Many surprise medical bills are now illegal(axios.com)
axios.com
Many surprise medical bills are now illegal
https://www.axios.com/surprise-medical-bills-illegal-doctors-insurers-faac35a7-a2db-4555-a172-7de5f4c3cc54.html
164 comments
I've got a story that might explain what happened. So when my kid was born in 2011, at Morristown Hospital in New Jersey, he was several weeks premature and spent 18 days in the NICU. At some point during his time there, they came to us and told that they did not participate in any insurance network; they would still bill our insurance but the full amount would have to be paid, either by us or the insurance, since they were not subject to a negotiated rate. I was confused, why would this be the case since the hospital was in-network? It turns out the entire NICU department - inside the hospital - was run by a separate, independent physician group with its own billing department and its own (non-existent) insurance relationships. Of course nobody mentioned this during the hospital tour. I mean why would the NICU docs give up their revenue by signing up for insurance rates when the families using their services have zero choice about where to go? I've heard anesthesiologists in the labor and delivery department are like this too. Your wife's screaming in pain during labor, are you really going to jump on your phone and check to see if the anesthesiologist in front of you is in-network? And what do you do if s/he's not?
So that's one reason why you might get a bunch of different bills from a bunch of different entities when you go to the hospital: all the doctors there may have the same hospital logo on their badges but some may be independent contractors.
Edit: for the curious, the final bill for 18 days in the NICU was ~$94,000. The insurance paid all but ~$10,000. We spent several months appealing that, arguing that "we had no choice", and they kept denying the appeals. Finally we gave up and called the rogue physician's group to arrange for a payment plan... and they told us the insurance had paid the balance.
So that's one reason why you might get a bunch of different bills from a bunch of different entities when you go to the hospital: all the doctors there may have the same hospital logo on their badges but some may be independent contractors.
Edit: for the curious, the final bill for 18 days in the NICU was ~$94,000. The insurance paid all but ~$10,000. We spent several months appealing that, arguing that "we had no choice", and they kept denying the appeals. Finally we gave up and called the rogue physician's group to arrange for a payment plan... and they told us the insurance had paid the balance.
I am sad to say this, but the insurance probably did not pay for the last $10K, that probably magically disappeared after the insurance paid for what they paid for. Again the explanation in the form of an example:
My wife's dentist always puts in big bills to our insurance company. We then get a check in the mail along with records detailing how much the dentist billed, and then how much they are paying (though us). We then send the check along, and every time that we have then talked to them they say that we don't have to pay the remainder.
This is just a negotiation tactic between our dentist and the insurance company. They are just trying to make sure that they capture every dollar that the insurance company will possibly pay. They never expected to get everything that they billed, that was more like an opening position in bargaining.
My wife's dentist always puts in big bills to our insurance company. We then get a check in the mail along with records detailing how much the dentist billed, and then how much they are paying (though us). We then send the check along, and every time that we have then talked to them they say that we don't have to pay the remainder.
This is just a negotiation tactic between our dentist and the insurance company. They are just trying to make sure that they capture every dollar that the insurance company will possibly pay. They never expected to get everything that they billed, that was more like an opening position in bargaining.
That confirms my suspicion that the business of present-day medicine is milking insurance companies and patients for every dollar that can be billed. The incentive is to keep patients sick, but alive, for as long as possible, hopefully managing to time the patient's death with the exhaustion of benefits/assets.
I'm not saying that doctors have this goal. I am saying that this is what the system incentives are, and we all know how systems respond to incentives.
I'm not saying that doctors have this goal. I am saying that this is what the system incentives are, and we all know how systems respond to incentives.
> The incentive is to keep patients sick, but alive, for as long as possible, hopefully managing to time the patient's death with the exhaustion of benefits/assets.
Hardly anybody is going to actually try to keep a patient sick, but there are many other ways to get the same result.
Does this patient have good insurance? Run lots of tests. All the tests. Do expensive procedures that might help regardless of their cost benefit ratio. Spending a quarter of a million dollars for something that has a 2% better result than an alternative that costs $20 is perfect, because the incremental improvement is real. It's just not worth a quarter of a million bucks. But the patient doesn't care about that when it's the insurance paying.
Hardly anybody is going to actually try to keep a patient sick, but there are many other ways to get the same result.
Does this patient have good insurance? Run lots of tests. All the tests. Do expensive procedures that might help regardless of their cost benefit ratio. Spending a quarter of a million dollars for something that has a 2% better result than an alternative that costs $20 is perfect, because the incremental improvement is real. It's just not worth a quarter of a million bucks. But the patient doesn't care about that when it's the insurance paying.
Health insurers do not approve/deny claims based on what level (platinum/gold/silver/bronze) insurance you have.
What might happen is a generous employer funded or government funded (such as Tricare) plan might offer more coverage for brand name drugs, or less requirements for pre authorizations. And a less generous plan such as Medicaid (state government) will try to minimize costs by only covering generics or requiring more pre authorizations.
But the people reviewing the claims at the managed care organizations are not looking at what kind of coverage a patient has to decide if they do or do not need a medical procedure or a lab.
What might happen is a generous employer funded or government funded (such as Tricare) plan might offer more coverage for brand name drugs, or less requirements for pre authorizations. And a less generous plan such as Medicaid (state government) will try to minimize costs by only covering generics or requiring more pre authorizations.
But the people reviewing the claims at the managed care organizations are not looking at what kind of coverage a patient has to decide if they do or do not need a medical procedure or a lab.
Try booking a doctor's appointment in the US on a Medicare plan vs. under private insurance. You'll find that the former gets pushed out weeks and months, whilst the latter finds availability within days.
If think you’re mixing up Medicare (old people) and Medicaid (poor people).
Doctors love Medicare. It pays them nearly instantly, steady stream of clients, and known fixed rates commensurate with most private negotiated rates.
Medicaid is the one that has much stricter benefit rules and tighter price guidelines.
Doctors love Medicare. It pays them nearly instantly, steady stream of clients, and known fixed rates commensurate with most private negotiated rates.
Medicaid is the one that has much stricter benefit rules and tighter price guidelines.
Steady stream of clients, but it doesn't pay much. Many docs limit the number of medicare patients they'll take because of this.
Quite possibly. Thanks.
The claim I was responding to was that a healthcare provider would pursue expensive procedures (presumably not medically necessary) based on what kind of insurance a person has.
To which I would say that is wrong because the person working at the MCO reviewing the claim would not be evaluating the expensive procedure based on if the insured has Medicare or Medicaid, they will approve or deny it the same if they deem it medically unnecessary.
I agree that healthcare providers get paid differently based on the patient’s coverage, and that would influence the priority they give the patient. In fact, I would say the whole point of the convoluted MCO system (versus a simple taxpayer funded system like UK) is to give the government plausible deniability for segmenting the population into various groups of people getting different quality levels of healthcare.
To which I would say that is wrong because the person working at the MCO reviewing the claim would not be evaluating the expensive procedure based on if the insured has Medicare or Medicaid, they will approve or deny it the same if they deem it medically unnecessary.
I agree that healthcare providers get paid differently based on the patient’s coverage, and that would influence the priority they give the patient. In fact, I would say the whole point of the convoluted MCO system (versus a simple taxpayer funded system like UK) is to give the government plausible deniability for segmenting the population into various groups of people getting different quality levels of healthcare.
I answered that indirectly. The point is that yes, services offered, both in time and manner, will vary by an individual's insurance status, coverage, and provider.
As someone with high end insurance then to Medicaid not in my experience. It's how the request or referral is worked. You get something for a right heart Cath it's months. If it's a right heart Cath for XYZ a lot reserved slots open up but even then there is no guarantee
> Health insurers do not approve/deny claims based on what level (platinum/gold/silver/bronze) insurance you have.
If the patient has good insurance, they don't really care about providers doing a lot of expensive unnecessary things, because they're not paying.
If they have less good insurance, either the patient is paying more to you out of pocket and is more likely to balk, or you're waiving the patient's portion of the cost and you don't want to be doing unprofitable unnecessary procedures for them.
So the incentive is for providers to do lots of expensive unnecessary things on the patients with better insurance.
If the patient has good insurance, they don't really care about providers doing a lot of expensive unnecessary things, because they're not paying.
If they have less good insurance, either the patient is paying more to you out of pocket and is more likely to balk, or you're waiving the patient's portion of the cost and you don't want to be doing unprofitable unnecessary procedures for them.
So the incentive is for providers to do lots of expensive unnecessary things on the patients with better insurance.
I will agree that a patient with a higher deductible and higher out of pocket maximum may be subject to less unnecessary things. And that is why I think high deductible health plans are the way to go.
I guess doctors could be basing their diagnoses and recommendations on the out of pocket costs for the patient, but I like to think that is not the case, by and large.
I guess doctors could be basing their diagnoses and recommendations on the out of pocket costs for the patient, but I like to think that is not the case, by and large.
High deductible health plans might as well not exist a lot of the time because people don't use them and don't get preventative care in order to save money short term. Health care is a racket and a joke in the US.
Anyone getting rich in the insurance business or hospital administration, writing overpriced administrative tools or telehealth software, selling overpriced medical equipment, etc. is profiting from death and suffering, and should feel terrible for it every time they cash a check, but the thing is, they don't. There are too many exploiters milking health care due to inelastic demand and the extreme depravity of people eager for money that passes for virtue among the depraved.
Anyone getting rich in the insurance business or hospital administration, writing overpriced administrative tools or telehealth software, selling overpriced medical equipment, etc. is profiting from death and suffering, and should feel terrible for it every time they cash a check, but the thing is, they don't. There are too many exploiters milking health care due to inelastic demand and the extreme depravity of people eager for money that passes for virtue among the depraved.
> But the people reviewing the claims at the managed care organizations are not looking at what kind of coverage a patient has to decide if they do or do not need a medical procedure or a lab.
Unless it either meets preselected criteria (or gets lucky with the RNG for orgs doing random spot review) for manual review, or is an appeal, the “people reviewing the claim” aren’t actually people in many cases.
But, people or not, they don’t care if the patient needs it (well, they do as one factor, but its not the ultimate question), they care whether it meets the plan’s coverage criteria. Outside of what is minimally mandatory under health insurance laws and regulations, the coverage conditions for certain treatments (and even certain tests) are often more restrictive in “less good” plans.
