What comes after the ACA?

[pecunia]

It's not rare at all for healthcare facilities to go out of business.  Do some searching - I actually posted a link to an article about it earlier in this thread.  It's not new news.  This was occurring even before the ACA.

OK

https://www.beckershospitalreview.com/finance/21-hospital-closures-in-2018.html

Looks like most of them closed due to lack of patients.  I particularly liked number 11, "the honest one." 

It does remind me what an odd world we live in.  These facilities make their money from others misfortunes.  When people are doing well i.e., not sick, they suffer financially.  Seems like there should be some incentive for these facilities to help people live well and not just benefit from their misfortunes.

When you look at the size of the healthcare industry in the US, 21 hospital closures does not impress me as severe.  In fact, since it is a capitalist system, one may make the claim it is normal.  This is dwarfed in relation to the massive closures of factories and other businesses.

I just thought of something - In relation to inflation, the average Joe has taken quite a cut in pay since, say 1980.  (I don't have a reference for this one, but is't known knowledge)  Has the same occurred for medical workers?

[seattlecyclone]

Next, Doctors pay a coding service 8-12% of collections to be able to code properly for billing.  Lets get rid of them and cut my pay by another 10%.

Help me understand this. Why is the billing computer system so complicated that you need to pay a third party ~10% of your gross receipts to properly record what you did, and not something that you can just click a couple of buttons yourself immediately after you see the patient? Who is making it this complicated? Which level of government should I contact to simplify this cost away to nothing, and what should I ask them to do?

Its not that simple.  You must meet certain criteria for billing a chart up to the maximum level it is entitled to.  It requires a human to read it, understand what they are reading and code it appropriately.  This also includes any procedures done, or any specific add-on codes.  There are thousands of billing codes that need to be understood and interpreted. The coding system is called ICD-10 and has 141,747 distinct codes.  CMS upgraded from ICD-9 in 2015 which only had 17,849 codes. I guess they felt more complex is better.  If a chart happens to miss 1 coding criteria the level of billing is dropped to the bear minimum and the reimbursement can be cut by 80% depending on how high of a chart you start with.  A computer system can help with coding but they are not perfect plus, to use said computer system takes a lot of time to put in each and every detail which is why one may need a scribe.  The documentation requirements were created by CMS and now adopted by every insurance company. In an attempt to cut costs by decreasing reimbursement through bureaucratically determined inadequate charting, they inadvertently increased the cost of healthcare for everyone. 

In case you are not aware CMS runs Medicare and Medicaid.

On a conceptual level it is that simple. All you're doing is mapping what you did for a patient to the canonical list of things you can bill a patient for, each having its own numeric code. Of course you can't bill for something you didn't actually do completely, so it makes sense that you wouldn't get paid if you try to bill for a procedure that you didn't properly record yourself doing. The fact that there are over 100,000 of these things does add complexity. You're saying that this complexity skims 10% off the top of a medical practice's billing, because a doctor can't possibly do it right and they have to hire an expert to do it. I'll take your word for that, as insane as it seems to me.

Do you think there's any other country where they use up 10% of their health care budget on deciding exactly what to bill patients for? This isn't even a "single-payer" vs. "multi-payer" issue as it seems to be our socialized Medicare/Medicaid that is taking the lead on enforcing this.

So again I ask, what do you think the most promising avenue of reforming this is? If we reduced the codes back to 10,000, would a doctor be able to do it herself in a minute or less per patient? What if it was only 1,000? Who do we write to reform this? The Secretary of Health and Human Services? Whoever directly manages Medicare? Congress (not that they actually do anything anymore)?

[EnjoyIt]

Next, Doctors pay a coding service 8-12% of collections to be able to code properly for billing.  Lets get rid of them and cut my pay by another 10%.

Help me understand this. Why is the billing computer system so complicated that you need to pay a third party ~10% of your gross receipts to properly record what you did, and not something that you can just click a couple of buttons yourself immediately after you see the patient? Who is making it this complicated? Which level of government should I contact to simplify this cost away to nothing, and what should I ask them to do?

Its not that simple.  You must meet certain criteria for billing a chart up to the maximum level it is entitled to.  It requires a human to read it, understand what they are reading and code it appropriately.  This also includes any procedures done, or any specific add-on codes.  There are thousands of billing codes that need to be understood and interpreted. The coding system is called ICD-10 and has 141,747 distinct codes.  CMS upgraded from ICD-9 in 2015 which only had 17,849 codes. I guess they felt more complex is better.  If a chart happens to miss 1 coding criteria the level of billing is dropped to the bear minimum and the reimbursement can be cut by 80% depending on how high of a chart you start with.  A computer system can help with coding but they are not perfect plus, to use said computer system takes a lot of time to put in each and every detail which is why one may need a scribe.  The documentation requirements were created by CMS and now adopted by every insurance company. In an attempt to cut costs by decreasing reimbursement through bureaucratically determined inadequate charting, they inadvertently increased the cost of healthcare for everyone. 

In case you are not aware CMS runs Medicare and Medicaid.

On a conceptual level it is that simple. All you're doing is mapping what you did for a patient to the canonical list of things you can bill a patient for, each having its own numeric code. Of course you can't bill for something you didn't actually do completely, so it makes sense that you wouldn't get paid if you try to bill for a procedure that you didn't properly record yourself doing. The fact that there are over 100,000 of these things does add complexity. You're saying that this complexity skims 10% off the top of a medical practice's billing, because a doctor can't possibly do it right and they have to hire an expert to do it. I'll take your word for that, as insane as it seems to me.

Do you think there's any other country where they use up 10% of their health care budget on deciding exactly what to bill patients for? This isn't even a "single-payer" vs. "multi-payer" issue as it seems to be our socialized Medicare/Medicaid that is taking the lead on enforcing this.

So again I ask, what do you think the most promising avenue of reforming this is? If we reduced the codes back to 10,000, would a doctor be able to do it herself in a minute or less per patient? What if it was only 1,000? Who do we write to reform this? The Secretary of Health and Human Services? Whoever directly manages Medicare? Congress (not that they actually do anything anymore)?

First of all, we need to reduce the documentation requirement.  30 years ago a surgeon's note can look like this:

Patient with 2 days of abdominal pain, fever and vomiting
abd tender in RUQ
WBC elevated,
Ultrasound shows Cholecystitis
Assesment: Cholecystitis
Plan: Laproscopic Cholecystectomy

Now the note has to have a more detailed history, a complete review of systems, family history, social history and a 10 point (maybe 8 point) physical exam.  (I might not be 100% accurate on a surgeon's requirements but this is the gist of it.)  If any one item is missing the chart is practically useless.  If the chart is not submitted within 48 hours CMS will not pay.  Keep in mind the coder/biller not only does the coding, they do the billing and work with the denials.  This is a full time job.  The scribe is a full time job as well.  BTW, this level of complexity requires expensive computer software and of course expensive IT team to keep it running properly.  These are people who have no added value to the patient but increase the cost of delivering care to the patient.  Then there is the dedicated Survey Company. 

Reimbursement is decreased further is patients are not 100% satisfied with their care.  The problem is that patients demand unnecessary antibiotics and testing and if they don't get it, they are unhappy and provide a poor survey and reimbursement is decreased.  On top of which one question on the survey is very specific.  How well was your pain controlled? So what happens?  Patient's get tons of narcotic pain medication that created the addiction epidemic we have today, they get useless imaging, and taking medication that does more harm than good for them.  Unfortunately most people don't understand if they received good medical care or not. How could they? 

A morbidly obese diabetic has a much higher chance of a surgical wound getting infected or opening up.  This is not the fault of a surgeon yet the surgeon gets financially dinged for it.  A person with emphysema who continues to smoke has a high chance of getting re-admitted to the hospital and the hospital won't get paid for the re-admission despite the patient refusing to put away their death stick. A patient continues to ignore their doctors recommendation on eating better and taking diabetes medication but gets dinged financially if the patients Hemaglobin A1C (a good marker of diabetic control) does not improve. 

One way to help mitigate the issue is to also have a consistent price for a laparoscopic cholecystectomy that is unchanged if you are self pay, Aetna, Blue Cross, other, or CMS.  Billing is too complex and too expensive.  I would like to believe price transparency will get us there, eventually.  What's interesting, the few physicians who have decided to forgo insurance and CMS find that they charge much less for their services while still making the same or better income and are able to spend more time with their patients to provide better care. Everybody wins as long as the patient has a credit card. This is an example of just a little touch of capitalism in a system ridden with corruption and waste.

