I'm glad I don't have an HMO, as I'm not organized, and tracking down referrals and such would be a nightmare for me. I've never found a doctor that isn't in my network, so I just figure out which doctor is closest to me and isn't a hack and schedule an appointment. I live a couple of miles from Northwestern University Medical, and Rush University Medical Center, and they've got almost any type of doctor you could possibly need to see.
I don't think my PPO is complicated, but I've never found technical documents that hard to understand. Most of the complications seem to be for emergency and urgent care, but office visits are as uncomplicated as I've made them seem. Some types of lab work might cost more, but I've never been charged for any diagnostic tests outside of cat scans and MRIs.
While this sounds nice, I've heard too many Kaiser horror stories from family in the DC area to ever consider them even if it were an option. They've nearly killed at least three relatives of mine. If your current doctor's approach is not working, there's usually nothing you can do about it. You are only allowed two opinions, both of whom work for the same people.
I was just talking with my wife the other night about how her aunt swears Kaiser killed her dad because he came in multiple times for this cough that bothered his throat. He kept being ignored and brushed aside, and low and behold full blown throat cancer took him out. From the initial doctor visit till his death a few years later or some significant chunk of time, he was estimated to have been in his early stages where treatment was on option. By the time it spread it was too late.
I work in investment banking and cover hospital facilities (i.e. the "hospital chains"). You are right that the Kaiser model, or what the industry calls fully integrated systems, can often produce more efficient healthcare. For people that aren't as familiar with the healthcare system, I thought it might be helpful to provide a brief overview of why that is the case.
Since the ACA, there has been an emphasis on shifting from a fee-for-service model (FFS) to a value-based care model (VBC). Under a FFS model, doctors and hospitals are paid for each service they provide and make their profit from the margins built into the prices they charge for their services. In an ideal VBC world, doctors and hospitals are paid a certain amount for each patient they cover, and don't make additional revenue when they provide services to patients.
You can immediately see the incentives in each model. In a FFS world, doctors and hospitals are incentivized to give you the most care possible at the highest possible prices. For example, you could see how a doctor could be motivated to give a patient an unnecessary MRI. In a VBC world, the best-case scenario for the doctor is that he never sees you, and that you never enter the hospital. Each time you receive care, he spends time and money providing that care, but doesn't get paid any additional money for it. In other words, his margins decrease when he provides care (or, as those in the industry think about it, his medical loss ratio increases). When you become sick, the doctor would prefer that you seek care in a setting that is as low-cost as possible - via telemedicine, an urgent care center, or his office. That way, he keeps more of the monthly premium.
Practically, though, in the VBC world, the doctor probably wants to see you once or twice a year, to make sure you are healthy and that you are taking preventative measures to avoid becoming sick and utilizing healthcare. That investment of resources can help reduce your need for healthcare in the future, protecting his profit margin going forward.
So in a perfect VBC world, everyone's incentives line up. You spend as little time in the hospital or at the doctor as possible, and check in every once in a while to make sure you are healthy. Doctors and hospitals make more money when they don't have to treat you, and want to keep you out of the healthcare system.
The problem is, the current system is a mix of FFS and VBC. Most hospitals and doctors aren't compensated on a fully capitated basis (capitation is a concept that, in layman's terms, measures how close the system is to VBC vs FFS - more highly capitated = closer to VBC). Under FFS, doctors don't make much money providing preventative care, so there is no incentive to keep people away from the hospital. Unless you are a member of a system like Kaiser, you are most likely covered by a plan that is partially capitated - your insurer may share profits over a certain % with your doctor as a reward for keeping you healthy, but still pays for services on a FFS basis. Often, this profit sharing does not compare with the potential revenue from providing additional acute care services, so the old FFS incentives are still at play. (Hence the $600 1-minute consultation.)
Now, wouldn't it be great if every health system operated like Kaiser, where all the incentives are aligned and the objective is to keep people out of the healthcare system? Yes, but the answer is not as simple as requiring healthcare systems to provide insurance. In fact, Kaiser is one of the only success stories involving provider-sponsored health plans (Presbyterian in New Mexico is another).
The reason why many of these provider-sponsored health plans fail is twofold:
First, most healthcare in the US (70% I believe - but that is from memory) is provided by regional or community healthcare systems. These systems only serve certain communities (their primary service area, or PSA) and therefore certain populations. These populations are often not of significant enough size to provide adequate risk diversification for healthcare systems that provide insurance plans. One of the key reasons insurance works is risk diversification - but these hospitals can't diversify their coverage beyond their community's population. In fact, one of the most common criticisms of Kaiser from the investor community is that its membership is too concentrated in California - and Kaiser has over 10 million members on the East and West coasts.
Second, these systems often don't have the capability to price their insurance and healthcare services correctly to account for the levels of risk embedded in their insurance plans. Sometimes that is due to lack of actuarial experience, sometimes that is due to lack of risk diversification causing risk to exceed estimates, and sometimes that is due to existing healthcare prices driving up costs to a level beyond where they can reasonably charge premiums. Also, it is hard for these systems to predict who will enroll in their health plan, and what their overall risk level will be after enrollment season. There are companies dedicated to helping systems operate provider-sponsored health plans (e.g. Evolent), but this has proved to be a difficult problem. For examples of premier systems getting this wrong, look up Partners (they own Mass Gen), Catholic Health Initiatives, Northwell, Banner Health.
While this is a hard problem to solve, and I don't have the answer, you are right that the Kaiser model has in many ways proven to be more cost effective than FFS or other capitated models. It might be a good intermediate step for some of the larger systems. But there is still a lot of work to do to fix the system, and even solutions that sound good on paper have unintended consequences (for example, if you move to a single payer system to reduce prices, would lower drug prices disincentivize pharma R&D, hurting development in the US and the rest of the world? Would medical device companies making prosthetics go out of business if prices decreased below their cost levels? etc.).
Hopefully this was helpful to people who aren't as familiar with the way the system works. A less-than-perfect analogy I often use is:
The old FFS model is a "supermarket" model: the supermarket makes money by selling you as many gallons of milk as possible, and pricing the milk at a premium to their cost. The higher they can price the milk, or the more milk they can convince you to buy, the better off they are.
The current model is a "Costco" model: you pay a recurring membership fee to Costco, and can buy their products at a lower price, but (let's assume) you still pay a slight margin on those products to Costco. So, Costco would love to have as many members as possible paying membership fees - and, in fact, could offer its products close to cost if there were enough members who didn't use the store. But, they would still prefer that members use the store as much as possible, and buy as much product as possible at the highest allowable margin for Costco.
The "ideal" VBC model is a "Netflix" model: you pay a recurring membership fee to Netflix, and can stream any of their videos for free. Netflix starts out the month with its $10 of revenue from your membership, and each video you stream causes them to incur streaming costs and royalty payments, reducing their margin on your $10 throughout the month. From a pure profit perspective, Netflix would love to have millions of members who never used the service, allowing Netflix to keep 100% of their membership fees. However, in order to grow and be successful, Netflix needs members to use and love the service, so it "invests" some of its membership fee by streaming videos to users. If users are going to stream, Netflix would prefer that users stream its proprietary content, which is lower-cost for them to provide. (That last part of the analogy is stretching it a bit, but meant to demonstrate that for the health of the system, some utilization is required, and the provider would prefer that utilization to be as low-cost as possible.)
I appreciate the time it took you to explain all that. You did a good job.
I am in the opposite camp and don't have the time to write out my position to the extent you did. However, I'd just like to take a moment to point out the ludicrousness of calling something that isn't Fee For Service "Value Based", as if there's anything in the world more "value based" than paying someone for the value rendered in a specific service.
Thanks. I would be interested to hear your perspective.
I agree that "value based care" is probably not the best name for a fully capitated system. (Population health might be closer, but still not perfect.) By definition the "value" of something is whatever someone is willing to pay for it. A doctor's reimbursement rate is negotiated with the insurer, so there is an explicit agreement to pay that rate for that service. And by being a member of that health plan, the patient explicitly agrees to pay whatever deductible or copay is required by the plan, based on the rate the insurer negotiated with the doctor. So in a FFS system everyone has actually agreed to pay the price that is charged.
The problem is that as a patient, it is hard to tell how much a medical service will cost before receiving it. In a grocery store, you can look at the price of milk and decide whether it is worth buying. But there are all sorts of reasons why price consciousness is harder with healthcare (for example: emergency care, lack of price transparency, agency issues). And so the idea of value is harder to measure from the patient's perspective, which is why value and price paid may not exactly match.
Thanks, I'm glad it was helpful. We work with 501c3 healthcare providers, like Kaiser, to (a) help them raise capital through the public debt markets and (b) provide strategic advisory/M&A services.
Similar story. Lab is "out of network", declined insurance's offer of payment. No one bothered to check coverage beforehand. I didn't even know to ask.
You may have some recourse with the insurance company because for emergency care that leads to an admission, the hospital being in-network is supposed to be what counts. Individual doctors being out-of-network should only come into play if you have a procedure done at their practice's office. I sincerely hope it works out for you. It might not hurt to get a 1-hr consult with a lawyer and send the insurance company a nasty letter?
That depends on the state. Most states have no laws against this.
Also, if you read your insurer's fine print, you'll find that they will only pay out-of-network providers to some limit that they and the provider agreed to. Even in an emergency situation, you will foot the bill for the delta.
This sounds like fraud to me. Fight it legally!
A co-worker told me that this happened to her, and that made me not take the in-network only plan, but I got the PPO instead. I still think it's illegal or morally not right what they are doing, so we should all fight this practice!!!
Sadly this is how hospital stays are conventionally billed. The cost of being admitted covers only the bed and routine nursing, literally everything else is billed separately. As unfair as it is, the best patients can do is vehemently question the necessity of any interaction with a physician, or else get billed for it. And good luck with that if your case is complicated and you're getting referrals to a wide range of specialists.
And honestly, when you're admitted to the hospital unexpectedly, you're probably not in the frame of mind to be questioning everyone who comes by. I know when I was in for a few days, I only recognized the name of one of the hospitalist doctors that later billed me. And the bills can come months later!
Most importantly, most states have laws mandating insurers use in network rates for certain instances of using out of network providers, including in factual instances like you described (i.e. in network hostitals and out of network providers). Seperately, most states have statutes awarding attorneys fees to the insured when claims have been denied in bad faith, like refusing to adjust bills to in network rates when mandated by law.
My wife and I had a mid-pregnancy scare last year (all is fine). We spent a week as petrified maybe-first-time parents waiting for our turn to get some genetic tests done. I kept returning to the thought about how we had to wait a week, but that people in less fortunate countries might end up facing a massive financial decision. I felt a mix of national pride, relief, and terrible anger for my friends who are forced to intermingle medicine and money.
I had a similar experience with some nurses that showed up during my daughter's birth. It was an in-network hospital, pre-approved by the insurance company. The provider that sent the out-of-network bills included a letter with word-for-word what to say to the insurance company (along the lines of "no in-network option was available to me"). I called and opened a grievance because my plan had no out-of-network coverage. Strangely, the insurance company accepted one out of two bills from the same provider. The second bill they passed through against the deductible which I was able to get reimbursed from my employers HRA. Needless to say, this year I moved back to a plan that included out-of-network benefits.
Wait it out until things settle (in processing, and until actual bills come in). I was in a similar situation and claimed this was news to me and inappropriate (others have said they have a window to notify you). Keep pestering them and they'll likely drop it.
> They are selling services without providing prices...
And it takes a state license for them to operate. The state could require them to provide an accurate and up-to-date price menu in order to remain in business.
I think the problem is also related to the opaque negotiated prices that "in network" providers negotiate with insurance companies, driving up the cost for uninsured or "out of network" consumers.
There are perfectly rational solutions short of single-payer.
Charlie Gard has nothing to do with single payer. In the UK, if the NHS won't fund something (normally because it doesn't work or is horrifically expensive - see NICE for the gory details) you're free to go private.
In Charlie Gard's case, the parents have raised the money to take him to the US for the pioneering 'treatment'. The court's barred them from taking him because they've ruled that doing so is not in his best interests, and that he should be allowed to die. Which is pretty damned unusual for the English courts, to be honest. And given he got a full hearing at the supreme court, and his own advocate, and it's not a matter of money, I'm inclined to believe the doctors and the judges.
But even if you think they're wrong, it's still not about single payer.
Single payer wasn't the problem with his case. No health insurance company would have voluntarily paid for an experimental treatment for him.
The state has power, even in the USA, to make decisions for the benefit of children if the state decides that the parents aren't acting in the best interest of the child.
There is a perfectly valid argument to be made that the state should not have intervened (this is subjective), but it had very little to do with the NHS being single payer.
And by choosing to use the single most emotionally charged case, you are also skipping all of the perfectly rational arguments against the broken health care system we have now.
In the U.S., the doctors do not have standing to appear in court and order treatment, or non-treatment, for a patient. That is solely up to the family, and if there is no family, the court appoints a guardian. There is no way this situation could have happened in the U.S., where the parents were forbid to pay for own treatment.
I think it does concern single-payer. I can only think of the quote, "A government powerful enough to give you everything you want, has the power to take everything you need away". In this case, where the government controls healthcare, it can make decisions for you, even if that is not what you want, or are willing to pay for yourself.
I'm not entirely sure that's true in the US, that people can make medical decisions on behalf of a minor without any legal coverage of whether it's in their best interests, but I'm not familiar enough with US law.
"One of the factors that influenced this decision was that Charlie’s brain was shown to be extensively damaged at a cellular level. The clinician in the US who is offering the treatment agrees that the experimental treatment will not reverse the brain damage that has already occurred.
The entire highly experienced UK team, all those who provided second opinions and the consultant instructed by the parents all agreed that further treatment would be futile – meaning it would be pointless or of no effective benefit."
Edit: oh yes, and the court submissions are interesting reading (via twitter:) https://t.co/Wjs7KrRWMU
> When the hospital was informed that the Professor had new laboratory findings causing him to believe NBT would be more beneficial to Charlie than he had previously opined, GOSH’s hope for Charlie and his parents was that that optimism would be confirmed. It was, therefore, with increasing surprise and disappointment that the hospital listened to the Professor’s fresh evidence to the Court. On 13 July he stated that not only had he not visited the hospital to examine Charlie but in addition, he had not read Charlie’s contemporaneous medical records or viewed Charlie’s brain imaging or read all of the second opinions about Charlie’s condition (obtained from experts all of whom had taken the opportunity to examine him and consider his records) or even read the Judge’s decision made on 11 April. Further, GOSH was concerned to hear the Professor state, for the first time, whilst in the witness box, that he retains a financial interest in some of the NBT compounds he proposed prescribing for Charlie. Devastatingly, the information obtained since 13 July gives no cause for optimism. Rather, it confirms that whilst NBT may well assist others in the future, it cannot and could not have assisted Charlie.
The issue is who gets to decide for the child. In the U.S. it's the parents, not the doctors or the court.
My concern is that if there is a single payer health care system here in the U.S., the patient will lose control of their health care decisions, as it appears the parents of Charlie Gard did.
Charlie Gard's parents were free to pay for experimental treatment throughout the course of his illness up until the point where legally they were stopped from doing something that was considered bad for him. Here in the UK we have a single payer public health service and privately paid services. People are free to choose which they use.
Even ignoring that fact though, the idea that hundreds of thousands of people should face financial ruin and all the negative societal effects that carries with it because extreme outliers need to be handled separately is an utterly broken way of running a healthcare system.
Note to bystanders: Trump mentioned Gard on Twitter; he's clearly being invoked in the context of the attempted Obamacare repeal. There is a very large industry invested in convincing people that healthcare that doesn't arbitrarily bankrupt people is a bad idea.
Yeah, it won't work. It works in every other developed nation in the world, and they all pay less money for better healthcare outcomes, but hey, the US is Totally Special.
> It works in every other developed nation in the world
The cost side works in every other developed nation? Surely you're aware of how much more expensive health care costs are in the US, so what might you be referring to?
Friend of mine ended up in hospital in the US for a while. He had an accountant visit him at his bedside! WTF does an accountant have to do with healthcare?!
The US already has single payer for a good fraction of the population and we still spend more than other nations on that fraction. The NHS in the UK can decide that certain treatments are not cost effective but in the US we have people raising the cry of "Death panels! Death panels!" at even vague gestures in that direction. And the US had never had a particularly high level of bureaucratic efficiency compared to most countries.
Which isn't to say that single payer wouldn't be an improvement on the current system. Just don't get your hopes up for how much money it'll save.
> The US already has single payer for a good fraction of the population
No, we don't. Medicare is not single payer, though it has (for a subset of the services covered by Medicare) a default public option; it also has private, partially-public-subsidized pland; Medicaid, at least in many states, is not single-payer, either, even at the state level, even before considering overlap with Medicare and other insurance.
Reminder: the US already spends more public money on healthcare as a percentage of GDP than Belgium, the UK, Switzerland, Finland, Canada and many others.
In addition to being wrong about the massive cost differential, this disparagement also ignores the fact that U.S. longevity hasn't kept pace for decades:
Before I answer this, let me frame my opinion: I very much want single payer in the United States, and were it plausible to do it on a state-by-state basis, I would support it.
Apparently, states are unable to restrict entry into state benefit programs such as healthcare. They can't set up a waiting period for people moving into the state before they are eligible; that was declared unconstitutional by a previous Supreme Court. So if states were to do their own single payer system, in theory sick people could move into the state and immediately gain free healthcare simply by virtue of being a resident. Conversely, they could then move back to their home state that doesn't charge higher taxes.
So it wouldn't be feasible on a state-by-state basis unless a future SCOTUS reverses their precedent. This is unlikely in the short term, given the current Court's make up.
> Changing things so all taxpayers are getting robbed rather than just the individual being treated
Government programs set maximum reimbursement rates and also mandate cost accounting mechanisms to assure that actual reimbursement is not merely within pre-set rates but also justified by actual provider costs. The government isn't buying services with no advance information about what the charges may be.
Private insurers impose similar controls.
So single payer (or even universal coverage through private insurers) eliminates the particular kind of “robbery” from undisclosed charges being discussed.
If you don't have a house that has more than 120k in equity, or a bucnch of expensive personal items; declare a chapter 7.
(I believe 120,000 of the personal home is safe in a bankruptcy in California. Texas has has am unlimited homestead exemption. Meaning you can own a mansion, and keep it in a bankruptcy.)
Don't pay the paracites a penny.
Look into doing a straight chapter 7 yourself. I'm planning on doing mine. You'll save $3000 by doing it yourself.
I'm glad you feeling better. They have become weasels. And to those that think hospitals, and doctors don't come after payment; they do. They can be very aggressive.
Is this considered normal? I honestly think I'll take my chances than pay that much per minute. Of course I'm thinking in ₹ and my current salary in ₹, which must be vastly lower in absolute terms than the average American.
Over here (in Europe) we get the impression that US has such a crazy healthcare system. Why aren't people marching in the streets? Is it not as crazy as it sounds for most users? If you're taken to ER how are you supposed to know if the doctors are all part of "your network" (whatever that even means)?
Fellow European (UK) here. From what I understand one argument often given, is that there's a mistrust of the government for anything like this and people prefer to "shop" for it themselves. By making their own choice (even if all that actually means is picking from 1 or 2 options given to them by their employer) - they feel empowered and in control of it. There is a general feeling of "if you want it, pay for it".
This StackExchange answer sums up it up succinctly: https://politics.stackexchange.com/a/16372. I find it immensely saddening; the same goes with the general population's attitude to education (in many countries) or providing housing.
For what it's worth I know a lot of people with private healthcare in the UK with the attitude that the NHS is complete trash (something I very much disagree with) - I fear this sort of mindset is spreading. "Pull the ladder up jack" as they say.
Unfortunately the NHS is, in many ways, pretty bad. They're pretty good at dealing with pregnancies, cancers, and emergencies but try getting seen for a chronic pain and you'll follow this rough timeline:
- Try see your GP. Wait 2 weeks until your appointment.
- GP will give a cursory examination and recommend a dietary change, taking ibuprofen/paracetamol, and to come back if problem persists.
- Problem persists. Book in with your GP and wait another 2 weeks.
- GP will actually examine you this time. They may then refer you to the local hospital, and so you should await a letter.
- about 2 weeks later, the a will arrive saying that you should phone up to make an appointment.
- within 8 weeks you should get another letter telling you when your appointment is, which will be within 4 weeks.
At this point you have spent 20 weeks just to get seen by a specialist. And that's assuming everything goes ok. Admin may not update your details, so the letters go to an old (or wrong) address. They may just entirely forget to make an appointment for you. Probably if you try phone them they just won't pick up the phone.
There's a fetishisation of the NHS in this country that protects it from a lot of criticism. Some will say "well you should put up with that because it's free" or some similar rubbish, ignoring that it costs £2200 per person.
None of these issues are restricted to the NHS. Any large organisation will have such issues. But it's utterly frustrating stuff like this that makes me consider going private - I shouldn't have to spend hours on the phone figuring out why I haven't been assigned an appointment despite being referred 3 months ago.
In contrast, to America working for a good employer:
1. Schedule with GP. Say I am in pain. Get in within 2 days.
2. Get a referral to Physical Therapy. Asked if I have any preference where to go. My doctor knows my network and gave me a number of choices that were within network (a number of which were within walking range of where I lived).
3. Call PT office. Schedule an appointment. They apologize that their next opening is a week away. Gladly accept.
Physical Therapy is interesting in that it is semi-free market and rather competitive, so it tends to work a bit better than some other scenarios.
Just to add another perspective also working in America for a good employer:
1. Schedule with GP, get appointment very quickly.
2. GP has no idea who is "in network" for you and doesn't seem to care very much. They also don't understand the different insurance plans so have no idea if you're covered for certain types of referral.
3. Schedule appointment with a specialist. Ask for up front cost estimate for consultation/procedure given your insurance plan. Unable to answer.
4. Go to appointment anyway as you don't have many other choices.
5. Receive astronomical bill for some obscure billing code that is not covered by your health plan.
6. Spend time calling doctors office and insurer to figure out the situation and try to avoid or reduce bill.
I've experienced the NHS too - for all its flaws, the peace of mind living in the UK from a health standpoint is worth every penny of the associated taxes IMO.
> In contrast, to America working for a good employer:
> 1. Schedule with GP. Say I am in pain. Get in within 2 days.
> 2. Get a referral to Physical Therapy. Asked if I have any preference where to go. My doctor knows my network and gave me a number
> of choices that were within network (a number of which were within walking range of where I lived).
> 3. Call PT office. Schedule an appointment. They apologize that their next opening is a week away. Gladly accept.
> Physical Therapy is interesting in that it is semi-free market and rather competitive, so it tends to work a bit better than some
> other scenarios.
Speaking from recent experience, on Obamacare:
1. Live with pain for 6 months because you know you're not getting out of a specialist's office for less than $750.
2. Cave in when the pain becomes unbearable and see a specialist.
3. Make an appointment for PT with a provider who doesn't take insurance at all, because the transparent pricing means no surprises.
4. Pay out of pocket for PT appointments.
5. Spend the next 4 months getting bills for your one specialist visit. Half of these are coded wrong so insurance won't pay. Spend 2h every week on the phone trying to get it sorted out.
If you talk to whoever does the specialist's billing at any point, you'll find that they're totally unable to estimate the cost of services. You might as well not even try to figure out how much it costs in advance.