So, yes, the systems and people reviewing claims do look at what kind of coverage you have when deciding whether or not a medical procedure or test is covered (and to what extent it is covered) by your insurance.
(I know, I’ve been deeply involved in building and maintaining some of the involved systems for a public sector payer.)
Unless it either meets preselected criteria (or gets lucky with the RNG for orgs doing random spot review) for manual review, or is an appeal, the “people reviewing the claim” aren’t actually people in many cases.
But, people or not, they don’t care if the patient needs it (well, they do as one factor, but its not the ultimate question), they care whether it meets the plan’s coverage criteria. Outside of what is minimally mandatory under health insurance laws and regulations, the coverage conditions for certain treatments (and even certain tests) are often more restrictive in “less good” plans.
So, yes, the systems and people reviewing claims do look at what kind of coverage you have when deciding whether or not a medical procedure or test is covered (and to what extent it is covered) by your insurance.
(I know, I’ve been deeply involved in building and maintaining some of the involved systems for a public sector payer.)
>Outside of what is minimally mandatory under health insurance laws and regulations
This is what I am referring to when talking about determining what is and is not medically necessary. If there is clear evidence of a lab or medication being helpful, then it will be covered due to stipulations in the ACA regardless of how expensive the insurance coverage is, since it is proven medically necessary.
Of course this gets into shades of gray, but such is life. However, I have not seen a treatment or lab well supported by data to not be covered because someone was on a worse insurance plan and the treatment or lab happens to be expensive.
One example of a controversial medicine to cover off the top of my head is palivizumab (Synagis) for RSV in babies. There is very sketchy data on its efficacy and in what conditions
https://publications.aap.org/pediatrics/article/134/2/415/33...
But lots of health plans will have varying levels of coverage with varying pre authorization criteria for it because it is extremely expensive. So would it be classified as medically necessary? Probably not in most cases. But still some plans might cover it for whatever political reasons.
This is what I am referring to when talking about determining what is and is not medically necessary. If there is clear evidence of a lab or medication being helpful, then it will be covered due to stipulations in the ACA regardless of how expensive the insurance coverage is, since it is proven medically necessary.
Of course this gets into shades of gray, but such is life. However, I have not seen a treatment or lab well supported by data to not be covered because someone was on a worse insurance plan and the treatment or lab happens to be expensive.
One example of a controversial medicine to cover off the top of my head is palivizumab (Synagis) for RSV in babies. There is very sketchy data on its efficacy and in what conditions
https://publications.aap.org/pediatrics/article/134/2/415/33...
But lots of health plans will have varying levels of coverage with varying pre authorization criteria for it because it is extremely expensive. So would it be classified as medically necessary? Probably not in most cases. But still some plans might cover it for whatever political reasons.
The most valuable person in a doctor’s office is the cranky oldtimer that handles the insurance.
I’ve learned to seek this person out (around here, it tends to be mostly women, and usually in their late forties, or so). They can be acerbic and abrupt, but I’ve found that it’s well worth it to treat them respectfully.
These are the “rainmakers.” They know how to make bills disappear by simply recoding a procedure, or will tell you how to approach your insurance company.
They will probably be unhappy at the new law; mostly because it will force them to have to learn a new workflow. I have every confidence that they will learn it, inside and out, in time.
I’ve learned to seek this person out (around here, it tends to be mostly women, and usually in their late forties, or so). They can be acerbic and abrupt, but I’ve found that it’s well worth it to treat them respectfully.
These are the “rainmakers.” They know how to make bills disappear by simply recoding a procedure, or will tell you how to approach your insurance company.
They will probably be unhappy at the new law; mostly because it will force them to have to learn a new workflow. I have every confidence that they will learn it, inside and out, in time.
Can I make it worse?
Of course I can! Obamacare requires that at least 80% of money must go to medical costs. Profits and administration come out of the rest. So the only way to keep profits rising for insurance companies is to arrange for payments to rise at a predictable rate. And therefore insurance companies are happy to be complicit in rising medical costs, so long as it is predictable and other insurance companies wind up with comparable rates.
Of course I can! Obamacare requires that at least 80% of money must go to medical costs. Profits and administration come out of the rest. So the only way to keep profits rising for insurance companies is to arrange for payments to rise at a predictable rate. And therefore insurance companies are happy to be complicit in rising medical costs, so long as it is predictable and other insurance companies wind up with comparable rates.
Is there any evidence for that? Graphs of US health costs over time show very little if any difference in the growth pattern from before the ACA and after the ACA.
I think people conflate two separate issues when considering health care costs in the US. The first is high costs. The second is increasing costs.
There is no doubt about it when it comes to high costs. We pay more than other first world countries for comparable levels of care.
When it comes to increasing costs though there isn't much difference between the US and many other first world countries. The US rates rise just a little faster than the rates in the other G7 countries, for example.
It's been this way for a long time. Here's how much various counties' costs went up from 2000 to 2018: US 2.3x, Germany 2.1x, France 1.8x, Canada 2.0x, Italy 1.7x, Japan 2.6x, and UK 2.6x. The US costs relative to 1980 were in 1990, 2000, 2010 2.6x, 4.4x, 7.7x, and 10.2x. For UK it was 2.0x, 4.1x, 7.5x, 10.6x. France did better: 2.2x, 4.1x, 6.1x, 7.5x.
Much of the focus on health care cost reform is on the high cost compared to other countries, with the assumption that we are doing something wrong that the others are avoiding and this is what leads to our high costs.
But our costs were about as much higher relative to the others 50 years ago as they are now. It is just that it wasn't as big a deal back then because costs were much lower as a percentage of GDP then both in the US and in the other first world countries.
In a sense then the US isn't actually doing much worse than the rest of the world (see note below). We are just farther ahead on the same curve they are all following, so we've reached the point where it is painful first.
This is not good. It means that fixing this is going to be a lot harder than most reform advocates think.
Note: when I say we aren't doing much worse this is just on costs. We are way behind in access.
Here are a couple of past comments with cites for the above numbers [1] [2].
[1] https://news.ycombinator.com/item?id=20923851
[2] https://news.ycombinator.com/item?id=22127566
I think people conflate two separate issues when considering health care costs in the US. The first is high costs. The second is increasing costs.
There is no doubt about it when it comes to high costs. We pay more than other first world countries for comparable levels of care.
When it comes to increasing costs though there isn't much difference between the US and many other first world countries. The US rates rise just a little faster than the rates in the other G7 countries, for example.
It's been this way for a long time. Here's how much various counties' costs went up from 2000 to 2018: US 2.3x, Germany 2.1x, France 1.8x, Canada 2.0x, Italy 1.7x, Japan 2.6x, and UK 2.6x. The US costs relative to 1980 were in 1990, 2000, 2010 2.6x, 4.4x, 7.7x, and 10.2x. For UK it was 2.0x, 4.1x, 7.5x, 10.6x. France did better: 2.2x, 4.1x, 6.1x, 7.5x.
Much of the focus on health care cost reform is on the high cost compared to other countries, with the assumption that we are doing something wrong that the others are avoiding and this is what leads to our high costs.
But our costs were about as much higher relative to the others 50 years ago as they are now. It is just that it wasn't as big a deal back then because costs were much lower as a percentage of GDP then both in the US and in the other first world countries.
In a sense then the US isn't actually doing much worse than the rest of the world (see note below). We are just farther ahead on the same curve they are all following, so we've reached the point where it is painful first.
This is not good. It means that fixing this is going to be a lot harder than most reform advocates think.
Note: when I say we aren't doing much worse this is just on costs. We are way behind in access.
Here are a couple of past comments with cites for the above numbers [1] [2].
[1] https://news.ycombinator.com/item?id=20923851
[2] https://news.ycombinator.com/item?id=22127566
Pretty much all businesses earn a percentage of revenue as profit, so the same condition of higher revenue resulting in higher profit (all else being equal) exists in all businesses, regardless of the Affordable Care Act regulations.
As long as there are competing businesses, and/or sufficiently low barriers to entry, then this mechanism to earn ever increasing profits is mitigated by the fact that a competitor will come in and take your business. Managed care organizations (MCOs), i.e. health insurance, has many competitors, UNH/Anthem/Cigna/Humana/CVS/Molina/Centene, etc.
Either they are all colluding to keep prices going up, or they actually are trying to negotiate the best prices they can with healthcare providers for their customers in order to offer the best value to continue to win business.
Considering all of the above companies have many years of single digit profit margins, almost all 5% and below, I would say the business line is quite competitive, and barring evidence of collusion, it seems spurious to claim they are profiting off of regulations requiring minimum medical loss ratios.
As long as there are competing businesses, and/or sufficiently low barriers to entry, then this mechanism to earn ever increasing profits is mitigated by the fact that a competitor will come in and take your business. Managed care organizations (MCOs), i.e. health insurance, has many competitors, UNH/Anthem/Cigna/Humana/CVS/Molina/Centene, etc.
Either they are all colluding to keep prices going up, or they actually are trying to negotiate the best prices they can with healthcare providers for their customers in order to offer the best value to continue to win business.
Considering all of the above companies have many years of single digit profit margins, almost all 5% and below, I would say the business line is quite competitive, and barring evidence of collusion, it seems spurious to claim they are profiting off of regulations requiring minimum medical loss ratios.
> Pretty much all businesses earn a percentage of revenue as profit
Pretty much no businesses have that percentage fixed by legislation.
If you make hammers and your customers are willing to pay $10 for a hammer and your costs are $9, your profit margin is 10%. If you can lower your costs to $8, you can still get $10, so now your profit margin is 20%. You have an incentive to reduce costs. And maybe even to reduce prices, because the higher number of hammers you sell at $9 might make up for the lower margin.
The main exception are utility companies and government contractors and it leads to the same perverse incentives there as in heath insurance.
> As long as there are competing businesses, and/or sufficiently low barriers to entry, then this mechanism to earn ever increasing profits is mitigated by the fact that a competitor will come in and take your business.
The way this works is that the lower cost insurer denies coverage for medically unnecessary procedures and the higher cost one doesn't. Then medical providers find someone who got denied and bring the story to the press that Discount Medical Insurance Co is intentionally murdering people by denying their health insurance claims! They must be stopped!