I am 100% positive that every physician in the US would sign up to be paid less if we also removed all the bullshit in their day to day practice.  BTW, it is this so called bullshit why I work part time now.  I'm just not interested in dealing with all  the crap for 40-60 hours a week.

[Malloy]

Sarah Kiff has been killing it on healthcare reporting:

https://www.vox.com/policy-and-politics/2019/1/7/18137967/er-bills-zuckerberg-san-francisco-general-hospital


SFGH does not take insurance of any kind, and this has incentivized billing practices that just pull numbers out of the air.  Insurance providers pay their reasonable rate, leaving patients stuck with the rest of the bills.  That would be sucky even if this were for elective visits, but SFGH is the only level 1 trauma center in the area.  May patients don't have a choice.  One interesting point is that California has laws protecting patients from balance billing, but they don't cover the type of self-insurance policy that many large corporations offer.  That has to be regulated at the federal level.  So, for everyone who thinks that your vote doesn't count, we are relying on our Senators and Reps to do right by us here.  There is some bipartisan movement on this, but it doesn't seem to have the urgency that other issues are commanding.  Also remember that the biggest group of reliable voters is on socialized healthcare already (try explaining that to them, though...), and they may not care what happens to the under 65 set.  It's up to us to vote and put pressure on our representatives if we want anything to happen.   

[DavidAnnArbor]

Chilling article.

[pecunia]

Maybe change is in the weather:

Looks like the New York Mayor is going to try to give universal medicine to people.

https://www.nbcnewyork.com/news/local/NYC-Health-Care-Guarantee-Mayor-de-Blasio-504046171.html

If he can pull this one off, it ought to boost his popularity.  They say 600,000 people in New York City do not have insurance.

This will be interesting to see how the insurance companies will want to stomp this one out.  I can imagine their overpaid executives discussing it while chomping cigars in a smoke filled room: "Imagine - A politician trying to solve a real problem.  This is a bad precedent.  Unless this socialist program is nipped in the bud, it could possibly be a precursor for things to come."

I don't live in New York state or city.  Could this be a reality or just politicians making noise?

[sol]

Maybe change is in the weather:

Looks like the New York Mayor is going to try to give universal medicine to people.

https://www.nbcnewyork.com/news/local/NYC-Health-Care-Guarantee-Mayor-de-Blasio-504046171.html

If he can pull this one off, it ought to boost his popularity.  They say 600,000 people in New York City do not have insurance.

This will be interesting to see how the insurance companies will want to stomp this one out.  I can imagine their overpaid executives discussing it while chomping cigars in a smoke filled room: "Imagine - A politician trying to solve a real problem.  This is a bad precedent.  Unless this socialist program is nipped in the bud, it could possibly be a precursor for things to come."

I don't live in New York state or city.  Could this be a reality or just politicians making noise?

It's not just NY.  CA and WA are doing the same thing, with slight variations.

But it's not as bad as you suggest on the creeping socialism front.  To me it mostly looks like using state funds to expand the existing ACA programs, in an effort to reverse the damage that republicans have done to the law.

[pecunia]

- SNIP -

It's not just NY.  CA and WA are doing the same thing, with slight variations.

But it's not as bad as you suggest on the creeping socialism front.  To me it mostly looks like using state funds to expand the existing ACA programs, in an effort to reverse the damage that republicans have done to the law.

That's good.  That's the right phrase "creeping socialism." If they started to help sick people, people would have ideas that they could have other socialist programs like libraries, public schools and even public paved roads.

[sol]

That's good.  That's the right phrase "creeping socialism." If they started to help sick people, people would have ideas that they could have other socialist programs like libraries, public schools and even public paved roads.

I'm calling Senator McCarthy.  I hope you're prepared to name names.

[talltexan]

The ACA chooses insurance companies to win on the backs of middle class America. We can not blame the insurance companies to win when our policies give them all the resources to do so.  BTW, I am very disgruntled at our health insurance industry.

We're all a little disgruntled, but are we more or less disgruntled than we were before the ACA?

The ACA is certainly an imperfect solution, as any solution must be, but I think it's a lot closer to perfect than what we had before.  No one else was able to get any other compromise solution passed for 40 years, and things just kept getting worse and worse.  Part of the reason the ACA was finally passed was because it offered insurance companies increased profits for increased work (by expanding their pool of paying customers but regulating their shittiest products to make them less shitty).  There were other proposed solutions on the table, but this was the only one that our elected representatives could agree on in sufficient numbers to do anything at all.  Every previous attempt, some of which resembled your solutions, resulted in jack shit because they couldn't get the votes.  The ACA was absolutely a step in the right direction if only because it was an actual step, after decades of dereliction.

Insurance skyrocketed after the ACA.  I have a couple dozen employees and I ended up canceling our insurance policy and sent the staff out on their own.  What used to be $2,000/mo for good coverage turned in to $7,500/mo for terrible coverage.  So I canceled it and don't offer insurance anymore.  Good luck, I didn't vote for it.  Go sign up for Obamacare.  Strangely, they didn't seem to like what they voted for and seem more disgruntled with the new setup.  But I guess I'm saving a ton of money, so it's cool. Thanks Obama! So I would argue that the people who were supposed to get the most help seem MORE disgruntled and get lesser care since the ACA.  Someone earning $30k/year is having a tough time with that $10,000 deductible.  The road to hell is paved with good intentions.... and bad policy.

Why can't people just accept that the ACA failed?  It would be the first real step to coming up with a better solution.  Learn from it, see what works and what didn't, and fix it.  But since it's so highly politicized, we all have to take the side of our "team."  We can't possibly let Trump win (even if it means WE win), we can't admit an Obama failure.... blah blah blah.  The ACA is a disaster.  But it won't get fixed because that would be bad politically for Team A or something.  And as we know, political power is all that matters in this country right now.

I think it's important to note that you are seeing this only from a single lens.

Your experience is an anecdote - we need to look further to more data.

As an example, my husband's insurance (through his employer) - got cheaper with the ACA when they set limits on how much could go towards administration.  In fact, the cost went down more than once.

My neighbor, who is self-employed, found that her insurance costs (premiums) went WAY down AND her coverage got a lot better (she went with silver, I believe).  She has Crohn's and the ACA has saved her bacon.

I have a few other friends with pre-existing conditions who were literally uninsurable before the ACA.  In fact, one of them had Blue Cross insurance (privately purchased) on the East Coast.  When he moved to the West Coast, they refused to insure him due to "pre-existing conditions".

Unfortunately, there are going to be winners and losers.  In general, it seems like the lower income people and the uninsured were the winners.  The "middle" folks, in many cases, ended up the "losers". 

(yes more anecdotes)

And this is fair.  I know from myself and my friends (who own businesses) that it's been a disaster.  That doesn't mean it's bad for everyone in all scenarios.

I would say, just because we can come up with some examples like your friend with pre-existing conditions doesn't mean the ACA is working.  That's kind of the big lie right now.  That if we dump the ACA, then people with pre-existing conditions are screwed.  It's simply not the case.

We still have the opportunity to dump the ACA and replace it with something better.  But that won't happen because it's way too highly politicized.  The Democrats couldn't have Trump get credit for fixing healthcare.

The conversation has shifted from here, but I recall the GOP: controlled the House and passed the "American Health Care Act"; controlled the Senate, yet couldn't get enough Republican votes to pass that same act, and also couldn't get enough votes to pass either Graham-Cassidy or the "skinny repeal", despite having a House majority that sure looked ready to pass those if necessary.

Yes, the Democrats oppose plenty of Trump's policies. But the Republicans failed to whip up their votes for this.

[pecunia]

*******SSSSSNNNNNNIIIIIPPPPP*********

The conversation has shifted from here, but I recall the GOP: controlled the House and passed the "American Health Care Act"; controlled the Senate, yet couldn't get enough Republican votes to pass that same act, and also couldn't get enough votes to pass either Graham-Cassidy or the "skinny repeal", despite having a House majority that sure looked ready to pass those if necessary.

Yes, the Democrats oppose plenty of Trump's policies. But the Republicans failed to whip up their votes for this.

Wouldn't you think mature people would work together to solve a common problem that besets the entire nation?  Maybe, I've been reading History books with rose colored glasses, but I think past politicians performed their jobs in the interest of the common folk and not so much big business.

