Author Topic: What comes after the ACA?  (Read 857264 times)

pecunia

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Re: What comes after the ACA?
« Reply #5000 on: November 25, 2018, 09:58:02 AM »
Seems like I got the opposite reaction to my post than I expected.  In those other countries that I mentioned, the insurance companies have been basically jettisoned.  These countries are paying for their health care with government money.  These countries are basically paying per capita for all their people with little more government money than we are already paying.

I was trying to make the point that with not too much more in taxes, we should be able to give health care to all the people in the United States through our tax dollars.  We wouldn't need the hassle of the insurance companies.  We wouldn't need to worry about loopholes in policies.  We wouldn't be able to pay for everything, but we would have basic health care at a fair price.  In other words, most health issues, not all, would be covered for little more than the money we are paying in taxes now.  They do it in other countries and I think we could do it too.

There are just too many conditions and restrictions being applied to the customer.  When you are buying insurance, you are essentially employing a contractor to help you with your health care.  The terms and conditions of this contract is not always apparent.  There are many stories of persons fighting with their insurers in the 100 or so pages of this post.  Isn't everyone tired of all the extra time and money consumed by the customer (patient)? 

Another aspect of this are the people in the insurance companies.  Are they really engaged in a productive activity that benefits society?  What this is really about is doling out health care to the people.  This is an example of an inefficient distribution system for a necessary product. Let's centralize it and use the economy of scale to replace this model.  We will all benefit. 

jim555

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Re: What comes after the ACA?
« Reply #5001 on: November 25, 2018, 10:24:22 AM »
The whole insurance layer is useless waste.  That is one good thing about just paying bills directly through taxation.  Also the practice of price gouging would come under extreme scrutiny.  The gravy train would be over for the medical establishment.

Exflyboy

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Re: What comes after the ACA?
« Reply #5002 on: November 25, 2018, 10:37:58 AM »
The whole insurance layer is useless waste.  That is one good thing about just paying bills directly through taxation.  Also the practice of price gouging would come under extreme scrutiny.  The gravy train would be over for the medical establishment.

But myGOD.. THAT would be Socialism.. And we ALL KNOW socialism is BAD... Dave Ramsey said it so it MUST be true!

He says watching a show about the UK's Air Ambulance service where they put a trauma doctor on every flight and stabilise the patient  before they reach hospital.. Top notch stuff!

sol

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Re: What comes after the ACA?
« Reply #5003 on: November 25, 2018, 11:07:43 AM »
How do I find a good health insurance policy that is HSA compliant, but not ACA compliant, that doesn't cover mental health or substance abuse, and allows for an annual maximum of $2,000,000?

I'm afraid you may be chasing unicorns.  Sometimes the things we want to buy are not available in the places we want to buy them at the prices we want to pay.  That's how marketplaces work.

ysette9

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Re: What comes after the ACA?
« Reply #5004 on: November 25, 2018, 11:16:11 AM »
How do I find a good health insurance policy that is HSA compliant, but not ACA compliant, that doesn't cover mental health or substance abuse, and allows for an annual maximum of $2,000,000?

I'm afraid you may be chasing unicorns.  Sometimes the things we want to buy are not available in the places we want to buy them at the prices we want to pay.  That's how marketplaces work.
In my personal experience and watching my immediate family members, you don’t need substance abuse nor mental health coverage until all of a sudden you do need them. And when you need them, you are in a desperately vulnerable point in your life where having access to the support you need makes the difference between keeping your life running or spiraling down into a big mess. Sort of like an umbrella policy or earthquake insurance on your house. I buy it and pray I never need to use it because not being covered in those two-sigma outlier cases would be significantly detrimental to my health, wealth, and happiness.

rantk81

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Re: What comes after the ACA?
« Reply #5005 on: November 26, 2018, 08:31:10 AM »
re: non-aca hdhp/hsa - Not 100% sure on this, but I thought I read somewhere that HDHP plans must also be ACA compliant, so they must include the mental health and substance abuse coverage.  You can only contribute to an HSA if you have an HDHP complaint plan.  Please someone correct me if I'm wrong.

re: nationalized healthcare and eliminating the middle men (insurance companies) - This would be great. But I don't think it will ever happen. The lobbyists for the insurance companies are too powerful, and the AMA union is too strong. 

PiobStache

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Re: What comes after the ACA?
« Reply #5006 on: November 27, 2018, 10:09:44 AM »
In those other countries that I mentioned, the insurance companies have been basically jettisoned.  These countries are paying for their health care with government money. 

snip

Let's centralize it and use the economy of scale to replace this model.  We will all benefit.

The country with the health system most often ranked as #1 in the world has these two features:

1)  Health insurance organizations
2)  Is highly decentralized.

Paul der Krake

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Re: What comes after the ACA?
« Reply #5007 on: November 27, 2018, 10:28:05 AM »
In those other countries that I mentioned, the insurance companies have been basically jettisoned.  These countries are paying for their health care with government money. 

snip

Let's centralize it and use the economy of scale to replace this model.  We will all benefit.

The country with the health system most often ranked as #1 in the world has these two features:

1)  Health insurance organizations
2)  Is highly decentralized.
Are you referring to Switzerland? It's a country smaller than West Virginia with drastic immigration rules, a mere 8 million people, and where 4k/month is low income. It's highly decentralized but highly regulated in every way.

PiobStache

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Re: What comes after the ACA?
« Reply #5008 on: November 27, 2018, 10:36:23 AM »
In those other countries that I mentioned, the insurance companies have been basically jettisoned.  These countries are paying for their health care with government money. 

snip

Let's centralize it and use the economy of scale to replace this model.  We will all benefit.

The country with the health system most often ranked as #1 in the world has these two features:

1)  Health insurance organizations
2)  Is highly decentralized.
Are you referring to Switzerland? It's a country smaller than West Virginia with drastic immigration rules, a mere 8 million people, and where 4k/month is low income. It's highly decentralized but highly regulated in every way.

So you're not disagreeing with the facts I've presented but saying the facts are irrelevant?  Um, okay.  Germany has nearly 83 million people and just took in hundreds of thousands of migrants.  Still decentralized, still has health care insurance organizations, and is ranked very highly.