Then the bad PR loses them more customers than the lower price gained them, and the higher price makes them more money anyway. This continues until nobody is offering the lower price anymore.
Pretty much no businesses have that percentage fixed by legislation.
If you make hammers and your customers are willing to pay $10 for a hammer and your costs are $9, your profit margin is 10%. If you can lower your costs to $8, you can still get $10, so now your profit margin is 20%. You have an incentive to reduce costs. And maybe even to reduce prices, because the higher number of hammers you sell at $9 might make up for the lower margin.
The main exception are utility companies and government contractors and it leads to the same perverse incentives there as in heath insurance.
> As long as there are competing businesses, and/or sufficiently low barriers to entry, then this mechanism to earn ever increasing profits is mitigated by the fact that a competitor will come in and take your business.
The way this works is that the lower cost insurer denies coverage for medically unnecessary procedures and the higher cost one doesn't. Then medical providers find someone who got denied and bring the story to the press that Discount Medical Insurance Co is intentionally murdering people by denying their health insurance claims! They must be stopped!
Then the bad PR loses them more customers than the lower price gained them, and the higher price makes them more money anyway. This continues until nobody is offering the lower price anymore.
>Pretty much no businesses have that percentage fixed by legislation.
Setting a minimum medical loss ratio is not setting a minimum profit margin.
>The way this works is that the lower cost insurer denies coverage for medically unnecessary procedures and the higher cost one doesn't. Then medical providers find someone who got denied and bring the story to the press that Discount Medical Insurance Co is intentionally murdering people by denying their health insurance claims! They must be stopped!
>Then the bad PR loses them more customers than the lower price gained them, and the higher price makes them more money anyway. This continues until nobody is offering the lower price anymore.
That is not how it works at all. MCOs do not have a team of doctors and pharmacists scheming to approve medically unnecessary procedures. The business is extremely competitive and much of the denial/approval criteria is in the hands of the payer, for example Medicaid/Medicare/Tricare/CMS.
Setting a minimum medical loss ratio is not setting a minimum profit margin.
>The way this works is that the lower cost insurer denies coverage for medically unnecessary procedures and the higher cost one doesn't. Then medical providers find someone who got denied and bring the story to the press that Discount Medical Insurance Co is intentionally murdering people by denying their health insurance claims! They must be stopped!
>Then the bad PR loses them more customers than the lower price gained them, and the higher price makes them more money anyway. This continues until nobody is offering the lower price anymore.
That is not how it works at all. MCOs do not have a team of doctors and pharmacists scheming to approve medically unnecessary procedures. The business is extremely competitive and much of the denial/approval criteria is in the hands of the payer, for example Medicaid/Medicare/Tricare/CMS.
> Setting a minimum medical loss ratios is not setting a minimum profit margin.
It's setting a maximum profit margin.
We don't have problems with businesses trying to minimize their own profit margin.
> MCOs do not have a team of doctors and pharmacists scheming to approve medically unnecessary procedures.
All their competitors have to do is convince one of their patients that one of the procedures they're denying is medically necessary and they still get the bad press.
It's setting a maximum profit margin.
We don't have problems with businesses trying to minimize their own profit margin.
> MCOs do not have a team of doctors and pharmacists scheming to approve medically unnecessary procedures.
All their competitors have to do is convince one of their patients that one of the procedures they're denying is medically necessary and they still get the bad press.
>It's setting a maximum profit margin.
Is this a problem? As demonstrated by audited financial reports, there are many competing MCOs with many years of very small profit margins. These businesses clearly do not have pricing power, and are not businesses you get into to pocket lots of profit.
>All their competitors have to do is convince one of their patients that one of the procedures they're denying is medically necessary and they still get the bad press.
There is bad press about every single MCO out there, and they are processing millions of claims per day. I would need evidence to see that the bad press even means anything. Majority or at least plurality of people do not even get to choose their MCO.
Is this a problem? As demonstrated by audited financial reports, there are many competing MCOs with many years of very small profit margins. These businesses clearly do not have pricing power, and are not businesses you get into to pocket lots of profit.
>All their competitors have to do is convince one of their patients that one of the procedures they're denying is medically necessary and they still get the bad press.
There is bad press about every single MCO out there, and they are processing millions of claims per day. I would need evidence to see that the bad press even means anything. Majority or at least plurality of people do not even get to choose their MCO.
> These businesses clearly do not have pricing power, and are not businesses you get into to pocket lots of profit.
You're arguing against yourself there. If the market is really competitive then there is no need to set a maximum profit margin because anyone who tried to charge that much would lose business.
Meanwhile, suppose that one provider was much better managed than the others. The mismanaged ones would simultaneously have high prices and low margins, because they're wasting the money. The well managed one could then have much higher margins even at the same or lower price.
But if there is a profit cap and you're already at it, searching for further efficiency improvements costs you profit. If your margin is 20% and that's the cap, but you can get a 10% cost reduction, what do you do? If you lower prices, your competitors lower prices, and then you still have a 20% margin and they drop to a 10% margin. You gain no customers and reduce your absolute profits by 10% by making the same 20% margin on a 10% smaller total. If you burn the efficiency improvement on purpose, or don't look for it to begin with, you make more money.
> Majority or at least plurality of people do not even get to choose their MCO.
Somebody is choosing for them and that person doesn't want to take the blame for choosing one that denies claims.
This is part of the reason why it works -- some HR drone making the decision isn't spending their own money, but they're the one who takes the blame for choosing the disreputable discount provider if there are problems.
You're arguing against yourself there. If the market is really competitive then there is no need to set a maximum profit margin because anyone who tried to charge that much would lose business.
Meanwhile, suppose that one provider was much better managed than the others. The mismanaged ones would simultaneously have high prices and low margins, because they're wasting the money. The well managed one could then have much higher margins even at the same or lower price.
But if there is a profit cap and you're already at it, searching for further efficiency improvements costs you profit. If your margin is 20% and that's the cap, but you can get a 10% cost reduction, what do you do? If you lower prices, your competitors lower prices, and then you still have a 20% margin and they drop to a 10% margin. You gain no customers and reduce your absolute profits by 10% by making the same 20% margin on a 10% smaller total. If you burn the efficiency improvement on purpose, or don't look for it to begin with, you make more money.
> Majority or at least plurality of people do not even get to choose their MCO.
Somebody is choosing for them and that person doesn't want to take the blame for choosing one that denies claims.
This is part of the reason why it works -- some HR drone making the decision isn't spending their own money, but they're the one who takes the blame for choosing the disreputable discount provider if there are problems.
I agree with your reasoning. I wonder if the Medical Loss Ratios are no longer a necessity, and were needed at the time of ACA’s passage due lack of all the other rules such as being able to deny for pre existing conditions and maximum lifetime benefit amounts (opposite of out of pocket maximums).
However, since current profit margins are no where near 100% minus minimum medical loss ratios, I do not see how the existence of the minimum medical loss ratios would cause any MCO to be less incentivized to seek further efficiencies.
However, since current profit margins are no where near 100% minus minimum medical loss ratios, I do not see how the existence of the minimum medical loss ratios would cause any MCO to be less incentivized to seek further efficiencies.
> Obamacare requires that at least 80% of money must go to medical costs. Profits and administration come out of the rest. So the only way to keep profits rising for insurance companies is to arrange for payments to rise at a predictable rate.
IIRC, in Germany and Switzerland medical insurance is mandated non-profit, and can only meet the costs of running the company. The insurers could just give themselves high salaries, but to cover those premiums would need to be higher, which could cause the insured folks to seek out lower priced coverage.
IIRC, in Germany and Switzerland medical insurance is mandated non-profit, and can only meet the costs of running the company. The insurers could just give themselves high salaries, but to cover those premiums would need to be higher, which could cause the insured folks to seek out lower priced coverage.
Some states have similar laws. It makes no difference in practice if insurance is non profit or not, the only difference is who gets the profits
It absolutely is a revenue maximizing exercise by hospitals and physicians.
SF General isn’t in network for any insurer. Let that sink in. Why? They mostly treat indigent, so shit, insurance has nothing to do with it most of the time. Otherwise it’s revenue maximizing. And this is a government run hospitals. Let that point sink in too.
And I wouldn’t give physicians such an easy pass. I had conversations with a few community oncologist practices and they know the game very well. Ask them to take a 1% cut in revenue and you’d think you were throwing them in the poorhouse.
SF General isn’t in network for any insurer. Let that sink in. Why? They mostly treat indigent, so shit, insurance has nothing to do with it most of the time. Otherwise it’s revenue maximizing. And this is a government run hospitals. Let that point sink in too.
And I wouldn’t give physicians such an easy pass. I had conversations with a few community oncologist practices and they know the game very well. Ask them to take a 1% cut in revenue and you’d think you were throwing them in the poorhouse.
Insurance companies aren't stupid. Why do they put up with it?
They could e.g. force hospitals to publish pricing information so that it becomes common knowledge and a market is created with accurate pricing.
Or offer to replace overpriced medical supplies used by doctors on their own, which they acquire separately from the manufacturer and in bulk.
Or - worst-case - start buying hospital stock at up to 2x market value so the profits accrue to them, and use investor pressure to start replacing hospital administrators with their own efficient bean counters.
These are public companies, if they could get that 3% quarterly growth cutting costs from somebody "milking" them, why isn't that priority #1?
They could e.g. force hospitals to publish pricing information so that it becomes common knowledge and a market is created with accurate pricing.
Or offer to replace overpriced medical supplies used by doctors on their own, which they acquire separately from the manufacturer and in bulk.
Or - worst-case - start buying hospital stock at up to 2x market value so the profits accrue to them, and use investor pressure to start replacing hospital administrators with their own efficient bean counters.
These are public companies, if they could get that 3% quarterly growth cutting costs from somebody "milking" them, why isn't that priority #1?
>> I'm not saying that doctors have this goal.
Maybe not an explicit goal, but I think it's pretty easy for say an anesthesiologist who blows into the OR, talks to the patient (maybe) for 30 seconds, then powers through the surgery and on to the next one to lose touch with the core motivations for why they are there. In fact anyone who works with sick and hurt people needs to develop this dettachment as a survival mechanism. The administrators who create and operate these money machines are never connected with the patients in the first place. Not unlike a lot of software developers in this aspect!