[EnjoyIt]

*******SSSSSNNNNNNIIIIIPPPPP*********

The conversation has shifted from here, but I recall the GOP: controlled the House and passed the "American Health Care Act"; controlled the Senate, yet couldn't get enough Republican votes to pass that same act, and also couldn't get enough votes to pass either Graham-Cassidy or the "skinny repeal", despite having a House majority that sure looked ready to pass those if necessary.

Yes, the Democrats oppose plenty of Trump's policies. But the Republicans failed to whip up their votes for this.

Wouldn't you think mature people would work together to solve a common problem that besets the entire nation?  Maybe, I've been reading History books with rose colored glasses, but I think past politicians performed their jobs in the interest of the common folk and not so much big business.

It’s a sad state of affairs @pecunia. When elections for congress costs millions to win, no wonder these politicians pander to big pockets. They really don’t have any other choice. We need term limits and campaign finance reform. I am hopeful that this is on Trumps agenda during his second term.

[Roland of Gilead]

It’s a sad state of affairs @pecunia. When elections for congress costs millions to win, no wonder these politicians pander to big pockets. They really don’t have any other choice. We need term limits and campaign finance reform. I am hopeful that this is on Trumps agenda during his second term.

How would a normal Joe get elected without pandering for the millions though?  Unless you are saying rich people are not allowed to self finance their campaigns in the interest of fairness?

[pecunia]

It’s a sad state of affairs @pecunia. When elections for congress costs millions to win, no wonder these politicians pander to big pockets. They really don’t have any other choice. We need term limits and campaign finance reform. I am hopeful that this is on Trumps agenda during his second term.

How would a normal Joe get elected without pandering for the millions though?  Unless you are saying rich people are not allowed to self finance their campaigns in the interest of fairness?

Well - It seems like there was one old geezer that kind of came out of nowhere in the last election.  He did pretty well.  I guess he got an average contribution of $27/ head.  He had a head start though as he was an active politician. 

On the other hand, maybe a normal Joe might not make the best president because he (or she) may not have political experience.  He might not be able to even recognize if the press was telling the truth about him or lying.  There would be no record to recognize if our average Joe was on the level or being a lying sleazebag.

[EnjoyIt]

One of the reasons why campaigns are expensive is because they are allowed to be.  Americans have an insatiable appetite to spend on everything..  Things like Super Pacs should not exist.  Ad time should only be allowed for more than 1 week pre election. There must be a cap on spending. We need term limits.  I'm sure there is more as we need to make it so that spending money on politicians buys much less than it does today.

[sol]

Ad time should only be allowed for more than 1 week pre election.

Exactly how are you going to enforce a rule like that?  Are you going to track down the people behind every social media account that mentions a candidate?  In today's world, campaigning is not restricted to traditional media like television commercials.  Recent elections have proved that quite handily.

Politics is a lot more complicated than it used to be.  Minority candidates can get elected with absolutely zero background or experience, based purely on made up bullshit lies, and then get to make life-altering decisions for the entire planet.  Basic human welfare issues like healthcare become political hot potatoes.  People who have devoted their lives to serving their country get held hostage for meaningless debates about symbolic construction projects that have nothing to do with them.  Patriotism means rooting for America's enemies.  We mock any attempt at thoughtful discourse, and rather than listen to seasoned professionals with decades of relevant experience we make spur-of-the-moment decisions based on "gut instinct".   

All of the old bulwarks of American exceptionalism are dead or dying.  Our compassion, our intelligence, our drive, our observance of the law, and our good intentions are all toppled sign posts in our collective rear view mirror, rather than our path forwards.  This is no way for a country to prosper, and from where I'm standing it looks like all of these changes were deliberate choices by people who did not want America to prosper.

If the richest country on Earth can't even come together on something as basic as providing medical care to our most impoverished citizens, what hope do we have?  How can we possibly help lead our species towards a brighter future when we fail so spectacularly at displaying basic humanity?

[former player]

First of all, we need to reduce the documentation requirement.  30 years ago a surgeon's note can look like this:

Patient with 2 days of abdominal pain, fever and vomiting
abd tender in RUQ
WBC elevated,
Ultrasound shows Cholecystitis
Assesment: Cholecystitis
Plan: Laproscopic Cholecystectomy

Now the note has to have a more detailed history, a complete review of systems, family history, social history and a 10 point (maybe 8 point) physical exam.  (I might not be 100% accurate on a surgeon's requirements but this is the gist of it.)  If any one item is missing the chart is practically useless.  If the chart is not submitted within 48 hours CMS will not pay.  Keep in mind the coder/biller not only does the coding, they do the billing and work with the denials.  This is a full time job.  The scribe is a full time job as well.  BTW, this level of complexity requires expensive computer software and of course expensive IT team to keep it running properly.  These are people who have no added value to the patient but increase the cost of delivering care to the patient.  Then there is the dedicated Survey Company. 

Reimbursement is decreased further is patients are not 100% satisfied with their care.  The problem is that patients demand unnecessary antibiotics and testing and if they don't get it, they are unhappy and provide a poor survey and reimbursement is decreased.  On top of which one question on the survey is very specific.  How well was your pain controlled? So what happens?  Patient's get tons of narcotic pain medication that created the addiction epidemic we have today, they get useless imaging, and taking medication that does more harm than good for them.  Unfortunately most people don't understand if they received good medical care or not. How could they? 

A morbidly obese diabetic has a much higher chance of a surgical wound getting infected or opening up.  This is not the fault of a surgeon yet the surgeon gets financially dinged for it.  A person with emphysema who continues to smoke has a high chance of getting re-admitted to the hospital and the hospital won't get paid for the re-admission despite the patient refusing to put away their death stick. A patient continues to ignore their doctors recommendation on eating better and taking diabetes medication but gets dinged financially if the patients Hemaglobin A1C (a good marker of diabetic control) does not improve. 

One way to help mitigate the issue is to also have a consistent price for a laparoscopic cholecystectomy that is unchanged if you are self pay, Aetna, Blue Cross, other, or CMS.  Billing is too complex and too expensive.  I would like to believe price transparency will get us there, eventually.  What's interesting, the few physicians who have decided to forgo insurance and CMS find that they charge much less for their services while still making the same or better income and are able to spend more time with their patients to provide better care. Everybody wins as long as the patient has a credit card. This is an example of just a little touch of capitalism in a system ridden with corruption and waste.

I am 100% positive that every physician in the US would sign up to be paid less if we also removed all the bullshit in their day to day practice.  BTW, it is this so called bullshit why I work part time now.  I'm just not interested in dealing with all  the crap for 40-60 hours a week.

Whenever someone has legislated for this level of "insane bullshit" it is necessary to work out why. Inevitably it was started to solve a problem, in a case like this usually poor service, overcharging or outright fraud.  There is then an arms race between the charger and the payer which ends up in the situation you currently have.  The only solution is to start again from scratch.

[radram]

We need term limits.

Wrong thread for this, but I am against term limits. This includes for president. Voting is the ultimate power given to the people. Why should we voluntarily relinquish that power. If 50.001% want someone to do a job, I think they should be allowed to do it(electoral college discussion set asind for now, of course).

If you want to discuss leveling the playing field for the election process, I am in favor of that, but have no idea how to do it.

Campaign ads: I might be opening a Pandora's box here, buy I am absolutely sick and tired of misleading and deceptive ads. I wish there was some way of "approving" an ad for accuracy BEFORE it gets aired. The ads should be factual, not interpretive.

For example, if a politician votes to lower funding for food stamps, say that. You should not be able to say he/she "took money from starving children". If a politician votes to lower the maximum prison sentences, say that, not "he/she wants rapists to be your neighbor". The current tone of political ads, though effective, are disgraceful.