Conversely, one of the countries the other poster held out as an example, Canada, has only 33 million people.  So in that case it's okay to draw conclusions to apply to the US with it's 10x population?

bacchi

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Re: What comes after the ACA?
« Reply #5009 on: November 27, 2018, 10:42:11 AM »
In those other countries that I mentioned, the insurance companies have been basically jettisoned.  These countries are paying for their health care with government money. 

snip

Let's centralize it and use the economy of scale to replace this model.  We will all benefit.

The country with the health system most often ranked as #1 in the world has these two features:

1)  Health insurance organizations
2)  Is highly decentralized.
Are you referring to Switzerland? It's a country smaller than West Virginia with drastic immigration rules, a mere 8 million people, and where 4k/month is low income. It's highly decentralized but highly regulated in every way.

So you're not disagreeing with the facts I've presented but saying the facts are irrelevant?  Um, okay.  Germany has nearly 83 million people and just took in hundreds of thousands of migrants.  Still decentralized, still has health care insurance organizations, and is ranked very highly.

Conversely, one of the countries the other poster held out as an example, Canada, has only 33 million people.  So in that case it's okay to draw conclusions to apply to the US with it's 10x population?

Switzerland has uniform fee schedules a la Medicare, premium subsidies, a coverage mandate, no pre-existing exclusions, and universal coverage -- sounds great to me. Let's do it.

Oh, and their universal coverage plan follows a strict government set of standards. Kinda like the ACA compliant plans.
« Last Edit: November 27, 2018, 10:44:09 AM by bacchi »

PiobStache

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Re: What comes after the ACA?
« Reply #5010 on: November 27, 2018, 10:47:38 AM »
Switzerland has uniform fee schedules a la Medicare, premium subsidies, a coverage mandate, no pre-existing exclusions, and universal coverage -- sounds great to me. Let's do it.

Agreed it would be great if the US had Switzerland's system.  In fact, I think the US could adopt it within the current ecosystem, with the necessary legislation.  However, per the other poster and push back I'm getting, it won't work or is no good because it's decentralized and has healthcare insurance organizations.

My point being is when it comes to the US healthcare discussion too many people, including our beloved politicians of all stripes, make sweeping conclusions and pronouncements without actually examining or understanding what the rest of the world other than Canada is doing.  And they usually don't even have a good handle on Canada's system.

Paul der Krake

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Re: What comes after the ACA?
« Reply #5011 on: November 27, 2018, 10:51:42 AM »
You misunderstand my position. I'm saying you can't draw conclusions on whether decentralization and having private companies is good or bad because there are too many factors at play. I would love to have the Swiss system here.

As for Germany, I'm well aware of how the system works, I lived in the country for years. German health insurance companies have almost nothing in common with their American counterparts, because the vast majority of Germans don't use them. Germany is also nowhere near as decentralized as the US, and they regulate the shit out of things.


PiobStache

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Re: What comes after the ACA?
« Reply #5012 on: November 27, 2018, 10:56:29 AM »
You misunderstand my position. I'm saying you can't draw conclusions on whether decentralization and having private companies is good or bad because there are too many factors at play. I would love to have the Swiss system here.

As for Germany, I'm well aware of how the system works, I lived in the country for years. German health insurance companies have almost nothing in common with their American counterparts, because the vast majority of Germans don't use them. Germany is also nowhere near as decentralized as the US, and they regulate the shit out of things.

To think the US has not also regulated the shit out of healthcare, both de facto and de jeure, would be erroneous.  And Germany is decentralized as a characteristic, but maybe not to the degree, just like the topic of regulation.

If you're point is we've got people making sweeping conclusions that don't hold up, I'm with you.  I get all kinds of universal advocates jump on me anytime I offer push back to their conclusions.  I'm a big advocate of universal but silly me wants it done right and not from the default position of the Canadian system which is what all the national level talk revolves around.

Paul der Krake

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Re: What comes after the ACA?
« Reply #5013 on: November 27, 2018, 11:21:16 AM »
You misunderstand my position. I'm saying you can't draw conclusions on whether decentralization and having private companies is good or bad because there are too many factors at play. I would love to have the Swiss system here.

As for Germany, I'm well aware of how the system works, I lived in the country for years. German health insurance companies have almost nothing in common with their American counterparts, because the vast majority of Germans don't use them. Germany is also nowhere near as decentralized as the US, and they regulate the shit out of things.

To think the US has not also regulated the shit out of healthcare, both de facto and de jeure, would be erroneous.  And Germany is decentralized as a characteristic, but maybe not to the degree, just like the topic of regulation.

If you're point is we've got people making sweeping conclusions that don't hold up, I'm with you.  I get all kinds of universal advocates jump on me anytime I offer push back to their conclusions.  I'm a big advocate of universal but silly me wants it done right and not from the default position of the Canadian system which is what all the national level talk revolves around.
I disagree on the premise that the US regulates the shit out of healthcare because there is almost no price control, anywhere. What good does it do the public that the latest and greatest medical device went through multiple rounds of 3-letter agency approval if they still can't get the hospital to fix a routine broken arm for less than 10k?

But I agree with the general point that it doesn't have to be "medicare for all" or bust. There is pervasive myth in Progressive America that every other country just has this magical single payer solution, but the reality is more of a hybrid approach.

PiobStache

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Re: What comes after the ACA?
« Reply #5014 on: November 27, 2018, 11:37:51 AM »
I disagree on the premise that the US regulates the shit out of healthcare because there is almost no price control, anywhere. What good does it do the public that the latest and greatest medical device went through multiple rounds of 3-letter agency approval if they still can't get the hospital to fix a routine broken arm for less than 10k?

But I agree with the general point that it doesn't have to be "medicare for all" or bust. There is pervasive myth in Progressive America that every other country just has this magical single payer solution, but the reality is more of a hybrid approach.

Well, there are more types of regulations than price controls, and even in the US there are some pricing and MLR controls.  Glad we agree with the overarching premise and like the way you stated it.

freya

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Re: What comes after the ACA?
« Reply #5015 on: November 28, 2018, 06:46:39 AM »
There most certainly are price controls in the US, but they don't apply to the cash price that you're billed if you have no insurance, and the way they're applied is nothing short of crazy.  A broken arm might cost you $10K if you have no insurance, but if you flash your United Healthcare card the bill would drop to, say, $2K (warning, made up number).  But, if you have a crafty physician who hired a billing & coding consultant to learn how to document irrelevant stuff (like a fundus exam) to optimize code levels while staying under the insurance company's radar, that $2K can go up to $3K.