Two days to schedule with a GP? That's insane... In Australia (with our universal healthcare) it's pretty much always same-day for a GP... X-rays and blood tests are generally same day and free, I've even had an MRI scheduled for next-day (just a knee thing, not an emergency) and again no out of pocket cost.
Another Australian report - I don't go to the doctor often, but can usually get a GP appointment the same day (they're often running late and waiting is boring, but that's the worst of it). When I recently needed a blood test, I showed up without an appointment and was finished and out of there within 10-15 minutes.
GP is same day for anything important, and if I am willing to see any GP I can go to a walk in clinic (urgent care). My GP is rather popular a it can take a day or two to get in and see her. The 20+ minute appointments are super nice though.
Chronic pain is an extremely tricky phenomena. A lot of US health care been "dealing" with it by handing out opioids and we can see the devastating effect of that. Even a given physical therapist may not be able to help a given patient (assuming some body of some sort could at all).
Similarly, a smart consumer may be able to find a massage therapist with skills in a bodywork subdiscipline that happens to really help them (I favor trigger point and Shiatsu massage after sample a bunch in my area). This is cost effective compared to just about everything and something I imagine someone in UK could find in the larger cities.
This is very true, but, what saddens me the most is that rather than attempt to fix it (for all of society), the failings are used as an excuse to push further privatisation.
It feels to me that we in the West are going ever faster backwards over fairness in issues like education, health and housing. I'm lucky to be well off & healthy enough to not (yet) be affected by a poor performing NHS but I wish we, as a country, would pull together on this - from top to bottom. Unfortunately, I just don't see it happening anytime soon, we seem to be increasingly more divided - religiously, economically, politically - than ever before.
Society feels increasingly like a "Mad Max" movie in operation. This is only going to end badly for everyone. There is way too much "me me me" from all levels. I find it emotionally exhausting to think about.
I don't begrudge anyone who has the means to get private health care from doing so (my girlfriend and many friends do) - so please don't think I am saying nobody should - I just wish there was a more proactive and pragmatic desire to fix the root issues. Of course, I realise I am living in cloud cuckoo land on that.
I should add that I can certainly empathise and can agree with your comment about chronic pain. My father is suffering from sciatica and it has been over a year to get an operation scheduled. This will involve him travelling from Northern Ireland to the Midlands because there is an even longer (multi year) wait to be seen in NI.
> They're pretty good at dealing with pregnancies, cancers, and emergencies
I agree with everything you say, except the part about cancer.
Even by European standards, the NHS is actually quite terrible at dealing with cancers - even "routine" cancers (like breast cancer and prostate cancer), let alone rare cancers. The five-year survival rate for prostate cancer in the UK is 55%, whereas in the US it's upwards of 90%. (Prostate cancer is an incredibly treatable form of cancer; for most people, as long as it's detected early and managed appropriately, they will die with prostate cancer as opposed to from it).
Of developed countries, only Japan, Portugal, and Denmark have worse five-year survival rates for prostate cancer.
> The five-year survival rate for prostate cancer in the UK is 55%, whereas in the US it's upwards of 90%.
Such survival rates are from date of diagnosis; IIRC, because prostate cancer detected early usually doesn't have interventions that are less harmful than the cancer is likely to be, there's considerable debate about the utility of screening; there has been considerable argument that the US tends to overscreen and over-intervene for prostate cancer.
If the UK doesn't do that and tends to screen in a way that tends to catch less of the less-imminently-dangerous prostate cancers, it would have a lower 5-year survival rate simply by not diagnosing prostate cancer where the diagnosis isn't usefully actionable; this doesn't mean they are actually worse at dealing with it.
> Prostate cancer is an incredibly treatable form of cancer; for most people, as long as it's detected early and managed appropriately, they will die with prostate cancer as opposed to from it
Prostate cancer is very often an extremely non-aggressive cancer with interventions that can have significant negative impacts, which is why, even when it's diagnosed “watchful waiting” or “active surveillance” are often the preferred management approaches; quite a lot of people will die with, rather than from, prostate cancer with no active intervention.
Population-wide 5-year survival rates from diagnosis are probably not a good metric for comparing countries with different screening practices; mortality rates are a better comparison metric, but also don't tell the whole story.
> Such survival rates are from date of diagnosis; IIRC, because prostate cancer detected early usually doesn't have interventions that are less harmful than the cancer is likely to be, there's considerable debate about the utility of screening; there has been considerable argument that the US tends to overscreen and over-intervene for prostate cancer.
Over-intervention and over-screening are two different problems, particularly for prostate cancer, where screening is low-cost and low-risk. In the US, most cases of prostate cancer do not require invasive intervention if detected early, but they will begin treatment, as well as more regular monitoring of the cancer. When screening costs are low, overscreening is not particularly problematic as long as it doesn't result in overtreatment (which is demonstrably true for prostate cancer in the US)
Again, this is not limited to prostate cancer. The difference is the most stark there because the screening costs and risks are both low, but the UK still does a much worse job at treating breast cancer, colorectal cancer, lymphoma and leukemia, which are the other deadly common cancers.
For all cancers, not just prostate cancer, the US over-screens a small amount, but the UK underscreens by a massive amount, resulting in many people detecting cancer when the window of optimal treatment has long passed. That's the reason that the UK is close to last place among developed countries for five-year cancer survival across all common forms of cancer, not just prostate cancer.
> Over-intervention and over-screening are two different problems, particularly for prostate cancer, where screening is low-cost and low-risk
They are distinct but not unrelated, particularly in a system where treatment decisions are highly patient driven, especially for patients with financial means.
But my point is less about over screening than that differences in screening practices naturally produce difference in five-year survival statistics even in cases when they have no meaningful outcone in terms of disease progression, mortality, and quality of life, because more screening will detect more cases of disease earlier, even cases for which intervention would never be clinically indicated. If you do a lot better job at diagnosing cases for which there would never be intervention, you get a better 5-yesr survival rate but haven't done any better at dealing with the disease.
Note that I'm not arguing about whether the UK does deal with prostate cancer well, in fact what I've seen using mortality rates suggest they are a bit worse than the US, though much less bad then you'd think from 5-year survival rates. I'm just staying there 5-year survival rates aren't great metrics for systems that are different in conditions that lead to diagnosis.
> I'm just staying there 5-year survival rates aren't great metrics for systems that are different in conditions that lead to diagnosis
I agree. That's why looking at all common cancers as well is important. Leukemia and lung cancer are the opposite end of the spectrum - early intervention is critical for leukemia and most lung cancers. And the UK does a much worse job at treating those than almost all other developed countries, and particularly the US.
So yes, some portion of the difference can be attributed to differences in screening practices, but screening practices are a relevant aspect of the entire system, and screening practices alone can't explain the UK's abysmal record for treating the more aggressive cancers which they do detect.
Last sentence in your post: would I be right in assuming that the incidence (e.g. cases per 100000 men) of prostrate cancer should be lower in UK than USA because more men in UK die with un-diagnosed prostrate cancer?
I'm unfamiliar with how the US stats get collected - is that 90% of "everyone who had prostate cancer" survives 5+ years; or is that "everyone who had prostate cancer and private medical insurance"? If so then that is rather shocking.
Prostate cancer may be something of an outlier given the hesitation people have in discussing it. This is something that has only really recently been attempted to be addressed in the UK. Campaigns fronted by comics like Bill Bailey have tried to make it normal to talk about. The British as a society are still so reserved that I imagine thousands die of preventable cancers and diseases simply out of embarrassment.
Edit - I've just had a look at Cancer Research's figures[1], [2] and, using data from 2010/11 - prostate cancer had a UK survival rate of ~84% or so - i.e. nearly the same as the US.
> I'm unfamiliar with how the US stats get collected - is that 90% of "everyone who had prostate cancer" survives 5+ years; or is that "everyone who had prostate cancer and private medical insurance"? If so then that is rather shocking.
It's looking at people with prostate cancer, regardless of insurance status.
> Prostate cancer may be something of an outlier given the hesitation people have in discussing it.
It's not limited to prostate cancer; for survival rates, the NHS does pretty terribly on almost every form of cancer compared to the US. I picked prostate cancer because it's something that's very treatable - the upper limit is close to 100% for five-year survival, which makes the UK's outcomes that much more unacceptable. But the story is the same for all other common cancers (let alone rare cancers, which the NHS is not optimized as a system to treat).
> I'm unfamiliar with how the US stats get collected - is that 90% of "everyone who had prostate cancer" survives 5+ years; or is that "everyone who had prostate cancer and private medical insurance"?
It's survival rate from point of diagnosis. Obviously, insurance and access will affect whether and when diagnosis occurs, but the effects aren't as simple as just limiting the scope to the insured or not.
> And yet the UK life expectancy is 81.2 vs 79.3 in the US.
I don't understand the point you're trying to make. [Treatable] cancer isn't the leading cause of death in any country[0], so no matter how good (or bad) a country is at treating cancer, you wouldn't expect that to be visible in the overall life expectancy rates.
[0] Ordinally, cancer is #2, but that includes untreatable cancers, and the tail is very long, so getting better at improving five-year survival rates for cancers won't budge your life expectancy at all, outside of the margin-of-error.
Do you have a better source for this data than, well, a bunch of numbers you posted to HN? In particular, an explanation by a researcher or other expert who has actually studied the difference and can explain it?
It's very easy to draw conclusions from statistics. It's much harder to draw correct conclusions from them.
> 2/3 of prostate cancer occurs in men over 65. That's the results of being on Medicare, the largest single payer health care system in the world.
First: no, the England branch of the NHS is still larger than Original Medicare (~53 million in England compared to 46 million on Original Medicare).
And that might be a reasonable way to interpret the data, except that two-fifths of Medicare patients (and growing) are not on Original Medicare - they use Medicare Advantage, which is privately run. Coincidentally, Medicare Advantage outperforms Original Medicare on medical outcomes across the board, including cancer treatment.
So no, the fact that the US is drastically better at keeping prostate cancer patients alive cannot be explained by the claim that Original Medicare is so phenomenally better that it accounts for the difference.
It is interesting that people go straight to single payer in their mental model when they think of changing the healthcare system. Germany has a multi payer system (although the government does provide a large % of the total funds) that seems to work for them. Why do so many in the US look to single payer systems as the ideal model?
Wow, in New Zealand on a similar public system it's quite different. Having had chronic pain myself I've been through this.
- Book a GP appointment. Generally get in the same day (costs $20-$80 depending on your GP. I have private insurance that pays up to $38)
- GP orders blood tests, these are free. Clinic is on-demand, just show up. Wait times are around 30 minutes. Also prescribes ibuprofen ($5 for 100 tablets) and paracetamol (non-subsidised. $10 for 100 tablets).
- GP will assess you and refer to a public or private specialist depending on your preference. In my case a public rheumatologist would have taken around a month to see, so I chose private. This cost $180 for the consultation and $120 for follow-up (insurance paid 80%).
- Specialist refers more tests. For me this was an MRI. Public wait times were around 3 months because the machine needed replacement and they'd only pay for serious cases to go to the private clinic. I went private, this cost $1400 (insurance paid 80%).
- Specialist orders more blood tests, still free.
And they still didn't find anything conclusive.
Personally I'd like GP visits to be free. They can be for people under a certain income level with the right GP. The public system also needs more funding, but in NZ we spend less per capita on socialised healthcare than the US, and the US has to add private insurance on top of that.
Not that I think the our system (US resident) is all that great but our government runs two of the worst systems that exist in the country, the Veterans Administration which nearly everyone hears about but also the Indian Health Service which sadly flies under the RADAR.
so it is a very hard sell to get more Federal involvement when we have constant stories of VA issues and more available just by searching. throw in rules that actively prevented insurers from making multi state offers and the system was bound to be a mess.
however one of the problems not discussed is that many receive their health insurance from their employers and while this has been going away slowly, this idea like income taxes, tends to remove the cost component from people's minds. you don't see the cost in whole or in large lump sums so its easy to not think about it.
the big hurdle will be convincing people there will be limits of what can be treated. the US infant mortality statistics are one area of exaggeration to the bad simply because to the extent money will be spent to save a newborn that many other system won't
> From what I understand one argument often given, is that there's a mistrust of the government for anything like this and people prefer to "shop" for it themselves
As a data point: the patient satisfaction scores for Original Medicare (government-run) are drastically lower than every single major provider of Medicare Advantage (privately-run).
As much as people dislike insurance companies, people in the US are even less happy with the government-run programs, compared to their private counterparts.
On the other hand, patient satisfaction correlates with increased rates of hospitalization, higher expenses, and increased mortality. You'd want to dig a little deeper than patient satisfaction before drawing any conclusions regarding medicare vs. medicare advantage, I would think.
> On the other hand, patient satisfaction correlates with increased rates of hospitalization, higher expenses, and increased mortality. You'd want to dig a little deeper than patient satisfaction before drawing any conclusions regarding medicare vs. medicare advantage, I would think.
I didn't in my previous comment, because we were talking about the overall public perception, which may or may not be connected to the tangible metrics that we actually want a healthcare system to focus on.
As it turns out, though, Medicare Advantage also consistently outperforms Original Medicare on medical outcomes, and it comes in under-budget for identical coverage. Medicaid options vary much more (and they're different in every state, because Medicaid is administered at the state level), but the equivalent private plans for Medicaid coverage also typically perform much better than the public ones.
Hacker News readers aren't generally in the demographic for Medicare[0], but for anyone who is: there's really no reason to use Original Medicare. Every jurisdiction should have Medicare Advantage plans that cost you the same amount as Original Medicare does, and your experience (and overall care) will be vastly improved.
[0] people over the age of 65, or people of any age who are on dialysis for more than two years, etc.
> Medicaid options vary much more (and they're different in every state, because Medicaid is administered at the state level), but the equivalent private plans for Medicaid coverage also typically perform much better than the public ones.
I'd be interested to see these findings. Do you have links?
As far as Medicare Advantage is concerned, it's not the least bit surprising that patient satisfaction is higher. But I wouldn't go treating that as some kind of referendum on Government-run healthcare:
"Many private [Medicare] plans require no additional monthly premiums, yet the government pays an average of $849.90 in monthly subsidies to insurance companies for a person on Medicare Advantage, according to the Kaiser Family Foundation. That is about 14 percent more than the government spends on people with standard Medicare, according to the nonpartisan Medicare Payment Advisory Commission."
MA was supposed to demonstrate that private insurers could deliver care at lower costs than Medicare, and it hasn't done that. Basically, for every $1.00 the gov spends on a medicare patient, it pays $1.14 in subsidies for an MA patient, with the evidence indicating a lot of that goes straight into the pockets of insurers as profit [2]
> Many private [Medicare] plans require no additional monthly premiums, yet the government pays an average of $849.90 in monthly subsidies to insurance companies for a person on Medicare Advantage, according to the Kaiser Family Foundation
That might be a reasonable comparison if Medicare's claims rates were self-sustaining, but they're not. As I explained in another comment on this thread, private insurers subsidize Original Medicare with their own payouts in claims, and that comes out a few orders of magnitude larger than 14% per Original Medicare patient.
Decades of propaganda has convinced half our electorate that the US's system is the best in the world, and that countries with socialized medicine are hellholes where you have to wait months to get a broken bone looked at.
Similarly, decades of propaganda in Canada has convinced far beyond half our electorate that the Canadian system is the best in the world even though you actually do have to wait several months for treatment if your issue is not "urgent", the definition of urgent being unknown.
I take it you have never experienced a true urgent health crisis?
Once you have you'll quickly realise that the 'long wait times' narrative is complete propaganda FUD.
Anecdote time: My sister is anaphylactic, when she goes to the ER she is admitted, hooked up, and given epi almost immediately. When my aunt couldn't move her arm one day, she got an MRI, diagnosed brain cancer, and had brain surgery in the same week.
I'm glad to have a system that when you are waiting it's because there are people with more urgent needs, rather than because there are people who paid more.
Sigh. Do you think I was suggesting that emergency rooms in Canada should adopt a FIFO approach?
> Once you have you'll quickly realise that the 'long wait times' narrative is complete propaganda FUD.
This is a decent example of the typical Canadian attitude I was referring to, blind refusal to even acknowledge any issues, such as the well documented long waiting times for non-emergency procedures, as well as the outright refusal to treat ailments deemed "not important enough" by your doctor.
My understanding, as an American, is that people in single-payer countries tend to see doctors much sooner than Americans do.
Say I'm sitting around and I finally decide to get pain in my wrist looked at that I've had since I broke it ten years ago. I could see a specialist in less than a week. However, I probably would have had it looked at 7 or 8 years ago if I was in a single-payer system. Maybe I would have had to wait 6 months to see a doctor, but that still puts me about 7.5 years ahead of where I am now.
I know a lot of people who have bones that never healed right because an emergency room visit is going to cost you a fortune whether or not you are insured, so they don't go to the ER because it doesn't hurt 'that bad'. I imagine that is somewhat less prevalent in places with socialized healthcare.
Indeed, there are benefits to both systems depending on the situation. My point is that a significant percentage of Canadians are very dishonest about the shortcomings of our particular system....so when non-Canadians read things like "'long wait times' narrative is complete propaganda FUD", they have no way of knowing that the person is not telling the truth.
This is a very interesting point. I actually thought Americans with insurance went to the doctor for absolutely anything, and felt very entitled to that since they pay so much for their insurance. What you point out is that it might be the exact opposite - and although I do often think "oh, I won't bother them with this..", I never consider cost to be an issue..
Yeah, the thing is that our health insurance has a deductible still, and it's generally a percentage of the cost of the visit. Since prices aren't published, you have no idea how much anything will cost until afterwards. Even the doctors can't tell you how much anything will cost.
It reminds me of an old joke about things that don't have a listed price: "If you have to ask, you can't afford it." I think that mentality is really prevalent in the US when it comes to healthcare, regardless of how expensive the procedure would actually be.
1. A friend of mine had severe back pains, all what he got from a family doctor was some painkillers and some stories that his back pain due to to weak muscles and he has to exercise more and wait a bit (3-6 months) before he can get some tests done. Anyways he moved to the US and week later made some tests to find that he has cancer in some serious stage. He started treatment but it was too late.
2. Another friend had spend 6 hours in ER with his eyelid cut in half (he got a branch into his eye while hiking).
3. I had some troubles with my daughter in Canada as well, don't want to go into details.
I eventually moved to the US and while healthcare here is outrageously and ridiculously expensive it is still years ahead of Canadian when you have a good insurance.
1 and 2 both sound quite familiar in the US system too. Ineffective and dismissive treatment for back pain is a common complaint, and long ER waits for non-life-threatening conditions are normal.
Anecdotes don't really do anything for us besides give us pointless things to argue about. You need to look at statistics like life expectancy, quality of life, average wait times, unnecessary deaths, etc.
The fact that you have to qualify your final statement with "when you have good insurance" is the whole problem. Before the ACA, that was far from a given, and even if you had good insurance it was too easy to lose. If Republicans have their way, we'll be back in that situation again.
I don't get it when people bring up situations like your #2. I'm sure it really, really sucked to wait six hours in the ER with an injury like that, but is it worse than staying home and trying to treat it yourself because you can't afford to visit the ER? Is it worse than dying from a simple condition because you can't afford to see a doctor?
Your doctor in Canada refusing to give you a referral to a specialist makes comparing these numbers not terribly useful.
> I don't get it when people bring up situations like your #2. I'm sure it really, really sucked to wait six hours in the ER with an injury like that, but is it worse than staying home and trying to treat it yourself because you can't afford to visit the ER? Is it worse than dying from a simple condition because you can't afford to see a doctor?
A system that allowed consumers to inject additional money into the system would increase the budget and managed properly(!), allow more total health care services to be provided to everyone.
Of course, "this will never work, all doctors will just move to the private sector" will be the refrain. Under our current society and so-called legal system perhaps, but put me in charge, I will put mandatory guidelines and levels of service in place, and then when doctors knowingly break the rules because based on history they well know they can do it without punishment, put a few of them in prison for 10 years, and watch compliance magically improve.
>you actually do have to wait several months for treatment if your issue is not "urgent", the definition of urgent being unknown.
Surely even in the actual best in the world, waiting for something that is no urgent simply makes sense and is the only way it can function. Do you expect a hospital to have 5x as many beds and staff as is often required so you can have instant surgery on your non-urgent problem? (i.e. knee replacement)
Of course you wait a little bit while they schedule it in, otherwise it would cost an insane amount of money to have all those resources waiting around for your non-urgent problem.
My experience with "urgent" problems has always been instant in Canada - my broken nose, my brother's separated shoulder and broken legs.
Even when I went in a week after being hit by a car I waited all of 5 minutes before a doctor saw me.
Because those in the middle and upper class have employer-paid health insurance which protects from the worst of bills. You only go bankrupt if you're uninsured and usually only those in the lower-middle or lower class are uninsured.
And those in the lower echelon of society economically are those least able to have the time or money to march or lobby for change.
I went to ER a couple of months ago for a relatively minor issue and stayed for a few hours total. This was in-network hospital, doctors and so on. Purely by co-pays this ended up being a ~$800 bill after all the insurance kicked in.
If I didn't have a comfy software engineer salary, and instead lived paycheck to paycheck, this would've been devastating, even with insurance.
Very similar story, in the US as well. Went in, had a couple of tests that ruled out anything serious and was on my way in ~1.5 hours including all of the various wait times. Saw one doctor for maybe 1 minute and had a couple of nurses spend about 10 minutes with me total during the various tests.
Insurance was billed ~10k, with coinsurance I had to pay $1,400. This is after the hospital billing in multiple rounds and forgetting to bill insurance on one of them and also forgetting to send the bill to me (which if I hadn't been proactive about following up with would have led to it getting sent over to collections).
I'm assuming I have better health insurance than a decent percentage of the population and I can afford the bill but how the hell can most people? What a terrible, terrible choice for someone to have to make between getting care when they're at their most desperate and avoiding financial ruin
As a Norwegian expat living in Australia for nearly two decades, that just comes across [insert many expletives] insane. Depending on the nature and urgency of the tests, my guess is you'd not be up for anything at all in either of Norway (which is very similar to all of Europe, I guess) or Australia.
I see USA as a country where, if the car crash didn't kill you, the medical bills certainly will.
Which is ridiculous. We're at the point where the insurance is just covering the cost of the overhead that necessitates having insurance in the first place. There's no way the real charge should be $800, let alone co-pay.
> Which is ridiculous. We're at the point where the insurance is just covering the cost of the overhead that necessitates having insurance in the first place. There's no way the real charge should be $800, let alone co-pay.
You're right. Of course the private insurance premiums have a negative expected value. Aside from insurance always having a negative expected cash value by definition, private insurance premiums are literally used to subsidize care of Medicare, Medicaid, and uninsured patients.
That $800 is cheap. I have a high deductible plan, and a recent visit will easily wipe out $4,500 of the $6,000 I had saved in my HSA. For a family of 4, I have been trying to save $8,500 (my OOP family maximum) for 3 years, but the HSA max contribution caps me at $6,750. Can't get there.
I just spent over a year and countless phone calls arguing with the hospital over bills for the birth of my son. We had two employer paid insurance companies and HRA, and they still managed to send us to collections until we threatened to take them to court. They eventually sent us a refund of $600.
Similar experience w/ twins in the NICU. when you have 2 employer paid insurance plans, the two insurers fight over who pays and the hospital doesn't get paid, which leads to them coming after you.