[DavidAnnArbor]

Meanwhile the CEO of BlueCross Blue Shield of Michigan makes a ridiculous amount of money, which seems to be doubling every 3 years, in part because of the ACA increasing the insurer's financial outlook

https://www.crainsdetroit.com/health-care/blues-ceos-compensation-rises-43-percent-192-million?utm_source=crain-s-health-care-extra&utm_medium=email&utm_campaign=20190304&utm_content=article1-headline

March 01, 2019 02:52 PM
Blues CEO's compensation rises 43 percent to $19.2 million

Daniel Loepp, president and CEO of Blue Cross Blue Shield of Michigan, earned total compensation of $19.2 million in 2018, a 43 percent increase from $13.42 million in 2017.
Loepp, who has been CEO at Blue Cross since 2005, is one of the highest-compensated health insurance CEOs in the nation. Most local publicly traded companies haven't reported 2018 compensation yet, but Loepp's compensation would have put him second on Crain's list of highest-paid CEOs in 2017 behind General Motors Co.'s Mary Barra, who earned about $21.9 million.
Over his 14-year tenure at Blue Cross, Loepp's compensation has steadily risen, especially the last six years. His total compensation has increased 397 percent from $3.86 million in 2012 to $19.2 million in 2018, primarily by reaping bonus payments due to Blue Cross' steady financial improvements since the Affordable Care Act of 2010 went into full effect in 2014.
In 2018, Loepp's total compensation included a base salary of $1.54 million, which has remained the same over the past five years; a bonus of $16.24 million and other compensation of $1.44 million that includes car allowance, health insurance premiums and retirement contributions.

The Michigan Blues reported net income of $580 million in 2018 on $29.3 billion in revenue, according to its annual financial statement released Friday. It was the second-highest net income figure the health insurer has posted in the past decade after a record 2017.
Though Loepp's performance always is based on the company's previous year, Vice President of Corporate Communications Andy Hetzel said other factors such as membership growth influence bonus compensation more than net income.

Comparing Loepp's 2018 total compensation with other Blue Cross or health insurance CEOs is difficult because the Michigan Blues submit their financial information earlier in the year than most.
But Hetzel said Loepp's compensation probably puts him in the top five of all Blues' CEOs.
Equilar, an executive compensation consulting firm, says the highest-paid health insurance CEOs are:
Michael Neidorff, $25.26 million, for-profit Centene
Joseph Zubretsky, $19.74 million, for-profit Molina Healthcare
David Cordani, $17.55 million, for-profit Cigna
Bruce Broussard, $14.87 million, for-profit Humana

A for-profit Blues' plan, Anthem Inc., which operates in 14 states, paid former CEO Joseph Swedish $18.6 million in total compensation in 2017. He was replaced by Gail Boudreaux, whose base salary is about $1.4 million and whose total 2018 compensation hasn't been reported yet but is expected to be much less.
Interestingly, Loepp's 2017 and 2018 total compensation also exceeds two of the investor-owned hospital industry's highest paid executives in 2017. One of the CEOs is Ron Rittenmeyer, who heads up Dallas-based Tenet Healthcare Corp, which owns six-hospital Detroit Medical Center. Rittenmeyer earned $3.65 million in 2017. R. Milton Johnson, for-profit HCA Healthcare, earned $13.71 million, said Equilar.
"Mr. Loepp's bonus is completely at risk and 85 percent of total compensation was highly leveraged to performance," Hetzel said. "All Blues plans structure it differently and comparing total compensation to (another company) is not apples to apples."
Hetzel said Loepp earns high compensation because he is "running a great business, rates are moderating along small group and Medicare business lines and we are paying out $68 million in claims every day.
"We think he earns the money he makes," Hetzel said.

Blue Cross Michigan, which converted in 2014 from the state's designated "insurer of last resort" to a nonprofit mutual health insurance company, now pays state, city and local taxes. Since 1986, Blue Cross has been paying federal income taxes on all its operations, which amounted to $422 million in 2018.

[Monkey Uncle]

Nah, we're not being price-gouged to fund exorbitant executive compensation.  We have to pay them that much so we can have the best damn health care in the world!  Those people who think we can get better health care for half the cost are just being duped by an elaborate socialist conspiracy.

[DaMa]

At BCBS Michigan, it's not just Dan Loepp.  All the execs have had huge increases over the past 15 years.  Also, the size of the executive staff has grown ridiculously.  I don't remember the exact numbers, but it's something like 65 directors in 1995 to 400 today.    Same with VPs.  They went from 4 layers: manager, director, VP, CEO, to 8 layers.  manager, sr manager, director, sr director, vp, sr vp, exec vp, ceo.  At the same time, the total number of employees didn't change much. 

I also think the membership is actually lower than it was in the early 90s.  BCBSM used to have huge membership with the autos and other big unions.

[pecunia]

From what you guys are saying, it sounds like Blue Cross isn't regulated very well.  Some insurance companies are a pseudo monopoly.

https://splinternews.com/michigans-new-dem-governor-is-already-flooding-her-admi-1830414812

Article says this Dan Loepp guy noted two entries below was on the new Michigan governor's transition team.  She may already be a bought and paid for governor.

Maybe , Michigan will do well with a governor so tied in with the big insurance company.  Maybe, there won't be big water problems like their last governor.

Maybe, this just points at another reason to somewhat nationalize the system so that it can be fairly regulated.  Open finances regularly reviewed by the public could be a real asset.

Looks like Michigan has the foxes loose in the chicken coop as far as medicine.

[DavidAnnArbor]

If pharmaceuticals and hospitals and staff keep raising prices, then insurance premiums have to go up to cover this. But if the insurance company is allowed to always make a consistent 20% margin of profit over these payouts, then this becomes a bonanza of extra money to pay all these bloated salaries for useless executives.

[pecunia]

If pharmaceuticals and hospitals and staff keep raising prices, then insurance premiums have to go up to cover this. But if the insurance company is allowed to always make a consistent 20% margin of profit over these payouts, then this becomes a bonanza of extra money to pay all these bloated salaries for useless executives.

Is this all that unusual for American businesses?  For some time I've heard people complain about the high pay of Chief Executive Officers (CEOs) versus the average pay of a typical employee.  I've heard a figure something like 350 times the pay of the average worker for some of these people.

Sometimes, there's been explanations given as to why these people are paid so much.  One common thing that is said is you need to pay more to attract the proper talent.  It is said there is definitely added value to getting the right individual.  I remember when I was much younger Lee Iococca saved the Chrysler corporation.  He may have been such an individual. 

However, to a business such as Blue Cross, there is no real competition.  There is no shortage of people who need the product.  The supply of medical professionals will not be a big problem for them.  Essentially, they simply gather money and distribute it to those whom they deem worthy of help.  The more of that money they can keep, the more they make.  They can do this in several ways.  One is to simply deny claims.  Another is to delay payments.  Retaining the money for additional time will allow money to be made from interest.  I can't envision how a leader of such a company can be worth 19.2 million dollars.

Are there no forces to minimize this high executive pay?  Are these businesses really run by a bunch of thieving cronies?

Why should this bother me?  I have a policy with a Blue Cross company.  I tried calling them today to ask a non normal question.  I couldn't get beyond the robot answering machine.  Pay these guys less and pay to have a human answer the phone.

[sol]

Are these businesses really run by a bunch of thieving cronies?

All of capitalism is run by thieving cronies.  It's the defining feature of practical economics in capitalist markets.

The answer to your question about why the BCBS CEO is paid so much has nothing at all to do with how well he does his job, and everything to do with who he went to college with, or plays golf with, or what other CEO he can help make even richer in his official capacity.  At that level it's all "I'll scratch your back if you scratch mine" quid pro quo, a carefully orchestrated dance of influence and favors and managing perceptions.  He was selected for that position the same way King Henry's court assigned sinecures, as a reward for faithful service to protecting the interests of court.  It's the same way the world's most wealthy and powerful people have always selected their own membership rolls, since the time of the pyramids, and it has no more to do with talent or ability now than it did then.  Unless you count the talent and ability to socialize appropriately with self-important rich people.

[zolotiyeruki]

Are these businesses really run by a bunch of thieving cronies?

All of capitalism is run by thieving cronies.  It's the defining feature of practical economics in capitalist markets.

You're not wrong, but such words are more accurate when applied to literally every other economic system.  As they say, "Capitalism is the worst economic system, except for all the others."

[EnjoyIt]

Are these businesses really run by a bunch of thieving cronies?

All of capitalism is run by thieving cronies.  It's the defining feature of practical economics in capitalist markets.

The answer to your question about why the BCBS CEO is paid so much has nothing at all to do with how well he does his job, and everything to do with who he went to college with, or plays golf with, or what other CEO he can help make even richer in his official capacity.  At that level it's all "I'll scratch your back if you scratch mine" quid pro quo, a carefully orchestrated dance of influence and favors and managing perceptions.  He was selected for that position the same way King Henry's court assigned sinecures, as a reward for faithful service to protecting the interests of court.  It's the same way the world's most wealthy and powerful people have always selected their own membership rolls, since the time of the pyramids, and it has no more to do with talent or ability now than it did then.  Unless you count the talent and ability to socialize appropriately with self-important rich people.