To its credit, Medicare is trying to solve these problems.  Recently they proposed dropping the stupid "Fisbin"-style documentation rules and condensing office visits to a single code for basic billing plus time-based billing for long visits.  Sounded great to me.  Naturally, the AMA and other major physician organizations went apes**t and forced them to can the idea.  The reasons cited completely ignored both the time-based billing option and the enormous reduction in workload from reduced documentation requirements.   Pretty clearly, those organizations are representing someone other than doctors and patients.


EnjoyIt

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Re: What comes after the ACA?
« Reply #5016 on: November 28, 2018, 01:16:01 PM »
There most certainly are price controls in the US, but they don't apply to the cash price that you're billed if you have no insurance, and the way they're applied is nothing short of crazy.  A broken arm might cost you $10K if you have no insurance, but if you flash your United Healthcare card the bill would drop to, say, $2K (warning, made up number).  But, if you have a crafty physician who hired a billing & coding consultant to learn how to document irrelevant stuff (like a fundus exam) to optimize code levels while staying under the insurance company's radar, that $2K can go up to $3K.

To its credit, Medicare is trying to solve these problems.  Recently they proposed dropping the stupid "Fisbin"-style documentation rules and condensing office visits to a single code for basic billing plus time-based billing for long visits.  Sounded great to me.  Naturally, the AMA and other major physician organizations went apes**t and forced them to can the idea.  The reasons cited completely ignored both the time-based billing option and the enormous reduction in workload from reduced documentation requirements.   Pretty clearly, those organizations are representing someone other than doctors and patients.

I am extremely disenchanted with the AMA and just about any specialty organization.  It appears they are in the pockets of the billing agencies, insurance companies, pharmaceutical industries, documentation industry...etc.  They seam to do very little for the actual physician.  I voted by stoping all dues to such organizations which used to amount to $1000-$1500 a year.

DreamFIRE

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Re: What comes after the ACA?
« Reply #5017 on: November 28, 2018, 10:20:34 PM »
To its credit, Medicare is trying to solve these problems. 

By underpaying healthcare facilities, just as Medicaid does, which increases the cost for everyone else.  Many hospitals are in the red and couldn't survive if everyone paid what those programs did.

pecunia

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Re: What comes after the ACA?
« Reply #5018 on: November 29, 2018, 09:44:51 AM »
To its credit, Medicare is trying to solve these problems. 

By underpaying healthcare facilities, just as Medicaid does, which increases the cost for everyone else.  Many hospitals are in the red and couldn't survive if everyone paid what those programs did.

I did find it hard to believe when I hear the cost of a single night in a hospital, but no longer.

https://bhmpc.com/2013/08/top-5-reasons-hospitals-are-losing-money/

sol

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Re: What comes after the ACA?
« Reply #5019 on: November 29, 2018, 10:00:45 AM »
By underpaying healthcare facilities, just as Medicaid does, which increases the cost for everyone else.  Many hospitals are in the red and couldn't survive if everyone paid what those programs did.

So you're telling me that every other country in the world that provides better care at lower cost has some secret sauce that America can't duplicate?  I'm not buying that line.

Hospitals operating in the red are spending too much money on things other than medical care.  Every hospital in my area is constantly under construction, building new facilities, not because they need the space but because they need to find some way to "invest" all of their profits back into the business in order to avoid showing a profit on paper.  They pay ridiculous salaries to hospital administrators whose only job is to figure out how to operate in the red on paper while still paying everyone ridiculous salaries and constantly expanding.  My local hospital gets new carpet every three years, and has a giant saltwater fistank in the lobby.  Are you telling me those are necessary costs?  Who's paying for that, if they're supposedly losing money?

Medicare doesn't "underpay" anyone.  It pays the agreed upon rates negotiated by the providers, who enter into that contract willingly.  Just because they can price gouge other patients into paying more doesn't mean medicaid isn't paying enough.

Like any other business, a hospital has income and expenses and has to figure out how to balance those two things in order to continue operating.  Despite your claims about "many hospitals are in the red" I've never heard of a big hospital closing its doors due to bankruptcy.  Have you?  How many other businesses, in other sectors, go bankrupt every year?  What is it about hospitals that makes them so incredibly profitable that they never ever go out of business, and yet still get to complain about not getting paid more?

EnjoyIt

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Re: What comes after the ACA?
« Reply #5020 on: November 29, 2018, 11:34:59 AM »

So you're telling me that every other country in the world that provides better care at lower cost has some secret sauce that America can't duplicate?  I'm not buying that line.

Hospitals operating in the red are spending too much money on things other than medical care.  Every hospital in my area is constantly under construction, building new facilities, not because they need the space but because they need to find some way to "invest" all of their profits back into the business in order to avoid showing a profit on paper.  They pay ridiculous salaries to hospital administrators whose only job is to figure out how to operate in the red on paper while still paying everyone ridiculous salaries and constantly expanding.  My local hospital gets new carpet every three years, and has a giant saltwater fistank in the lobby.  Are you telling me those are necessary costs?  Who's paying for that, if they're supposedly losing money?

There is a little lack of knowledge in that statement.  The hospitals need to show a profit otherwise they go bankrupt.  The reason why these hospitals are in the red is because the cost of delivering healthcare is far far more expensive in this country compared to the rest of the developed world.  And it is not because of CEO salaries.  Believe me the administrators in my hospital do not make millions a year like so many believe.  They get paid well, but it is not as obscene as you make it out to be.  Yes, there are some very large hospital systems with multiple facilities, inpatient and outpatient centers whose CEO can command a $1 million+ salary but it is far more rare than you imagine for the rest. 

What I see is hospitals being forced to partner up and join forces to keep cutting overhead.  Many hospitals that are in the black have profit margins of 1-5% which isn't really that great.  And as any good corporation their goal is to grow and increase profits.

The reasons why hospitals keep building is because they fight for their market share of the insured patients who provide the real profit for the hospital.  So yes, they believe a nice lobby will bring in the wealthier clientele and it does.  Some hospitals have suites for the rich with a private chef.  People from around the world get healthcare at such facilities.  It is just good business sense in todays market.

I do agree that the US needs to implement a pathway to decreasing the cost of delivering medical care to its citizens, legal residents and those staying here on vacation.  Another reasonable and effective pathway could exists for those illegal in this country where they can get medical care, a reasonable pathway to citizenship or deported depending on circumstances. But that is another discussion.