Maybe not an explicit goal, but I think it's pretty easy for say an anesthesiologist who blows into the OR, talks to the patient (maybe) for 30 seconds, then powers through the surgery and on to the next one to lose touch with the core motivations for why they are there. In fact anyone who works with sick and hurt people needs to develop this dettachment as a survival mechanism. The administrators who create and operate these money machines are never connected with the patients in the first place. Not unlike a lot of software developers in this aspect!
You last paragraph is exactly the problem. All the massive mark ups, etc are negotiations between hospital and insurer.
The problem is that patients are being pulled into BS that normally they wouldn’t with other insurance.
When my car got damaged, I just brought it to a garage and gave them my insurance details. If they didn’t get paid it wasn’t on me.
The problem is that patients are being pulled into BS that normally they wouldn’t with other insurance.
When my car got damaged, I just brought it to a garage and gave them my insurance details. If they didn’t get paid it wasn’t on me.
Auto repair shops face competition and few operate as networks which would deny you access across a broad geographical area. Those seeking repair have alternative and are not a risk of death or permanent disability when shopping for services.
Hospitals don't. Patients are.
Hospitals don't. Patients are.
Those seeking repair have alternative and are not a risk of death or permanent disability when shopping for services.
I most certainly have options for my in-network healthcare provides and no, a crappy auto repair can certainly include an element of risk of death or permanent disability. Maybe not to the same degree, but if some shop forgets to reconnect the brakes it ain’t good.
I most certainly have options for my in-network healthcare provides and no, a crappy auto repair can certainly include an element of risk of death or permanent disability. Maybe not to the same degree, but if some shop forgets to reconnect the brakes it ain’t good.
In the case of healthcare services, it is the delay involved in shopping for a willing provider which imposes the constraint. Care delayed is itself a direct risk factor.
In the case of an automobile repair, this is virtually never the case. Tow services if you've broken down on the road might be an exception, but few if any auto-repair issues (standard maintenance, component failure, collission repair) *will not suffer additional harm if repair is delayed by hours, or days, even months or years in many cases.
That's not the case for medical treatment.
This is fully independent of the quality or appropriateness of treatemnt / repair itself.
I do hope I've made the distinction sufficiently clear.
In the case of an automobile repair, this is virtually never the case. Tow services if you've broken down on the road might be an exception, but few if any auto-repair issues (standard maintenance, component failure, collission repair) *will not suffer additional harm if repair is delayed by hours, or days, even months or years in many cases.
That's not the case for medical treatment.
This is fully independent of the quality or appropriateness of treatemnt / repair itself.
I do hope I've made the distinction sufficiently clear.
Care delay? How much of healthcare is urgent? Not much. Last figure I saw was 30%. So 70% is not urgent.
If you need surgery for your back, you can take the time to evaluate different doctors and hospitals, get their opinions and make a choice.
If you need surgery for your back, you can take the time to evaluate different doctors and hospitals, get their opinions and make a choice.
I'm basing my comments off your own original point here: https://news.ycombinator.com/item?id=29766485
In the US healthcare system, "patients are being pulled into BS that normally they wouldn’t with other insurance". Without choice. And as numerous others have noted in this thread, sufficiently often in cases where the consequence of delay is critical. The newborn requiring NICU treatment is a case in which care is both urgent and consent or shopping by the patient is a complete impossibility (https://news.ycombinator.com/item?id=29766079).
I stand by my point. I'm a bit confused why you're arguing against your own earlier position.
In the US healthcare system, "patients are being pulled into BS that normally they wouldn’t with other insurance". Without choice. And as numerous others have noted in this thread, sufficiently often in cases where the consequence of delay is critical. The newborn requiring NICU treatment is a case in which care is both urgent and consent or shopping by the patient is a complete impossibility (https://news.ycombinator.com/item?id=29766079).
I stand by my point. I'm a bit confused why you're arguing against your own earlier position.
If your wife's dentist in-network? Because if s/he is, then what you're describing is a "contractual write-off" - that's the amount the doctor or dentist has to give up because they contractually agreed to a negotiated rate with the insurance company. You may or may not see it on your final bill.
I just happened to have paid a bill with that! Here it is, right out of the trash:
https://imgur.com/a/NDFSeeF
These guys wanted a $708 "emergency room" payment for an urgent care visit (it was not an ER! We saw a physician's assistant, not even a real doctor!) plus $157 for a lab test. The insurance gave them $140, the remaining $690 is considered a contractual write-off.
I just happened to have paid a bill with that! Here it is, right out of the trash:
https://imgur.com/a/NDFSeeF
These guys wanted a $708 "emergency room" payment for an urgent care visit (it was not an ER! We saw a physician's assistant, not even a real doctor!) plus $157 for a lab test. The insurance gave them $140, the remaining $690 is considered a contractual write-off.
My dentist charges me the full amount. I then get a check for about 1/3rd from the insurance company. The dentist got the full amount. I work for a FAAMG company so supposedly my dental insurance is considered good. She billed $3000 for a deep cleaning and a crown and I paid her $3000. I got back $1162 from insurance
Dental insurance is really weak insurance. It is mostly a mechanism that allows employers that can afford the paperwork of offering benefits to give you the benefit of being able to pay for your dental expenses with pre tax money.
The maximum benefit amount is usually $1k to $2k. Maybe $3k at a generous employer. So if you ever had a really bad dental problem that exceeded those amounts, you are not insured from having to spend on dental problems that cost a lot of money.
Contrast with health insurance, where due to out of pocket maximums, you can suffer a very expensive healthcare event, and you are insured against having to pay $500k for the bypass surgery or NICU stay.
The maximum benefit amount is usually $1k to $2k. Maybe $3k at a generous employer. So if you ever had a really bad dental problem that exceeded those amounts, you are not insured from having to spend on dental problems that cost a lot of money.
Contrast with health insurance, where due to out of pocket maximums, you can suffer a very expensive healthcare event, and you are insured against having to pay $500k for the bypass surgery or NICU stay.
Yes, as someone with extreme outlier dental costs, I have come to the realization that dental insurance is not insurance at all, it’s simply a routine maintenance plan. The point of insurance is to act as a buffer for large unexpected expenses, and dental explicitly excludes those from coverage.
I was hit on my bike and had some broken teeth and such. The dentist asked for my regular insurance carrier to pay for the work.
Two things to note.
1) >>>>>>>> and every time that we have then talked to them they say that we don't have to pay the remainder.
This is actually in default of the contract between doctor and insurer. However, lots of physicians do it anyway. The minimum legal requirement is that physician must attempt to bill difference 3 times. If insurance audits and finds a pattern of these "writeoffs" it will claw back insurance claims. IN short, insurance doesn't want to pay more than the patient. Of course, the doctor will side with the patient, and then lose a bunch of money during an audit.
2) >>>>>This is just a negotiation tactic between our dentist and the insurance company. They are just trying to make sure that they capture every dollar that the insurance company will possibly pay.
You get half right. Its not a negotiation tactic. Its straight up capturing 100% of the potential reimbursement. Doctors have an extremely hard time maintaining different pricing for every contract, by CPT code. If doctors could easily maintain different pricing for different services, they would, because it would "true up" their AR Aging. Therefore they instead have 1 price, the highest possible, and just work to writeoff any underpayments. This is why healthcare costs keep going up. Doctors have no market incentive, they only have a maximizing incentive. That's why an increasing number of doctors do not take medicare or medicaid.
Something as simple as making doctor visits ("fee for service") payable via pre-tax dollars would probably make a big dent in the insurance game. HSAs were a step in the right direction, but its incredibly expensive from the employer perspective. You can have an stellar insurance plan and an avg one that offers HSA, and the premiums for the latter will be more expensive!
Source: Working in a healthcare startup that lets doctors not play these games. Former exec for brick and mortar healthcare companies.
1) >>>>>>>> and every time that we have then talked to them they say that we don't have to pay the remainder.
This is actually in default of the contract between doctor and insurer. However, lots of physicians do it anyway. The minimum legal requirement is that physician must attempt to bill difference 3 times. If insurance audits and finds a pattern of these "writeoffs" it will claw back insurance claims. IN short, insurance doesn't want to pay more than the patient. Of course, the doctor will side with the patient, and then lose a bunch of money during an audit.
2) >>>>>This is just a negotiation tactic between our dentist and the insurance company. They are just trying to make sure that they capture every dollar that the insurance company will possibly pay.
You get half right. Its not a negotiation tactic. Its straight up capturing 100% of the potential reimbursement. Doctors have an extremely hard time maintaining different pricing for every contract, by CPT code. If doctors could easily maintain different pricing for different services, they would, because it would "true up" their AR Aging. Therefore they instead have 1 price, the highest possible, and just work to writeoff any underpayments. This is why healthcare costs keep going up. Doctors have no market incentive, they only have a maximizing incentive. That's why an increasing number of doctors do not take medicare or medicaid.
Something as simple as making doctor visits ("fee for service") payable via pre-tax dollars would probably make a big dent in the insurance game. HSAs were a step in the right direction, but its incredibly expensive from the employer perspective. You can have an stellar insurance plan and an avg one that offers HSA, and the premiums for the latter will be more expensive!
Source: Working in a healthcare startup that lets doctors not play these games. Former exec for brick and mortar healthcare companies.
It's not as dramatic but this is the same thing that happens when you have an automobile accident and need repairs. The cost to the insurance company is much higher than what you'd pay directly, but then you end up paying it through premiums with the added margin that goes to the insurance company. This is also a highly regulated market like healthcare, yet once again some of the most egregious behaviour is observed. The legislation in these industries reminds me of the jokes about central control on manufacturing by the USSR.
That definitely sounds like lots of fraud and probably so e tax complications
> Your wife's screaming in pain during labor, are you really going to jump on your phone and check to see if the anesthesiologist in front of you is in-network? And what do you do if s/he's not?
I think it was the economist Kenneth Arrow that used situations like this as an example of why health care cannot be treated like other markets. Free Markets™ require information by buyers, and there tends to be asymmetry in this regard in medicine more than in many other markets.