The misinformation on corporate structure is astounding.  Sure as in all things, knowing someone helps get the foot in the door but skill and ability land one a job.  The reason why this CEO makes so much money is because he gets a percentage of the profit the company makes even if that percentage is not dictated specifically in the contract as a percent figure.  The more money the company makes the more will be given to the CEO.  Sometimes CEOs make money in a failing company because they are able to navigate a restructuring to improve the corporations viability.  Sometimes CEOs get paid a large chunk of cash because it was in the contract and the corporation is forced to pay the contracted rate even if that CEO fails and runs a company into the ground.  We have another thread on this forum talking about leadership jobs and how good leaders are not that common.  Look at all the fuck you money posts about horrible work experience.  It takes years of building one's skill and knowledge to gain the acumen required to lead a multibillion dollar company.

I agree that our insurance industry is failing the healthcare needs of the United States population and I would say it has gotten worse since the ACA passage which can be clearly seen by the significant increase in profits in the insurance industry since the law came into affect in conjunction with ever increasing financial burden to the middle class American.  This law has chosen the winners which are the poor, those with preexisting conditions, and more importantly, the insurance companies.

No matter what happens, we as a US population are paying for healthcare.  Those who pay something are paying for those who pay nothing. It makes no difference if it is private or public, we are all paying for healthcare. As the price of administering healthcare increases those who pay will be paying more. The laws today have allowed this crazy opaque system in which these business flourish and are able to skim money between every healthcare transaction which is inefficient and expensive.  You want to limit CEO pay, then we must removed this vail that all healthcare transaction must have an insurance middle man (private or government.)  We must lift the vail of secret convoluted pricing structures and allow even a small semblance of market forces to act.  With lower insurance profits, CEO profits will plummet as well and I guess some of you will be happier.

[pecunia]

- SNIP -



I agree that our insurance industry is failing the healthcare needs of the United States population and I would say it has gotten worse since the ACA passage which can be clearly seen by the significant increase in profits in the insurance industry since the law came into affect in conjunction with ever increasing financial burden to the middle class American.  This law has chosen the winners which are the poor, those with preexisting conditions, and more importantly, the insurance companies.

No matter what happens, we as a US population are paying for healthcare.  Those who pay something are paying for those who pay nothing. It makes no difference if it is private or public, we are all paying for healthcare. As the price of administering healthcare increases those who pay will be paying more. The laws today have allowed this crazy opaque system in which these business flourish and are able to skim money between every healthcare transaction which is inefficient and expensive.  You want to limit CEO pay, then we must removed this vail that all healthcare transaction must have an insurance middle man (private or government.)  We must lift the vail of secret convoluted pricing structures and allow even a small semblance of market forces to act.  With lower insurance profits, CEO profits will plummet as well and I guess some of you will be happier.

US population is paying too much for this product  It's a service like firemen, policemen or teachers.  It's time it ought to be treated that way.  Then an honest price will be paid for an honest service.  The great skill which the CEO has obtained over the years in stealing from the sick and potentially sick will not be needed.  His cronies can help him take these "leadership" skills elsewhere.

[EnjoyIt]

- SNIP -



I agree that our insurance industry is failing the healthcare needs of the United States population and I would say it has gotten worse since the ACA passage which can be clearly seen by the significant increase in profits in the insurance industry since the law came into affect in conjunction with ever increasing financial burden to the middle class American.  This law has chosen the winners which are the poor, those with preexisting conditions, and more importantly, the insurance companies.

No matter what happens, we as a US population are paying for healthcare.  Those who pay something are paying for those who pay nothing. It makes no difference if it is private or public, we are all paying for healthcare. As the price of administering healthcare increases those who pay will be paying more. The laws today have allowed this crazy opaque system in which these business flourish and are able to skim money between every healthcare transaction which is inefficient and expensive.  You want to limit CEO pay, then we must removed this vail that all healthcare transaction must have an insurance middle man (private or government.)  We must lift the vail of secret convoluted pricing structures and allow even a small semblance of market forces to act.  With lower insurance profits, CEO profits will plummet as well and I guess some of you will be happier.

US population is paying too much for this product  It's a service like firemen, policemen or teachers.  It's time it ought to be treated that way.  Then an honest price will be paid for an honest service.  The great skill which the CEO has obtained over the years in stealing from the sick and potentially sick will not be needed.  His cronies can help him take these "leadership" skills elsewhere.

Can't argue with you in essence.  We are paying too much for the delivery of healthcare.  The real question is, where is all that money going? 
A very large portion of every dollar spent covers administrative costs such as working through our convoluted billing structure which BTW is created by CMS.  There is also significant overhead for absurd compliance regulations that provide no patient value, but do provide lots of jobs for compliance officers and those involved in meeting compliance.  This overhead has forced many physicians out of private practice and into the corporate structure.  Then there is the insurance industry who wants their cut.  BTW, there are plenty of private insurance companies who manage medicare so even though people have government funded healthcare, the insurance company gets their 20%.  Then there are unscrupulous physicians who have figured out how to game the out of network billing structure and billing at overly inflated rates making the rest of us look bad. There is the pharm and tech industry that charges ridiculous prices for certain meds and treatments some of which is due to the overburdening FDA requirements.  We can't forget those families that just can let their loved one die and instead insist on torturing them with expensive testing and treatments despite being bed-ridden and eating through a tube in their stomach.

I know that you keep touting universal healthcare as a solution, and saying those words sure sound great, but it will not fix the problem.  It will initially help a little.  But we have a fundamental problem that needs to be fixed otherwise we will continue on our current path irrespective of how we pay the bills.

You also need to realize that if we went to universal healthcare in the US, the same insurance companies that you are trying to squeeze out will be managing  these new universal policies you so adamantly think will fix everything.

[sol]

I know that you keep touting universal healthcare as a solution, and saying those words sure sound great, but it will not fix the problem.

That totally depends how we go universal, doesn't it?

If Congress made a law that mandated everyone buy healthcare, you could theoretically call that "universal" because only criminals would be without it, but it wouldn't actually change anything about how care is provided or paid for.

But if we provided medicaid to everyone that would be an entirely different animal.  Millions of people working in the insurance industry would be put out of work, and there would be economic pain, but the cost to provide care would drop for the vast majority of patients.  Taxes would have to go up by almost as much as per-person spending on healthcare premiums would go down, but at least the taxes wouldn't be regressive the way health insurance premiums are.  We'd have "death panels" like the Candadians do!  Hooray!

[pecunia]

- SNIP -

If Congress made a law that mandated everyone buy healthcare, you could theoretically call that "universal" because only criminals would be without it, but it wouldn't actually change anything about how care is provided or paid for.

- SNIP -

Sol:  You are obviously an honest man.  Criminals will not be without it.  They are not without it now.  Federal prisoners get health care.  It may not always be best health care, but I am quite sure it is better than the "no" health care that many honest hard working Americans get by our current system.

The more Enjoy It gives reasons and rationales for why we can't change the current system radically, the more I am convinced that we not only ought to but we've got to.

[EnjoyIt]

@sol, Today we have private insurance managing Medicare for the government. You think that will change?

@pecunia, I agree, we need to fix this problem that affects every American. To me, healthcare is the number 1 issue. I believe a solid public option is a good idea, but as it stands the cost of delivering healthcare is too expensive and we can’t just turn a switch and think all will be perfect. I suggest a more realistic multi-prong approach which starts with full transparency of cost where the price is the same regardless of which insurance you have. Price should be cheaper if paid outside of insurance since that option cuts overhead costs. Insurance companies also need to clearly show how much they pay for services so that everyone knows before hand what they will be on the hook for.  This needs to be coupled with removing much of the regulatory burdens imposed in those delivering healthcare services.

Next provide a public option where people get inexpensive barebones healthcare that is rationed as in other countries. The services are paid for by taxes and free to the users. These services provide evidence based medicine with minimal testing and minimal procedures. Only what evidence has proven to be affective at a reasonable cost. No lawsuits are allowed, minimal documentary overhead and the providers are paid via salary as opposed to fee for service.

Those who are uninsured get redirected to the above facilities. True medical emergencies are stabilized and transferred out.

This who have the desire to pay more for their healthcare can do so, and the providers of this out of pocket will be forced to provide a good product at a low cost to entice customers.