Mr. Green

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Re: What comes after the ACA?
« Reply #5021 on: November 29, 2018, 06:18:16 PM »

So you're telling me that every other country in the world that provides better care at lower cost has some secret sauce that America can't duplicate?  I'm not buying that line.

Hospitals operating in the red are spending too much money on things other than medical care.  Every hospital in my area is constantly under construction, building new facilities, not because they need the space but because they need to find some way to "invest" all of their profits back into the business in order to avoid showing a profit on paper.  They pay ridiculous salaries to hospital administrators whose only job is to figure out how to operate in the red on paper while still paying everyone ridiculous salaries and constantly expanding.  My local hospital gets new carpet every three years, and has a giant saltwater fistank in the lobby.  Are you telling me those are necessary costs?  Who's paying for that, if they're supposedly losing money?

There is a little lack of knowledge in that statement.  The hospitals need to show a profit otherwise they go bankrupt.  The reason why these hospitals are in the red is because the cost of delivering healthcare is far far more expensive in this country compared to the rest of the developed world.  And it is not because of CEO salaries.  Believe me the administrators in my hospital do not make millions a year like so many believe.  They get paid well, but it is not as obscene as you make it out to be.  Yes, there are some very large hospital systems with multiple facilities, inpatient and outpatient centers whose CEO can command a $1 million+ salary but it is far more rare than you imagine for the rest. 

What I see is hospitals being forced to partner up and join forces to keep cutting overhead.  Many hospitals that are in the black have profit margins of 1-5% which isn't really that great.  And as any good corporation their goal is to grow and increase profits.

The reasons why hospitals keep building is because they fight for their market share of the insured patients who provide the real profit for the hospital.  So yes, they believe a nice lobby will bring in the wealthier clientele and it does.  Some hospitals have suites for the rich with a private chef.  People from around the world get healthcare at such facilities.  It is just good business sense in todays market.

I do agree that the US needs to implement a pathway to decreasing the cost of delivering medical care to its citizens, legal residents and those staying here on vacation.  Another reasonable and effective pathway could exists for those illegal in this country where they can get medical care, a reasonable pathway to citizenship or deported depending on circumstances. But that is another discussion.
Whatever it is you're seeing sure isn't what I see. Sure there are a few struggling hospitals out there but for the most part they are cash cows. Hospitals, in general, are so profitable that private equity companies are buying them up, and, as a general rule, PE firms are only interested in the businesses they can squeeze the most profit out of.

Monkey Uncle

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Re: What comes after the ACA?
« Reply #5022 on: November 29, 2018, 06:25:55 PM »
To its credit, Medicare is trying to solve these problems. 

By underpaying healthcare facilities, just as Medicaid does, which increases the cost for everyone else.  Many hospitals are in the red and couldn't survive if everyone paid what those programs did.

I did find it hard to believe when I hear the cost of a single night in a hospital, but no longer.

https://bhmpc.com/2013/08/top-5-reasons-hospitals-are-losing-money/

Hmm, they didn't include the executives' 6 and 7-figure salaries in their list.

DreamFIRE

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Re: What comes after the ACA?
« Reply #5023 on: November 29, 2018, 06:26:27 PM »

So you're telling me that every other country in the world that provides better care at lower cost has some secret sauce that America can't duplicate?  I'm not buying that line.

Hospitals operating in the red are spending too much money on things other than medical care.  Every hospital in my area is constantly under construction, building new facilities, not because they need the space but because they need to find some way to "invest" all of their profits back into the business in order to avoid showing a profit on paper.  They pay ridiculous salaries to hospital administrators whose only job is to figure out how to operate in the red on paper while still paying everyone ridiculous salaries and constantly expanding.  My local hospital gets new carpet every three years, and has a giant saltwater fistank in the lobby.  Are you telling me those are necessary costs?  Who's paying for that, if they're supposedly losing money?

There is a little lack of knowledge in that statement.  The hospitals need to show a profit otherwise they go bankrupt.  The reason why these hospitals are in the red is because the cost of delivering healthcare is far far more expensive in this country compared to the rest of the developed world.  And it is not because of CEO salaries.  Believe me the administrators in my hospital do not make millions a year like so many believe.  They get paid well, but it is not as obscene as you make it out to be.  Yes, there are some very large hospital systems with multiple facilities, inpatient and outpatient centers whose CEO can command a $1 million+ salary but it is far more rare than you imagine for the rest. 

What I see is hospitals being forced to partner up and join forces to keep cutting overhead.  Many hospitals that are in the black have profit margins of 1-5% which isn't really that great.  And as any good corporation their goal is to grow and increase profits.

The reasons why hospitals keep building is because they fight for their market share of the insured patients who provide the real profit for the hospital.  So yes, they believe a nice lobby will bring in the wealthier clientele and it does.  Some hospitals have suites for the rich with a private chef.  People from around the world get healthcare at such facilities.  It is just good business sense in todays market.

I do agree that the US needs to implement a pathway to decreasing the cost of delivering medical care to its citizens, legal residents and those staying here on vacation.  Another reasonable and effective pathway could exists for those illegal in this country where they can get medical care, a reasonable pathway to citizenship or deported depending on circumstances. But that is another discussion.

Well said.  That matches up with the reality I've been seeing for years with actual experience working in the healthcare sector.  It's good to see that someone gets it after reading sol's post, which read like a total work of fiction.

pecunia

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Re: What comes after the ACA?
« Reply #5024 on: November 29, 2018, 06:32:57 PM »
Interesting, so the hospitals spend their money on making things better for the very rich.  Sooner or later someone somewhere somehow is going to figure out a way to get decent health care at a reasonable price to the rest of us.  This profit motive thing doesn't seem to be doing the best job in helping this to happen.

EnjoyIt

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Re: What comes after the ACA?
« Reply #5025 on: November 30, 2018, 03:26:45 AM »
Interesting, so the hospitals spend their money on making things better for the very rich.  Sooner or later someone somewhere somehow is going to figure out a way to get decent health care at a reasonable price to the rest of us.  This profit motive thing doesn't seem to be doing the best job in helping this to happen.

You missed a little there. There are some hospitals that create suites like I described above for the rich. Those are rare and mainly found in large health care centers such as in New York City or Houston. The rest of them are just trying to create a nice experience for those with hprivate health insurance since they reimburse better than Medicare/Medicaid. They want to increase their market share from the slightly more profitable patients.