* https://web.stanford.edu/~jay/health_class/Readings/Lecture0...
Usually when buying a product or service you know the price ahead of time, but with medical treatment this is often impossible for non-elective / emergency procedures.
I think it was the economist Kenneth Arrow that used situations like this as an example of why health care cannot be treated like other markets. Free Markets™ require information by buyers, and there tends to be asymmetry in this regard in medicine more than in many other markets.
* https://web.stanford.edu/~jay/health_class/Readings/Lecture0...
Usually when buying a product or service you know the price ahead of time, but with medical treatment this is often impossible for non-elective / emergency procedures.
I did nasal surgery (deviated septum) and I asked around for quotes on how much it'd cost.
I was verbally quoted about $2500 out of pocket expenses. I have a really good hdhp plan that covers $1500 hdhp before a 10k max coverage at 90% coinsurance.
I ended up costing close to $7000 out of pocket anyhow...
The medical insurance system is really stupid in America. It's basically fraud.
Coinsurance coverage doesn't work as intended because the hospital can charge any amount they want, meaning your forced to pay close to your max coverage even if you have a high % coverage.
Your forced to sign a "please bill me on anything you want" to get medical services rendered.
I got billed $400 per post visit just for a camera to be shoved up my nose.
The anesthesia was out of network and didn't get covered by insurance
I was verbally quoted about $2500 out of pocket expenses. I have a really good hdhp plan that covers $1500 hdhp before a 10k max coverage at 90% coinsurance.
I ended up costing close to $7000 out of pocket anyhow...
The medical insurance system is really stupid in America. It's basically fraud.
Coinsurance coverage doesn't work as intended because the hospital can charge any amount they want, meaning your forced to pay close to your max coverage even if you have a high % coverage.
Your forced to sign a "please bill me on anything you want" to get medical services rendered.
I got billed $400 per post visit just for a camera to be shoved up my nose.
The anesthesia was out of network and didn't get covered by insurance
>The anesthesia was out of network and didn't get covered by insurance
This actually is specifically illegal, it's a pain in the ass to fight it against both the hospital and your insurance but if you insist hard enough they will cover it and you'll only pay what you would normally through your insurance. As long as the hospital itself is in network they aren't allowed to play "gotcha" with specific doctors/providers just not being in network all the sudden.
This actually is specifically illegal, it's a pain in the ass to fight it against both the hospital and your insurance but if you insist hard enough they will cover it and you'll only pay what you would normally through your insurance. As long as the hospital itself is in network they aren't allowed to play "gotcha" with specific doctors/providers just not being in network all the sudden.
This is soo strange! Why do _you_ have to insist for anything? Why is this thing even legal?
It's not legal, but the amount of people that will just rollover and take it is incredibly high, and the absolute worst case scenario is that end up having to pay what they would have anyways so there's literally no downside for them pulling this bullshit.
I thought this was only just made illegal as of Jan 1, 2022.
So for any kind of emergency care they are not allowed to "gotcha" with out of network providers at in network hospitals, this has always been the case. However, according to my quick Google research apparently anything else is state-law dependent so what I said doesn't apply equally in the country.
You are not correct about coinsurance when using in-network hospital and providers. There is a contracted rate with the insurer and your out of pocket is usually 20%+ of that up to your out of pocket limits. The hospital does have arbitrary made up prices called a chargemaster which is just essentially numbers pulled out of a hat but when you are using an in-network provider there is a fixed rate for every covered code.
It's straight greed on every level... Providers and hospitals will bill the absolute maximum allowed for each item and they track everything extensively. Insurance companies do their hardest to find literally any excuse to not cover claims, while also barely fulfilling their contractual obligations to members.
Unfortunately, hospitals will never be able to consolidate or pass-thru bills from all providers, because admins would want a cut of the amount paid, plus they would know what everyone is charging and use that info strategically. So no provider in their right mind would go for it. Sending bills directly cuts out any middleman and increase their margins.
Unfortunately, hospitals will never be able to consolidate or pass-thru bills from all providers, because admins would want a cut of the amount paid, plus they would know what everyone is charging and use that info strategically. So no provider in their right mind would go for it. Sending bills directly cuts out any middleman and increase their margins.
If you are insured, you should assume your annual out of pocket maximum is the cost at in network providers.
If you are insured, supposedly there are measures to limit costs due to out of network providers, but I am not sure if you are entitled to find out the costs beforehand. I presume you are entitled to get a “good faith estimate”.
https://www.cms.gov/nosurprises/consumer-protections/What-ar...
If you are not insured, healthcare providers are obliged to give you a “good faith estimate” upfront now:
https://www.cms.gov/nosurprises/consumers/understanding-cost...
https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bill...
If you are insured, supposedly there are measures to limit costs due to out of network providers, but I am not sure if you are entitled to find out the costs beforehand. I presume you are entitled to get a “good faith estimate”.
https://www.cms.gov/nosurprises/consumer-protections/What-ar...
If you are not insured, healthcare providers are obliged to give you a “good faith estimate” upfront now:
https://www.cms.gov/nosurprises/consumers/understanding-cost...
https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bill...
I've got power of attorney for an elderly relative who is in a nursing facility and just got one of these -- a bill from "PDQ Medical, Inc." (not the actual name) with no other information on it. Their web site lets you log in with the patient name and date of birth, but there's also no information there. Just the amount that is supposedly due.
I'll be calling them Monday and telling them that unless they send me an itemized bill detailing what doctor (or other medical professional) she saw, what the treatment date was, and what service was provided, I'm not paying squat.
Frankly, she's got more important things to worry about than an account getting sent to collections, and I'm legally responsible for how I spend her money. I'm not going to pay bills from any rando who feels like sending one. Not gonna happen.
I'll be calling them Monday and telling them that unless they send me an itemized bill detailing what doctor (or other medical professional) she saw, what the treatment date was, and what service was provided, I'm not paying squat.
Frankly, she's got more important things to worry about than an account getting sent to collections, and I'm legally responsible for how I spend her money. I'm not going to pay bills from any rando who feels like sending one. Not gonna happen.
I had a similar issue with my dad at a rehab facility. In his case, the mysterious bill was for a psychiatric session from a doctor we had never heard of.
We kept digging and had to threaten the facility with a referral to the Medicare inspector general to get information. Turned out that the guy prescribed some random drugs and billed for a “3 hour evaluation”, which supposedly took place on a day where my dad was accompanied by family members or in physical therapy for the entire day. (Context: he had a stroke and was unable to speak)
The doc just showed up and wrote random scripts. We didn’t get the feds to care, but the state medical licensing people did censure the doctor.
Good luck. These facilities aren’t very forthright and will retaliate against your helpless relative.
We kept digging and had to threaten the facility with a referral to the Medicare inspector general to get information. Turned out that the guy prescribed some random drugs and billed for a “3 hour evaluation”, which supposedly took place on a day where my dad was accompanied by family members or in physical therapy for the entire day. (Context: he had a stroke and was unable to speak)
The doc just showed up and wrote random scripts. We didn’t get the feds to care, but the state medical licensing people did censure the doctor.
Good luck. These facilities aren’t very forthright and will retaliate against your helpless relative.
We usually call this "organized crime": a gangster in a white suit, pretending to be a psychiatrist, commits fraud and enjoys the protection of the mafia bosses who run the casino 'Hospital'.
Well, it's not the actual nursing facility sending this bill, just some unknown provider.
It may even be legit. But I don't know that.
Edit: at least yours had a doctor's name! This bill doesn't even have that.
It may even be legit. But I don't know that.
Edit: at least yours had a doctor's name! This bill doesn't even have that.
It's probably a subsidiary unit of the nursing facility. Most of these have the room/apartment rental, the skilled care, the unskilled services, and the facility administrators all employed by separate legal entities. Be prepared for a notice of eviction for your relative if the bill is not paid.
If they satisfy me that the bill is for a legitimate service, I will pay it. That's not the issue.
In India at least, the healthcare is not as super advanced but the public healthcare is free. Private hospitals have 2 modes. Either pay cash or cashless insurance.
If you have a heath insurance card, you just pick one and you are done.
If you are paying by cash, you ask for a price. Then you price shop all hospitals. There are no "surprises" as hospitals expect customers to pay upfront the cost of procedure and or a deposit for room/incidentals.
The good thing with this is, you say "hey hospital A, how much for a cataract surgery", same for all hospitals. The bad thing is, if you don't have the cash, you either have to borrow or sell off property which throws people into poverty faster.
Recently government made a public insurance scheme where every family is covered for like 1200 procedures and is cashless. The good about it is, even poorest of poor can get private healthcare and hospitals get a steady revenue stream, albeit at a lower profit but in the long run they are expected to turn a profit.
In India, health insurance and insurance in general is missold. Agents sell " return of premium" and "money back" instead of risk cover because they get a fatter commission. I have talked to dozens of agents and they dislike term life insurance like the plague. "Why would you do that, its stupid. Yuck. Ew". Same for medical, the result being only rich could afford good care till now.
If you have a heath insurance card, you just pick one and you are done.
If you are paying by cash, you ask for a price. Then you price shop all hospitals. There are no "surprises" as hospitals expect customers to pay upfront the cost of procedure and or a deposit for room/incidentals.
The good thing with this is, you say "hey hospital A, how much for a cataract surgery", same for all hospitals. The bad thing is, if you don't have the cash, you either have to borrow or sell off property which throws people into poverty faster.
Recently government made a public insurance scheme where every family is covered for like 1200 procedures and is cashless. The good about it is, even poorest of poor can get private healthcare and hospitals get a steady revenue stream, albeit at a lower profit but in the long run they are expected to turn a profit.
In India, health insurance and insurance in general is missold. Agents sell " return of premium" and "money back" instead of risk cover because they get a fatter commission. I have talked to dozens of agents and they dislike term life insurance like the plague. "Why would you do that, its stupid. Yuck. Ew". Same for medical, the result being only rich could afford good care till now.
In the US the game comes from the fact that different people pay difference pricing depending on what combination of cash and insurance they have.
Basically "list" vs "actual" pricing depending on what "discounts" you are eligible for.
Basically "list" vs "actual" pricing depending on what "discounts" you are eligible for.
"How much does it cost?"
"How much you got?"
Mobsters.