Lastly, physicians need to be able to tell a family that they will no longer provide treatment for their bed ridden brain dead loved one. No more chemo, no surgeries, no feeding tubes. Doctors need to stop allowing the torture of these patients.
A
Government funded insurance is not the solution as nothing will really change. We need to to fix the root of the problem in a multi-pronged approach that cuts the cost of dickering healthcare.

[sol]

Government funded insurance is not the solution as nothing will really change.

Again, that totally depends on how the government funds it.

If the governments just pays private for-profit corporations to insure people, bill people, and provide the care, then yes of course that doesn't change anything.  But there are lots of countries where the goverment "funds" insurance by doing none of those things, and instead supports a federal single-payer option that implements many of the changes you want to see under an umbrella with minimum overhead costs.  That would absolutely change things.

@sol, Today we have private insurance managing Medicare for the government. You think that will change?

Is there some reason why it can't?  We let private insurers get their hooks into medicare as a profit-seeking venture because some republican politicians were bought by the insurance industry to promote what they called this "free-market approach" to public health care.  I think public health care, like public education and public policing, is one of those fields where the free market approach is the worst of all possible solutions.

And besides, I didn't suggest we expand medicare to everyone.  I suggested we expand medicaid to everyone. 

[EnjoyIt]

Government funded insurance is not the solution as nothing will really change.

Again, that totally depends on how the government funds it.

If the governments just pays private for-profit corporations to insure people, bill people, and provide the care, then yes of course that doesn't change anything.  But there are lots of countries where the goverment "funds" insurance by doing none of those things, and instead supports a federal single-payer option that implements many of the changes you want to see under an umbrella with minimum overhead costs.  That would absolutely change things.

And there are plenty f countries that outsource to private industry.  Since this country already outsources to private industry, what do you think will happen here?  It would be pretty naive to think otherwise.

@sol, Today we have private insurance managing Medicare for the government. You think that will change?

Is there some reason why it can't?  We let private insurers get their hooks into medicare as a profit-seeking venture because some republican politicians were bought by the insurance industry to promote what they called this "free-market approach" to public health care.  I think public health care, like public education and public policing, is one of those fields where the free market approach is the worst of all possible solutions.

And besides, I didn't suggest we expand medicare to everyone.  I suggested we expand medicaid to everyone.

[/quote]

We can't expand Medicaid to everyone as it currently stands.  Medicaid does not pay enough to even cover overhead.  Providers take on Medicaid because they also want Medicare which is a decent payer. You can't have one without the other.  If we want to expand Medicaid to all then we need to lower the administrative burden to providers and increase reimbursement otherwise we will find even more providers that leave CMS behind and go fee for service only.

I'm all for a public option for everyone, but it can't be done in a vacuum as you describe.  It is really simple.  We all pay for healthcare one way or another.  We either pay via higher insurance prices or we pay via increased taxes.  If do very little to nothing with regards to cutting cost then we are simply shifting how it is getting paid without changing anything.  Once again the middle class gets screwed over which should not be the goal here. 

I just don't understand why I can't get through to you that simply going government funded healthcare is not the solution on its own.  It needs to be a multi-prong approach.  In addition the US population wants to be able to pay extra for better amenities and faster service and there is no reason why we can't offer them that option for an out of pocket price.  It is just good business that will help make the model work just as it does in other countries.

For example the government option will cover Penicillin VK which needs to be taken 4 times a day while those who pay out of pocket can get Cefdnir twice a day.  Government option will cover Acyclovir that is taken 5 times a day, Private pay can get Valcyclovir which needs to be taken only twice a day.  Government option will fund hospital stays where you share a room with 2-4 other people.  Additional out of pocket cash will get you a private room with a better meal. Government option will fund your gall bladder surgery once a spot is available.  One can pay extra to schedule surgery next Monday.  Government option will not do chemo on a patient with little to no mental activity though a family can pay tens to hundreds of thousands if they choose to.  Government option has clinics that you can see a primary care physician but you will need to wait several hours to be seen.  You can pay extra cash to make an appointment and be seen within 20 minutes. I can go on and on.

[pecunia]

" Government option has clinics that you can see a primary care physician but you will need to wait several hours to be seen.  You can pay extra cash to make an appointment and be seen within 20 minutes. I can go on and on."

I like that.  I've waited several hours on numerous occasions in the past and have had to pay a princely sum for the privilege.  I'd rather pay it via some sort of payroll tax and eliminate insurance.

[EnjoyIt]

" Government option has clinics that you can see a primary care physician but you will need to wait several hours to be seen.  You can pay extra cash to make an appointment and be seen within 20 minutes. I can go on and on."

I like that.  I've waited several hours on numerous occasions in the past and have had to pay a princely sum for the privilege.  I'd rather pay it via some sort of payroll tax and eliminate insurance.

Exactly, once real market forces set in, doctors that don't see their patients timely will lose patients. If they want to keep those that are paying out of pocket they will need to provide a better product.  The only ones who will be able to get away with long waits are the best of the best specialists that customers are willing to wait for them.

[pecunia]

You misunderstood.  I have been waiting anyway.  I'll take the government paid for service rather than the elite service.  I generally don't select boutique anything.

[EnjoyIt]

You misunderstood.  I have been waiting anyway.  I'll take the government paid for service rather than the elite service.  I generally don't select boutique anything.

As many people will. Others will find value in a more concierge care environment. The US is full of consumerists willing to pay extra.

[stoaX]

Government funded insurance is not the solution as nothing will really change.

Again, that totally depends on how the government funds it.

If the governments just pays private for-profit corporations to insure people, bill people, and provide the care, then yes of course that doesn't change anything.  But there are lots of countries where the goverment "funds" insurance by doing none of those things, and instead supports a federal single-payer option that implements many of the changes you want to see under an umbrella with minimum overhead costs.  That would absolutely change things.

@sol, Today we have private insurance managing Medicare for the government. You think that will change?

Is there some reason why it can't?  We let private insurers get their hooks into medicare as a profit-seeking venture because some republican politicians were bought by the insurance industry to promote what they called this "free-market approach" to public health care.  I think public health care, like public education and public policing, is one of those fields where the free market approach is the worst of all possible solutions.

And besides, I didn't suggest we expand medicare to everyone.  I suggested we expand medicaid to everyone.

To be fair to EnjoyIt, insurance companies like Kaiser and the various Blue Cross and Blue Shield organizations administer Medicaid for the government like they administer Medicare.  But you're right it is conceivable that the government could create the administrative apparatus to run these programs without insurance industry help.

[pecunia]

- SNIP -


To be fair to EnjoyIt, insurance companies like Kaiser and the various Blue Cross and Blue Shield organizations administer Medicaid for the government like they administer Medicare.  But you're right it is conceivable that the government could create the administrative apparatus to run these programs without insurance industry help.

Who would do a better job?  Some semi radical thinking has been introduced to me lately.  We have these big financial companies.  One of which is Vanguard.  Vanguard has their system setup where they are somehow owned by the people who invest in them.  They have known fees that are known to be lower.  They serve the customer who is also the owner.  Their fees are often less.  Many people on this site have pointed to Vanguard as their investment vehicle of choice.  The Vanguard people serve one master who is both the customer and the owner which seems to work out well and creates a company with greater efficiencies.

Recently, some financial companies have released products with fees lower than Vanguard.  I believe those are loss leaders.  They are products to bring in new customers and retain customers.  They are only a product for marketing.  It is not the "normal" ways these companies do business.  Their employees serve two masters, the owner and the customer.  The owner wants the biggest cut they can get.  This leads to these companies generally charging higher fees.  This can be looked at as a less efficient way of doing business.

Would it be different in health care?

Is it better for health care administrators to serve two masters, those who wish to profit and those who are the customer?  Is it better to simply serve one customer?  The government is supposed to represent the people's interests.  I believe a public health entity would do just that.  The public health entity would represent the people and not other interests whose main interest is maximizing profit.  There are a lot of good people out there who should and would consider it an honor to serve public health.  Some say to serve your fellow man is the highest calling.

I think a public health service would do a better job to serve the public overall.  It would be more efficient.  The evidence shows this.  It would serve the basic health needs which are not being met now.

[sol]

Since @EnjoyIt so enjoys arguing about healthcare, I came back around to this thread.

I just don't understand why I can't get through to you that simply going government funded healthcare is not the solution on its own...