>NerdWallet estimates nearly 10 million adults with year-round health-insurance coverage will still accumulate medical bills that they can't pay off this year.
That's only saying that you'll have bills you can't pay, not that you'll go bankrupt from it. Most (if not all) insurance plans have a maximum out-of-pocket expense amount that's like $10k. Yes, that's more than some middle-class Americans can afford to pay in a year, but it's not enough to go bankrupt over. They just defer paying it until they can afford to.
> That's only saying that you'll have bills you can't pay, not that you'll go bankrupt from it.
This is one of the things Obama-care addressed, because before that most bankruptcy's in America where caused by medical bills. I'll see if I can find the article. [1] But with Obama-care going away/being changed this might be a thing again.
[1] "A study done at Harvard University indicates that this is the biggest cause of bankruptcy, representing 62% of all personal bankruptcies. One of the interesting caveats of this study shows that 78% of filers had some form of health insurance, thus bucking the myth that medical bills affect only the uninsured.
Rare or serious diseases or injuries can easily result in hundreds of thousands of dollars in medical bills - bills that can quickly wipe out savings and retirement accounts, college education funds and home equity. Once these have been exhausted, bankruptcy may be the only shelter left, regardless of whether the patient or his or her family was able to apply health coverage to a portion of the bill or not. (Find out what you can do to avoid a financial meltdown when there's a medical emergency. " http://www.investopedia.com/slide-show/top-5-reasons-why-peo...
I just logged in to say this (trying to comment less and read more) but this needed said.
Even with a vanishing middle class, the middle and upper class that remains still have largely great healthcare and healthcare plans, it's the poor who are largely being screwed. Even then, they don't support universal healthcare (it's mostly us hipsters or whatever) because they are still weary of the government and we're still dealing with post-mccarthyism where any sort of government service for the public benefit is socialism.
Not to mention the historical "lifetime limits", which only since the ACA have been lifted. You could have an unimaginable great plan with a huge network and no deductible, but an extended hospital would still bankrupt you.
> With copays and out of network stuff a lot of people will go bankrupt in case of a serious illness.
By law, those are capped for people with insurance. The maximum that you will have to pay out-of-pocket can be no more than about $7,000, and many private plans set the cap at a lot less.
$7,000 is a non-trivial amount, but it's not a large number of people that both are insured and can't afford their out-of-pocket maximum without bankruptcy.
Max contribution to an HSA is about $6,800/year. I have been putting $600/month into it for three years and have never been able to get more than $6k saved; family of 4 and no dental insurance (employer dropped it).
This is the equivalent of a car payment for the rest of my working life.
I know people who have run up medical bills in the hundreds of thousands due to a long term illness despite having insurance. I don't know how this could happen, but it did.
> I know people who have run up medical bills in the hundreds of thousands due to a long term illness despite having insurance. I don't know how this could happen, but it did.
The bills themselves aren't capped. The amount they are obligated to pay is. Insurers make up some of the difference, and the rest is forgotten about. (It's not written down in the accounting sense, because the hospital doesn't necessarily actually treat the entire billed amount as receivable.)
I explained in a top-level comment how this works and why it works this way.
Indeed it doesn't take much imagination: chronic illness + prescriptions + high deductibles. Worse if multiple family members are sick (so many problems are inheritable and so on).
Also worth mentioning, it's been broken for a while (e.g.: ACA is not even broken in yet).
Those in the lower echelon of society are unfortunately too stupid not to support powerful groups that have the opposite of their best interests in mind. Ie not many rural poor or lower class support single payer -- the support mostly comes from middle and upper middle class.
Because people don't get sick every day. Most people don't run into these bad situations and, in general, americans lack empathy for others who do wind up in bad situations. We have a media that tells us -- and religion before -- that you get what you deserve. So, if you're rich, you deserve it. If you're sick, you deserve it.
The idea that life is unfair and random is not accepted by america.
There is a lot of propaganda how bad systems in other countries are. Plus, this is the only system most people ever have seen so they think this is just the way things are and have to be.
Additionally, the U.S. working class (who are most affected) is disorganized and politically weak. Other democracies often have "labor" parties; that doesn't exist in the U.S. Labor unions have been under attack for decades. There is a saying that the U.S. has one political party, the Business Party, with two factions. Elements of the working class are so desperate and underserved by establishment Democrats that some are turning to Trump-ian false promises and easy answers. Remember Trump (falsely) promised to fix their health care and offer cheap, quality plans.
Essentially, poor white Americans oppose any kind of social service that might benefit black Americans. Virtually every problem that America faces is complicated by this one simple fact, which is an echo of the fact that half the country literally went to war over their preference to enslave black people. Despite this glaring and obvious reality, most commentators are afraid to mention it.
poor white americans oppose any kind of social service that might benefit anybody but themselves including other white people.
Black americans oppose any kind of social service that might benefit anybody but themselves including other black americans.
People are people and ignorance doesn't have a color. It has always been like this. Blaming one or the other doesn't actually fix anything and it is also why nobody brings it up any longer not because they are afraid to mention it.
Because it didn't used to be like this. Healthcare in the US was 5 times cheaper in 1970. The cost has been ballooning up since then and no one can explain why or how to stop it.
We don't necessarily need socialized medicine. If we just went back to the way things were done in 1970 everything would be solved. The money the government currently spends on healthcare subsidies could buy free healthcare for everyone at 1970 prices.
Life expectancy was a bit shorter in 1970, but not by that much. And most of the increase is due to other factors than healthcare (e.g. the smoking rate has dropped a lot, cars are much safer, air pollution is reduced, etc.) And there have been studies done that show increased spending on health care doesn't really correlate with increased life expectancy.
It is exactly as crazy as it sounds, unfortunately. But due to many years (decades!) of pre-meditated political maneuvering, one of our political parties has managed to inextricably relate any kind of desire for "single-payer" or "socialized" medical system with effectively being a communist USSR apologist. No exaggeration.
Medicare is not a single payer system (which is why I get confused when sibgle-payer advocates say they want “Medicsre for All”); it's more like “Obamacare with an public option for some services”; the prescription drug program (Part D) is private plans with public subsidy, and Medicare Advantage (Part C) is private plans for public subsidy as well. Parts A and B are public plans for core inpatient and outpatient services, but theres been a big push to Advantage plans (including as a vehicle to handle Medicare/Medicaid “dual eligibles”.)
This last Saturday, there was a peaceful protest of around 200 people held in DC in front of Congress. One of my friends attended this protest. Around 150 of them were arrested, and then given bullshit charges, like crowding, obstructing, incommoding, or resisting arrest (of what charge were they being arrested for, angering Trump...).*
When you try to "peacably protest", and "redress the government for a redress of grievances" and are arrested, detained for 6 hours, and then given a $25 citation of 'crowding' - what else do you do? Molotov Cocktails? AR-15's?
The answer, unfortunately, is nothing. You keep your job, eat decent food, and live a life under whomever the current 'king' is. And hope to the gods that nothing knocks you down to a lower socioeconomic ladder rung.
in europe a $50/year increase in public university tuition results in 500 burned police cars. In france you can legally kidnap your CEO as long as you feed him.
We have rules in place that allow the population to peacefully protest without interfering with the business of others. These people didn't follow the rules and were punished accordingly just like every other law on the books.
If you are unable to enact the change you want from within the system it's because not enough people agree with the change you are proposing.
Welcome to the complexities of Society.
If you don't want to participate you don't have to. Abandon the laws of man and return to the laws of nature. Just remember the law of nature demands conflict be resolved in the favor of the more powerful will. I doubt very much you would fair well.
So protest is fine as long as its easy to completely ignore?
Most of the great social and political progress in western nations has come from mass civil disobedience. You take that away and you begin to stagnate.
I don't think that anybody really believes that the mess we've made of billing/paying-for services via insurance + government + hospital/doctor is a good idea. At least nobody who has dealt with it for more than 5 minutes, which is most people over 25.
The problem is that nobody can agree on how to fix it. One side wants to socialize the whole thing, the other side wants to do... something else, I guess. Regardless, neither side has enough power to just do what they want, so we're stuck with this bizarre Frankenstein's monster instead.
Meanwhile it's almost impossible to escape from the mess. You can't just have no insurance and pay for yourself, because they've made the prices for most things ludicrously high and then basically rebated them to the insurance companies.
Actually, it reminds me just a bit of that paraphrase of the Laws of Thermodynamics: you can't win, you can't break even, and you can't get out of the game.
Propaganda. Pure and simple. People have been lied to about how healthcare should and could work for so long that they hold political beliefs that are completely at odds with their best interests.
We have the resources to fix many of these problems. But we won't. The powers that be would prefer lower taxes.
The guest is an economic historian who details the historical forces which led us to where we are right now. She also describes a few different, more effective and rational models (not just single payer) which could potentially have existed, but which sadly are, for all practical purposes, impossible to get to now.
Yes, it is not as crazy as it sounds for most users.
Media outlets like to publish horror stories because it attracts eyeballs.
Yes they can happen and there are bad actors in the system. But most ER patients either don't pay a dime because they don't have a dime, or their insurance picks up the tab subject to deductible. "In Network" rules specifically don't apply in true emergencies under most plans. Of course if you go to the ER for a runny nose, there may be some pushback.
It's primarily lots of Byzantine rules in small print buried in long policies that few people read and even fewer memorize. If you are lucky and are conscious when you need to use a policy to visit a health care provider, you can bring your policy with you to ensure you follow it, but it's not always that easy. The health insurance company claims they told you how to follow the policy, but they don't make it any easier than they legally have to.
If you skip a rule (like calling your health insurance company before you visit an emergency room), that might violate your policy.
If you visit an "out of network" hospital when you should have visited an "in network" hospital, you may be liable for the difference in cost (which is huge due to health insurance distortions in the medical market).
If you try to go to a medical specialist without first going to your primary provider (as defined by your health insurance company), they likely won't cover it.
There are usually dozens or hundreds of pages of these rules in booklets that you get when you join an insurance policy.
If you don't know about / forget about a rule, you are responsible for the costs associated with the violation.
It's easy to unwittingly ask a health insurance question about your policy to the office manager at a doctor's office (who isn't qualified to speak about specific health insurance policies) and getting bad information that you then assume is good.
> Why aren't people marching in the streets?
I think most people see this as a "free market" problem (since 60%+ are covered by their employer-sponsored health insurance), not a political one. ~20% of Americans are covered by Medicare (the retirement-aged national health coverage) or have military veteran benefits, which are generally considered pretty good (unless you listen to political arguments). How would "marching in the street" fix a problem that people have with the "free market"?
The remaining 20% are among the most politically apathetic. We are lucky to get 50% participation of the voting-eligible electorate, even in presidential elections (which have higher turnout than other elections).
I think lots of Americans pride themselves on being stubborn and pretending like painful things aren't painful, then trying to ignore them.
Lastly, I think most Americans simply don't think that marching works. Rural America doesn't march. Urban America only seems to march for generic social justice causes, not for specific policy improvements.
UK but live in the US now - simply because to them this is always how it has been.
The UK cried and moaned when the NHS was introduced but now (aside from Conservative efforts to "starve the beast" on it) most wouldn't go back for the world (though it could be improved, obviously).
The US has a mentality that it's the best in the world for everything. Even when it's objectively not true (like in healthcare) this colors the debate.
Some are beginning to march in the streets, actually. Especially those who stand to lose their lives or a relative's should a Republican repeal bill pass. (Ironically, many of these people votes for those Republicans in the first place.)
For the rest who aren't, there's a simple reason: services operated by the government tend to suck (or are at least perceived to be so). It is an American tradition to stand in long lines at the Department of Motor Vehicles to renew your driver's license, or to get your vehicle inspected. The TSA exists to inconvenience travelers. Public schools are perceived to be failing (they are in some places; I was lucky enough to get a very good education in public schools) even if they are not necessarily. The Postal Service is not profitable (even if it doesn't need to be...) and there are always lines at post offices. And so on. (typing on mobile, could give more examples but I'm sure others have their own)
Whether these problems are real or not is irrelevant. Americans distrust the government, especially the federal one. You could call it indoctrination, to a degree. Those who benefit from the system are allowed to persuade the populace, even from birth, and are supported by both major parties. (Drug and other healthcare advertising is legal.)
It is also part of our history. The tradition of the US is a distrust of big government. Before the US Constitution was written, we had a federal government under the Articles of Confederation. It was meant to be permanent. The federal government was extremely weak, gave too much power to the states, and ultimately did not work. So the Founders had to go back and try a second time and gave the federal government more power. And that's where we are today...but that feeling of distrust has persisted through the centuries.
So to sum it up: many like the idea of private healthcare not because they have a choice, but because they believe that the government(s) will screw it up worse.
Basically, events like TFA where someone gets shafted even with insurance are fairly rare. The system is bad, but many (most?) people aren't exposed to just how bad it really is. The elderly, who require the most healthcare, have Medicare helping them. Working adults often get insurance subsidized by their employer, and young adults/kids under age 26 can stay on their parents insurance plans. With insurance, especially "good" insurance, you don't see all the insanity unless you dig into the itemized details of your medical bills... even then most people will shake their heads, pay their (relatively small) portion of the bill, and move on.
Because, literally, one side of the street would be the Republicans and the other side of the street would be the Democrats. Nothing would get done as neither side feels the need to concede anything.
In a past life, I worked in health insurance fraud detection.
Everybody should know, the health insurance system in the US is fundamentally broken and has been almost since its inception in the early 20th century. The lack of adequate consumer protection, transparency, health systems and appropriate government regulation, in addition to organizational oversight, has lead to a situation where we have poor systems that can easily be exploited. And they are exploited.
What the third party care outsourcing/billing company mentioned in the article (Emcare) was doing sounds like upcoding. They bill the highest cost service they legitimately can to maximize profit. In this case, as a third party billing organization, they both want to maximize the profit for their customer (the hospital system), but also for themselves, as they surely take a cut as a middle man.
Likely, they were operating within the gray area where illegal upcoding has to be proven in a court of law. It is an expensive process, that requires review and comparison of huge amounts of medical records with claims to determine whether the more expensive procedure billed was medically necessary/appropriate, or if it was egregious. That legal process does pan out sometimes in the end, but it can take years and just adds even more overhead.
Coding correctly, fairly and getting reimbursed correctly and fairly is incredibly complex. There are an enormous number of combinations of services (usually represented by codes called HCPCs and CPT codes) and diagnoses (ICD-10... which has 100,000s of codes), as well as all different regulations and scenarios for settings of care (inpatient, outpatient, doctor's office, etc.).
Props go to the hospital system for taking back their coding after they realized what the third party was doing, but the reality is, it was probably financially benefiting the hospital system too.
Every technology that I know of has been tried to address these issues, such as data mining, machine learning, rule-based expert systems, etc. and none of them has addressed the root cause, which is the basic system is fundamentally flawed.
All the politics you see about US healthcare in the news are, in a way, representative of the root problem - how big and complex the systems are now, how much money they represent, and how many interests are involved. We have a tangled web.
I don't know the solution (and many have been proposed).
> Every technology that I know of has been tried to address these issues, such as data mining, machine learning, rule-based expert systems, etc. and none of them has addressed the root cause, which is the basic system is fundamentally flawed.
There's no technology cure for the insatiable greed of a few. Sad reality.
> Props go to the hospital system for taking back their coding after they realized what the third party was doing, but the reality is, it was probably financially benefiting the hospital system too.
I doubt the hospital system got anything from it, physician groups usually keep all their revenue from professional services claims - the hospital gets paid whatever they do for their facility claim regardless of what the professional claim pays.
It's possible you're right. Without knowing the details of the relationship, you never know.
The reason I say that is the article points out another glaring issue - the shortage of ER docs that we are currently facing. I know this first-hand, as I have a family member who is one and is working harder than ever.
Some of these arrangements are to make up for the shortage, and the hospital systems and physician groups are often working in partnership... so it could be there was benefit for both since the hospital system needed coverage for their ER (due to physician shortages), and Emcare is providing the physicians. Without the physicians doing the services in the hospital, there would be no facility claim either...
> It's possible you're right. Without knowing the details of the relationship, you never know.
This is true, and being a mere software developer I'm in the dark on the contents of any of the contracts my parent company has with facilities either.
> The reason I say that is the article points out another glaring issue - the shortage of ER docs that we are currently facing. I know this first-hand, as I have a family member who is one and is working harder than ever.
Insert my standard rant about restricted med-school/residency admissions and cost of tuition here.
It's sad but true that we are getting to a point where all we have are standard rants about these topics, but can't find the solution. I'm guilty of the same too.
Stalemate.
We need to go through Kurt Lewin's change model process -
"unfreezing, change, and refreezing" and find something better. It's like, we need agile healthcare or something - fail fast and iterate faster... without costing people their lives or their savings.
https://en.wikipedia.org/wiki/Kurt_Lewin#Change_process
Hi sixdimensional, thank you for the insightful comment here. I've been researching this area, and I'd love to chat more with you, would you be open to that? My email is on my profile page, feel free to email me on that address and I'll follow up.
how big and complex the systems are now, how much money they represent, and how many interests are involved
I don't follow what you're saying. Are you proposing that the root of the problem is that it's a huge, expensive, complex industry, where a lot of people work?
Yes, I'm proposing that the high level of complexity and ambiguity involved (which originates from the intersection of the technology, organizations, politics, finances and people) in the US healthcare and health insurance system is the root cause of the problem. It is another giant machine, like the military industrial complex, for example.
I don't want to go so far as to say all huge institutions have problems like this, but I am thinking along those lines.
Some have proposed simplifying health insurance greatly by running a "single payor" system, where the emphasis is on a single health insurance entity that covers claims for every person in the US. While that might seem like a simplification in terms of process, procedure and organizations, it is very unlikely to happen in the US, and I'm not sure we could even administer that well either.
If you look at other countries that are closer to single payor, maybe say, the British NHS system - even in those countries, private insurance still exists and competes. The NHS does provide care for everyone and eliminates some issues by having a stricter control system, but the quality, availability and timeliness of that care is often called into question.
In the end, being able to dictate quality, access, and affordability (and preventing fraud) comes down to control vs. morals/ethics. Many are vying for control, for many different reasons and this often tears apart the basic industry, while morals/ethics are difficult to maintain.
Thanks for clarifying. I think however it's the wrong measure. There are industries that are as large or larger with as much if not more complexity that aren't failing to such a degree that their size is a systemic risk.
For example the US Real estate market is 7.4 Trillion, about 2X the size of the health care market with many more players and much more predicable outcomes. Finance and insurance are about the same size as well and are not terribly broken.
So, basically, if you visit any emergency room then your handing them a blank Check and they can write whatever number on there they want. That's egregious beyond belief. I'm never one to call for legislation and price controls, but in the face of such adversity, I think it may be our last hope. I think they should either provide a quote before they offer the services or there should be a law limiting the amount that can be billed per service.
This is the fundamental problem of treating healthcare like any other market distributed good; you just don't have the ability to use consumer choice.
People using an emergency room are not in a position to negotiate price or seek an alternative service. An unconcious accident victim can't say, "That price is crazy I am going to the hospital across town."
I would say single payer, or a single regulatory arbiter of procedure and drug prices (within a multi payer context).
When you look at the healthcare costs GDP, the single payer systems still tend to come out ahead multi-payer + regulatory oversight (its one more level of abstraction you pay a complexity cost for...).
> I would say single payer, or a single regulatory arbiter of procedure and drug prices (within a multi payer context).
As someone who works for a medical billing agency either would make my life easier, having to juggle dozens of insurance contracts and rates stinks. France does the latter, insurance companies and the state plan negotiate and a single group - at the best this could make a good stepping stone to single payer in the US.
I recently hurt myself and needed an ambulance to take me to an ER. They asked me if the nearest one was ok. Worrying about network was simply not going to be possible, I was in massive pain and wanted it to be helped out asap
Turned out alright, I think. I'm still concerned I'll get an "oh by the way" bill in the mail.
A physician relative pointed out the Dutch healthcare system as a compelling, hybrid public/private alternative to strict single-payer schemes. Gist of his recommendation was that single-payer systems may not be the silver bullet they're touted to be, and that alternative models are being tried out. I.e., viable solutions may turn out to be hybrid healthcare systems, where negative effects can really only be minimized rather than eliminated. https://en.wikipedia.org/wiki/Healthcare_in_the_Netherlands
Germany is two-tier. Public health for the masses, private for those making over 80k or so and healthy.
The public system premiums are a % of income. The private is a flat cost, so as you make more become much more attractive (even costing less in many cases).
Doctors are sometimes private only or have separate private insurance waiting rooms. Hospitals have separate public and private rooms/beds, etc.
It's a two-tier system that works pretty well, at least in comparison to the US system.
My info is a few years dated, but is based on having been a patient in both US and German hospitals. From friends, I've heard the English system is similar in some respects to the German.
Amazingly to me, the German system was instituted under Otto von Bismark in the 1800s.
Aren't the public premiums only a % of income up to a certain cap? So it's not like super high income people would pay an outrageously huge amount to use the public system, they would just potentially pay somewhat more than they would if they got private insurance.
This ensures that the system works better than the US system, as the hospitals do not need to deal with having to treat uninsured patients who cannot pay. This is a major problem for the US healthcare system, and a critical threat to the solvency and continued operation of many hospitals, especially rural hospitals and clinics.
The insurance mandate is a principal component of the ACA. In the US you have to have health insurance or you pay a fine, and there are subsidies to help people pay for insurance. To further lower the number of uninsured in the US would involve increasing the penalties for not having insurance, paired with further expansion of subsidies or Medicaid. Honestly sounds like that area of the Swiss healthcare system is pretty similar to what the ACA provides.
Switzerland also regulates drug prices... and has much tighter governmental oversight over their insurance industries. But is also the most costly by percent GDP of european nations... still much much cheaper than the US though.
In a sense Germany works very similar to Obamacare. Private doctors, health insurances, mandatory insurance for everyone. The difference is that it's much more regulated and the insurances are non-profit as far I know.
Yep. Took my wife to the ER last week for suspect appendicitis or diverticulitis. Last time this happened a CT scan alone was $3k ($11k prior to insurance reduction). My HDP is $4,500 OOP max per family member; $8,500 for family.
What really pisses me off is that the HSA max contribution has not kept up with family OOP max. I contribute the max every year and can't end up with $8,500 saved.
I had a decent insurance plan prior to Obamacare. Now it's 3x as much and a HDP. Don't even have dental insurance anymore; use the HSA for that. Work for a Fortune 100 Company too.
Yes, no argument there. I work for Fortune #75 (hint; it's probably hanging on your wall). Lost dental insurance last year, vision the previous year, and switched to an HDP the year before (with massive premium increases every year). But hey, the stock price was at an all-time high on Friday.
Funny thing about HR directors is that they don't last more than 1 year before rotating out. Don't want them to become too attached to the people they are there to screw.
To be fair, health insurance doesn't HAVE TO be provided through work. It's easier than ever to find a private plan. To the employer it's just another employee cost along with salary so if you didn't ask for a raise when that happened, that's on you then.
I did get a raise; had to threaten to quit, but did get one. It's the HSA contribution limit that pisses me off. I don't have an issue paying, but I'd at least like the benefit of pre-tax $. The HSA limit has not kept up with the ACA OOP limit. Other than inflation adjustments, it's up to congress to raise it.