"How much you got?"
Mobsters.
Huh, sounds like how they price tuition for my daughter's college education (private college w/ a good name).
They also talk about how they are making it more affordable for everyone.
They also talk about how they are making it more affordable for everyone.
But isn't this what we have been advocating for on some levels? Everyone pays according to their ability? Rich pay more and poor pay less.
Except that the rich people have insurance that can negotiate a lower rate than the poor people
The simple solution to this is to completely disconnect insured patients from hospital billing. If a person is insured then they only pay to the insurance company, a specific dollar amount copay they previously agreed on their insurance contract, all hospital billing should be handled by the insurance company.
Because the end game is expanding access to healthcare by increasing supply of less qualified (or lower quality) healthcare providers, and then price segmenting different populations to different qualities of healthcare.
You pay more, you get higher probability of access to MDs. You pay less, you get higher probability of access to PA/NP. And many other variations of that.
You can accomplish the goal of politically expanding access to healthcare, but without the costs of getting everyone access to the same healthcare.
You pay more, you get higher probability of access to MDs. You pay less, you get higher probability of access to PA/NP. And many other variations of that.
You can accomplish the goal of politically expanding access to healthcare, but without the costs of getting everyone access to the same healthcare.
We could just train more MDs and/or make that training process more efficient like Germany. Also, medical training and residency need not infringe on the health and safety of pregnant women and the unborn for no purpose whatsoever with 24 hour shifts and other complete nonsense for internist trainees. As some budding doctors would like to have 5 or 6 children in their twenties.
Edit: we could also generally waste less human potential and train more people by you know, having college kids go to school 48 weeks a year instead of 36, like real adults who enlist in the military or trades.
Edit: we could also generally waste less human potential and train more people by you know, having college kids go to school 48 weeks a year instead of 36, like real adults who enlist in the military or trades.
Of course, I think doctors who were lobbying to restrict supply overplayed their hands and many future doctors are now stuck "supervising" 10 NP/PA.
Whoever or whatever was preventing supply of doctors from increasing for the past few decades really did the doctors who worked 1980s to 2010s a big favor, but a big disservice to pretty much all future doctors.
Whoever or whatever was preventing supply of doctors from increasing for the past few decades really did the doctors who worked 1980s to 2010s a big favor, but a big disservice to pretty much all future doctors.
> Can the hospital not act as a mediary and collate all of the charges on a single line itemed bill? Because that is how everything else in the world works.
Hello. I'm from the rest of the world, and I or my family have never received a bill from a hospital. The idea seems crazy. Just providing a perspective.
Hello. I'm from the rest of the world, and I or my family have never received a bill from a hospital. The idea seems crazy. Just providing a perspective.
From the US. Neither has mine, except when we forgot to pay our copay during an ER visit once. We got a bill for that exact amount a couple of months later from our insurance company. It was $100.
I recently took two of my kids to the emergency room, after I found an empty box of children’s Tylenol. Their blood levels turned out to be normal, thankfully, but we were kept there for around 4 hours as a precaution. That empty box of Tylenol cost me $6k.
I had surgery and actually had a good experience. My hospital would provide a cost estimate prior by actually contacting my insurance. The estimate was pretty close.
But I’m kind of surprised that hospitals don’t try and get ahead of it. If I had two options for hospitals and one provided financial management (say guaranteed a final cost) and the other was like “fuck off, call your insurance”, I’d opt for the former easily.
But I’m kind of surprised that hospitals don’t try and get ahead of it. If I had two options for hospitals and one provided financial management (say guaranteed a final cost) and the other was like “fuck off, call your insurance”, I’d opt for the former easily.
Medicine is the only profession that seems to have its own specialized "coding and billing" co-professions with schools around the country that train only "medical code and billing" to their pupils.
Any other business in the country would just have products / services and prices without any of these games.
Had the same experience as you, FWIW.
Any other business in the country would just have products / services and prices without any of these games.
Had the same experience as you, FWIW.
Had a similar experience & some of those bills turned out to be scams. I think some scammers somehow obtain that info & rush to send you fake bills.
It doesn't save them money if you save money. This idiotic way of doing things is obviously very lucrative for them, no collating needed!
> Can the hospital not act as a mediary and collate all of the charges on a single line itemed bill?
No, because the status quo allows the various providers to extract every penny of value that they can out of you.
No, because the status quo allows the various providers to extract every penny of value that they can out of you.
This is truly a great improvement, but not including ground ambulances in this is messed up. And reeks of a special-interest lobbying group pushing for it.
This also really bothers me:
> Out-of-network doctors also must inform patients about what their care might cost, and they may ask patients to sign a form that waives their protections. (Be leery of signing this, consumer rights experts say.)
It's a very weak law when you can still sign away your rights to someone who has the stronger end of a power/information imbalance. Emergency care is supposed to be covered by this law, but if you're in bad shape and show up at the ER, you might sign anything just to get care.
This also really bothers me:
> Out-of-network doctors also must inform patients about what their care might cost, and they may ask patients to sign a form that waives their protections. (Be leery of signing this, consumer rights experts say.)
It's a very weak law when you can still sign away your rights to someone who has the stronger end of a power/information imbalance. Emergency care is supposed to be covered by this law, but if you're in bad shape and show up at the ER, you might sign anything just to get care.
Especially with last minute doctor allocations. Arrive for your critical surgery that must be done ASAP and get met by an anesthesiologist (thank you spellchecker) who says "by the way I'm out of network, do you agree to pay me an arbitrary amount? If not, your surgery is cancelled."
Then if you do say no, could the hospital then charge you for cancelling surgery at late notice? Especially given insurance generally doesn't cover such fees.
Honestly any law that doesn't say "if the facility is in network, the insurance company must cover all costs as in network" and get rid of this bullshit concept of "out of network" people in an in network facility is fundamentally insufficient.
Then if you do say no, could the hospital then charge you for cancelling surgery at late notice? Especially given insurance generally doesn't cover such fees.
Honestly any law that doesn't say "if the facility is in network, the insurance company must cover all costs as in network" and get rid of this bullshit concept of "out of network" people in an in network facility is fundamentally insufficient.
The anesthesiologist scenario is addressed in the recent legislation that went into effect Jan 1, 2022 (Consolidated Appropriations Act of 2021):
https://www.cms.gov/nosurprises/consumer-protections/What-ar...
>Ban out-of-network charges and balance billing for ancillary care (like an anesthesiologist or assistant surgeon) by out-of-network providers at an in-network facility.
https://www.cms.gov/nosurprises/consumer-protections/What-ar...
>Ban out-of-network charges and balance billing for ancillary care (like an anesthesiologist or assistant surgeon) by out-of-network providers at an in-network facility.
Right, but the bit I quoted above seems to suggest that this "ban" is weak and can be circumvented by the out-of-network doctor explaining there will be extra, non-covered charges, and then getting you to sign a waiver saying that's ok.
If not signing that waiver means your surgery gets canceled (especially in an emergency situation), most people will feel coerced to sign. Hell, most people will probably feel coerced to sign in most situations.
If not signing that waiver means your surgery gets canceled (especially in an emergency situation), most people will feel coerced to sign. Hell, most people will probably feel coerced to sign in most situations.
Yes, the article links to this form:
https://www.cms.gov/files/document/standard-notice-consent-f...
Which instructs the provider to list the "good faith estimated cost" on page 4. Presumably, this will then bind the provider to having to deal with you via the dispute resolution process:
https://www.cms.gov/nosurprises/consumers/medical-bill-disag...
Of course, the effectiveness of all of this remains to be seen, and will depend on what kind of teeth this dispute resolution process has:
>If after getting your bill you realize that any of your providers or facilities billed you for an amount that’s $400 or more than what’s on your good faith estimate, you can use a new dispute resolution process to request that an independent third-party, called a dispute resolution entity, review your case and determine an appropriate payment. This process is referred to as “patient-provider dispute resolution.” The dispute resolution entity will review the good faith estimate, your bill, and information submitted by your provider or facility to determine if you should pay the amount on your good faith estimate, the billed charge, or an amount in between the two. There’s a $25 non-refundable administrative fee to start this process.
https://www.cms.gov/files/document/standard-notice-consent-f...
Which instructs the provider to list the "good faith estimated cost" on page 4. Presumably, this will then bind the provider to having to deal with you via the dispute resolution process:
https://www.cms.gov/nosurprises/consumers/medical-bill-disag...
Of course, the effectiveness of all of this remains to be seen, and will depend on what kind of teeth this dispute resolution process has:
>If after getting your bill you realize that any of your providers or facilities billed you for an amount that’s $400 or more than what’s on your good faith estimate, you can use a new dispute resolution process to request that an independent third-party, called a dispute resolution entity, review your case and determine an appropriate payment. This process is referred to as “patient-provider dispute resolution.” The dispute resolution entity will review the good faith estimate, your bill, and information submitted by your provider or facility to determine if you should pay the amount on your good faith estimate, the billed charge, or an amount in between the two. There’s a $25 non-refundable administrative fee to start this process.
[deleted]
I usually compare US hospitals to upscale mexican cartels. A cartel gives you a choice: "pay this arbitrary amount now, or have your arm chopped off". A hospital gives you the same choice, but does that with style: "sign these papers here and here, saying you agree to pay us arbitrary amount, or our surgeon, who's supposed to save your arm, isn't available today."
Yeah, you'll get in there, and it will be one of 20 forms you have to sign.
The form makes it very clear that signing it is totally optional, and still requires the hospital to provide a cost estimate.
Signing something when you are in the ER is the definition of duress.
It’s purely insane that the term ‘financial ruin’ is even in TFA. I’m glad I live in a country where I can’t wake up from a coma a million dollars in debt.
The comment thread that is soon to follow is predictable.
Someone will reply: Medical costs are responsible for X% of personal bankruptcies in America.
Someone will reply: Most Americans don't have to worry about medical bills because they have coverage through their employer.
Someone will concur: Yeah, I have fantastic benefits with my company.
Someone will provide a counter anecdote: I also have great benefits with my employer. But I still have to pay a $5000 deductible before coverage kicks in.
Someone will reply to the parent with: The US has the best health care in the world. Why do you think people fly from overseas to receive treatment in the US?