For example the government option will cover Penicillin VK which needs to be taken 4 times a day while those who pay out of pocket can get Cefdnir twice a day.  Government option will cover Acyclovir that is taken 5 times a day, Private pay can get Valcyclovir which needs to be taken only twice a day.  Government option will fund hospital stays where you share a room with 2-4 other people.  Additional out of pocket cash will get you a private room with a better meal. Government option will fund your gall bladder surgery once a spot is available.  One can pay extra to schedule surgery next Monday.  Government option will not do chemo on a patient with little to no mental activity though a family can pay tens to hundreds of thousands if they choose to.  Government option has clinics that you can see a primary care physician but you will need to wait several hours to be seen.  You can pay extra cash to make an appointment and be seen within 20 minutes. I can go on and on.

Every single one of your examples is a current private insurance system that would be improved by offering a government backed healthcare option.  Every one.  I don't see how you could look at that paragraph you wrote and possibly conclude that we don't need a government option.  We already have the private sector side, and no one is advocating for outlawing that.  But things would be better in every case you cited if there was ANOTHER option available, funded by taxes and universally available. 

I know you think that Medicaid "doesn't pay enough" to cover costs but I would counter that our costs are too high, because other countries do provide the same or better medical outcomes at those lower costs.  It's hard, when it's your own industry on the chopping block, to say "people in my professions should get paid less" but that's honestly where I think we're at with medical care in America.  Our costs are too high, including overhead and insurance and yes even the salaries.  They all need to come down to be competitive with the rest of the industrialized world.

It's unpopular to say, but I don't think doctors are special.  They are not smarter or more godly than other professionals.  As a group, they do not have more education or more responsibility or work worse hours than other similar professions that make less money.  They are just overpaid, for cultural and historical reasons supported by the AMA limiting the supply of available workers relative to the number of jobs available.  It's one of those grossly distorted markets that would provide better service at lower cost if it were less heavily regulated.

I don't think the ACA is going away anytime soon, in part because the AMA and the insurance industry like it.  There are currently record profits being generated in the healthcare sector as a direct result of the ACA.  Costs are still going up, of course, but in theory costs could come down significantly and those businesses would still be profitable.  Capitalism doesn't really care about that, though.  If you have crazy high profit margins, that just means you have a successful business.

Who would do a better job?  Some semi radical thinking has been introduced to me lately.  We have these big financial companies.  One of which is Vanguard.  Vanguard has their system setup where they are somehow owned by the people who invest in them.  They have known fees that are known to be lower.  They serve the customer who is also the owner.  Their fees are often less.  Many people on this site have pointed to Vanguard as their investment vehicle of choice.  The Vanguard people serve one master who is both the customer and the owner which seems to work out well and creates a company with greater efficiencies.

Vanguard is a socialist corporation.  Yes it provides a superior product at a lower cost than its privately owned competitors, but it does so because it does not have to pay profits to shareholders.  When it has extra profits, it just reduces costs to its customers, who ARE the shareholders.  That's like the definition of socialism, and it's kind of shocking that certain political parties don't just RAIL against vanguard as a threat to our capitalist utopia the same way they rail against socialist healthcare solutions.  Which, I agree, could also provide superior service at lower cost if they didn't have to pay profit margins to shareholders.  Just like Medicaid doesn't.

Is it better for health care administrators to serve two masters, those who wish to profit and those who are the customer?  Is it better to simply serve one customer?  The government is supposed to represent the people's interests.  I believe a public health entity would do just that. 

Wait, are you Bernie Sanders in disguise?  Don't astroturf us, Bernie.  Only a radical like you would suggest that Americans deserve a better deal than they currently get by being ripped off by private healthcare companies, when there's a proven alternative sitting right in front of us. 

Suggesting that Americans adopt socialized healthcare the same way that every other industrialized western nation has is akin to suggesting that we adopt the metric system.  It's blasphemy!  We like our stupid American system and you can pry it from our cold dead hands!

[former player]

Lastly, physicians need to be able to tell a family that they will no longer provide treatment for their bed ridden brain dead loved one. No more chemo, no surgeries, no feeding tubes. Doctors need to stop allowing the torture of these patients.

There's an answer to this.  Actually there are several answers to this.  Strengthened medical ethics is one.  Tighter cost control by the payers (insurance companies or medicare?) is another.  Control of perverse financial and other incentives on hospital management is another.  A doctor who cared about these things is probably in a good position to start agitating for change with the people and organisations who control these issues.

[ysette9]

In some ways Kaiser is like Vanguard already in the sense that it is not-for-profit and focuses on overall well being rather than a fee-for-service model.

From wiki:

“KP's quality of care has been highly rated and attributed to a strong emphasis on preventive care, its doctors being salaried rather than paid on a fee-for-service basis, and an attempt to minimize the time patients spend in high-cost hospitals by carefully planning their stay.”

I’ll admit to being biased as I have been a happy Kaiser member for most of my life. My two babies are alive today due to Kaiser specialists and NICU doctors and nurses. I’ve has two doctors independently and completely unprompted say in my presence how glad they are to be salaried, and to not feel any pressure to make medical decisions based on cost or revenue it would bring to the HMO. I know that “Medicare for all” is a nice slogan, but honestly I’d get more excited by “Kaiser for all”.

[pecunia]

In some ways Kaiser is like Vanguard already in the sense that it is not-for-profit and focuses on overall well being rather than a fee-for-service model.

From wiki:

“KP's quality of care has been highly rated and attributed to a strong emphasis on preventive care, its doctors being salaried rather than paid on a fee-for-service basis, and an attempt to minimize the time patients spend in high-cost hospitals by carefully planning their stay.”

I’ll admit to being biased as I have been a happy Kaiser member for most of my life. My two babies are alive today due to Kaiser specialists and NICU doctors and nurses. I’ve has two doctors independently and completely unprompted say in my presence how glad they are to be salaried, and to not feel any pressure to make medical decisions based on cost or revenue it would bring to the HMO. I know that “Medicare for all” is a nice slogan, but honestly I’d get more excited by “Kaiser for all”.

You know how Kaiser got started?  It was a way to provide health care to the six companies building the Hoover Dam for Uncle Sam.  It got started as a government program kind of - Sort of.  Ole Henry J Kaiser made a lot of money from the government.  He even got them to pay for boats made of concrete.  I guess the health care thing is another example.  See link.  (Nothing about the Liberty Ships)

https://share.kaiserpermanente.org/about-us/history/

Maybe, they were half way there back then.

[exige]

I have worked for Kaiser for the last 2 years and actually completely agree on what was said above. They are great and truly do want to take care of people and make it better. However, they seem to have a very uphill battle.... Since having their benefits as an employee they have found / resolved a LOT of health issues my wife has had for years that were simply overlooked or brushed off. We have been very very happy.

**Sadly I took a new Job with a 40% raise so we will be back to the normy insurance :( **

[Paul der Krake]

Serious question for you Kaiser experts: how do you see a list of physical therapists?

For example, I can find MDs and DOs for San Diego:
https://healthy.kaiserpermanente.org/southern-california/doctors-locations#/search-result?region=SCA&searchType=doctors&city_label=San%20Diego&medical_specialty_label=Physical%20Med/Rehabilitation

But where are the clinics with a bunch of physical therapists? Is there a better search tool once you are a member?

[ysette9]

Serious question for you Kaiser experts: how do you see a list of physical therapists?

For example, I can find MDs and DOs for San Diego:
https://healthy.kaiserpermanente.org/southern-california/doctors-locations#/search-result?region=SCA&searchType=doctors&city_label=San%20Diego&medical_specialty_label=Physical%20Med/Rehabilitation

But where are the clinics with a bunch of physical therapists? Is there a better search tool once you are a member?

I got a referral to physical therapy from my primary care doctor and she made a recommendation for a specific person she thought was good. I see for my nearest facility there is a department page for their providers. https://thrive.kaiserpermanente.org/care-near-you/northern-california/redwoodcity/departments/physical-occupational-therapy/ maybe you need to ask your doctor first?

**
We have friends who bought their own Kaiser insurance on the open market rather than use a regular insurance system when she took a job that didn’t offer Kaiser. Thankfully that only lasted a year for them until one half of the couple got a new job that did offer that benefit. I hear horror stories from my friends of getting random bills in the mail up to a year after giving birth for random out of network anesthesiology fees or whatnot, and I can understand why my friends made the decision to buy their own coverage.

[Paul der Krake]

Serious question for you Kaiser experts: how do you see a list of physical therapists?