It's doubtful we would be in a different situation without Obamacare. Health care costs have been rising faster than inflation for literally decades. There are too many bad actors at every level trying to grab whatever they can, while they can.
If you work for a company with 10,000 employees or more and don't have a gold-plated health plan then it is by deliberate effort on the part of the company to save money.
At that level a company that wants a good plan can demand no exclusions for pre-existing conditions (an issue prior to ACA), same-day partner additions, better drug tiers, lower copays, etc. Often they pay less per person than a 1,000 person company does for a much worse plan.
I know because I looked. Two employers ago we got acquired by a very large company (over 80k employees). They paid ~$800/mo for my family. When I moved to a startup, they were paying ~$1200/mo and the benefits were worse. I'm back at a large company again and it's back to ~900/mo for a better plan.
You are getting screwed because the company has decided to do so.
"You are getting screwed because the company has decided to do so."
Ha ha, didn't have to tell me that! I bet my coworkers we won't have company health insurance in a few years. Gotta keep that stock high.
Crazy thing is, now that I'm middle age, and my 401k approaches 7 figures, I'm beginning to care more about fund performance to get me to retirement in 20 years than benefits. It's all coasting from now.
Wouldn't the mandate against dropping coverage for people with pre-existing conditions result in price increases across the board? (Because now insurers can't take your money, and then tell you to fuck off once you get sick.)
You're probably now paying the 'true' cost of healthcare. (Of course, inflated by the peculiarities of the American system.)
They didn't get to be in the fortune 100 by handing out benefits to their resources. Resources are there to benefit the company; not the other way around.
Another approach would be that a hospital actually has to take responsibility for the doctors and all other care teams working inside. Legislation to this effect would work, but in some cities there is enough competition that a marketing campaign along the lines of "guaranteed no out of network bills!" would catch my attention. I'd happily drive an extra hour for that piece of mind. And the reality is that a large number of ER visits are not true time-critical emergencies. Many times the standard admission procedure starts with reporting to the ER.
I spent 4+ hours before a small outpatient procedure at a local hospital trying to find out if the anesthesia group and surgeons were in-network. I never got a straight answer -- no one knew the answer and I was forced to roll the dice.
Hospitals are currently more like co-working spaces where each room (ORs, radiology, etc.) is rented out. The support staff is included, but everyone else is their own small business.
I learned about these independent groups during a jury stint on a medical malpractice trial. This was actually a four way fingerprinting exercise (plaintiff's family, hospital, nurse, physician's group). The incentives in the system are perverse and corrupting. I think the system will need to be reinvented from the ground up.
That was a weird concept for me to learn as well. When your surgeon is in-network, you kind of expect the anesthesiologist to also be in-network. But surprise! $3500 for anesthesia. Not sure how the average person would know to expect this... http://consumersunion.org/2014/08/surprise-your-anesthesiolo...
The thing is, if you're in an emergency room, for the most part, you're there because of a medical emergency. (I know this isn't universally true, etc.)
If you're bleeding, and someone hands you a price quote, what are you going to do?
Or if you're unconscious, they can't even hand you a price quote. (I guess they could shove it in your pocket.)
I know the one time I needed to go to the ER, for emergency surgery, I'd have done it if they'd said it was a million billion dollars, because my life was literally on the line. I wasn't going to go shopping around, because leaving that ER would've meant death.
What's a price quote supposed to do in those situations?
We just need universal coverage, whether single payer or actually universal insurance.
Your text is grey and you may be getting downvoted and I'm not sure why. You are absolutely right and anyone who has ever been to ER will agree. I was in ER a couple of months ago, and it wasn't even a life-threatening issue, but I felt terrible. I went to the closest hospital with ER department (thankfully, it was in-network), and I was going to get their treatment no matter what price quote they hand me (not that I asked). When you're deeply, physically unwell, nothing else matters to your mind.
I think you may be getting downvoted for your last sentence, but the points you're making are very real.
Cost control right now in the medical industry is all up to your insurance provider, from the article it looks like EmCare is skirting this by simply not participating in any (or very few) provider networks.
I work for a medical billing company owned by a competitor to EmCare, we participate it a large number of insurance networks at each site we staff because it's the best way to get reimbursed - I'm rather shocked the hospital didn't investigate how their contracted providers handled insurance contracts and billing.
The problem with trying to provide quotes for emergency services is you don't know ahead of time what E&M code will apply to the visit, what labs will be run, what procedures may be required for treatment, and since physician and facility billing are separate the right hand doesn't know what the left is doing.
I also have some suspicions about the jump from 6% to 28% rates for billing what I assume is a 99285 (highest level non-trauma ED E&M code) and why it may explain the lack of their participation in insurance networks, but I don't want to tread into libel territory so I'll keep my mouth shut.
Disclaimer: I work for MedAmerica Billing Services, Inc. a subsidiary of CEP America - these views, opinions and statements are my own and don't necessarily reflect those of my employer.
> I'm never one to call for legislation and price controls, but in the face of such adversity, I think it may be our last hope.
I'm always one to call for legislation and price controls, because time and time again, without the legislation in place, situations like this arise. It's the sad reality. Regulating companies is apparently our only hope to keep people from constantly being stepped on.
sinks the whole 'the free market will self-police' fallacy. esp re: health and environment, finance, and worker safety, corporations need regulation, badly.
this is a unique situation. Customers can't shop around for the best price because there are laws in place that prevent insurance companies from offering plans that are sufficiently cost effective in such emergency room visits (and a host of other conditions as well). Otherwise, I'm sure someone would have recognized these problems and offered an insurance plan that protects you from this. Free-market can't do anything when it's hands are tied behind it's back.
What if there was a group or coop or company somewhere, where people could get together and collectively fund their health care. Then this entity could make deals with providers like EmCare to ensure that the care provided was as efficient as possible.
Sarcasm aside: this problem is solved, and it's called insurance. Private entities sell it. The government does it too. It works. We just need to make sure everyone actually has it.
The article shows that this issue affects people with insurance.
It's not that the patients don't have insurance, it's not even that they go to a hospital without an agreement in place with their insurer - it's that the ER has a number of people outside that insurance contract, you don't know who they are, you don't get to choose whether they treat you, you just get a bill at the end - despite being insured, and choosing a hospital recognised by your insurer.
Canadian here. Had a pain in my right side for about 3 weeks (thinking muscle pull). Called Doctor's office at 10am had appointment at 11am, had exam and referred electronically to local hospital for X-Ray, had X-Ray at 11:45am, out the door at 12pm. Doctor called me personally the next day to say it's probably a muscle pull and call back in a couple of weeks if still sore.
$0 out of pocket, just showed my government issued card everywhere.
Couple of years ago my father was in an ICU for two weeks with Parkinson's related complications. That one had a $0 out of pocket bill as well. The ICU was in a world class university teaching hospital.
System works here. Sure people can cite edge cases, but they are relatively rare. The single payer, $0 out of pocket system also encourages pro-active care as opposed to waiting until the problem is severe, which in turn keeps costs down.
Wouldn't trade our single payer, socialized medicine for anything. There's reason why Tommy Douglas, the father of Canadian socialized medicare, was voted the greatest Canadian of all time by the public in a recent CBC poll.
(Shameless plug: software industry is booming in Toronto and there's lots of jobs. Just sayin'...)
My family lives in Canada. My grandfather had a heart attack when he was 84. My dad drove him to the ER, he got surgery, a stent implanted, a prescription, and follow-up appointments and care.
$0 out of pocket for the hospital work, a small co-pay for the prescription.
He also spent a few months on a waiting list for surgery. Cataracts surgery. They fixed him, he can now see better. Out of pocket cost? $0.
The system works. If the trade-off for free life-saving treatment is waiting on non-critical surgery, it's a good trade-off. When you're ill, the last thing you want to weigh is whether you will put pay the heating bill, or the ER bill, or whether you should go to some other hospital, because this one will gouge you, even though you're in-network.
The whole point of health insurance is that the healthy pay for the sick. We will all eventually be sick.
If you want to understand how medical billing works and why these ridiculously high bills get created, there's a lot of important context that this article unfortunately leaves out.
Large hospital systems accept patients who have a range of payers (Original Medicare, Medicare Advantage, various Medicaid plans, private insurance, and uninsured patients). On the aggregate, they want to make sure that their entire system is cashflow-positive - however, they do that in a rather roundabout way, because they only have the ability to negotiate with some of their payers, whereas the others are able to set their rates at whatever price they want.
Medicare and Medicaid set their reimbursement rates by fiat, and providers have essentially no ability to negotiate those. Except in critical access areas, Medicare actually reimburses much less than the marginal costs of care for its patients (7% in the aggregate)[0]. These rates are so low that Medicare actually has a separate program to pay extra money to hospitals that treat a lot of Medicare patients - otherwise, they would literally go under. The reason they provide this money as a separate program and don't count it in claims is entirely political.
As a result, providers present very large bills to everyone else (privately insured and uninsured patients) to make up for this loss - you can't stay in business if you're literally making a loss on every patient! Uninsured patients see the large bill and assume they have to pay the entire amount (they don't!), and private insurers end up negotiating that down to some multiple of what Medicare pays.
A typical insurer will negotiate an agreement like, "we'll pay 350% of what Medicare pays for this category of services".
[0] This is not looking at any markup that the hospital provides - we're talking about how much the hospital has to pay its suppliers. So, for a hypothetical vaccine that costs $100 wholesale, Medicare might reimburse $93, which doesn't even cover the cost of the equipment, let alone the entire hospital infrastructure (wages, etc.).
We're talking about how much the hospital has to pay its suppliers
Except suppliers can engage in their own fiat prices, as the OP demonstrates.
But your narrative does show the basic situation - where you have an elaborate digraph of buyers and sellers, most of which have a more or less monopolistic position. These monopolistic suppliers initially/formally set their prices based on "what they could possibly imagine getting", expecting regulators/down-stream-buyer to be the ones who will push things back into sanity (or not).
American health care, of course, has bounced from regulatory regime to another, with all of the players having to adjust. And moreover, all the players are now adept at adjusting, able to switch gears to leverage whatever ad-hoc cost reductions might go with any new system (cautious enough to lay-low when the new system comes since they know the politicians need to point to gains but will move on - see the way Obamacare worker great for two years, etc, etc).
And with all the bouncing, the situation has gotten only broadly more catastrophic. Health care was ~18% of GDP a year or two ago and no doubt is higher still.
Not only does health care have a problem but the four or eight cycle of ad-hoc fixes to health care has itself broken. Which might relate to the general breakdown of the countries political system, and so-on. I assume when (part of) Rome fell apart, no had seen an empire disintegrate on quite those terms (where a lot of civilization still remained on higher terms than Rome's neighbors). Perhaps our descendants will look back on this era in similar terms.
> Except suppliers can engage in their own fiat prices, as the OP demonstrates.
Those aren't fiat prices by any stretch. Aside from the fact that there is a competitive market of providers, patients don't have the obligation to pay the entire billed price (a key point which this article does not mention). That's neither a monopsony nor a monopoly.
Medicare, on the other hand, is a legal monopsony over its patient population and does set its prices by fiat. (There is no competitive market; patients can opt to receive their Medicare benefits privately, but they cannot opt out of Original Medicare entirely. Similarly, most providers cannot legally opt out of accepting Medicare, in practice).
(in high population areas it doesn't make sense to comply with the limits imposed by the program, for instance, only having 25 beds, that's why there aren't any in Connecticut and such)
(Just adding a bit of info, I think CAHs are pretty high jargon)
For surgery centers, the Affordable Care Act has limited a lot of plans to daily center maxes (on the facility side) so in theory the doctors are being paid market rates for their services. But the differences in prices between Medicare rates and out of network are significant.
Start with the fact that even the hospitals themselves do not even know the cost/price of their procedures and goods.
Notice here, in 2013, an article about how "For the very first time, the federal government is publicly releasing the "rate card" (the full charge before insurance company discounts) prices hospitals throughout the nation charge for the one hundred most common procedures and services."
https://www.forbes.com/sites/rickungar/2013/05/08/the-great-...
Price discovery, the most basic element of a free market, is literally impossible, even for expert executives within their own organizations. Vast price discrepancies exist for procedures just a few towns apart. Discovery for consumers in advance is impossible, and of course absurd in the situation where you are being rushed to the nearest hospital in an emergency.
Do not let anyone get away with claiming that this is somehow a "Free Market" until reliable prices, and outcome rates (with case difficulty information) are as easily available as prices and reviews on Amazon.
The entire pricing scheme is an elaborate sham if you ask me. My wife had to have surgery. A outpatient laparoscopic procedure that required cutting a tendon. The time she spent at the facility (from the when they took her back and discharged her) was about 3 hours. A month later we got a statement showing they tried to charge $67k and were denied… followed by a separate bill for $7.5k We ignored the bill and contacted Anthem who said the hospital didn’t code it correctly. Anthem said they would resolve it. A month later… another attempt to charge $67k another separate bill for $7.5k. Again we repeated the same process. This time it appears it went through. Final total when they “coded it correctly” was $74k.
I have a friend who had to have an emergency appendectomy this year. She paid $1500 for it after insurance. My father had knee surgery he says they tried to charge the insurance company $64k for it.
At this point I think the pricing is all arbitrary. It’s about them trying to charge what they think they can get away with and sticking you for the rest. Kind of like raising the price so you can offer a deep discount later on. I think the real price of the surgery (without insurance) was probably the $7.5k.
I can think of no other business where you agree to have work done without an agreed upon price. The insurance company will tell you it’s covered but the hospital you go to may decide to play games with you. At the very least I suppose they are just hopping you pay so they can collect interest on your money on it before sending it back.
> I can think of no other business where you agree to have work done without an agreed upon price.
You can't really compare this with other businesses. Unless you want the doctors to stop the moment they hit your negotiated price (like lets say a building constructor would).
However you should be able to get a rough quote for the procedure (assuming no unexpected complications).
And I agree with you in general, US health care is a total scam (very high-quality to be fair).
That's good point. I wouldn't expect pricing to function like that, especially in life or death situations. In our case, this was a surgery that was planned and scheduled a month in advance and at no time was a price ever mentioned. Just a letter from Anthem saying it was covered. We didn't start to see anything on the monetary side until after it was all said and done with. In advance of the procedure I tried to find some pricing data on the surgery but struck out. Apart from some articles about hospitals in California publishing prices for procedures, I could find nothing for the east cost.
Does anyone know if a lawsuit has been lodged questioning these practices?
I've always thought that my informed consent should also apply to cost of procedure - I have a right to say "NO" to something in the medical establishment. And had I known the price and the success rate, I would have said "No".
Now, I'm not asking "What is my exact rate?", although that would indeed be nice. But given minimal complications, I should be able to get a range of what to expect.
I tried to get a doctor to tell me how much they would bill me for an office visit (not ER) and they kicked me out of the office. It was literally, sign this document agreeing to pay any charge we decide to bill or we will not see you. This was a doctor that I went to only because they were recommended by my insurance company as being in network.
They also didn't understand why anyone would even ask the question. They kept saying, "for patients that can't afford to pay we usually work out a payment plan." They didn't understand that I could afford anything and that was the problem. I can write a seven figure check which is why I'm careful not to open myself up to that kind of liability.
I also tried to ask "how much?" on my last doctor's visit. I was looking for a ballpark estimate, not an exact figure. The person at the desk refused to give me one, citing that insurance plans make that too difficult. I insisted that since I was covered by a major insurer that she must surely deal with regularly given their customer base, and that their office was in-network for my plan, she must have some idea, but again, she refused, saying she didn't know.
It's ridiculous, and it should be illegal. At the time, my reason for visiting was a condition that required treatment, so not going to the doctors really wasn't an option. But the inability to even begin to determine what I'm going to pay is ridiculous.
(I did this after a prior visit to a different doctor stiff'd me something like $3k for the use of what amounts to glorified camera. A camera whose photos I never obtained, despite asking for them — to which the doctor replied "we've never had anyone ever ask for that" — i.e., for their medical records. I could understand that medical-grade cameras might not be cheap, but at $3k per use, my gut says money is raining from the sky.)
And most of them are conscious, in control of their capacities, and may be willing to trade off some time for cheaper treatment. They can't get a quoted price, either.
According to the article, ~50% of hospital admissions today go through the ER.
Price transparency is pretty meaningless for ER care. Anything that is serious enough for an ER visit probably distracts you from making good economic choices, plus it's likely impractical to change ER (plus you'll pay for that ambulance ride!)
Further, it shouldn't be necessary for people to be making financial decisions in the middle of medical emergencies, even if it was easy.
> Anything that is serious enough for an ER visit probably distracts you from making good economic choices, plus it's likely impractical to change ER (plus you'll pay for that ambulance ride!)
there are all sorts of folks using ERs for non-emergency issues, simply because ERs are required to treat everyone.
both of my trips to the ER (subluxed knee; particulate matter lodged in my eye) would've been amenable to at least a few moments of financial consideration, had any information been available to me.
Every time I read a story about ER-billing I have to fight the urge to spend a few hundred bucks on the materials and equipment required to produce "official enough looking" forms of ID.
Seems like getting a hospital to think they treated someone who doesn't exist is a better bet and no more stressful than getting your insurance to cover things to the extent you are lead to believe they would be covered
Similar experience where I went to an ER and like six people interacted with me for less than 1-2 minutes apiece plus scans and an unneeded IV which came with a generous offer of Opioid pain meds when I specifically said, multiple times, I wasn't in pain. I got like seven different bills, each for randomint(0,1000). Worse, after wasting a day there - all they could do is just refer me to a specialist. The bills didn't even really explain what they were for, they just kept coming for almost a year after - apparently one for every person who may have looked in my direction plus each scan or test.
So I switched to Kaiser which is slightly better from the billing side but feels pretty mediocre care-wise. I don't hear back from the GP about questions/tests ordered and I've waited literally all night just to get something for a bad cough.
Healthcare in America is truly and thoroughly fucked.
Im curious how many supporters of GOP's free market rhetoric would support regulations around these practices once they are hit with a surprise bill like that
We will have our universal healthcare, eventually. More and more people are scorned every day by the perils of our system. The Democrats couldn't manage to pass a public option during Obama's honeymoon period but the country might be ready for it once the pendulum swings back in 2020. Even my somewhat economically-conservative father admits that it is inevitable.
These next two to four years are going to suck, though.
I am a New Jerseyan and the medical industry is going to fight tooth and nail on this. My district swung (!) and even the Democrat won't endorse single-player.
Hopefully we can effect change as the Boomer leaders die off, at the very latest.
What are the specific benefits to having an immensely expensive administrative bureaucracy lodged between the actual patient and actual health care provider?
Shifting costs from the hospitals and insurance to the patients, plain and simple.
This is merely the tip of the iceberg for what for-profit healthcare is developing into. You cannot have sound medical decisions being made when money is so deeply intertwined in the process.
In any other field all of these billing scams would be a federal crimes.
Congress could solve this issue overnight by passing a 1 line law:
If a patient is using services that is not covered by their insurance, or if they have no insurance, no medical service provider can change more than the official medicare standard rate for any services rendered.
I feel like there must be something I'm missing here. Isn't providing health care the core purpose of a hospital? Why are they outsourcing that? Outsourcing might make sense for ancillary stuff (e.g. running the cafeteria), but I'm confused why they'd look to outsource their core job. And if the outsourcing company can do it so much more efficiently, why don't they just open their own hospitals and take all of the profit?
Think of a doctor as being an specialist independent contractor affiliated with the primary business.
Imagine if you would, a small hospital. They probably don't see enough patients with diagnosis X to keep staff specialized for X busy year round. There is a doctor in town that specializes in X. This doctor needs a place to get their patients stabilized and where the doctor can see the patients periodically. When one of the patients needs hospitalization, the doctor can write an admission order telling the hospital to take care of a patient in a certain way. When somebody comes into the ER and the generalist/hospitalist discovers that person has condition X, then the hospital knows they can call on the doctor to consult with them on how to treat X.
A historical artifact of the hospital/physician relationship is that there are separate billing streams for each side. There is just enough information sharing so that the doctor's billing system knows who the patient is and it is up to the doctor to claim that certain actions were performed for a valid medical reason and documented.
The current state ranges from very arms length relationships to total economic integration, which is rare enough to have a term for it, Single Billing Office.
I have learned, directly from people that would know, that even in affluent cities in the US one-third of the people having surgery do not have insurance and simply refuse to pay any of their hospital bills. In some cities, hospitals have virtually no paying patients.
This surprised me, but I suppose it makes sense that cost have to be born by those of us that have the means to do so.
One thing to keep in mind: when you go to the emergency room as a relatively well-off individual who has insurance and pays their bills, you're not only paying for your emergency room visit - you're also paying for the visits of people who don't have insurance and can't afford to pay their medical bills.
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This is ludicrous! I have insurance, & still this will completely drain me financially. I'm at the point where I almost think it would be easier to declare bankruptcy and start over!
Curious, can you perhaps provide evidence of this? Seems like a good thing to know.
> Call an attorney.
This is itself a cost, and maybe only makes sense if you owe ≥ $10k but for procedures billed as $1k when they should be $400 I don't think warrants the cost and time of an attorney; what other recourse is there except to pay?
I agree, I do, which is why I tried making my statement as much a question as possible. I am unaware that attorney's would fight for cases like this, if they are more common and do not lead to lawsuits.
I agree that an attorney only makes sense if you're facing a significant bill. On a smaller bill I would go to the hospital billing department and negotiate.
You can of course negotiate as well.
If someone bought a car or house, they knew their obligations exactly. If they declare bankruptcy, I would lay some fault with them, if not all.
But with medical billing, you cannot get a straight answer. If they cannot tell you what a simple procedure would cost you, then you don't owe them anything.
Also hopefully if enough people don't pay surprise bills, then medical industry would have motivation to simplify their systems.
I don't get this statement. Not protecting your credit score can cost you real money. Yeah, the whole thing is a racket, and I frickin' hate it, but, pretending like you can ignore your credit score without impact seems counterproductive.
I would really rather see this whole racket of a medical billing system held to account versus advocating that we allow them to punish us in any way for not playing their fraudulent game.
Despite this, I have been able to get a car loan, I got a VA loan for a house, I have opened two credit cards (which I use responsibly) since then, and also was able to get a personal loan for an emergency six years ago. It is absolutely possible to do "normal" things. It's just been a matter of explaining the situation.
Clearing errors involves a byzantine maze and way too much time in an era when everything is digital. There should be stringent regulation around accuracy and we should all have free year-round, real-time access to our credit scores.
But, my point here is not that you can't live a normal life with a few credit dings. It's that those dings represent punishment that can impact you. For instance, you may not have gotten the best interest rate available on your subsequent credit. So, we should be advocating an end to these fraudulent medical billing practices vs accepting punishment from them, then trying to live with it.
BTW, I predict Verizon will soon be the target of some hefty class-action. They are very shady when it comes to contracts. They also have periods wherein substantial numbers of customers report mysterious, frequently dramatic data overages for a time [0] that suddenly disappear. But, they refuse to acknowledge any issues.
And they specialize in making it extremely difficult to achieve resolution, with multiple phone calls, etc.
[0] https://www.wirelessweek.com/news/2016/09/thousands-verizon-...
My perception is that the problem is typically framed as a lack of insurance problem for financially challenged people, but the "abuse" on the billing side to me seems like at least as big of a problem. And if this is being conveniently ignored, it feeds my conspiracy thinking that the Democrats are actually largely indistinguishable from Republicans - they may wear a different mask, but their actions are only slightly different, in this case altering who is getting robbed.