Then someone will reply: The US has the best health care ... if you can afford it. The last time I saw my doctor, he looked at me for five minutes and prescribed me a bottle of aspirin.
Someone will reply: You need a new doctor. I once had an experience like yours. I found a new doctor, who truly cares about my health and well being.
Someone else will reply to the comment two spots above:
> The US has the best health care ... if you can afford it.
"No, the US has the best health care in the world, including for middle class people and poor people. I once injured myself in [insert first world country] and their health care system was practically third world."
_______
Someone will reply: Medical costs are responsible for X% of personal bankruptcies in America.
Someone will reply: Most Americans don't have to worry about medical bills because they have coverage through their employer.
Someone will concur: Yeah, I have fantastic benefits with my company.
Someone will provide a counter anecdote: I also have great benefits with my employer. But I still have to pay a $5000 deductible before coverage kicks in.
Someone will reply to the parent with: The US has the best health care in the world. Why do you think people fly from overseas to receive treatment in the US?
Then someone will reply: The US has the best health care ... if you can afford it. The last time I saw my doctor, he looked at me for five minutes and prescribed me a bottle of aspirin.
Someone will reply: You need a new doctor. I once had an experience like yours. I found a new doctor, who truly cares about my health and well being.
Someone else will reply to the comment two spots above:
> The US has the best health care ... if you can afford it.
"No, the US has the best health care in the world, including for middle class people and poor people. I once injured myself in [insert first world country] and their health care system was practically third world."
_______
Being a European, I'm fascinated by the crazy healthcare and I love reading these US healthcare topics. You really captured the gist of the conversation :)
Hey me too.
I know it's real people suffering and because of personal relationships with US citizens I feel for them.
Yet it's a fascinating lesson in how complex social problems can be acknowledged by pretty much everyone while at the same no-one is able to implement a workable solution.
PS: I'm glad there will always be someone who reminds me that here in central Europe I can not choose my doctor, have to wait months for an appointment and that we don't have health insurance here because it's covered by taxes. Since that's not how it works at all I always forget ;)
PPS: Obviously it's not all sunshine and roses here either and we have our fair share of problems but large unexpected bills for scheduled or emergency procedures just don't happen frequently enough to matter in the grand scheme of things.
I know it's real people suffering and because of personal relationships with US citizens I feel for them.
Yet it's a fascinating lesson in how complex social problems can be acknowledged by pretty much everyone while at the same no-one is able to implement a workable solution.
PS: I'm glad there will always be someone who reminds me that here in central Europe I can not choose my doctor, have to wait months for an appointment and that we don't have health insurance here because it's covered by taxes. Since that's not how it works at all I always forget ;)
PPS: Obviously it's not all sunshine and roses here either and we have our fair share of problems but large unexpected bills for scheduled or emergency procedures just don't happen frequently enough to matter in the grand scheme of things.
Love these abstractions of HN flamewar threads, it reminds me how me little information gain there is over time. Here is one of my all-time favourites: https://news.ycombinator.com/item?id=23003595
That first comment nails it as well. Everyone wants to feel like they're contributing something novel or unique to a comment thread but....
That’s not limited to US healthcare threads, there’s plenty of similar topics (prison systems come to mind). I appreciate your response, I’d love to see a resolution to the groundhogday-esk parts of HN.
The socialising of healthcare and de-privatisation of prisons would probably resolve it ;).
Add that to the template!
I would love it if you could write a reply like this for all the major HN topics and create a bot that automatically pinned it to the top.
Dang, that’d be a heck of a feature.
It's been done:
http://n-gate.com/
http://n-gate.com/
Haha, I'm just linking this comment every time the issue comes up.
One of my app ideas was to make it so you can have that "graph" for every issue, and then instead of rehashing the same debate every time, you just tell people to find where their argument is in the graph, and they can link it or improve what's there.
One of my app ideas was to make it so you can have that "graph" for every issue, and then instead of rehashing the same debate every time, you just tell people to find where their argument is in the graph, and they can link it or improve what's there.
This comment needs to be immortalized somehow
Poor people are eligible for Medicaid, which means they pay nothing.
It's the middle class that takes it in the neck.
It's the middle class that takes it in the neck.
As of ~5 years ago, you could be cripplingly poor and still not qualify for Medicaid. I've lived it.
Depends on the state.
Most states use 100% to 138% of the federal poverty level, which would cut off a single person from Medicaid if they make ~$12k to ~$16k a year.
[deleted]
I don't understand what your comment adds to the discussion... Are you saying it's OK for some states not to have healthcare for poor people? Or that poor people should move to better states (they can't because moving costs money; poor people aren't mobile)? I don't see how pointing out that some states are worse than others is useful.
It is very useful, factual information. One might not know that Medicaid is a program run by the individual states, or that it is possible to move to a state with better options - and many "poor people" can and do move long distance for various reasons. Also, it's important to understand that if you want to change things you should be directing your efforts toward your state government.
States that have accepted Medicaid expansion make you eligible if you make up to 138% of the poverty level.
Not all of them have, of course. Without going through every single state, Texas allows you to make up to $25,503 for a household of one and still be eligible for Medicaid.
Those who make more are eligible for free or subsidized Obamacare plans.
What do you mean by "cripplingly poor", and what state was this?
Not all of them have, of course. Without going through every single state, Texas allows you to make up to $25,503 for a household of one and still be eligible for Medicaid.
Those who make more are eligible for free or subsidized Obamacare plans.
What do you mean by "cripplingly poor", and what state was this?
In Texas a household of one is ineligible for Medicaid at any income unless you're blind or otherwise disabled.
[deleted]
Depends on the state. States like Florida and Texas did not expand Medicaid, so if you make under the minimum for ACA subsidies, your choice is pay full price ACA or nothing.
For example, in Florida, to be eligible for Medicaid, you must be below the poverty line AND:
> You must also be one of the following: Pregnant, or Be responsible for a child 18 years of age or younger, or Blind, or Have a disability or a family member in your household with a disability, or Be 65 years of age or older.
For example, in Florida, to be eligible for Medicaid, you must be below the poverty line AND:
> You must also be one of the following: Pregnant, or Be responsible for a child 18 years of age or younger, or Blind, or Have a disability or a family member in your household with a disability, or Be 65 years of age or older.
There tens of millions of people who live in states that never expanded Medicaid under the ACA, so Medicaid is not available to them unless they're disabled.
Expanded Medicaid in states that accepted it cuts people off at 100% to 138% of the FPL, meaning if you make more than $12k to $16k a year, you're ineligible for Medicaid.
If you have more than $2k worth of assets, you must sell them before being eligible for Medicaid.
Expanded Medicaid in states that accepted it cuts people off at 100% to 138% of the FPL, meaning if you make more than $12k to $16k a year, you're ineligible for Medicaid.
If you have more than $2k worth of assets, you must sell them before being eligible for Medicaid.
The asset test is gone in states that expanded Medicaid too.
Not poor people, indigent people. Like you need to sell your car to qualify for some doctor 50 miles away.
And if you live in certain states, they throw in all sorts of impossible restrictions and surprises. Sometimes they’ll suggest that you move.
And if you live in certain states, they throw in all sorts of impossible restrictions and surprises. Sometimes they’ll suggest that you move.
It does vary by state. In this state, you're allowed to own a car or even a home and still qualify for Medicaid.
Many doctors refuse Medicaid patients.
Tell me again why national health insurance in the us means the terrorists have won and we lost our exceptionalism? And why a good half the country things this would ruin us? I despair about the future of my country.
As long as this is done via Congress passing laws to cover up loopholes, it's not going to work. It takes too many years to push through legislation, and the health care industry can reorient to bilk their customers some other way too fast. A competently run agency with a ton of authority is required.
Not sure that you could get that past the Supreme Court, or run it competently over the long term given our depressing partisan split on health care, but you know. If this were Canada, that would be the way to make this work.
Not sure that you could get that past the Supreme Court, or run it competently over the long term given our depressing partisan split on health care, but you know. If this were Canada, that would be the way to make this work.
This is kinda an absurd take. On one hand you have people saying 'hey if you want x congress should make it law, the courts can't do anything about it.' but you're saying 'if Congress passes a law it won't work and only the courts can do something about x' it can't be both...
> but you're saying 'if Congress passes a law it won't work and only the courts can do something about x'
That isn't at all what they were saying.
They were saying that instead of Congress trying to make rules through the legislative process (which moves to slow to work), Congress needs to create and authorize a federal agency to make these rules (like the FAA or FCC.) The portion about the supreme court is regarding whether such an agency would be deemed constitutional.
That isn't at all what they were saying.
They were saying that instead of Congress trying to make rules through the legislative process (which moves to slow to work), Congress needs to create and authorize a federal agency to make these rules (like the FAA or FCC.) The portion about the supreme court is regarding whether such an agency would be deemed constitutional.
IMO the people with said power and responsibility just want to finger point. But what do you do when no one is willing to put on the pants?
It could also take years for it to change in practice. If someone bills you improperly you might be dealing with it for years and have no recourse outside of the courts.
Extremely different mechanisms protect a hospital from a patient lifting a box of bandaids and some OTC pain reliever vs a hospital unlawfully billing them zillions of dollars.
Extremely different mechanisms protect a hospital from a patient lifting a box of bandaids and some OTC pain reliever vs a hospital unlawfully billing them zillions of dollars.
Congress can delegate authority to any existing or new agency.
The real court case to upend this country would be one that limits or nullifies the delegation capability.
But at least we’ll have small government again lol.
The real court case to upend this country would be one that limits or nullifies the delegation capability.
But at least we’ll have small government again lol.
They are currently fighting about Chevron deference, which would functionally be a way for the courts to squash agency independence.
Clarence Thomas has this bit where he says "you guys are doing all these crazy contortions to do stare decisis on these old New Deal decisions that enable the modern administrative state, but the real answer is that they were never constitutional to begin with and should be reversed." This would clearly be a giant disaster, but I think his argument is probably correct.
We don't really do constitutional amendments any more though, so I'm not sure if there are any answers other than court packing to ensure continuous Constitutional Calvinball.
Clarence Thomas has this bit where he says "you guys are doing all these crazy contortions to do stare decisis on these old New Deal decisions that enable the modern administrative state, but the real answer is that they were never constitutional to begin with and should be reversed." This would clearly be a giant disaster, but I think his argument is probably correct.