Since profit margins are razor thin, even a 5% boost in managed care patients can be the difference between staying in the red vs in the black.
« Last Edit: November 30, 2018, 03:28:27 AM by EnjoyIt »

toganet

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Re: What comes after the ACA?
« Reply #5026 on: November 30, 2018, 11:02:38 AM »
Interesting, so the hospitals spend their money on making things better for the very rich.  Sooner or later someone somewhere somehow is going to figure out a way to get decent health care at a reasonable price to the rest of us.  This profit motive thing doesn't seem to be doing the best job in helping this to happen.

You missed a little there. There are some hospitals that create suites like I described above for the rich. Those are rare and mainly found in large health care centers such as in New York City or Houston. The rest of them are just trying to create a nice experience for those with hprivate health insurance since they reimburse better than Medicare/Medicaid. They want to increase their market share from the slightly more profitable patients.

Since profit margins are razor thin, even a 5% boost in managed care patients can be the difference between staying in the red vs in the black.

I wonder how their incentives would change if each procedure cost the same regardless of who the patient was?

des999

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Re: What comes after the ACA?
« Reply #5027 on: November 30, 2018, 03:32:34 PM »
Some hospitals have suites for the rich with a private chef.  People from around the world get healthcare at such facilities.  It is just good business sense in todays market.

wow.  I have spent many months sleeping on a couch in a hospital while my son was getting chemo and trying to stay alive, glad to know the 'rich' are getting steaks and foot massages.  good business sense, don't worry about saving lives.

pecunia

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Re: What comes after the ACA?
« Reply #5028 on: November 30, 2018, 07:04:58 PM »
Some hospitals have suites for the rich with a private chef.  People from around the world get healthcare at such facilities.  It is just good business sense in todays market.

wow.  I have spent many months sleeping on a couch in a hospital while my son was getting chemo and trying to stay alive, glad to know the 'rich' are getting steaks and foot massages.  good business sense, don't worry about saving lives.

Saving lives and curing diseases.  You know - I had this thought.  "An ounce of prevention is worth a lb of cure."  I'll bet that if some type of socialized medicine came along, that would soon be realized.  We'd have more preventive medicine, less sick people and these places would have fewer patients, rich and otherwise.   Those hospitals would probably lose billions in revenue.

I'll bet they know it too.

Monkey Uncle

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Re: What comes after the ACA?
« Reply #5029 on: December 01, 2018, 04:28:19 AM »
http://www.msn.com/en-us/news/opinion/the-slow-motion-collapse-of-the-american-health-care-system/ar-BBQicMB

I thought this article was interesting, mainly for the graphs it contains.  They clearly show that healthcare utilization in the US, particularly inpatient care, is actually declining while the total cost continues to skyrocket.  This would imply that the unit cost is rising even more steeply than the total cost.  So much for the argument that over-utilization (i.e., unnecessary tests and procedures) is driving our cost increases.

Despite abundant evidence that US health care costs roughly twice as much as it should, when an observer tries to finger a particular part of the health care system as costing too much, howls of protest erupt about how that particular segment of the system is not overpaid, and in fact, they are barely squeaking by.  (And I'm not just ragging on the health care professionals who post in this forum - that reaction seems to be universal wherever the discussion is taking place.) 

Why is it that no one in the healthcare-industrial complex can provide a credible answer to this question: where the fuck is all that extra money going?

Monkey Uncle

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Re: What comes after the ACA?
« Reply #5030 on: December 01, 2018, 07:16:34 AM »
Well, I should have looked before I ranted.  Here's a piece from the JAMA forum that basically fingers excessive overhead costs on the part of insurers and providers:

https://newsatjama.jama.com/2017/04/25/jama-forum-where-does-the-health-insurance-premium-dollar-go/

Quote
According to the report, “Where Does Your Premium Dollar Go?,” an average of 79.7 cents per premium dollar is spent by insurers on health care proper and 17.8 cents on the insurers’ “operating costs,” leaving only 2.7 cents per premium dollar as profits.

Quote
These operating costs are about twice as high as are the overhead costs of insurers in simpler health insurance systems in other countries. A 2010 study comparing per capita health spending in Canada and the United States, for example, found that administrative costs in 2002 accounted for 39% of the total per capita spending difference between the 2 countries. The differential amounted to US $616 per capita in 2002. If these costs had grown by a modest 3% per year since then, they would be close to $1000 per capita now.

Also worthy of note is that the 18 cents per premium dollar that insurers report as their “production costs” exclude 2 additional forms of administrative overhead. First, the number excludes the value of the time US patients must spend dealing with insurers, mainly over enrollment and over claims. It can be very time-consuming. Second, the insurers’ cost naturally excludes also the sizeable outlays that physicians, hospitals, and other health care workers and facilities make to negotiate prices for health care and to argue over medical bills.

A study of the cost to medical practices of interacting with health plans published in Health Affairs in 2011 found “that practices spent an average of $82,975 per year interacting with health plans. Duke University’s hospital system (with 3 hospitals) has 957 beds and about 1600 billing clerks. In contrast, as Harvard economist David Cutler, PhD, observed in a 2013 interview, “The typical Canadian hospital has [only] a handful of billing clerks.”

A more recent cross-national study of total administrative costs of hospitals, including also costs other than billing insurers, found that “the proportion of hospital costs devoted to administration was highest in the United States, at 25.3%” and that “reducing US per capita spending for hospital administration to Scottish or Canadian levels would have saved more than $150 billion in 2011” in hospital costs alone.  In its 2012 The Best Care at Lower Cost report, the Institute of Medicine estimated that excess administrative costs in US health care in 2009 amounted to $190 billion.

Quote
A “must read” in this regard is a recent article by Elizabeth Rosenthal, MD, “Indecipherable Medical Bills? They’re One Reason Health Care Costs So Much.” Rosenthal describes a costly “coding war” in which physicians, hospitals, and others who treat patients seek to maximize their profits by hiring legions of consultants who know how to “upcode” procedures in their medical bills. For their part, insurers hire legions of coding consultants who know how to protect insurers from such upcoding. Rosenthal vividly describes how individual patients can get mauled in the process.

We can think of the extraordinarily high overhead imposed on insured individuals and patients in the United States as the price they seem to be willing to pay for the privilege of choice among health insurers and, for each insurer, among multiple different insurance products. US consumers seem so fanatic about this choice that to keep it, they have been willing to give up their erstwhile freedom of choice among physicians, hospitals, and other clinicians and health care facilities. Citizens of most other countries have made that trade-off in exactly the opposite direction.


pecunia

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Re: What comes after the ACA?
« Reply #5031 on: December 01, 2018, 07:28:30 AM »
In response to the Monkey's Uncle:

It sure looks like we would all be better, doctor's, patients and country if we just eliminated those greedy middlemen.