It only makes sense to at least postulate that the converse is true as well: if you find yourself stuck out-of-network, it's because these regulations created an environment where the insurance companies could do better by eliminating the providers it partners with. So it's reasonable, at a first approximation, to guess that this problem is the result of ACA.
Also: this idea that the "Democrats are the party of the people" and the "Republicans are the party of corporations" is pretty silly.
The Republicans are a conservative political party. The Democrats are a coalition of blacks (~25%), latinos (~10%), women (+10% share), labor unions, and urban (but not suburban) college-educated whites. Liberals are an important component of the Democratic party (and have no home whatsoever in the GOP), but they don't run the table.
Republicans can't win the numbers game so they hammer home on right wing populism. Unfortunately, the last 30-40 years hasn't been kind to the "Main Street" centrist republicans of the past.
Probably the most important realization for the average American in the current political climate is how no party establishment represents you. Both have their sponsors, and none of them are the American people. Individual politicians might have more empathy than others and some might try to help the common man more than another, but they all still have their bosses and despite whatever rhetoric we throw around in almost every election (aside the scant few in contested states and counties) the people are not holding their leash, so they don't work for you.
It is like climate change. It doesn't matter how you want to argue about solving it, it is simply acknowledging the reality that has to happen first and moving on from there on a unified foundation of fact.
A lot of people forget that the GOP does not, as a political party, believe in universal coverage. Moving the country closer to universal coverage is not a GOP political objective. What is a GOP objective is minimizing federal interference and involvement with business. Health care is something like 15-20% of the entire economy, so the GOP's stated objectives run directly counter to universal coverage.
And yet, repeated efforts to eliminate the ACA have all retained policies built around universal coverage, including a massive federal expenditure in Medicaid (block granted or otherwise) and an extremely intrusive regulatory requirement for guaranteed issue insurance, something that only Ted Cruz has tried to push back on.
If that's not a win for the Democrats it's hard to imagine what plausible outcome would be. Nothing that involves 15-20% of the American economy will be simple, or will happen in one legislative session.
Any number of effective cost-saving measures could be passed that would have the effect of increasing your premiums.
If you're paying for your own insurance, you're in the individual market, which is significantly more expensive, and what you're seeing is, in part, the market absorbing the cost of guaranteed issue, something we decisively did not have before the ACA, when health insurers could lock people out of coverage on suspicion of a medical condition, and later rescind care. Pre-ACA and post-ACA insurance is for that reason also not an apples-apples comparison.
Is the actuarial and outcomes data corpus of the health insurance industry so bad that it makes actuarial sense to segment the markets to individual, medium group, large group, etc.? I've always wondered what the explanation is for so many cohorts.
Are state insurance regulations preventing medical insurance providers using more sophisticated risk modeling to create larger pools, or co-marketing with life insurance companies that gather pretty detailed data on individuals before underwriting?
Especially post-ACA, there are very strict limits on what factors can be used to set premiums. Risk-based assessments are basically outlawed except for a few defined variables like age and smoking habits.
Regardless of the cause, it's extremely frustrating to be hit with such a large monthly bill for rather poor coverage. I'm not quite as bad off as 0xbear, but we're at $1550/mo for a family of three for much crappier coverage than we had a few years back.
Here in Phoenix we've seen double digit increases every year for years, and are down to a single provider on the individual market.
Paying $18k/yr before you even use a plan is insane. Use it at all and you're looking at $20 or 25k total, with coverage limits not really kicking in to stop the bleeding until you've shelled out 30k or so.
Somebody making $80k/yr just hits the subsidy payout and is spending 20-40% of income on health care. Unsustainable.
Argue the whys all you want, these sky high rates have to change.
If you don't argue the whys, you're mostly providing a lot of noise that is convenient cover for the next attempt to bilk insured people.
Yes, premiums are way too high. They are not high "because ACA", though. In fact, they'll rise at a much faster rate if we get rid of ACA. (The latest bill had an annual rise of $11.4K for a single male adult >62 years, with an annual income of $12K.)
There's no question ACA is broken, and we need to fix it. But we need to know and understand what is broken to fix it. A repeal won't do that.
There's a good argument to be made that e.g. enforcing cost transparency would do that. (Right now, you have no idea what insane cost your provider will charge you - they make shit up as they go). Single payer is one possible way to do that. Not the only one.
There's another good argument to be made that we need to talk about the right to die. Numerous patients are kept alive at insane costs, even though they would rather live out the last few quiet moments at home, with their family.
There's another good argument that for a decent risk pool, everybody needs to be insured. (This is an argument that stands little chance until being insured is actually somewhat affordable)
There's a good argument to be made that Medicare should be allowed to actually get competitive bids. (Right now it's rejected to "pilot projects" and "test markets").
There's a good argument to be made we need to focus much harder on preventative care. Follow-up costs from acute episodes are much higher than a decent investment in preventative care.
There's a good argument to be made we should talk about our test and prescription obsession. The amount of stuff unnecessarily prescribed "just in case" is ludicrous.
None of these will immediately lower rates. But each day we spend wasting on the theatre that is the junk the current GOP tries to ram down everybody's throats is a day they rise. And should this pass, they'll rise tremendously.
If we don't all inform ourselves as to the why's and then hold our representatives feet to the fire using well-formed arguments, so they can't weasel out, we're stuck with a shitshow. So, while I understand the frustration - I've got health care bills too, after all - an attitude of demanding change without informing ourselves what change to ask for leads to an even worse disaster.
And that feet-to-the-fire thing applies to all parties, in case you were thinking I have a particular partisan view. But it needs to be an informed roasting, or we'll merely end up with the loudest guy making the good sounding promises.
I'm ranting against those who continually tell me "it's not that bad", "suck it up", "you're lucky you have insurance" or some variation of the above.
The first step in fixing the problem is to recognize the problem, and there's many I've talked with that reflexively reject the premise that there is a problem in the first place because of what that means for the ACA.
The foundational issue is that we're stuck in an uncanny valley between single payer and private insurance. Either single payer or private could be viable, but not the unholy menagerie we have now.
The high costs, over prescription and under prevention that are bloating the system all driven by that issue and could be solved with a single arbiter that gets the bill, whether that be the government or the citizen.
The best proposal I've seen is a two-tier system like Germany has, with public healthcare for all and private healthcare available for the rich. That tends to rub Americans the wrong way because fairness, but really solves most of the problems because it gets universal coverage to spread the risk pool while accepting the natural impulse to want to pay for better care if you can rather than rejecting that option out of hand like some single payer systems do.
I lol'ed. Because... we already have private healthcare for the rich, we just don't have public healthcare for all. Because fairness ;)
And I'm very much enamored with the German system as well, but then, I'm biased. I'm from there. (And currently pondering going back there, because as much as I love what the US could be, I hate what it currently is)
The NHS costs about £3,500 a year per person.
As for the increase premiums are up 25% in 2017 alone. At the same time deductibles are also rising, its much more money for much less coverage if you are unlucky enough to make over 50k a year or so.
http://fortune.com/2016/10/25/obamacare-insurance-premiums-2...
https://www.brookings.edu/wp-content/uploads/2016/07/Fall201...
It's remarkable that premiums didn't rise more under the ACA, despite how many new previously-uninsurable people were covered.
That's why factcheck should not be used to check... facts. Just as they claim the RNC have twisted this and that to make themselves looks better factcheck is twisting things here as well, to make someone else look better. Health insurance providers had raised premiums in anticipation of the vote and the legislation passing. So it's specifically important to look not at 2010 when it was signed into law but a few years below when there was this uncertainty about it. One way market deal with uncertainty is to hedge their bets. "Not sure what will happen, but this might pass, and why don't we just raise the rate now" kind of idea.
I've heard this directly from the health insurance representative who came and told us told us, "sorry but rates are going up sharply because we anticipate this new legislation".
But they did during 2009. By July, a number of bills were already approved by committees in the House. And the Fall is usually when the companies get prices for the next year. So it went up sharply then. Then in again in 2010. Price is not always comparable because the level of coverage had also changed. We had to get new plans and while they covered some mandatory free procedures and didn't have lifetime maximum, they had also bigger deductibles and a reduction in options and procedures covered.
That doesn't mean we'll find a larger jump there, I found it for my self, but the KFF study shows there wasn't in general. However discarding date legislation has passed is also dishonest as factcheck did. Companies which are affected by regulations monitor them closely and adjust to them correspondingly.
Without adjusting for inflation, this growth is ~60% growth in 6 years, or a doubling time of ~9 years. After adjusting, it's more like 40% over the same 6 years or a doubling time of ~12 years.
So you could have the impression that you had "cheap insurance" as long as you never need to have significant healthcare paid for.
The very year ACA took effect my health plan was canceled, my doctor went off-network, my new plan had 3x the annual premium and has grown 30% year over year, as have deductibles, and I fight tooth and nail every single charge to make sure it is in network and covered.
Yes, one anecdote is not data. But there is no more validity to the politician's lie that I can "keep my health plan, keep my doctor, and health care costs will go down."
Something like 80,000 Floridans lost that policy because it didn't carry the minimum services under ACA/Obamacare. But it wasn't just losing the policy, they were never able to afford the new blue cross blue sheild policies, having to purchase from a new insurer most of whom had reputations as fly by night operations (many not existing before ACA and shutting down 1 and 2 years in), and finally losing the good BCBS network.
Here is a copy of the actual letter sent out by BCBS when they had to cancel the policy: https://www.floridablue.com/blog/my-policy-being-canceled-no...
Same here, and I hear the same exact story from most people I talk to. Plans dropped, premiums skyrocketing. Here in Phoenix we've got a single insurer left, and we'll see if we have anybody next year.
What I haven't seen is stories of average joes who were substantially helped by ACA. Sure, if you didn't have coverage before by cost or pre-existing condition, or get subsidies now, maybe you're happier. But the vast middle class, not so much.
So there's a face for you, 32 year old, healthy, middle class, white woman who likes cats, rides horses, and has a pet bearded dragon who she talks to in a baby voice can get regular cancer screenings because of ACA.
Post-ACA, I could once again buy health insurance.
I consider no longer being locked out of the US medical system a substantial help.
Consider also the not middle-class recipients of medicaid expansion.
If that's the case, then the difference between Democrats and Republicans is that the Dems want to insure the poor while still ensuring high profits for the industry, while the Republicans want to screw the poor while ensuring high profits for the industry. They differ on one very important issue, but are still mostly the same.
Actually reducing medical costs requires a far more thorough overhaul of the system.
It hasn't been like this since LBJ. Both parties are completely driven by corporate lobbies. All that differ are the excuses why.
We need a single payer system because, at the societal level, it makes sense for government to make sure people get their healthcare needs met for the same reason it makes sense for government to provide police and fire protection. But forcing all Americans to get private health insurance makes no sense and indicates a fundamental misunderstanding of what the insurance industry does.
Direct Primary Care, single payer and wellness programs all have a good track record of genuinely getting people healthier while bringing down costs. Obamacare cannot do any of those things and just runs expenses up.
Source/qualifications: Among other things, I worked in insurance for over five years. I have a certificate from a technical college in life and health insurance, paid for by my former employer.
The provider must set a high sticker price so that they can give the insurer the expected 60-80% discount to get in-network (and still tolerate underpayment and other shenanigans). The consumer is either intentionally misled or confused (usually both) about basically everything cost-related, and often won't learn the true out-of-pocket cost of a service until ~1 year after receiving it, when the billing process has (mostly) finished.
Example: just yesterday I got a new bill for a routine lab test I received in December. It says that the insurance discount applied, but they never sent a payment, and thus I owe a balance of over $200 to the lab company. Now I have to call the insurer to figure out why they denied payment, which is sometimes due to an administrative error, sometimes a paperwork thing like signing a document that verifies there is no other possible insurance carrier whom may have been responsible for the bill, etc.
Obamacare is thus anything but up front, because honestly working to fix the American medical system would involve excising market-breaking, paper-pushing leeches from the marketplace, but Obamacare props up this destructive apparatus by forcing every American to pay in or get fined.
Almost any economist will say this is one of the largest problems with US health care costs and employment mobility.
Every employer outside of the health insurance and drug industries should be furious at the price they pay to pay their employees health benefits. Besides having a distraction that operating businesses in other nations don't have, they're likely paying more than double than what they need to in this area to maintain competitiveness against other nations. It's even worse for startups.
It also probably should have used subsidies instead of Medicaid expansion. Expensive, but a bunch of healthy people would have been good for the exchanges (Medicaid expansion almost by definition was for healthy working people).
Have you been watching anything that's been happening with the healthcare debate over the past, oh, 25 years? The Democrats have been trying with varying degrees of success to inch this country in the direction of a more sensible healthcare system and the Republicans have pitched a generation-long hissy fit about it.
On the coverage side, the two parties have contrasting stances.
Healthcare and Health Insurance are related but distinct topics.
I'm actually not sure the BHCA or AHCA or whatever it's called now has much in it besides slogans and major spending cuts which aren't aimed at making care less expensive -- they're aimed and reducing the overall amount of care provided by shifting costs to those less capable of bearing them.
That's a pretty big contrast.
Cost of healthcare, other than the occasional conversation about drug prices and definitions of necessary care (which continues to be abused by practitioners), continues to take a back seat.
For what it is worth, my personal opinion is that the medical professional lobby is a single issue voting constituency that is just as powerful as the NRA and the teachers unions.
Until then, I will continue to believe democrats and republicans serve the same master and only differ in language to provide an illusion of choice.
It's been that way for decades.
Source: http://voices.washingtonpost.com/ezra-klein/2009/12/the_deat...
By contrast, Lieberman single-handedly killed the public option.
But that's not always the case - Neil Gorsuch was confirmed by a vote to suspend the 60 vote rule. So the rule is available for things that a strong party consensus.
https://www.nytimes.com/2017/04/06/us/politics/neil-gorsuch-...
No, as your source accurately states, he was confirmed after a vote to abolish the rule for Supreme Court nominations.
Both sorts of actions decrease the power of individual senators. If anything, abolishing for a whole category reduces senator's power more - if you also read the article, the basic point is the action indeed altered the power dynamic, what those considering individual senator power are worried about.
However, it remains the case that in 2009, 59 senators were ready to vote for a public option, but there was no 60th. By contrast, there were nowhere close to even 50 votes for removing the filibuster and changing to a 50 vote threshold.
Please do not miss the fact that Lieberman had no rational justification for opposing the public option and that one of the keenest observers at the time accused him of being "driven more by a pathological dislike of the liberals who dogged him in 2006 than by any remotely rational policy judgment." http://voices.washingtonpost.com/ezra-klein/2009/12/lieberma...
Those are the facts. You are laying emphasis on the one person who wouldn't vote and I'm laying emphasis on the 51+ wouldn't take take stronger action.
I think it's reasonable to give my emphasis given the way the Democratic Party has behaved over time.
I suppose that voters could have hypothetically had a positive reaction to the public option once actually set up, and rewarded Democrats for it in subsequent elections. But I doubt it. Although Medicare already exists, the public option would represent a significant expansion which would probably come with serious growing pains - plenty of material for Republicans to make horror stories out of. Probably fewer actual cases of huge premiums (which are already not that common), but it's not like statistics have ever been much barrier to politicians and their preconceived narratives. I guess the GOP wouldn't have been able to weaken the law through a constitutional challenge, as they did with Medicaid expansion - after all, the public option can't be unconstitutional unless Medicare is. But the Supreme Court is highly political, and I wouldn't be surprised if the law ended up being weakened some other way by a 5-4 majority...
But politically, Republicans would have a stronger alternative to offer: ACA without the public option. Y'know, the thing they currently portray as the root of all evil; I think they'd have ended up seeing it as a good conservative compromise, that preserved universal coverage availability without requiring the government to be involved directly. Arch-conservatives might not like that outcome (then again, they might) - but they'd likely accept it as an intermediate step, that still accomplished the substantive change of repealing a huge government program (the public option). It would be much easier to get consensus on than the repeal-in-name-only bills they're tossing around in the real world.
I suppose I'm getting way too speculative; the last two paragraphs aren't even directly related to the nuclear option, although they're meant to question the upside of Democrats hypothetically having deployed it. There would've been serious downsides, not just in health care; it's quite possible the 60 vote rule would end up being killed entirely rather than only for 'special' bills, so Republicans in the current Congress would've been able to pass a wide variety of their priorities, and repeal a wide variety of Democrats'. (For all I know you might support the Republicans on their other priorities, but the Democrats whose votes we're talking about certainly didn't.)
A suspension is both procedurally (or textually) more complicated (it either requires changing the rules twice, changing the rules to add a suspension provision and then acting separately to exercise it, or changing the rules to include a tailored exception that applied only to the case at issue) and more politically fraught (rather than publicly defending the case that the general rule is outdated, it requires legislators to defend that the rule is generally valid but should not be applied to the immediate case.) It's very much not the same thing as abolishing the filibuster for a well-defined class of cases.
This is particularly true in the Gorsuch case where the recent Democratic action to remove the filibuster from other Presidential appointees made applying the “nuclear option” to Supreme Court justices much less “nuclear” than it had seemed previously when it been considered.
And then watched it get blown away by next congress as soon as the GOP gained 51 seats to do whatever they want. Blowing away the fillibuster is an awful, terrible, no good idea and there is almost no legislative agenda which would validate it.
And to be clear, the GOP senators were and still are slimey bastards for basically everything they did leading up to Gorsuch. It should have never been done. They will almost certainly regret it as soon as they lose the senate.
Public option is a great solution, because it does not prevent the people who prefer (and can afford) to pay for private services from doing so.
And that is counting Lieberman as a D; a person who backed McCain for president and who later personally killed the public option.
I do think we will get to the public option at some point. It just makes too much sense not to and would strengthen the healthcare as a whole while allowing people more choice.
1) Indian Health Service - the US agency tasked with providing and paying for Native American health care on reservations or "health service areas". http://www.richheape.com/american-indian-healthcare.htm
How does single payer fix that? If the hospital gives you a bill and won't negotiate down, how does the government "fix" this? Which is kind of what my question is: were specifics given in the ACA on how that problem will be fixed?
On national health insurance (monthly cost depends on your salary but for an average person it is a few hundred bucks per month) the hospital pays 70% and patient pays 30%.
It means basic visits to the doctor or dentist are very cheap here. Like $20 for consultation + medicine. ER+X-rays and MRI (appendicitis, sigh) was a little bit over $100.
If anything, the billing abuse is a much, much larger problem than lack of insurance. At least, that has generally been true since the ACA/"Obamacare" changes passed.
My thought experiment for some of this. Suppose the US government had a rider on every insurance policy in the US that said the government would pick up the tab for any amount over say $100,000 (think catastrophe insurance). Now, you would make the assumption that looking at the actuarial tables this would reduce the cost of health insurance because no insurance company is on the hook over $100,000 (thus no need to worry about the million $ payout).
I am more and more convinced that hospitals would screw this up with over billing for every damn thing and every visit requiring a stay would get jacked to > $100,000.
We have a solution. It is called "make it a personal criminal liability". Go after individuals. No matter how low they are on a totem pole and no matter how high they are on a totem pole. Committing such fraud should lead to bankruptcy ( all assets wiped out ) and jail time.
You would be amazed how quick those "accidents" and "mistakes" stop happening.
Unfortunately, as the society we do not want to throw Suzi the billing clerk into the slammer, which means that Mike, the Billing Manager, does not get a slap on the wrist, which in turn means that Jack, the VP of Billing Revenue Optimization, does not get Jackie his wife go bananas on him when their bank accounts, house and kids college fund is seized which means that Jack is represented by the public defender and ends up in a slammer together with Suzi, who actually pushed the buttons, Mike, who told Suzi to do it, and Jack, who came up with this wonderful idea.
Socializing this theft turns it into Just Another Crisis among the hundreds of others the US has.
The "true" purpose of the ACA was to do something about spiraling health care costs. What was passed was a "compromise" where the people pushing for a public option got nothing and the most onerous restrictions on the monied interests were rolled back. This has not been an effective solution in many senses. I decline to further characterize the issue, however; this is extremely close to a political discussion, and those are ban-worthy here.
I would not put too much weight on conspiracy theories though. The healthcare system is massively complex. It will take multiple reforms to eat this elephant.
http://www.cnbc.com/2015/11/20/obamacare-architect-high-dedu...
The previous administration was working to move to different payment models to try to address it (it's not clear that the different models will have much long term impact):
http://www.reuters.com/article/us-usa-healthcare-reform-idUS...
What a terrible industry.
The employees at an insurance company have an ethical responsibility to the company to deny any claims that do not perfectly align with the policy they sold. I don't think every insurance company is the antagonist in The Rainmaker or the car company in Fight Club, but insurance companies will try to reject as many claims as they can, straddling the line of losing reputation with consumers.
the health insurance industry shouldn't exist.
Then you get to sit in an "emergency room" for hours, when you're physically unable to move, and with your phone dead so you can't even let anyone know where you are. When you're finally wheeled to where you need to be, you're basically dumped in a hallway facing a wall for half an hour, and you're in a wheelchair and so weak that you can't even turn to face anything interesting. I paid about $1000 for that luxury. At that price I'd expect a decent waiting room...
Yes I just needed to vent about that situation. It sucked, especially for a college student. I was hounded for months afterward to pay those bills, because of course when you're throwing up you can pick which ambulance gives you a ride.
The out of network doctors were resolved the fastest for us, and the longest was the hospital stay itself, which our insurance didn't agree to pay until 8 months after the stay. It was a seriously draining experience, and luckily my wife doesn't work so I didn't have to take time off for all the phone calls and following up that was required.
I don't fault our insurer. The hospital charged more for our one night stay than another slightly further hospital recently charged us for three nights stay. It was completely ridiculous. But completely out of our hands.
I've had to deal with that and more in the last couple years. In my experience there are no "good" or "bad" guys in this fight. It's a bunch of individually rational entities that when taken as a whole are completely fucking over the rest of us.
So, yes, if you refuse to be transparent in your billing and you extort money from your patients by refusing them treatment unless they agree to pay literally anything for service, you are a "bad" person.
Sounds like dental care in Canada.
I'm told this came about because historically more people had to pay for dental services out of pocket, so dental offices were used to having standard fees that they could just look up.
Apropos of outliers, this type of attitude is problematic and emblematic of issues in the US.
"Needing healthcare" is not "abusing medical insurance".
There are of course shitty doctors, but playing devil's advocate for a minute: you were arguing about theoretical billing scenarios while there were other patients in line waiting to be seen. So it's not exactly surprising that he got fed up and kicked you out.
This.
This is so horrifically true, it takes call after call after call (and emails, and faxes, and snail-mail claims forms that take "30 days" to "process") to get anything changed, and by then you have collections companies harassing you and your credit goes down the drain. Meanwhile you must keep working and taking care of family and dealing with the actual illness/issue that led to the medical visit in the first place. It is insane.
He fractures his pelvis into 14 pieces, and broke another dozen major bones including both femurs.
The surgeries are still ongoing although he is mostly himself again. But even two years later, he is facing a daily barrage of calls, being put on hold, no callbacks, paper shuffling, records from hospital to hospital, faxing permission sheets, fighting with the insurance company (who has threatened to drop his insurance multiple times) and on top of it all, his landlord is trying to evict him.