For example, I can find MDs and DOs for San Diego:
https://healthy.kaiserpermanente.org/southern-california/doctors-locations#/search-result?region=SCA&searchType=doctors&city_label=San%20Diego&medical_specialty_label=Physical%20Med/Rehabilitation

But where are the clinics with a bunch of physical therapists? Is there a better search tool once you are a member?

I got a referral to physical therapy from my primary care doctor and she made a recommendation for a specific person she thought was good. I see for my nearest facility there is a department page for their providers. https://thrive.kaiserpermanente.org/care-near-you/northern-california/redwoodcity/departments/physical-occupational-therapy/ maybe you need to ask your doctor first?

I should have been more clear: I'm not a Kaiser member, just trying to evaluate how far I would need to go to see a therapist should I decide to become one.

[ysette9]

I had an appointment with my primary care doctor for an annual physical. I mentioned an ongoing issue and asked to be referred to a physical therapist. I was. My experience was pretty straight forward.

[EnjoyIt]

Since @EnjoyIt so enjoys arguing about healthcare, I came back around to this thread.

I just don't understand why I can't get through to you that simply going government funded healthcare is not the solution on its own...

For example the government option will cover Penicillin VK which needs to be taken 4 times a day while those who pay out of pocket can get Cefdnir twice a day.  Government option will cover Acyclovir that is taken 5 times a day, Private pay can get Valcyclovir which needs to be taken only twice a day.  Government option will fund hospital stays where you share a room with 2-4 other people.  Additional out of pocket cash will get you a private room with a better meal. Government option will fund your gall bladder surgery once a spot is available.  One can pay extra to schedule surgery next Monday.  Government option will not do chemo on a patient with little to no mental activity though a family can pay tens to hundreds of thousands if they choose to.  Government option has clinics that you can see a primary care physician but you will need to wait several hours to be seen.  You can pay extra cash to make an appointment and be seen within 20 minutes. I can go on and on.

Every single one of your examples is a current private insurance system that would be improved by offering a government backed healthcare option.  Every one.  I don't see how you could look at that paragraph you wrote and possibly conclude that we don't need a government option.  We already have the private sector side, and no one is advocating for outlawing that.  But things would be better in every case you cited if there was ANOTHER option available, funded by taxes and universally available. 

@sol, I don't think you read anything I had to say.  I am all for a public option.  We have one already called Medicare/Medicaid and we need to improve on it to be able to make it available for every American citizen and those in the US legally.  I think we need a low cost public option that is sustainable.  Current practices are unsustainable because of the massive overhead.  Public option would be free but it would include long waits, low cost generic medications, shared rooms in hospitals, low cost procedures vs cutting edge expensive ones that show little to no additional benefit, loss off ability to sue outside of malicious injury such as a surgeon carving their initials into a patient, eliminate the ridiculous complexity in documentation, billing, and compliance overhead, pay providers of healthcare a flat salary that is reasonable for the work they do (will discuss further below.) instead of a fee for service model which incentivizes waste, and I'm sure there are more cost cutting endeavors that needs to happen. 

I know you think that Medicaid "doesn't pay enough" to cover costs but I would counter that our costs are too high, because other countries do provide the same or better medical outcomes at those lower costs.  It's hard, when it's your own industry on the chopping block, to say "people in my professions should get paid less" but that's honestly where I think we're at with medical care in America.  Our costs are too high, including overhead and insurance and yes even the salaries.  They all need to come down to be competitive with the rest of the industrialized world.

A few things we must understand about physician wages in the US compared to other more socialized models in the rest of the world.  Doctors don't pay for their training while in the US it is not uncommon to be $300k-$400 in debt once out of residence.  I personally owed a little under $350k.  So yeah, pay me back my money and pay me less for my work.  I'm OK with that.  Next, physicians in the US work way more than 40 hours a week.  It is not uncommon for some to work 60+ hours and it should make sense that those doctors make more per year as opposed to physicians working 40 hours a week.  Lastly, eliminate all the regulatory overhead that costs physicians money and remove that overhead from our wages.  I do not think anyone will complain.  Just this year alone I will be paying over $5k for certification and licensing.  Recent legislation that created a new building structure called MACRA has cost physicians 10s of thousands of dollars in compliance costs. Make it easier and less costly for us to practice medicine and we would gladly cut our wages.  Also, we need to eliminate this out of network billing where providers overcharge the insurance companies and patients. 

It's unpopular to say, but I don't think doctors are special.  They are not smarter or more godly than other professionals.  As a group, they do not have more education or more responsibility or work worse hours than other similar professions that make less money.  They are just overpaid, for cultural and historical reasons supported by the AMA limiting the supply of available workers relative to the number of jobs available.  It's one of those grossly distorted markets that would provide better service at lower cost if it were less heavily regulated.

Doctors are not special they are humans like the rest of us.  They are smarter than average because the system titrates out those less capable. I discussed their wages above.  In my undergrad it seams like almost half the school said they were pre-med, but only a handful of us went to med school.  Maybe doctors have something that most of the population doesn't have.  It still doesn't make them special or godly but they are above average because they have to be.

BTW, there will always be professions that get payed better than others. Should we curtail the reimbursement to west cost engineers and programers as well?  Why should they get paid more?  What about actors and professional athletes? What about waiters in high end restaurants vs waiters in denny's  Maybe we should equalize their wages as well.  What do you think?  I am not saying doctors wages can't be cut.  They could be, but do so in a reasonable way as described above.

I don't think the ACA is going away anytime soon, in part because the AMA and the insurance industry like it.  There are currently record profits being generated in the healthcare sector as a direct result of the ACA.  Costs are still going up, of course, but in theory costs could come down significantly and those businesses would still be profitable.  Capitalism doesn't really care about that, though.  If you have crazy high profit margins, that just means you have a successful business.

The ACA is designed to help the insurance companies.  The AMA is in bed with the insurance and pharma industry and not the physicians.  As you have requested physician pay has decreased thanks to the ACA, a little because of decreased reimbursement but cut significantly due to increased overhead and idiotic regulations that provide no benefit to the patient.  In addition current reimbursement regulations are cutting physician wages every year.

Who would do a better job?  Some semi radical thinking has been introduced to me lately.  We have these big financial companies.  One of which is Vanguard.  Vanguard has their system setup where they are somehow owned by the people who invest in them.  They have known fees that are known to be lower.  They serve the customer who is also the owner.  Their fees are often less.  Many people on this site have pointed to Vanguard as their investment vehicle of choice.  The Vanguard people serve one master who is both the customer and the owner which seems to work out well and creates a company with greater efficiencies.

Vanguard is a socialist corporation.  Yes it provides a superior product at a lower cost than its privately owned competitors, but it does so because it does not have to pay profits to shareholders.  When it has extra profits, it just reduces costs to its customers, who ARE the shareholders.  That's like the definition of socialism, and it's kind of shocking that certain political parties don't just RAIL against vanguard as a threat to our capitalist utopia the same way they rail against socialist healthcare solutions.  Which, I agree, could also provide superior service at lower cost if they didn't have to pay profit margins to shareholders.  Just like Medicaid doesn't.

Vanguard is a public company.  It is not a socialist company.  Very different.  It does not benefit everyone, it benefits those who own a piece of Vanguard which are the people that have Vanguard funds.

Is it better for health care administrators to serve two masters, those who wish to profit and those who are the customer?  Is it better to simply serve one customer?  The government is supposed to represent the people's interests.  I believe a public health entity would do just that. 

Wait, are you Bernie Sanders in disguise?  Don't astroturf us, Bernie.  Only a radical like you would suggest that Americans deserve a better deal than they currently get by being ripped off by private healthcare companies, when there's a proven alternative sitting right in front of us. 

Suggesting that Americans adopt socialized healthcare the same way that every other industrialized western nation has is akin to suggesting that we adopt the metric system.  It's blasphemy!  We like our stupid American system and you can pry it from our cold dead hands!

Sol,
You are a bright guy full of idealism but not looking at the whole picture.  Yelling socialized healthcare in a vacuum, yelling cut doctors wages in a vacuum, and just throwing out comments that only pander to the left accomplish nothing except maybe make you feel good about all that yelling.  We have a real problem in the US and we need the far left and the far right to come together and make progress as opposed to simple pandering.  The fact that you thought I am against a public option which I several times in this thread fully endorse just goes to show how blinded you are to those who even slightly disagree with you.