Monkey Uncle

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Re: What comes after the ACA?
« Reply #5032 on: December 01, 2018, 07:35:55 AM »
And from a fellow named Dr. David Belk, who runs a blog called The True Cost of Healthcare:

http://truecostofhealthcare.org/hospital_financial_analysis/

He blames insurance companies who allow themselves to be over-billed so that they can keep growing their revenues.


The section "where is all this money going" on this page is worth a quick read:

http://truecostofhealthcare.org/conclusion/
« Last Edit: December 01, 2018, 07:45:40 AM by Monkey Uncle »

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #5033 on: December 01, 2018, 03:26:52 PM »
I want to get back to the practical question I had.

How do I find a good health insurance policy that is HSA compliant, but not ACA compliant, that doesn't cover mental health or substance abuse, and allows for an annual maximum of $2,000,000?

Looking on Blue Cross Blue Shield Texas website I can't find this.

Has anybody had luck finding non-ACA plans with one of the big insurance groups (United, Blue Cross, Aetna, Kaiser)?

Paying $1,000/month in premiums for ACA compliant plans with deductibles of $6,000/person is absolutely crazy.




More importantly, will they release these plans after the December 15 deadline for those looking for ACA plans? Maybe the big guys are hoping that they will get everybody on the more expensive ACA plans before releasing more non-ACA plans?

Thanks!

Are you not eligible to get premium subsidies for your ACA plan ?

pecunia

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Re: What comes after the ACA?
« Reply #5034 on: December 01, 2018, 09:09:25 PM »
I think the income cutoff is $47,000 for a single person and somewhere in the sixties for a couple.

PiobStache

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Re: What comes after the ACA?
« Reply #5035 on: December 03, 2018, 01:41:43 PM »
Don't forget there are far more than just hospitals too.  From ESRD clinics to home health to post-hospital rehab there's a lot of non-hospital care going on.

rantk81

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Re: What comes after the ACA?
« Reply #5036 on: December 04, 2018, 05:08:14 PM »
To be 100% honest, I’m far less concerned with the eye-poppingly high deductibles and out-of-pocket maximums in ACA plans, and MUCH MUCH more concerned with the doctor-and-hospital networks that are available through the ACA plans... In my area, they seem to only include the shittiest and lowest rated facilities.

bacchi

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Re: What comes after the ACA?
« Reply #5037 on: December 04, 2018, 05:47:05 PM »
And from a fellow named Dr. David Belk, who runs a blog called The True Cost of Healthcare:

http://truecostofhealthcare.org/hospital_financial_analysis/

He blames insurance companies who allow themselves to be over-billed so that they can keep growing their revenues.


The section "where is all this money going" on this page is worth a quick read:

http://truecostofhealthcare.org/conclusion/

It sounds like the US needs a single-payer payment system (which isn't the same as a single-payer system). All claims flow into one gatehouse and then out to insurance plans. The gatehouse uses a standardized system for coding and (this is the kicker) sets fees for procedures.

No negotiating, no code finagling, no hordes of coding employees trying to eke out more profit. An MRI at the local hospital is the same cost as an MRI at the local radiology clinic.

Like Switzerland. Or Japan.

Holyoak

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Re: What comes after the ACA?
« Reply #5038 on: December 09, 2018, 07:14:38 AM »
However the reason for the current mess, it seems it's real easy for 'them' to simply charge whatever the fuck they want, without a goddamn explanation...  Or recourse for me, other to change plans.  My plan premiums for this year with the same plan, are up 100% over last.  Nothing has changed but my age, and was computed with the same income.  Nice too the county in which I reside only has one provider option (UPMC), but if I wish to use any doctor in my county, they are on a different tier and office visits are double cost, etc.

Pricing is a mess too.  Local hospital colorectal exam cost is $1700...  20 miles away at a UPMC hospital is $990.  When I ER'd back in 2013 health insurance cost was my biggest concern, and it seems I was correct in this belief.  Fucking madness, and yes, it does piss me off as a frugal, minimalist person who takes very good care of themselves, doesn't abuse the system, and is held hostage by this situation.

Roadrunner53

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Re: What comes after the ACA?
« Reply #5039 on: December 09, 2018, 09:52:21 AM »
I just transitioned from ACA to Medicare this year and it is not cheap either if you buy the supplements.

Medicare Part A (hospital costs) Free if you have worked 10 years.

Medicare Part B (Dr. visits, tests) as of January $135.50 per month.

Medicare Part D (prescriptions drugs) I pay $72 per month but there are cheaper plans. Mine has no annual deductible, others have $415 per year.

Supplements...if you don't have one, you will pay 20% of what Medicare doesn't pay. If Medicare pays $800 (80%) on a $1,000 bill, you pay $200 ($20%).

I have Plan F. I pay $228.42 per person, per month or $456.84 per month for the two of us. It is the most expensive one but pays for everything Medicare doesn't plus Part A & B deductibles.

The Medicare Part A inpatient hospital deductible that beneficiaries will pay when admitted to the hospital will be $1,364 in 2019.
The annual deductible for all Medicare Part B beneficiaries is $185 in 2019.

In 2020, Plan F will no longer be offered but will be grandfathered to those who keep it.

My Hub and I have identical plans and per month we are paying $871.74, per year $10,460.88 for two people.

I live in HCOL state so the prices I stated will be different in each state.

Hub had serious health issues and part 1 of the saga we were on ACA. He had surgery and believe it or not we really didn't pay a ton out of pocket. Maybe a total of $5,000 as the bills filtered in. On part 2 of the saga (he was now on Medicare & supplements) he had to have treatments that were probably over $150,000 and with the Medicare choices we made, we paid nothing other than our insurance premiums.

It is all a gamble. Serious illness requires expensive treatments. We never know if or when we will get sick.

I know there are cheaper plans and Medicare Advantage plans. But I think if you are not sick, then you make out great with the cheaper plans. However, if you do become sick or need treatments, you will pay thru the nose with deductibles, copays and every other thing they can stick you with. It really is a no win situation. My Hub was never 'sick' until after he retired about one year later at age 64. You just never know.








pecunia

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Re: What comes after the ACA?
« Reply #5040 on: December 09, 2018, 02:18:44 PM »
Wow!  Medicare certainly does seem cheaper than conventional health insurance and it treats the portion of the population most likely to be ill.