It's been horrible to watch. It's like the insurance company is trying to kill him with stress.
Is it a 'won't happen to me' sentiment? Preferring the freedom of literally landing on the streets with one accident since you're presumably fully in charge? I do not understand, though there must be an understandable reason.
I think the only reason anyone can think it's OK is (1) they haven't had a major medical expense yet and (2) their political tribe tells them capitalism is the answer for everything.
Honestly, healthcare in the US is so broken I don't see how we avoid a crisis in the next few years because of it. Maybe it will somehow pop like a real estate bubble (sad when that's the most optimistic thing you can hope for).
That sounds horrific. What sport was this?
A health insurance company, no less.
If you take an ambulance to the emergency department, see a doctor, they order a scan, the scan shows appendicitis, and your appendix is subsequently removed, this can easily lead to six different bills:
And that's assuming that the ED and hospital are under the same company (not always), and that no off-site labs are used. You may not have ever heard of the radiologist or anesthesiologist. I once had bill collectors calling me re: a radiologist I'd never heard of, who managed to ruin my credit for a good six months until I figured out what the bill was actually for.I don't buy for a minute they are just cogs in the machine. I really used to respect anyone in the industry. That respect is almost completely gone.
I am now furious thinking about our lovely medical system, along with the FDA.
I worked in insurance for over five years. Not this kind of insurance, but it was a kind of health insurance.
a) Get a letter of "medical necessity" drafted by your primary care physician.
b) Call the insurance company and ask about the policies concerning emergency treatment. Don't accuse them of anything. They get cussed out all the time and it will not help you. Be nice and start from the assumption that there must be some mistake.
c) If you make no progress with that, have a lawyer send the insurance company a letter requesting a copy of your records. This sometimes makes them look very carefully at the bill and sometimes is enough to get you whatever benefits you are legally due. Which may not be your wildest dreams of avarice, but may stave off your desire to declare bankruptcy.
If you do have a lawyer request your medical records, expect the insurance company to come back with a form letter stating they need a third party auth. Yes, a lawyer will need a third party authorization to get your medical records, but I wouldn't bother supplying them with one at the start. Just make the request without it and supply it if you really need to. If you get your bill paid because a lawyer wrote them, your lawyer doesn't really need your records. The initial inquiry sometimes gets the claim looked over more thoroughly. I am basically recommending this as a scare tactic.
There are actually a lot of errors made in paying complex medical bills at insurance companies for the simple reason that the claims processor may not see an 8 day hospital stay all that often and may have about 10 minutes in which to look your bill over and decide what is payable before moving on. I had to process 60 claims a day to keep my job. This meant I had minutes to decide what the benefits were and people who were very fast were actively rewarded for it. I often cleaned up their messes and, no, this did not get me promoted or anything, even though it sometimes kept the company out of court because the people were threatening to lawyer up.
Best.
I went to the ER for a broken hand a couple years ago, got a $450 bill in the mail when I should have just had a co-pay. Called the hospital, they said I had to pay. Called my insurance, insurance company said I didn't have to pay. Got in a three way call with the insurance company and the hospital... The billing specialist at the hospital literally said "Sorry, that's a known billing error!"
I'm generally not a conspiracy theorist, but I've never heard of a medical billing error that was in favor of the patient... If you see something alarmingly high or out of whack (especially if you've done your due diligence, read and understood your policy, and researched covered hospitals) you'd be silly not to fight it.
https://nextshark.com/youll-love-what-this-startup-does-with...
Here are some thoughts:
Fixed takes a percentage of the dollar value of tickets that get dismissed and you pay nothing for the service if it is not fixed.
Trying to get money out of an insurance company is sort of the opposite problem, though it gets monetized essentially the same way. Independent adjusters monetize by taking a cut of claims paid. This is basically the same monetization scheme that lawyers use for things like suing someone over an accident: They take a cut of cases they win, and you pay nothing if they lose. As far as I know, independent adjusters only work on real estate related claims, not health claims.
Last I checked, the only people legally entitled to talk to the insurance company on your behalf are your insurance agent of record, a lawyer or an independent adjuster. So, in practice, you would be talking about independent adjusters for the health insurance space. I am not clear that would even fly, legally.
Health insurance is a pain in part because it is very highly regulated. It has to comply with both federal and state laws in all jurisdictions in which it operates and laws for both health companies and financial services companies. Thus, it is subject to both HIPAA (Health Insurance Portability and Accountability Act) and The Gramm–Leach–Bliley Act (GLBA), also known as the Financial Services Modernization Act of 1999. I got annual training in Gramm-Leach-Bliley when I had an insurance job. Furthermore, claims must be reviewed and paid in accordance with various state laws. The company where I worked kept a database of "state exceptions." If you don't know those state exceptions yourself, good luck arguing the matter with an insurance company.
You are talking about a very challenging problem space.
I have had it cross my mind to offer a service helping people file claims with the company I once worked for. Although I haven't worked there in a while and some things have no doubt changed, I probably could help some people get more money out of their policy. But I have never gotten past the idle thought stage in part because insurance is such a pain of an industry, and in part for other reasons.
I am with Kaiser now and it is the most BS free medical experience I have ever had. To fix healthcare without single payer the government should just make a law that medical insurance can only be offered by hospital chains and the doctors and specialists cannot bill insurance separately, but must be paid by the hospitals. This is how Kaiser works. That way the hospitals can pay a fair market rate to doctors and not have them demanding a surprise emergency room rate from distressed patients.
If I had been on Blue Cross Blue Shield, I probably would've sucked it up given my super high deductible and navigating the in-network maze.
My biggest complaint about the medical industry is the cost of prescription drugs. It's ridiculous how much we pay for drugs in this country.
It's not terribly expensive either. I just started COBRA and it is $750 a month or so.
I'm glad I don't have an HMO, as I'm not organized, and tracking down referrals and such would be a nightmare for me. I've never found a doctor that isn't in my network, so I just figure out which doctor is closest to me and isn't a hack and schedule an appointment. I live a couple of miles from Northwestern University Medical, and Rush University Medical Center, and they've got almost any type of doctor you could possibly need to see.
I don't think my PPO is complicated, but I've never found technical documents that hard to understand. Most of the complications seem to be for emergency and urgent care, but office visits are as uncomplicated as I've made them seem. Some types of lab work might cost more, but I've never been charged for any diagnostic tests outside of cat scans and MRIs.
Since the ACA, there has been an emphasis on shifting from a fee-for-service model (FFS) to a value-based care model (VBC). Under a FFS model, doctors and hospitals are paid for each service they provide and make their profit from the margins built into the prices they charge for their services. In an ideal VBC world, doctors and hospitals are paid a certain amount for each patient they cover, and don't make additional revenue when they provide services to patients.
You can immediately see the incentives in each model. In a FFS world, doctors and hospitals are incentivized to give you the most care possible at the highest possible prices. For example, you could see how a doctor could be motivated to give a patient an unnecessary MRI. In a VBC world, the best-case scenario for the doctor is that he never sees you, and that you never enter the hospital. Each time you receive care, he spends time and money providing that care, but doesn't get paid any additional money for it. In other words, his margins decrease when he provides care (or, as those in the industry think about it, his medical loss ratio increases). When you become sick, the doctor would prefer that you seek care in a setting that is as low-cost as possible - via telemedicine, an urgent care center, or his office. That way, he keeps more of the monthly premium.
Practically, though, in the VBC world, the doctor probably wants to see you once or twice a year, to make sure you are healthy and that you are taking preventative measures to avoid becoming sick and utilizing healthcare. That investment of resources can help reduce your need for healthcare in the future, protecting his profit margin going forward.
So in a perfect VBC world, everyone's incentives line up. You spend as little time in the hospital or at the doctor as possible, and check in every once in a while to make sure you are healthy. Doctors and hospitals make more money when they don't have to treat you, and want to keep you out of the healthcare system.
The problem is, the current system is a mix of FFS and VBC. Most hospitals and doctors aren't compensated on a fully capitated basis (capitation is a concept that, in layman's terms, measures how close the system is to VBC vs FFS - more highly capitated = closer to VBC). Under FFS, doctors don't make much money providing preventative care, so there is no incentive to keep people away from the hospital. Unless you are a member of a system like Kaiser, you are most likely covered by a plan that is partially capitated - your insurer may share profits over a certain % with your doctor as a reward for keeping you healthy, but still pays for services on a FFS basis. Often, this profit sharing does not compare with the potential revenue from providing additional acute care services, so the old FFS incentives are still at play. (Hence the $600 1-minute consultation.)
Now, wouldn't it be great if every health system operated like Kaiser, where all the incentives are aligned and the objective is to keep people out of the healthcare system? Yes, but the answer is not as simple as requiring healthcare systems to provide insurance. In fact, Kaiser is one of the only success stories involving provider-sponsored health plans (Presbyterian in New Mexico is another).
The reason why many of these provider-sponsored health plans fail is twofold:
First, most healthcare in the US (70% I believe - but that is from memory) is provided by regional or community healthcare systems. These systems only serve certain communities (their primary service area, or PSA) and therefore certain populations. These populations are often not of significant enough size to provide adequate risk diversification for healthcare systems that provide insurance plans. One of the key reasons insurance works is risk diversification - but these hospitals can't diversify their coverage beyond their community's population. In fact, one of the most common criticisms of Kaiser from the investor community is that its membership is too concentrated in California - and Kaiser has over 10 million members on the East and West coasts.
Second, these systems often don't have the capability to price their insurance and healthcare services correctly to account for the levels of risk embedded in their insurance plans. Sometimes that is due to lack of actuarial experience, sometimes that is due to lack of risk diversification causing risk to exceed estimates, and sometimes that is due to existing healthcare prices driving up costs to a level beyond where they can reasonably charge premiums. Also, it is hard for these systems to predict who will enroll in their health plan, and what their overall risk level will be after enrollment season. There are companies dedicated to helping systems operate provider-sponsored health plans (e.g. Evolent), but this has proved to be a difficult problem. For examples of premier systems getting this wrong, look up Partners (they own Mass Gen), Catholic Health Initiatives, Northwell, Banner Health.
While this is a hard problem to solve, and I don't have the answer, you are right that the Kaiser model has in many ways proven to be more cost effective than FFS or other capitated models. It might be a good intermediate step for some of the larger systems. But there is still a lot of work to do to fix the system, and even solutions that sound good on paper have unintended consequences (for example, if you move to a single payer system to reduce prices, would lower drug prices disincentivize pharma R&D, hurting development in the US and the rest of the world? Would medical device companies making prosthetics go out of business if prices decreased below their cost levels? etc.).
Hopefully this was helpful to people who aren't as familiar with the way the system works. A less-than-perfect analogy I often use is:
The old FFS model is a "supermarket" model: the supermarket makes money by selling you as many gallons of milk as possible, and pricing the milk at a premium to their cost. The higher they can price the milk, or the more milk they can convince you to buy, the better off they are.
The current model is a "Costco" model: you pay a recurring membership fee to Costco, and can buy their products at a lower price, but (let's assume) you still pay a slight margin on those products to Costco. So, Costco would love to have as many members as possible paying membership fees - and, in fact, could offer its products close to cost if there were enough members who didn't use the store. But, they would still prefer that members use the store as much as possible, and buy as much product as possible at the highest allowable margin for Costco.
The "ideal" VBC model is a "Netflix" model: you pay a recurring membership fee to Netflix, and can stream any of their videos for free. Netflix starts out the month with its $10 of revenue from your membership, and each video you stream causes them to incur streaming costs and royalty payments, reducing their margin on your $10 throughout the month. From a pure profit perspective, Netflix would love to have millions of members who never used the service, allowing Netflix to keep 100% of their membership fees. However, in order to grow and be successful, Netflix needs members to use and love the service, so it "invests" some of its membership fee by streaming videos to users. If users are going to stream, Netflix would prefer that users stream its proprietary content, which is lower-cost for them to provide. (That last part of the analogy is stretching it a bit, but meant to demonstrate that for the health of the system, some utilization is required, and the provider would prefer that utilization to be as low-cost as possible.)
I am in the opposite camp and don't have the time to write out my position to the extent you did. However, I'd just like to take a moment to point out the ludicrousness of calling something that isn't Fee For Service "Value Based", as if there's anything in the world more "value based" than paying someone for the value rendered in a specific service.
I agree that "value based care" is probably not the best name for a fully capitated system. (Population health might be closer, but still not perfect.) By definition the "value" of something is whatever someone is willing to pay for it. A doctor's reimbursement rate is negotiated with the insurer, so there is an explicit agreement to pay that rate for that service. And by being a member of that health plan, the patient explicitly agrees to pay whatever deductible or copay is required by the plan, based on the rate the insurer negotiated with the doctor. So in a FFS system everyone has actually agreed to pay the price that is charged.
The problem is that as a patient, it is hard to tell how much a medical service will cost before receiving it. In a grocery store, you can look at the price of milk and decide whether it is worth buying. But there are all sorts of reasons why price consciousness is harder with healthcare (for example: emergency care, lack of price transparency, agency issues). And so the idea of value is harder to measure from the patient's perspective, which is why value and price paid may not exactly match.
Mind me asking what kind of work your investment bank does with the healthcare industry?
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My state's bad ass Insurance Commissioner is trying to mitigate this problem:
Surprise billing legislation passes state House of Representatives
https://www.insurance.wa.gov/news/surprise-billing-legislati...
Be sure to call and voice support. Public pressure matters.
Long-term fix is single payer, universal coverage. Remove the (worst) profiteering from our healthcare system (racket).
Please elaborate. How did that happen?
Also, if you read your insurer's fine print, you'll find that they will only pay out-of-network providers to some limit that they and the provider agreed to. Even in an emergency situation, you will foot the bill for the delta.
This is exactly why Congress should not be exempt from any health care legislation. They need to go through this also, so it can be fixed.
(the Gold plans are closest to other federal government provided health insurance...)
Of course, many members of Congress are quite wealthy and wouldn't be much more than annoyed by a bill in the tens of thousands of dollars.
When US citizens en mass realise they pay three times as much as a country for healthcare that other western countries do, maybe it will change.
Most importantly, most states have laws mandating insurers use in network rates for certain instances of using out of network providers, including in factual instances like you described (i.e. in network hostitals and out of network providers). Seperately, most states have statutes awarding attorneys fees to the insured when claims have been denied in bad faith, like refusing to adjust bills to in network rates when mandated by law.
There's no free market in healthcare. They are selling services without providing prices... it completely breaks any market that might exist.
And it takes a state license for them to operate. The state could require them to provide an accurate and up-to-date price menu in order to remain in business.
I think the problem is also related to the opaque negotiated prices that "in network" providers negotiate with insurance companies, driving up the cost for uninsured or "out of network" consumers.
There are perfectly rational solutions short of single-payer.
In Charlie Gard's case, the parents have raised the money to take him to the US for the pioneering 'treatment'. The court's barred them from taking him because they've ruled that doing so is not in his best interests, and that he should be allowed to die. Which is pretty damned unusual for the English courts, to be honest. And given he got a full hearing at the supreme court, and his own advocate, and it's not a matter of money, I'm inclined to believe the doctors and the judges.
But even if you think they're wrong, it's still not about single payer.
The state has power, even in the USA, to make decisions for the benefit of children if the state decides that the parents aren't acting in the best interest of the child.
There is a perfectly valid argument to be made that the state should not have intervened (this is subjective), but it had very little to do with the NHS being single payer.
And by choosing to use the single most emotionally charged case, you are also skipping all of the perfectly rational arguments against the broken health care system we have now.
I think it does concern single-payer. I can only think of the quote, "A government powerful enough to give you everything you want, has the power to take everything you need away". In this case, where the government controls healthcare, it can make decisions for you, even if that is not what you want, or are willing to pay for yourself.
However if we look at the facts of this case: http://www.gosh.nhs.uk/frequently-asked-questions-about-char...
"One of the factors that influenced this decision was that Charlie’s brain was shown to be extensively damaged at a cellular level. The clinician in the US who is offering the treatment agrees that the experimental treatment will not reverse the brain damage that has already occurred.
The entire highly experienced UK team, all those who provided second opinions and the consultant instructed by the parents all agreed that further treatment would be futile – meaning it would be pointless or of no effective benefit."
Edit: oh yes, and the court submissions are interesting reading (via twitter:) https://t.co/Wjs7KrRWMU
> When the hospital was informed that the Professor had new laboratory findings causing him to believe NBT would be more beneficial to Charlie than he had previously opined, GOSH’s hope for Charlie and his parents was that that optimism would be confirmed. It was, therefore, with increasing surprise and disappointment that the hospital listened to the Professor’s fresh evidence to the Court. On 13 July he stated that not only had he not visited the hospital to examine Charlie but in addition, he had not read Charlie’s contemporaneous medical records or viewed Charlie’s brain imaging or read all of the second opinions about Charlie’s condition (obtained from experts all of whom had taken the opportunity to examine him and consider his records) or even read the Judge’s decision made on 11 April. Further, GOSH was concerned to hear the Professor state, for the first time, whilst in the witness box, that he retains a financial interest in some of the NBT compounds he proposed prescribing for Charlie. Devastatingly, the information obtained since 13 July gives no cause for optimism. Rather, it confirms that whilst NBT may well assist others in the future, it cannot and could not have assisted Charlie.
My concern is that if there is a single payer health care system here in the U.S., the patient will lose control of their health care decisions, as it appears the parents of Charlie Gard did.
Even ignoring that fact though, the idea that hundreds of thousands of people should face financial ruin and all the negative societal effects that carries with it because extreme outliers need to be handled separately is an utterly broken way of running a healthcare system.
This is why people are talking about Charlie Gard and not, say, Maatthew Stewart http://theweek.com/articles/666799/how-american-health-care-...
(Does anyone track suicide rates linked to medical bankruptcy? That's got to be the ultimate negative outcome.)
The cost side works in every other developed nation? Surely you're aware of how much more expensive health care costs are in the US, so what might you be referring to?
There are other effects as well - nobody is getting away with billing $600 for a 5 minute visit, for instance.
Which isn't to say that single payer wouldn't be an improvement on the current system. Just don't get your hopes up for how much money it'll save.
No, we don't. Medicare is not single payer, though it has (for a subset of the services covered by Medicare) a default public option; it also has private, partially-public-subsidized pland; Medicaid, at least in many states, is not single-payer, either, even at the state level, even before considering overlap with Medicare and other insurance.
Everywhere else the government shoves a telephone pole up the ass of taxpayers and then takes a few splinters to pay for healthcare.
http://data.worldbank.org/indicator/SH.XPD.PUBL.ZS?year_high...
https://ourworldindata.org/the-link-between-life-expectancy-...
America isn't special.
Apparently, states are unable to restrict entry into state benefit programs such as healthcare. They can't set up a waiting period for people moving into the state before they are eligible; that was declared unconstitutional by a previous Supreme Court. So if states were to do their own single payer system, in theory sick people could move into the state and immediately gain free healthcare simply by virtue of being a resident. Conversely, they could then move back to their home state that doesn't charge higher taxes.
So it wouldn't be feasible on a state-by-state basis unless a future SCOTUS reverses their precedent. This is unlikely in the short term, given the current Court's make up.
Government programs set maximum reimbursement rates and also mandate cost accounting mechanisms to assure that actual reimbursement is not merely within pre-set rates but also justified by actual provider costs. The government isn't buying services with no advance information about what the charges may be.
Private insurers impose similar controls.
So single payer (or even universal coverage through private insurers) eliminates the particular kind of “robbery” from undisclosed charges being discussed.
Don't pay the paracites a penny.
Look into doing a straight chapter 7 yourself. I'm planning on doing mine. You'll save $3000 by doing it yourself.
I'm glad you feeling better. They have become weasels. And to those that think hospitals, and doctors don't come after payment; they do. They can be very aggressive.
Good luck!
Is this considered normal? I honestly think I'll take my chances than pay that much per minute. Of course I'm thinking in ₹ and my current salary in ₹, which must be vastly lower in absolute terms than the average American.
This StackExchange answer sums up it up succinctly: https://politics.stackexchange.com/a/16372. I find it immensely saddening; the same goes with the general population's attitude to education (in many countries) or providing housing.
For what it's worth I know a lot of people with private healthcare in the UK with the attitude that the NHS is complete trash (something I very much disagree with) - I fear this sort of mindset is spreading. "Pull the ladder up jack" as they say.
- Try see your GP. Wait 2 weeks until your appointment.
- GP will give a cursory examination and recommend a dietary change, taking ibuprofen/paracetamol, and to come back if problem persists.
- Problem persists. Book in with your GP and wait another 2 weeks.
- GP will actually examine you this time. They may then refer you to the local hospital, and so you should await a letter.
- about 2 weeks later, the a will arrive saying that you should phone up to make an appointment.
- within 8 weeks you should get another letter telling you when your appointment is, which will be within 4 weeks.
At this point you have spent 20 weeks just to get seen by a specialist. And that's assuming everything goes ok. Admin may not update your details, so the letters go to an old (or wrong) address. They may just entirely forget to make an appointment for you. Probably if you try phone them they just won't pick up the phone.
There's a fetishisation of the NHS in this country that protects it from a lot of criticism. Some will say "well you should put up with that because it's free" or some similar rubbish, ignoring that it costs £2200 per person.
None of these issues are restricted to the NHS. Any large organisation will have such issues. But it's utterly frustrating stuff like this that makes me consider going private - I shouldn't have to spend hours on the phone figuring out why I haven't been assigned an appointment despite being referred 3 months ago.
1. Schedule with GP. Say I am in pain. Get in within 2 days.
2. Get a referral to Physical Therapy. Asked if I have any preference where to go. My doctor knows my network and gave me a number of choices that were within network (a number of which were within walking range of where I lived).
3. Call PT office. Schedule an appointment. They apologize that their next opening is a week away. Gladly accept.
Physical Therapy is interesting in that it is semi-free market and rather competitive, so it tends to work a bit better than some other scenarios.
1. Schedule with GP, get appointment very quickly.
2. GP has no idea who is "in network" for you and doesn't seem to care very much. They also don't understand the different insurance plans so have no idea if you're covered for certain types of referral.
3. Schedule appointment with a specialist. Ask for up front cost estimate for consultation/procedure given your insurance plan. Unable to answer.
4. Go to appointment anyway as you don't have many other choices.
5. Receive astronomical bill for some obscure billing code that is not covered by your health plan.
6. Spend time calling doctors office and insurer to figure out the situation and try to avoid or reduce bill.
I've experienced the NHS too - for all its flaws, the peace of mind living in the UK from a health standpoint is worth every penny of the associated taxes IMO.
> 1. Schedule with GP. Say I am in pain. Get in within 2 days.
> 2. Get a referral to Physical Therapy. Asked if I have any preference where to go. My doctor knows my network and gave me a number > of choices that were within network (a number of which were within walking range of where I lived).
> 3. Call PT office. Schedule an appointment. They apologize that their next opening is a week away. Gladly accept.
> Physical Therapy is interesting in that it is semi-free market and rather competitive, so it tends to work a bit better than some > other scenarios.
Speaking from recent experience, on Obamacare:
1. Live with pain for 6 months because you know you're not getting out of a specialist's office for less than $750.
2. Cave in when the pain becomes unbearable and see a specialist.
3. Make an appointment for PT with a provider who doesn't take insurance at all, because the transparent pricing means no surprises.
4. Pay out of pocket for PT appointments.
5. Spend the next 4 months getting bills for your one specialist visit. Half of these are coded wrong so insurance won't pay. Spend 2h every week on the phone trying to get it sorted out.
If you talk to whoever does the specialist's billing at any point, you'll find that they're totally unable to estimate the cost of services. You might as well not even try to figure out how much it costs in advance.
Tests are all same day.
Chronic pain is an extremely tricky phenomena. A lot of US health care been "dealing" with it by handing out opioids and we can see the devastating effect of that. Even a given physical therapist may not be able to help a given patient (assuming some body of some sort could at all).
Similarly, a smart consumer may be able to find a massage therapist with skills in a bodywork subdiscipline that happens to really help them (I favor trigger point and Shiatsu massage after sample a bunch in my area). This is cost effective compared to just about everything and something I imagine someone in UK could find in the larger cities.
It feels to me that we in the West are going ever faster backwards over fairness in issues like education, health and housing. I'm lucky to be well off & healthy enough to not (yet) be affected by a poor performing NHS but I wish we, as a country, would pull together on this - from top to bottom. Unfortunately, I just don't see it happening anytime soon, we seem to be increasingly more divided - religiously, economically, politically - than ever before.
Society feels increasingly like a "Mad Max" movie in operation. This is only going to end badly for everyone. There is way too much "me me me" from all levels. I find it emotionally exhausting to think about.
I don't begrudge anyone who has the means to get private health care from doing so (my girlfriend and many friends do) - so please don't think I am saying nobody should - I just wish there was a more proactive and pragmatic desire to fix the root issues. Of course, I realise I am living in cloud cuckoo land on that.
I should add that I can certainly empathise and can agree with your comment about chronic pain. My father is suffering from sciatica and it has been over a year to get an operation scheduled. This will involve him travelling from Northern Ireland to the Midlands because there is an even longer (multi year) wait to be seen in NI.
I agree with everything you say, except the part about cancer.
Even by European standards, the NHS is actually quite terrible at dealing with cancers - even "routine" cancers (like breast cancer and prostate cancer), let alone rare cancers. The five-year survival rate for prostate cancer in the UK is 55%, whereas in the US it's upwards of 90%. (Prostate cancer is an incredibly treatable form of cancer; for most people, as long as it's detected early and managed appropriately, they will die with prostate cancer as opposed to from it).
Of developed countries, only Japan, Portugal, and Denmark have worse five-year survival rates for prostate cancer.
Such survival rates are from date of diagnosis; IIRC, because prostate cancer detected early usually doesn't have interventions that are less harmful than the cancer is likely to be, there's considerable debate about the utility of screening; there has been considerable argument that the US tends to overscreen and over-intervene for prostate cancer.
If the UK doesn't do that and tends to screen in a way that tends to catch less of the less-imminently-dangerous prostate cancers, it would have a lower 5-year survival rate simply by not diagnosing prostate cancer where the diagnosis isn't usefully actionable; this doesn't mean they are actually worse at dealing with it.
> Prostate cancer is an incredibly treatable form of cancer; for most people, as long as it's detected early and managed appropriately, they will die with prostate cancer as opposed to from it
Prostate cancer is very often an extremely non-aggressive cancer with interventions that can have significant negative impacts, which is why, even when it's diagnosed “watchful waiting” or “active surveillance” are often the preferred management approaches; quite a lot of people will die with, rather than from, prostate cancer with no active intervention.
Population-wide 5-year survival rates from diagnosis are probably not a good metric for comparing countries with different screening practices; mortality rates are a better comparison metric, but also don't tell the whole story.
Over-intervention and over-screening are two different problems, particularly for prostate cancer, where screening is low-cost and low-risk. In the US, most cases of prostate cancer do not require invasive intervention if detected early, but they will begin treatment, as well as more regular monitoring of the cancer. When screening costs are low, overscreening is not particularly problematic as long as it doesn't result in overtreatment (which is demonstrably true for prostate cancer in the US)
Again, this is not limited to prostate cancer. The difference is the most stark there because the screening costs and risks are both low, but the UK still does a much worse job at treating breast cancer, colorectal cancer, lymphoma and leukemia, which are the other deadly common cancers.
For all cancers, not just prostate cancer, the US over-screens a small amount, but the UK underscreens by a massive amount, resulting in many people detecting cancer when the window of optimal treatment has long passed. That's the reason that the UK is close to last place among developed countries for five-year cancer survival across all common forms of cancer, not just prostate cancer.
They are distinct but not unrelated, particularly in a system where treatment decisions are highly patient driven, especially for patients with financial means.
But my point is less about over screening than that differences in screening practices naturally produce difference in five-year survival statistics even in cases when they have no meaningful outcone in terms of disease progression, mortality, and quality of life, because more screening will detect more cases of disease earlier, even cases for which intervention would never be clinically indicated. If you do a lot better job at diagnosing cases for which there would never be intervention, you get a better 5-yesr survival rate but haven't done any better at dealing with the disease.
Note that I'm not arguing about whether the UK does deal with prostate cancer well, in fact what I've seen using mortality rates suggest they are a bit worse than the US, though much less bad then you'd think from 5-year survival rates. I'm just staying there 5-year survival rates aren't great metrics for systems that are different in conditions that lead to diagnosis.
I agree. That's why looking at all common cancers as well is important. Leukemia and lung cancer are the opposite end of the spectrum - early intervention is critical for leukemia and most lung cancers. And the UK does a much worse job at treating those than almost all other developed countries, and particularly the US.
So yes, some portion of the difference can be attributed to differences in screening practices, but screening practices are a relevant aspect of the entire system, and screening practices alone can't explain the UK's abysmal record for treating the more aggressive cancers which they do detect.
Prostate cancer may be something of an outlier given the hesitation people have in discussing it. This is something that has only really recently been attempted to be addressed in the UK. Campaigns fronted by comics like Bill Bailey have tried to make it normal to talk about. The British as a society are still so reserved that I imagine thousands die of preventable cancers and diseases simply out of embarrassment.
Edit - I've just had a look at Cancer Research's figures[1], [2] and, using data from 2010/11 - prostate cancer had a UK survival rate of ~84% or so - i.e. nearly the same as the US.
[1] http://www.cancerresearchuk.org/health-professional/cancer-s...
[2] http://www.cancerresearchuk.org/health-professional/cancer-s...
It's looking at people with prostate cancer, regardless of insurance status.
> Prostate cancer may be something of an outlier given the hesitation people have in discussing it.
It's not limited to prostate cancer; for survival rates, the NHS does pretty terribly on almost every form of cancer compared to the US. I picked prostate cancer because it's something that's very treatable - the upper limit is close to 100% for five-year survival, which makes the UK's outcomes that much more unacceptable. But the story is the same for all other common cancers (let alone rare cancers, which the NHS is not optimized as a system to treat).
It's survival rate from point of diagnosis. Obviously, insurance and access will affect whether and when diagnosis occurs, but the effects aren't as simple as just limiting the scope to the insured or not.
https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...
I don't understand the point you're trying to make. [Treatable] cancer isn't the leading cause of death in any country[0], so no matter how good (or bad) a country is at treating cancer, you wouldn't expect that to be visible in the overall life expectancy rates.
[0] Ordinally, cancer is #2, but that includes untreatable cancers, and the tail is very long, so getting better at improving five-year survival rates for cancers won't budge your life expectancy at all, outside of the margin-of-error.
It's very easy to draw conclusions from statistics. It's much harder to draw correct conclusions from them.
First: no, the England branch of the NHS is still larger than Original Medicare (~53 million in England compared to 46 million on Original Medicare).
And that might be a reasonable way to interpret the data, except that two-fifths of Medicare patients (and growing) are not on Original Medicare - they use Medicare Advantage, which is privately run. Coincidentally, Medicare Advantage outperforms Original Medicare on medical outcomes across the board, including cancer treatment.
So no, the fact that the US is drastically better at keeping prostate cancer patients alive cannot be explained by the claim that Original Medicare is so phenomenally better that it accounts for the difference.
So... less than 1/3rd of what the US pays on a per capita basis? I'd be cool with that...
- Book a GP appointment. Generally get in the same day (costs $20-$80 depending on your GP. I have private insurance that pays up to $38) - GP orders blood tests, these are free. Clinic is on-demand, just show up. Wait times are around 30 minutes. Also prescribes ibuprofen ($5 for 100 tablets) and paracetamol (non-subsidised. $10 for 100 tablets). - GP will assess you and refer to a public or private specialist depending on your preference. In my case a public rheumatologist would have taken around a month to see, so I chose private. This cost $180 for the consultation and $120 for follow-up (insurance paid 80%). - Specialist refers more tests. For me this was an MRI. Public wait times were around 3 months because the machine needed replacement and they'd only pay for serious cases to go to the private clinic. I went private, this cost $1400 (insurance paid 80%). - Specialist orders more blood tests, still free.
And they still didn't find anything conclusive.
Personally I'd like GP visits to be free. They can be for people under a certain income level with the right GP. The public system also needs more funding, but in NZ we spend less per capita on socialised healthcare than the US, and the US has to add private insurance on top of that.
so it is a very hard sell to get more Federal involvement when we have constant stories of VA issues and more available just by searching. throw in rules that actively prevented insurers from making multi state offers and the system was bound to be a mess.
however one of the problems not discussed is that many receive their health insurance from their employers and while this has been going away slowly, this idea like income taxes, tends to remove the cost component from people's minds. you don't see the cost in whole or in large lump sums so its easy to not think about it.
the big hurdle will be convincing people there will be limits of what can be treated. the US infant mortality statistics are one area of exaggeration to the bad simply because to the extent money will be spent to save a newborn that many other system won't
As a data point: the patient satisfaction scores for Original Medicare (government-run) are drastically lower than every single major provider of Medicare Advantage (privately-run).
As much as people dislike insurance companies, people in the US are even less happy with the government-run programs, compared to their private counterparts.
I didn't in my previous comment, because we were talking about the overall public perception, which may or may not be connected to the tangible metrics that we actually want a healthcare system to focus on.
As it turns out, though, Medicare Advantage also consistently outperforms Original Medicare on medical outcomes, and it comes in under-budget for identical coverage. Medicaid options vary much more (and they're different in every state, because Medicaid is administered at the state level), but the equivalent private plans for Medicaid coverage also typically perform much better than the public ones.
Hacker News readers aren't generally in the demographic for Medicare[0], but for anyone who is: there's really no reason to use Original Medicare. Every jurisdiction should have Medicare Advantage plans that cost you the same amount as Original Medicare does, and your experience (and overall care) will be vastly improved.
[0] people over the age of 65, or people of any age who are on dialysis for more than two years, etc.
I'd be interested to see these findings. Do you have links?
As far as Medicare Advantage is concerned, it's not the least bit surprising that patient satisfaction is higher. But I wouldn't go treating that as some kind of referendum on Government-run healthcare:
"Many private [Medicare] plans require no additional monthly premiums, yet the government pays an average of $849.90 in monthly subsidies to insurance companies for a person on Medicare Advantage, according to the Kaiser Family Foundation. That is about 14 percent more than the government spends on people with standard Medicare, according to the nonpartisan Medicare Payment Advisory Commission."
MA was supposed to demonstrate that private insurers could deliver care at lower costs than Medicare, and it hasn't done that. Basically, for every $1.00 the gov spends on a medicare patient, it pays $1.14 in subsidies for an MA patient, with the evidence indicating a lot of that goes straight into the pockets of insurers as profit [2]
[1] http://www.washingtonpost.com/wp-dyn/content/article/2009/10... [2] http://theincidentaleconomist.com/medicare-advantage-cuts-on...
That might be a reasonable comparison if Medicare's claims rates were self-sustaining, but they're not. As I explained in another comment on this thread, private insurers subsidize Original Medicare with their own payouts in claims, and that comes out a few orders of magnitude larger than 14% per Original Medicare patient.
Once you have you'll quickly realise that the 'long wait times' narrative is complete propaganda FUD.
Anecdote time: My sister is anaphylactic, when she goes to the ER she is admitted, hooked up, and given epi almost immediately. When my aunt couldn't move her arm one day, she got an MRI, diagnosed brain cancer, and had brain surgery in the same week.
I'm glad to have a system that when you are waiting it's because there are people with more urgent needs, rather than because there are people who paid more.
> Once you have you'll quickly realise that the 'long wait times' narrative is complete propaganda FUD.
This is a decent example of the typical Canadian attitude I was referring to, blind refusal to even acknowledge any issues, such as the well documented long waiting times for non-emergency procedures, as well as the outright refusal to treat ailments deemed "not important enough" by your doctor.
Say I'm sitting around and I finally decide to get pain in my wrist looked at that I've had since I broke it ten years ago. I could see a specialist in less than a week. However, I probably would have had it looked at 7 or 8 years ago if I was in a single-payer system. Maybe I would have had to wait 6 months to see a doctor, but that still puts me about 7.5 years ahead of where I am now.
I know a lot of people who have bones that never healed right because an emergency room visit is going to cost you a fortune whether or not you are insured, so they don't go to the ER because it doesn't hurt 'that bad'. I imagine that is somewhat less prevalent in places with socialized healthcare.
It reminds me of an old joke about things that don't have a listed price: "If you have to ask, you can't afford it." I think that mentality is really prevalent in the US when it comes to healthcare, regardless of how expensive the procedure would actually be.
1. A friend of mine had severe back pains, all what he got from a family doctor was some painkillers and some stories that his back pain due to to weak muscles and he has to exercise more and wait a bit (3-6 months) before he can get some tests done. Anyways he moved to the US and week later made some tests to find that he has cancer in some serious stage. He started treatment but it was too late.
2. Another friend had spend 6 hours in ER with his eyelid cut in half (he got a branch into his eye while hiking).
3. I had some troubles with my daughter in Canada as well, don't want to go into details.
I eventually moved to the US and while healthcare here is outrageously and ridiculously expensive it is still years ahead of Canadian when you have a good insurance.
Anecdotes don't really do anything for us besides give us pointless things to argue about. You need to look at statistics like life expectancy, quality of life, average wait times, unnecessary deaths, etc.
The fact that you have to qualify your final statement with "when you have good insurance" is the whole problem. Before the ACA, that was far from a given, and even if you had good insurance it was too easy to lose. If Republicans have their way, we'll be back in that situation again.
I don't get it when people bring up situations like your #2. I'm sure it really, really sucked to wait six hours in the ER with an injury like that, but is it worse than staying home and trying to treat it yourself because you can't afford to visit the ER? Is it worse than dying from a simple condition because you can't afford to see a doctor?
Your doctor in Canada refusing to give you a referral to a specialist makes comparing these numbers not terribly useful.
> I don't get it when people bring up situations like your #2. I'm sure it really, really sucked to wait six hours in the ER with an injury like that, but is it worse than staying home and trying to treat it yourself because you can't afford to visit the ER? Is it worse than dying from a simple condition because you can't afford to see a doctor?
A system that allowed consumers to inject additional money into the system would increase the budget and managed properly(!), allow more total health care services to be provided to everyone.
Of course, "this will never work, all doctors will just move to the private sector" will be the refrain. Under our current society and so-called legal system perhaps, but put me in charge, I will put mandatory guidelines and levels of service in place, and then when doctors knowingly break the rules because based on history they well know they can do it without punishment, put a few of them in prison for 10 years, and watch compliance magically improve.
Surely even in the actual best in the world, waiting for something that is no urgent simply makes sense and is the only way it can function. Do you expect a hospital to have 5x as many beds and staff as is often required so you can have instant surgery on your non-urgent problem? (i.e. knee replacement)
Of course you wait a little bit while they schedule it in, otherwise it would cost an insane amount of money to have all those resources waiting around for your non-urgent problem.
My experience with "urgent" problems has always been instant in Canada - my broken nose, my brother's separated shoulder and broken legs. Even when I went in a week after being hit by a car I waited all of 5 minutes before a doctor saw me.
And those in the lower echelon of society economically are those least able to have the time or money to march or lobby for change.
If I didn't have a comfy software engineer salary, and instead lived paycheck to paycheck, this would've been devastating, even with insurance.
Insurance was billed ~10k, with coinsurance I had to pay $1,400. This is after the hospital billing in multiple rounds and forgetting to bill insurance on one of them and also forgetting to send the bill to me (which if I hadn't been proactive about following up with would have led to it getting sent over to collections).
I'm assuming I have better health insurance than a decent percentage of the population and I can afford the bill but how the hell can most people? What a terrible, terrible choice for someone to have to make between getting care when they're at their most desperate and avoiding financial ruin
I see USA as a country where, if the car crash didn't kill you, the medical bills certainly will.
You're right. Of course the private insurance premiums have a negative expected value. Aside from insurance always having a negative expected cash value by definition, private insurance premiums are literally used to subsidize care of Medicare, Medicaid, and uninsured patients.
This is absolutely not true [1]
[1] http://www.cnbc.com/id/100840148
That's only saying that you'll have bills you can't pay, not that you'll go bankrupt from it. Most (if not all) insurance plans have a maximum out-of-pocket expense amount that's like $10k. Yes, that's more than some middle-class Americans can afford to pay in a year, but it's not enough to go bankrupt over. They just defer paying it until they can afford to.
This is one of the things Obama-care addressed, because before that most bankruptcy's in America where caused by medical bills. I'll see if I can find the article. [1] But with Obama-care going away/being changed this might be a thing again.
[1] "A study done at Harvard University indicates that this is the biggest cause of bankruptcy, representing 62% of all personal bankruptcies. One of the interesting caveats of this study shows that 78% of filers had some form of health insurance, thus bucking the myth that medical bills affect only the uninsured.
Rare or serious diseases or injuries can easily result in hundreds of thousands of dollars in medical bills - bills that can quickly wipe out savings and retirement accounts, college education funds and home equity. Once these have been exhausted, bankruptcy may be the only shelter left, regardless of whether the patient or his or her family was able to apply health coverage to a portion of the bill or not. (Find out what you can do to avoid a financial meltdown when there's a medical emergency. " http://www.investopedia.com/slide-show/top-5-reasons-why-peo...
It's more like $6800 for 2016 and $7100 for 2017. That's the federally-mandated cap; many private plans set their cap even lower.
Even with a vanishing middle class, the middle and upper class that remains still have largely great healthcare and healthcare plans, it's the poor who are largely being screwed. Even then, they don't support universal healthcare (it's mostly us hipsters or whatever) because they are still weary of the government and we're still dealing with post-mccarthyism where any sort of government service for the public benefit is socialism.
With copays and out of network stuff a lot of people will go bankrupt in case of a serious illness.
By law, those are capped for people with insurance. The maximum that you will have to pay out-of-pocket can be no more than about $7,000, and many private plans set the cap at a lot less.
$7,000 is a non-trivial amount, but it's not a large number of people that both are insured and can't afford their out-of-pocket maximum without bankruptcy.
This is the equivalent of a car payment for the rest of my working life.
It doesn't matter, because that's still capped.
The bills themselves aren't capped. The amount they are obligated to pay is. Insurers make up some of the difference, and the rest is forgotten about. (It's not written down in the accounting sense, because the hospital doesn't necessarily actually treat the entire billed amount as receivable.)
I explained in a top-level comment how this works and why it works this way.
Also worth mentioning, it's been broken for a while (e.g.: ACA is not even broken in yet).
The idea that life is unfair and random is not accepted by america.
Black americans oppose any kind of social service that might benefit anybody but themselves including other black americans.
People are people and ignorance doesn't have a color. It has always been like this. Blaming one or the other doesn't actually fix anything and it is also why nobody brings it up any longer not because they are afraid to mention it.
We don't necessarily need socialized medicine. If we just went back to the way things were done in 1970 everything would be solved. The money the government currently spends on healthcare subsidies could buy free healthcare for everyone at 1970 prices.
Life expectancy was a bit shorter in 1970, but not by that much. And most of the increase is due to other factors than healthcare (e.g. the smoking rate has dropped a lot, cars are much safer, air pollution is reduced, etc.) And there have been studies done that show increased spending on health care doesn't really correlate with increased life expectancy.
http://time.com/4829103/mitch-mcconnell-protest-senate-healt...
This last Saturday, there was a peaceful protest of around 200 people held in DC in front of Congress. One of my friends attended this protest. Around 150 of them were arrested, and then given bullshit charges, like crowding, obstructing, incommoding, or resisting arrest (of what charge were they being arrested for, angering Trump...).*
When you try to "peacably protest", and "redress the government for a redress of grievances" and are arrested, detained for 6 hours, and then given a $25 citation of 'crowding' - what else do you do? Molotov Cocktails? AR-15's?
The answer, unfortunately, is nothing. You keep your job, eat decent food, and live a life under whomever the current 'king' is. And hope to the gods that nothing knocks you down to a lower socioeconomic ladder rung.
* https://www.washingtonpost.com/local/public-safety/police-ar...
If you are unable to enact the change you want from within the system it's because not enough people agree with the change you are proposing.
Welcome to the complexities of Society.
If you don't want to participate you don't have to. Abandon the laws of man and return to the laws of nature. Just remember the law of nature demands conflict be resolved in the favor of the more powerful will. I doubt very much you would fair well.
Because that's some bullshit.
Most of the great social and political progress in western nations has come from mass civil disobedience. You take that away and you begin to stagnate.
I don't think that anybody really believes that the mess we've made of billing/paying-for services via insurance + government + hospital/doctor is a good idea. At least nobody who has dealt with it for more than 5 minutes, which is most people over 25.
The problem is that nobody can agree on how to fix it. One side wants to socialize the whole thing, the other side wants to do... something else, I guess. Regardless, neither side has enough power to just do what they want, so we're stuck with this bizarre Frankenstein's monster instead.
Meanwhile it's almost impossible to escape from the mess. You can't just have no insurance and pay for yourself, because they've made the prices for most things ludicrously high and then basically rebated them to the insurance companies.
Actually, it reminds me just a bit of that paraphrase of the Laws of Thermodynamics: you can't win, you can't break even, and you can't get out of the game.
We have the resources to fix many of these problems. But we won't. The powers that be would prefer lower taxes.
http://www.econtalk.org/archives/2017/06/christy_ford_ch.htm...
The guest is an economic historian who details the historical forces which led us to where we are right now. She also describes a few different, more effective and rational models (not just single payer) which could potentially have existed, but which sadly are, for all practical purposes, impossible to get to now.
Media outlets like to publish horror stories because it attracts eyeballs.
Yes they can happen and there are bad actors in the system. But most ER patients either don't pay a dime because they don't have a dime, or their insurance picks up the tab subject to deductible. "In Network" rules specifically don't apply in true emergencies under most plans. Of course if you go to the ER for a runny nose, there may be some pushback.
It's primarily lots of Byzantine rules in small print buried in long policies that few people read and even fewer memorize. If you are lucky and are conscious when you need to use a policy to visit a health care provider, you can bring your policy with you to ensure you follow it, but it's not always that easy. The health insurance company claims they told you how to follow the policy, but they don't make it any easier than they legally have to.
If you skip a rule (like calling your health insurance company before you visit an emergency room), that might violate your policy. If you visit an "out of network" hospital when you should have visited an "in network" hospital, you may be liable for the difference in cost (which is huge due to health insurance distortions in the medical market). If you try to go to a medical specialist without first going to your primary provider (as defined by your health insurance company), they likely won't cover it. There are usually dozens or hundreds of pages of these rules in booklets that you get when you join an insurance policy. If you don't know about / forget about a rule, you are responsible for the costs associated with the violation.