"It is a good thing we have medicare for our older Americans and not that Socialist stuff."

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #5041 on: December 09, 2018, 06:28:05 PM »
However the reason for the current mess, it seems it's real easy for 'them' to simply charge whatever the fuck they want, without a goddamn explanation...  Or recourse for me, other to change plans.  My plan premiums for this year with the same plan, are up 100% over last.  Nothing has changed but my age, and was computed with the same income.  Nice too the county in which I reside only has one provider option (UPMC), but if I wish to use any doctor in my county, they are on a different tier and office visits are double cost, etc.

Pricing is a mess too.  Local hospital colorectal exam cost is $1700...  20 miles away at a UPMC hospital is $990.  When I ER'd back in 2013 health insurance cost was my biggest concern, and it seems I was correct in this belief.  Fucking madness, and yes, it does piss me off as a frugal, minimalist person who takes very good care of themselves, doesn't abuse the system, and is held hostage by this situation.


You get a free colonoscopy cancer screening with insurance plans under the ACA/Obamacare

jim555

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Re: What comes after the ACA?
« Reply #5042 on: December 09, 2018, 07:01:16 PM »
Medicare Savings Programs (MSP) and Social Security Extra Help for Part D can help pay for Medicare out of pocket expenses for low income people.  Also state programs may be available for other programs to reduce costs of Medicare.

EnjoyIt

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Re: What comes after the ACA?
« Reply #5043 on: December 10, 2018, 01:47:11 AM »
Interesting, so the hospitals spend their money on making things better for the very rich.  Sooner or later someone somewhere somehow is going to figure out a way to get decent health care at a reasonable price to the rest of us.  This profit motive thing doesn't seem to be doing the best job in helping this to happen.

You missed a little there. There are some hospitals that create suites like I described above for the rich. Those are rare and mainly found in large health care centers such as in New York City or Houston. The rest of them are just trying to create a nice experience for those with hprivate health insurance since they reimburse better than Medicare/Medicaid. They want to increase their market share from the slightly more profitable patients.

Since profit margins are razor thin, even a 5% boost in managed care patients can be the difference between staying in the red vs in the black.

I wonder how their incentives would change if each procedure cost the same regardless of who the patient was?

I'm not sure I understand the question.  Different procedures require different tools, people, time, and expertise and therefor they can not all cost the same to perform. 

http://www.msn.com/en-us/news/opinion/the-slow-motion-collapse-of-the-american-health-care-system/ar-BBQicMB

I thought this article was interesting, mainly for the graphs it contains.  They clearly show that healthcare utilization in the US, particularly inpatient care, is actually declining while the total cost continues to skyrocket.  This would imply that the unit cost is rising even more steeply than the total cost.  So much for the argument that over-utilization (i.e., unnecessary tests and procedures) is driving our cost increases.

Despite abundant evidence that US health care costs roughly twice as much as it should, when an observer tries to finger a particular part of the health care system as costing too much, howls of protest erupt about how that particular segment of the system is not overpaid, and in fact, they are barely squeaking by.  (And I'm not just ragging on the health care professionals who post in this forum - that reaction seems to be universal wherever the discussion is taking place.) 

Why is it that no one in the healthcare-industrial complex can provide a credible answer to this question: where the fuck is all that extra money going?

Thanks for sharing. The article I believe is a bit misleading regarding utilization.  The reason why inpatient utilization appears to go down is two fold.  First hospitals are incentivized to cut length of stay as short as possible.  Shorter length of stay means another patient can take the bed.  The second is CMS has created such a thing called observation stay.  It is an overnight stay in the hospital for observation that is considered as outpatient care.  CMS reimburses less for this service but pays $0 if someone is placed as inpatient but does not qualify based on their rules.  BTW, a case manager is hired to make sure that patients are placed into the right status of inpatient vs. observation so that the hospital does not lose money.  Just one of the places we spend resources on that increases cost but provides no value to patient care. 

As for your comments regarding incomes.  I will agree that incomes are higher in the US compared to other countries.  But, the cost of becoming a doctor is higher as well as the cost of actually practicing medicine is higher.  Is that a good enough reason to have higher incomes?  The average debt for a physician is starting to get close to $300k coming out of residency with plenty of people looking at $400k and $500k school loans.  I doubt many people would go into medicine expecting $300k debt but an income of $100k.  Another reason why doctors make significantly more money in the US is because they work longer hours as compared to docs in Europe.  60 hour work weeks are very common in the US.  I have a friend who works 7 x 12 hour shifts in a row every other week.  On his week "off" he moonlights Monday-Friday for another 10 hours a day. Yes, he works 134 hours every 2 weeks and he makes a very good income.

You want to know where all the money is going.  It is going into the pharmaceutical industry, insurance industry, and generally wasted via bureaucracy such as inpatient vs observation stays alluded to above.  Sure cutting physician and administrative salaries would help curb those costs some, but it is a tiny fraction compared to the massive elephant in the room

To be 100% honest, I’m far less concerned with the eye-poppingly high deductibles and out-of-pocket maximums in ACA plans, and MUCH MUCH more concerned with the doctor-and-hospital networks that are available through the ACA plans... In my area, they seem to only include the shittiest and lowest rated facilities.

Sadly I see the same thing in our area as well.  Plus, non of the good specialists I know take the marketplace plan. Seriously, not a single one. They are all out of network.

In response to the Monkey's Uncle:

It sure looks like we would all be better, doctor's, patients and country if we just eliminated those greedy middlemen.

I fully agree.  We should not need a middle man insurance company to act as a payment center for every tiny cost of healthcare utilization.  Why should we need insurance to buy a $4 medication?  What a bout a $60 doctors visit that now costs $120 because insurance is involved?  Why even have a government based middle man for those low cost items?  Sure, we still need a way to help those less fortunate to cover healthcare expenses but why does it have to be through the farce of insurance when in fact all it is, is a payment processing center? Disclaimer I am a proponent of government paying for cost effective evidence based healthcare via taxes for those without the resources to pay for it themselves.

Some hospitals have suites for the rich with a private chef.  People from around the world get healthcare at such facilities.  It is just good business sense in todays market.

wow.  I have spent many months sleeping on a couch in a hospital while my son was getting chemo and trying to stay alive, glad to know the 'rich' are getting steaks and foot massages.  good business sense, don't worry about saving lives.

@des999, I'm sorry your son required chemo.  No parent or child should have to go through such hardship.  I hope he is doing well and now fully recovered.  People with money will always find ways to spend it while entrepreneurs will keep looking for ways to help them.  It makes no difference what industry we discuss and I do not think it is a bad thing. The rich may even be subsidizing some of our expenses.  For example: The few first class seats on a plane make over 50% of the profit allowing for cheaper seats in the back.  The Tesla Model S payed by the rich paved the way for the 3 series as well as showed the way for other electric car manufacturers.  Those fancy suites upstairs in the hospital help cover the cost for areas in the hospital that may be losing money or subsidizing the cost for the underinsured.


Our healthcare industry is an embarrassing mess and screaming socialized healthcare at the top of our lungs will not fix the problem.  For one, because healthcare is such a massive part of US spending, completely gutting the system would force millions of people to lose their jobs and may very well put us into a steep recession.  Which means, the transition must happen gradually over many many years.  I still think it needs to start with lower the cost of delivering care.  I don't mean more hoops to jump through so that the middle man pays less.  I mean serious policy that starts to brings the cost of delivering care in line with the rest of the world.  Just simply decreasing cost by 10% would provide enough resources to cover every American.

Lastly, I believe physicians should be the front line of the solution, but in my experience most physicians are pussies who don't fight back.  They either don't fight because they are beat down into submission or they have created a lifestyle that even a 3 month loss of wages is unsustainable and therefor they are forced to accept whatever pile of shit is thrown their way.  For most, it is the combination of the two.  I hope things improve, but I have yet to see any real policy that is setting us in the right direction.  I think it is going to get a whole lot worse before it gets better.

DaMa

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Re: What comes after the ACA?
« Reply #5044 on: December 10, 2018, 07:00:50 AM »

You get a free colonoscopy cancer screening with insurance plans under the ACA/Obamacare

Unless a polyp is removed.  Then it's not screening, it's diagnostic and subject to whatever copays, deductibles, and coinsurance applies to outpatient surgery.

This is one of the worst examples of the BS that is our health insurance system. 

PiobStache

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Re: What comes after the ACA?
« Reply #5045 on: December 10, 2018, 08:10:02 AM »
It sounds like the US needs a single-payer payment system (which isn't the same as a single-payer system). All claims flow into one gatehouse and then out to insurance plans. The gatehouse uses a standardized system for coding and (this is the kicker) sets fees for procedures.

No negotiating, no code finagling, no hordes of coding employees trying to eke out more profit. An MRI at the local hospital is the same cost as an MRI at the local radiology clinic.

Like Switzerland. Or Japan.

Agreed there is a need to simplify the quagmire that is medical billing in the US.  Also of help would be if insurance companies was stop the game of denying your UBs multiple times in hopes you'll give up.

pecunia

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Re: What comes after the ACA?
« Reply #5046 on: December 10, 2018, 08:52:26 AM »


- HUUGE SNIP

Our healthcare industry is an embarrassing mess and screaming socialized healthcare at the top of our lungs will not fix the problem.  For one, because healthcare is such a massive part of US spending, completely gutting the system would force millions of people to lose their jobs and may very well put us into a steep recession.  Which means, the transition must happen gradually over many many years.  I still think it needs to start with lower the cost of delivering care.  I don't mean more hoops to jump through so that the middle man pays less.  I mean serious policy that starts to brings the cost of delivering care in line with the rest of the world.  Just simply decreasing cost by 10% would provide enough resources to cover every American.


Lastly, I believe physicians should be the front line of the solution, but in my experience most physicians are pussies who don't fight back.  They either don't fight because they are beat down into submission or they have created a lifestyle that even a 3 month loss of wages is unsustainable and therefor they are forced to accept whatever pile of shit is thrown their way.  For most, it is the combination of the two.  I hope things improve, but I have yet to see any real policy that is setting us in the right direction.  I think it is going to get a whole lot worse before it gets better.

I like it - a man with a sort of a plan.  It will be better this time to make the change incrementally.  The dog's tail should be cut off a piece at a time rather than all at once.  People should know what is coming for the change and be able to prepare for it.

I'm going to the doctor this afternoon for a checkup.  Typically, I ask what the cost of the checkup is to the girls behind the glass.  They never know.  Sometimes, they tell me your insurance will pay for the checkup.  I still get a bill two months down the road.  Would you buy a car from these folks?

sol

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Re: What comes after the ACA?
« Reply #5047 on: December 10, 2018, 09:05:36 AM »
Also of help would be if insurance companies was stop the game of denying your UBs multiple times in hopes you'll give up.

Unfortunately, it's the consumers who suffer from this practice, in the form of dings to their credit rating. 

After your hospitals's coding staff chooses one of the six different codes that could apply to your procedure, the insurance company uses an ever-shifting subset of those codes to decide which to pay and which to deny.  If they deny, the hospital asks the patient to cover the cost for their mistake, and we have learned that it doesn't matter that the exact same procedure was covered under the exact same plan last year, if it's coded wrong by the hospital this time then the patient is on the hook.  Eventually they will sell your debt to a collection agency, your credit rating takes a nosedive, and you start getting annoying phone calls from skeevy debt collectors.

Who benefits from this madness?  Why are insurance companies constantly finding ways to deny hospitals payment for insured work?  (because they are profit driven, and want to reduce their expenses.)  Why do hospitals then turn to the patient instead of fixing their codes?  (because they are profit driven, and make more money collecting or selling the debt than fixing the coding.)  Why do patients have to suffer for these mistakes?  (because patients are the one group without a powerful political lobby representing their interests.)  The whole thing is just a case study on the ills of capitalism, an example of what happens when we let dollars become more important than human welfare.

PiobStache

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Re: What comes after the ACA?
« Reply #5048 on: December 10, 2018, 10:20:56 AM »
I can assure you it's more than hospitals that use UBs and that it's not always the consumer that eats the bill.

sol

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Re: What comes after the ACA?
« Reply #5049 on: December 10, 2018, 10:48:51 AM »

it's not always the consumer that eats the bill.

No, only if they give in to the high pressure tactics and agree to pay for the hospital's mistakes.  Otherwise the hospital eats part of it, selling of the debt, and the debt collector eats the rest.  But it's the consumer who takes the credit score hit in that scenario.