It's easy to unwittingly ask a health insurance question about your policy to the office manager at a doctor's office (who isn't qualified to speak about specific health insurance policies) and getting bad information that you then assume is good.
> Why aren't people marching in the streets?
I think most people see this as a "free market" problem (since 60%+ are covered by their employer-sponsored health insurance), not a political one. ~20% of Americans are covered by Medicare (the retirement-aged national health coverage) or have military veteran benefits, which are generally considered pretty good (unless you listen to political arguments). How would "marching in the street" fix a problem that people have with the "free market"?
The remaining 20% are among the most politically apathetic. We are lucky to get 50% participation of the voting-eligible electorate, even in presidential elections (which have higher turnout than other elections).
I think lots of Americans pride themselves on being stubborn and pretending like painful things aren't painful, then trying to ignore them.
Lastly, I think most Americans simply don't think that marching works. Rural America doesn't march. Urban America only seems to march for generic social justice causes, not for specific policy improvements.
The UK cried and moaned when the NHS was introduced but now (aside from Conservative efforts to "starve the beast" on it) most wouldn't go back for the world (though it could be improved, obviously).
The US has a mentality that it's the best in the world for everything. Even when it's objectively not true (like in healthcare) this colors the debate.
Fundamentalism, basically.
Or maybe fanaticism is a better word.
For the rest who aren't, there's a simple reason: services operated by the government tend to suck (or are at least perceived to be so). It is an American tradition to stand in long lines at the Department of Motor Vehicles to renew your driver's license, or to get your vehicle inspected. The TSA exists to inconvenience travelers. Public schools are perceived to be failing (they are in some places; I was lucky enough to get a very good education in public schools) even if they are not necessarily. The Postal Service is not profitable (even if it doesn't need to be...) and there are always lines at post offices. And so on. (typing on mobile, could give more examples but I'm sure others have their own)
Whether these problems are real or not is irrelevant. Americans distrust the government, especially the federal one. You could call it indoctrination, to a degree. Those who benefit from the system are allowed to persuade the populace, even from birth, and are supported by both major parties. (Drug and other healthcare advertising is legal.)
It is also part of our history. The tradition of the US is a distrust of big government. Before the US Constitution was written, we had a federal government under the Articles of Confederation. It was meant to be permanent. The federal government was extremely weak, gave too much power to the states, and ultimately did not work. So the Founders had to go back and try a second time and gave the federal government more power. And that's where we are today...but that feeling of distrust has persisted through the centuries.
So to sum it up: many like the idea of private healthcare not because they have a choice, but because they believe that the government(s) will screw it up worse.
Americans seem to have always preferred so-called "freedom" to social solidarity. It's every man for himself over there in the land of the free.
Everybody should know, the health insurance system in the US is fundamentally broken and has been almost since its inception in the early 20th century. The lack of adequate consumer protection, transparency, health systems and appropriate government regulation, in addition to organizational oversight, has lead to a situation where we have poor systems that can easily be exploited. And they are exploited.
What the third party care outsourcing/billing company mentioned in the article (Emcare) was doing sounds like upcoding. They bill the highest cost service they legitimately can to maximize profit. In this case, as a third party billing organization, they both want to maximize the profit for their customer (the hospital system), but also for themselves, as they surely take a cut as a middle man.
Likely, they were operating within the gray area where illegal upcoding has to be proven in a court of law. It is an expensive process, that requires review and comparison of huge amounts of medical records with claims to determine whether the more expensive procedure billed was medically necessary/appropriate, or if it was egregious. That legal process does pan out sometimes in the end, but it can take years and just adds even more overhead.
Coding correctly, fairly and getting reimbursed correctly and fairly is incredibly complex. There are an enormous number of combinations of services (usually represented by codes called HCPCs and CPT codes) and diagnoses (ICD-10... which has 100,000s of codes), as well as all different regulations and scenarios for settings of care (inpatient, outpatient, doctor's office, etc.).
Props go to the hospital system for taking back their coding after they realized what the third party was doing, but the reality is, it was probably financially benefiting the hospital system too.
Every technology that I know of has been tried to address these issues, such as data mining, machine learning, rule-based expert systems, etc. and none of them has addressed the root cause, which is the basic system is fundamentally flawed.
All the politics you see about US healthcare in the news are, in a way, representative of the root problem - how big and complex the systems are now, how much money they represent, and how many interests are involved. We have a tangled web.
I don't know the solution (and many have been proposed).
There's no technology cure for the insatiable greed of a few. Sad reality.
I doubt the hospital system got anything from it, physician groups usually keep all their revenue from professional services claims - the hospital gets paid whatever they do for their facility claim regardless of what the professional claim pays.
The reason I say that is the article points out another glaring issue - the shortage of ER docs that we are currently facing. I know this first-hand, as I have a family member who is one and is working harder than ever.
Some of these arrangements are to make up for the shortage, and the hospital systems and physician groups are often working in partnership... so it could be there was benefit for both since the hospital system needed coverage for their ER (due to physician shortages), and Emcare is providing the physicians. Without the physicians doing the services in the hospital, there would be no facility claim either...
This is true, and being a mere software developer I'm in the dark on the contents of any of the contracts my parent company has with facilities either.
> The reason I say that is the article points out another glaring issue - the shortage of ER docs that we are currently facing. I know this first-hand, as I have a family member who is one and is working harder than ever.
Insert my standard rant about restricted med-school/residency admissions and cost of tuition here.
Stalemate.
We need to go through Kurt Lewin's change model process - "unfreezing, change, and refreezing" and find something better. It's like, we need agile healthcare or something - fail fast and iterate faster... without costing people their lives or their savings. https://en.wikipedia.org/wiki/Kurt_Lewin#Change_process
I don't follow what you're saying. Are you proposing that the root of the problem is that it's a huge, expensive, complex industry, where a lot of people work?
I don't want to go so far as to say all huge institutions have problems like this, but I am thinking along those lines.
Some have proposed simplifying health insurance greatly by running a "single payor" system, where the emphasis is on a single health insurance entity that covers claims for every person in the US. While that might seem like a simplification in terms of process, procedure and organizations, it is very unlikely to happen in the US, and I'm not sure we could even administer that well either.
If you look at other countries that are closer to single payor, maybe say, the British NHS system - even in those countries, private insurance still exists and competes. The NHS does provide care for everyone and eliminates some issues by having a stricter control system, but the quality, availability and timeliness of that care is often called into question.
In the end, being able to dictate quality, access, and affordability (and preventing fraud) comes down to control vs. morals/ethics. Many are vying for control, for many different reasons and this often tears apart the basic industry, while morals/ethics are difficult to maintain.
For example the US Real estate market is 7.4 Trillion, about 2X the size of the health care market with many more players and much more predicable outcomes. Finance and insurance are about the same size as well and are not terribly broken.
[1]https://en.wikipedia.org/wiki/Economy_of_the_United_States#G...
People using an emergency room are not in a position to negotiate price or seek an alternative service. An unconcious accident victim can't say, "That price is crazy I am going to the hospital across town."
Single payer is the only viable solution.
I would say single payer, or a single regulatory arbiter of procedure and drug prices (within a multi payer context).
When you look at the healthcare costs GDP, the single payer systems still tend to come out ahead multi-payer + regulatory oversight (its one more level of abstraction you pay a complexity cost for...).
As someone who works for a medical billing agency either would make my life easier, having to juggle dozens of insurance contracts and rates stinks. France does the latter, insurance companies and the state plan negotiate and a single group - at the best this could make a good stepping stone to single payer in the US.
Turned out alright, I think. I'm still concerned I'll get an "oh by the way" bill in the mail.
That's not true. Plenty of European systems are not single payer and work fine.
The public system premiums are a % of income. The private is a flat cost, so as you make more become much more attractive (even costing less in many cases).
Doctors are sometimes private only or have separate private insurance waiting rooms. Hospitals have separate public and private rooms/beds, etc.
It's a two-tier system that works pretty well, at least in comparison to the US system.
My info is a few years dated, but is based on having been a patient in both US and German hospitals. From friends, I've heard the English system is similar in some respects to the German.
Amazingly to me, the German system was instituted under Otto von Bismark in the 1800s.
https://en.wikipedia.org/wiki/Timeline_of_healthcare_in_Germ...
https://en.wikipedia.org/wiki/Healthcare_in_Switzerland
This ensures that the system works better than the US system, as the hospitals do not need to deal with having to treat uninsured patients who cannot pay. This is a major problem for the US healthcare system, and a critical threat to the solvency and continued operation of many hospitals, especially rural hospitals and clinics.
Edit: a common thread among these systems is that the private payers are not for profit and highly regulated.
This statement is close to the fallacy "Something must be done. This is something. Therefore it must be done."
Consider counterexamples: http://marginalrevolution.com/marginalrevolution/2013/08/a-f...
More to the point...is this the America we want to live in?
What really pisses me off is that the HSA max contribution has not kept up with family OOP max. I contribute the max every year and can't end up with $8,500 saved.
I had a decent insurance plan prior to Obamacare. Now it's 3x as much and a HDP. Don't even have dental insurance anymore; use the HSA for that. Work for a Fortune 100 Company too.
Your HR department is shit. I manage a 30 person company and our benefits are better than what you've mentioned.
Funny thing about HR directors is that they don't last more than 1 year before rotating out. Don't want them to become too attached to the people they are there to screw.
Honeywell; thermostats?
http://www.riverradiology.co.nz/diagnostic-solutions/price-l...
$500 NZ versus $11000 US - maybe there is something wrong with your health system.
Average price for a CT scan is probably between $1000 and $2000 though.
At that level a company that wants a good plan can demand no exclusions for pre-existing conditions (an issue prior to ACA), same-day partner additions, better drug tiers, lower copays, etc. Often they pay less per person than a 1,000 person company does for a much worse plan.
I know because I looked. Two employers ago we got acquired by a very large company (over 80k employees). They paid ~$800/mo for my family. When I moved to a startup, they were paying ~$1200/mo and the benefits were worse. I'm back at a large company again and it's back to ~900/mo for a better plan.
You are getting screwed because the company has decided to do so.
Ha ha, didn't have to tell me that! I bet my coworkers we won't have company health insurance in a few years. Gotta keep that stock high.
Crazy thing is, now that I'm middle age, and my 401k approaches 7 figures, I'm beginning to care more about fund performance to get me to retirement in 20 years than benefits. It's all coasting from now.
You're probably now paying the 'true' cost of healthcare. (Of course, inflated by the peculiarities of the American system.)
In Russia fully out-of-pocket (no insurance, no subsidy) CT scan will cost you $50-$200 (depending on body part).
So, this is likely around its prime cost. And the rest of your $(3000-200) is split and pocketed by hospital shareholders and insurance company.
I spent 4+ hours before a small outpatient procedure at a local hospital trying to find out if the anesthesia group and surgeons were in-network. I never got a straight answer -- no one knew the answer and I was forced to roll the dice.
Hospitals are currently more like co-working spaces where each room (ORs, radiology, etc.) is rented out. The support staff is included, but everyone else is their own small business.
If you're bleeding, and someone hands you a price quote, what are you going to do?
Or if you're unconscious, they can't even hand you a price quote. (I guess they could shove it in your pocket.)
I know the one time I needed to go to the ER, for emergency surgery, I'd have done it if they'd said it was a million billion dollars, because my life was literally on the line. I wasn't going to go shopping around, because leaving that ER would've meant death.
What's a price quote supposed to do in those situations?
We just need universal coverage, whether single payer or actually universal insurance.
I think you may be getting downvoted for your last sentence, but the points you're making are very real.
I work for a medical billing company owned by a competitor to EmCare, we participate it a large number of insurance networks at each site we staff because it's the best way to get reimbursed - I'm rather shocked the hospital didn't investigate how their contracted providers handled insurance contracts and billing.
The problem with trying to provide quotes for emergency services is you don't know ahead of time what E&M code will apply to the visit, what labs will be run, what procedures may be required for treatment, and since physician and facility billing are separate the right hand doesn't know what the left is doing.
I also have some suspicions about the jump from 6% to 28% rates for billing what I assume is a 99285 (highest level non-trauma ED E&M code) and why it may explain the lack of their participation in insurance networks, but I don't want to tread into libel territory so I'll keep my mouth shut.
Disclaimer: I work for MedAmerica Billing Services, Inc. a subsidiary of CEP America - these views, opinions and statements are my own and don't necessarily reflect those of my employer.
I'm always one to call for legislation and price controls, because time and time again, without the legislation in place, situations like this arise. It's the sad reality. Regulating companies is apparently our only hope to keep people from constantly being stepped on.
Sarcasm aside: this problem is solved, and it's called insurance. Private entities sell it. The government does it too. It works. We just need to make sure everyone actually has it.
It's not that the patients don't have insurance, it's not even that they go to a hospital without an agreement in place with their insurer - it's that the ER has a number of people outside that insurance contract, you don't know who they are, you don't get to choose whether they treat you, you just get a bill at the end - despite being insured, and choosing a hospital recognised by your insurer.
Insurance is not the solution for this problem.
$0 out of pocket, just showed my government issued card everywhere.
Couple of years ago my father was in an ICU for two weeks with Parkinson's related complications. That one had a $0 out of pocket bill as well. The ICU was in a world class university teaching hospital.
System works here. Sure people can cite edge cases, but they are relatively rare. The single payer, $0 out of pocket system also encourages pro-active care as opposed to waiting until the problem is severe, which in turn keeps costs down.
Wouldn't trade our single payer, socialized medicine for anything. There's reason why Tommy Douglas, the father of Canadian socialized medicare, was voted the greatest Canadian of all time by the public in a recent CBC poll.
(Shameless plug: software industry is booming in Toronto and there's lots of jobs. Just sayin'...)
$0 out of pocket for the hospital work, a small co-pay for the prescription.
He also spent a few months on a waiting list for surgery. Cataracts surgery. They fixed him, he can now see better. Out of pocket cost? $0.
The system works. If the trade-off for free life-saving treatment is waiting on non-critical surgery, it's a good trade-off. When you're ill, the last thing you want to weigh is whether you will put pay the heating bill, or the ER bill, or whether you should go to some other hospital, because this one will gouge you, even though you're in-network.
The whole point of health insurance is that the healthy pay for the sick. We will all eventually be sick.
Not sure these are just "edge cases"...
http://www.cbc.ca/news/canada/british-columbia/patients-live...
Total cost: $0, 9 stitches, and a lecture from the nurse on the dangers of drinking.
Large hospital systems accept patients who have a range of payers (Original Medicare, Medicare Advantage, various Medicaid plans, private insurance, and uninsured patients). On the aggregate, they want to make sure that their entire system is cashflow-positive - however, they do that in a rather roundabout way, because they only have the ability to negotiate with some of their payers, whereas the others are able to set their rates at whatever price they want.
Medicare and Medicaid set their reimbursement rates by fiat, and providers have essentially no ability to negotiate those. Except in critical access areas, Medicare actually reimburses much less than the marginal costs of care for its patients (7% in the aggregate)[0]. These rates are so low that Medicare actually has a separate program to pay extra money to hospitals that treat a lot of Medicare patients - otherwise, they would literally go under. The reason they provide this money as a separate program and don't count it in claims is entirely political.
As a result, providers present very large bills to everyone else (privately insured and uninsured patients) to make up for this loss - you can't stay in business if you're literally making a loss on every patient! Uninsured patients see the large bill and assume they have to pay the entire amount (they don't!), and private insurers end up negotiating that down to some multiple of what Medicare pays.
A typical insurer will negotiate an agreement like, "we'll pay 350% of what Medicare pays for this category of services".
[0] This is not looking at any markup that the hospital provides - we're talking about how much the hospital has to pay its suppliers. So, for a hypothetical vaccine that costs $100 wholesale, Medicare might reimburse $93, which doesn't even cover the cost of the equipment, let alone the entire hospital infrastructure (wages, etc.).
Except suppliers can engage in their own fiat prices, as the OP demonstrates.
But your narrative does show the basic situation - where you have an elaborate digraph of buyers and sellers, most of which have a more or less monopolistic position. These monopolistic suppliers initially/formally set their prices based on "what they could possibly imagine getting", expecting regulators/down-stream-buyer to be the ones who will push things back into sanity (or not).
American health care, of course, has bounced from regulatory regime to another, with all of the players having to adjust. And moreover, all the players are now adept at adjusting, able to switch gears to leverage whatever ad-hoc cost reductions might go with any new system (cautious enough to lay-low when the new system comes since they know the politicians need to point to gains but will move on - see the way Obamacare worker great for two years, etc, etc).
And with all the bouncing, the situation has gotten only broadly more catastrophic. Health care was ~18% of GDP a year or two ago and no doubt is higher still.
Not only does health care have a problem but the four or eight cycle of ad-hoc fixes to health care has itself broken. Which might relate to the general breakdown of the countries political system, and so-on. I assume when (part of) Rome fell apart, no had seen an empire disintegrate on quite those terms (where a lot of civilization still remained on higher terms than Rome's neighbors). Perhaps our descendants will look back on this era in similar terms.
Those aren't fiat prices by any stretch. Aside from the fact that there is a competitive market of providers, patients don't have the obligation to pay the entire billed price (a key point which this article does not mention). That's neither a monopsony nor a monopoly.
Medicare, on the other hand, is a legal monopsony over its patient population and does set its prices by fiat. (There is no competitive market; patients can opt to receive their Medicare benefits privately, but they cannot opt out of Original Medicare entirely. Similarly, most providers cannot legally opt out of accepting Medicare, in practice).
http://www.flexmonitoring.org/wp-content/uploads/2013/06/CAH...
(in high population areas it doesn't make sense to comply with the limits imposed by the program, for instance, only having 25 beds, that's why there aren't any in Connecticut and such)
(Just adding a bit of info, I think CAHs are pretty high jargon)
Notice here, in 2013, an article about how "For the very first time, the federal government is publicly releasing the "rate card" (the full charge before insurance company discounts) prices hospitals throughout the nation charge for the one hundred most common procedures and services." https://www.forbes.com/sites/rickungar/2013/05/08/the-great-...
Yet two years later, a CEO of a hospital cannot even get the costs at the hospital of which she is CEO: https://www.nytimes.com/2015/09/08/health/what-are-a-hospita...
Price discovery, the most basic element of a free market, is literally impossible, even for expert executives within their own organizations. Vast price discrepancies exist for procedures just a few towns apart. Discovery for consumers in advance is impossible, and of course absurd in the situation where you are being rushed to the nearest hospital in an emergency.
Do not let anyone get away with claiming that this is somehow a "Free Market" until reliable prices, and outcome rates (with case difficulty information) are as easily available as prices and reviews on Amazon.
I have a friend who had to have an emergency appendectomy this year. She paid $1500 for it after insurance. My father had knee surgery he says they tried to charge the insurance company $64k for it.
At this point I think the pricing is all arbitrary. It’s about them trying to charge what they think they can get away with and sticking you for the rest. Kind of like raising the price so you can offer a deep discount later on. I think the real price of the surgery (without insurance) was probably the $7.5k.
I can think of no other business where you agree to have work done without an agreed upon price. The insurance company will tell you it’s covered but the hospital you go to may decide to play games with you. At the very least I suppose they are just hopping you pay so they can collect interest on your money on it before sending it back.
You can't really compare this with other businesses. Unless you want the doctors to stop the moment they hit your negotiated price (like lets say a building constructor would).
However you should be able to get a rough quote for the procedure (assuming no unexpected complications).
And I agree with you in general, US health care is a total scam (very high-quality to be fair).
I've always thought that my informed consent should also apply to cost of procedure - I have a right to say "NO" to something in the medical establishment. And had I known the price and the success rate, I would have said "No".
Now, I'm not asking "What is my exact rate?", although that would indeed be nice. But given minimal complications, I should be able to get a range of what to expect.
They also didn't understand why anyone would even ask the question. They kept saying, "for patients that can't afford to pay we usually work out a payment plan." They didn't understand that I could afford anything and that was the problem. I can write a seven figure check which is why I'm careful not to open myself up to that kind of liability.
It's ridiculous, and it should be illegal. At the time, my reason for visiting was a condition that required treatment, so not going to the doctors really wasn't an option. But the inability to even begin to determine what I'm going to pay is ridiculous.
(I did this after a prior visit to a different doctor stiff'd me something like $3k for the use of what amounts to glorified camera. A camera whose photos I never obtained, despite asking for them — to which the doctor replied "we've never had anyone ever ask for that" — i.e., for their medical records. I could understand that medical-grade cameras might not be cheap, but at $3k per use, my gut says money is raining from the sky.)
They can't just ask about price while unconcious.
According to the article, ~50% of hospital admissions today go through the ER.
Further, it shouldn't be necessary for people to be making financial decisions in the middle of medical emergencies, even if it was easy.
there are all sorts of folks using ERs for non-emergency issues, simply because ERs are required to treat everyone.
both of my trips to the ER (subluxed knee; particulate matter lodged in my eye) would've been amenable to at least a few moments of financial consideration, had any information been available to me.
Seems like getting a hospital to think they treated someone who doesn't exist is a better bet and no more stressful than getting your insurance to cover things to the extent you are lead to believe they would be covered
So I switched to Kaiser which is slightly better from the billing side but feels pretty mediocre care-wise. I don't hear back from the GP about questions/tests ordered and I've waited literally all night just to get something for a bad cough.
Healthcare in America is truly and thoroughly fucked.
Im curious how many supporters of GOP's free market rhetoric would support regulations around these practices once they are hit with a surprise bill like that
These next two to four years are going to suck, though.
I am a New Jerseyan and the medical industry is going to fight tooth and nail on this. My district swung (!) and even the Democrat won't endorse single-player.
Hopefully we can effect change as the Boomer leaders die off, at the very latest.
This should be easy to answer and explain.
This is merely the tip of the iceberg for what for-profit healthcare is developing into. You cannot have sound medical decisions being made when money is so deeply intertwined in the process.
Congress could solve this issue overnight by passing a 1 line law:
If a patient is using services that is not covered by their insurance, or if they have no insurance, no medical service provider can change more than the official medicare standard rate for any services rendered.
Problem solved.
Imagine if you would, a small hospital. They probably don't see enough patients with diagnosis X to keep staff specialized for X busy year round. There is a doctor in town that specializes in X. This doctor needs a place to get their patients stabilized and where the doctor can see the patients periodically. When one of the patients needs hospitalization, the doctor can write an admission order telling the hospital to take care of a patient in a certain way. When somebody comes into the ER and the generalist/hospitalist discovers that person has condition X, then the hospital knows they can call on the doctor to consult with them on how to treat X.
A historical artifact of the hospital/physician relationship is that there are separate billing streams for each side. There is just enough information sharing so that the doctor's billing system knows who the patient is and it is up to the doctor to claim that certain actions were performed for a valid medical reason and documented.
The current state ranges from very arms length relationships to total economic integration, which is rare enough to have a term for it, Single Billing Office.
http://healthaffairs.org/blog/2016/05/09/the-tangled-hospita...
This surprised me, but I suppose it makes sense that cost have to be born by those of us that have the means to do so.
In theory, the high reimbursements are so out of network doctors can get paid market rates. There's also a fair amount of propaganda from insurance companies on this issue which makes the reality hard to discern. Yet they pay 10-20% on average of the bills they receive, so it's just another way to punish the patient while both the insurance company and doctor are taken care of.
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