We don't really do constitutional amendments any more though, so I'm not sure if there are any answers other than court packing to ensure continuous Constitutional Calvinball.
Yeah, I reached the same conclusion myself, a long time ago.
Most of the New Deal was gutted by the courts in the 1930s and 1940s and everything else that remains from it just has never been challenged, mostly from a lack of inspiration, lack of awareness, or distraction by other causes.
I would be skeptical of anything we’ve just assumed is American that came about from the New Deal.
I’ve got a couple full agencies in my crosshairs, and I’m excited about that.
Sure, its going to be a disaster, and I’m empathic about people losing other civil rights they have gotten used to that this court is going to re-evaluate, but I’m glad I can leave and that my particular causes will give me the openings I want.
Most of the New Deal was gutted by the courts in the 1930s and 1940s and everything else that remains from it just has never been challenged, mostly from a lack of inspiration, lack of awareness, or distraction by other causes.
I would be skeptical of anything we’ve just assumed is American that came about from the New Deal.
I’ve got a couple full agencies in my crosshairs, and I’m excited about that.
Sure, its going to be a disaster, and I’m empathic about people losing other civil rights they have gotten used to that this court is going to re-evaluate, but I’m glad I can leave and that my particular causes will give me the openings I want.
> Out-of-network doctors may ask patients to sign a form that waives their protections.
What prevents this from becoming standard practice as a part of all the other stuff you have to sign?
What prevents this from becoming standard practice as a part of all the other stuff you have to sign?
Yeah that looks like a big loophole that is ripe for abuse.
It’s not everyday we hear something good about American healthcare. Kudos to those who worked on this bill!
this push has been going for years now. One decisive factor is how the structure of these systems have been better understood by people outside the system and outrages across the country erupted, people are getting more educated on the matters, thanks to the Internet in many ways, social media has its benefit in also fast spreading genuine information and facilitate healthy discussions.
kudo to everyone who has contributed to this incredible outcome indeed.
I think as the understanding of the health system continues to spread, it will become more and more difficult for certain unethical practices to survive the backslash.
I think as the understanding of the health system continues to spread, it will become more and more difficult for certain unethical practices to survive the backslash.
Seriously.
Isn't it only relatively recently they've even had to show us prices? And so draw attention to the $15 bandaids, etc?
(I've never had any actual hospital stays while living in the US so have never seen a receipt, and so don't know the progression)
Isn't it only relatively recently they've even had to show us prices? And so draw attention to the $15 bandaids, etc?
(I've never had any actual hospital stays while living in the US so have never seen a receipt, and so don't know the progression)
You have always been able to see that, even before ACA I remember seeing itemized healthcare provider bills with inflated figures.
It just so happened that the meteoric rise in healthcare costs came to a head when the social media and the internet was also blowing up.
Even without the internet, it was still well known enough to be a sufficiently important political flashpoint to actually result in Affordable Care Act passing. But I remember Clinton debating about healthcare costs in the 90s on national TV, it just had not effected sufficient number of voters yet to become a big enough issue.
I also assume it has something to do with baby boomers reaching the age where they start experiencing healthcare costs and so you have a huge portion of the US population gaining experience for the first time of how much money they will have to spend on healthcare.
It just so happened that the meteoric rise in healthcare costs came to a head when the social media and the internet was also blowing up.
Even without the internet, it was still well known enough to be a sufficiently important political flashpoint to actually result in Affordable Care Act passing. But I remember Clinton debating about healthcare costs in the 90s on national TV, it just had not effected sufficient number of voters yet to become a big enough issue.
I also assume it has something to do with baby boomers reaching the age where they start experiencing healthcare costs and so you have a huge portion of the US population gaining experience for the first time of how much money they will have to spend on healthcare.
Thanks!
One thing I've always been curious about: what insurance plan, if any, do the rich use in the US? I'm not talking about the 1% but the 0.1%. Let's say, a famous movie actor or singer. Do they use fully non-insurance, out of pocket healthcare for primary physicians and specialists? What about surgeries? I wonder if there is in practice a separate health care system for them.
I’m far from in the .1% but can afford to self insure.
I still carry a high end insurance plan because if I break my leg on the ski slopes I don’t want to end up being triaged into the “indigent” bucket at the ER (this happened to me once, luckily with something less serious than a broken leg). Likewise it’s hard to get into some specialists unless you are in network. This isn’t a case when a call from my primary can’t get me an appointment (that call has gotten me seen even by docs who are “not accepting new patients”) but because the hospital administration doesn’t like cash payers even though they are charged the most.
The real differences lie elsewhere. For example my primary doctor simply doesn’t accept insurance of any sort. I see her, I pay the bill as I leave. She chooses tests and therapies based on whether she thinks they are worth it (risk vs informative value), and has the time to discuss with me. The longest I’ve had to wait for an appointment was once when I called in the morning and couldn’t be seen until the afternoon. She seems to be friends with the heads of various departments of a few local hospitals which cuts through red tape.
The wealthy 1%ers and 0.1%ers have special areas of high end hospitals and various sherpas who can make sure the patient gets the attention they want. I wonder how that system is operating these days in light of what COVID has done to the hospital infrastructure.
Apart from my primary care physician, I’ve had better care from more egalitarian systems in Europe and Australia. Even there though, the informal networks are quite valuable.
I still carry a high end insurance plan because if I break my leg on the ski slopes I don’t want to end up being triaged into the “indigent” bucket at the ER (this happened to me once, luckily with something less serious than a broken leg). Likewise it’s hard to get into some specialists unless you are in network. This isn’t a case when a call from my primary can’t get me an appointment (that call has gotten me seen even by docs who are “not accepting new patients”) but because the hospital administration doesn’t like cash payers even though they are charged the most.
The real differences lie elsewhere. For example my primary doctor simply doesn’t accept insurance of any sort. I see her, I pay the bill as I leave. She chooses tests and therapies based on whether she thinks they are worth it (risk vs informative value), and has the time to discuss with me. The longest I’ve had to wait for an appointment was once when I called in the morning and couldn’t be seen until the afternoon. She seems to be friends with the heads of various departments of a few local hospitals which cuts through red tape.
The wealthy 1%ers and 0.1%ers have special areas of high end hospitals and various sherpas who can make sure the patient gets the attention they want. I wonder how that system is operating these days in light of what COVID has done to the hospital infrastructure.
Apart from my primary care physician, I’ve had better care from more egalitarian systems in Europe and Australia. Even there though, the informal networks are quite valuable.
Thank you, that's very informative! If you don't mind me asking, what would be an example of a high end insurance plan? Is this like a low deductible ("Gold") plan from regular carriers like Kaiser and Anthem?
Since aca I just use a platinum aca plan though I would not choose either of the companies you mention. Kaiser has its own network which defeats the purpose for me while Anthem is…just so terrible a company I will never ever buy from them.
In my experience, they have the same doctors and insurance; the difference is they have their doctors cell numbers and hang out on the weekends. Doctors want the perks of billionaire friends too.
It sounds like a nice day for the US but the comments don't look optimistic. I cannot help to continue to think that we, as humanity, need to remove perverse incentives for critical infrastructure. How can an insurance company, which needs to make profit, have your interest at heart? I am for state Healthcare without insurance and sure, I know a lot of people whine about the quality in countries where they have this, but it seems people whine about stuff in their bubble regardless. They don't actually compare with countries that do not have this. I had a young-stroke (as they called it) when I was thinner and fitter than I had ever been, but I was stressed at that time (company was burning over 1m a month and our biggest clients left; shortly after the 2000 crash). They did not find anything wrong with me and the team of experts (what I had was rare apparently so I am a university case study) spent 100s of 1000s euros of perceived care (where I live now this costs a fraction of that) on me to prove it was not stress. I am sure it was and they could not find anything else. All was practically free for me (total was less than 300 euros for tons of mri's, blood panels, hospital bed and 15 experts visiting me daily) but I cannot get private insurance because of it. Hopefully someone will jump in there as I now have the same chance as anyone of this returning but whatever. It's one of the first exclusion boxes on the form for insurance. In Spain and Portugal I had much better care without insurance; I know people cry how bad it is (see above). As someone who had things (including cancer) I can tell you, it is lovely compared to the nhs or Dutch healthcare; far less clinical, overstaffed, you can have a fecking beer when they told you it's going to be rough etc. And you can view the sea from your bed (where I am) instead of an airconditioner filled wall. It feels just nicer even when you are ill. And that helps making you better I think, at least it helped me. My wife could sleep there 247, screw visiting hours. You just need to know how to navigate the system. The surgeons, oncologists and internists working for the public Healthcare might moonlight for the private ones, but the care is most excellent.
I like the US for obvious reasons; nature, freedom, startups, VCs but without this fixed, I would never consider it and that's a shame. I would love to live with the many people I know there and build companies.
I like the US for obvious reasons; nature, freedom, startups, VCs but without this fixed, I would never consider it and that's a shame. I would love to live with the many people I know there and build companies.
*Out-of-network doctors also must inform patients about what their care might cost, ___________________and they may ask patients to sign a form that waives their protections. (Be leery of signing this, consumer rights experts say.)*
Why is it even possible to have forms that allow dodging laws?
Why is it even possible to have forms that allow dodging laws?
This seems like a step in the right direction. It establishes the principle that the government has a say in healthcare pricing and patients must be held unharmed. Obviously it doesn't cover all cases. But it does bring us closer to a single-payer system or at least a cost-regulated system, which I think is demonstrably a good thing based on its success in other parts of the world, and more importantly, the abject failure of the American system to both protect from financial ruin and provide the best care.
I hope to see the day when nobody avoids care - preventative and acute - due to cost. It costs lives, and in other cases diminishes lives. I avoid care myself, despite having health insurance and being relatively high income, because you can mysteriously get a $1250 "room fee" added onto a $300 bill to stick a camera up your nose for 5 seconds when an ENT casually suggests it, which actually happened to my partner during a simple consult recently (you can buy a similar camera to hook up to a smartphone display for $10). This sort of "surprise bill" and outsized costs for trivial diagnostics with almost no cost to the providers needs to end. When I made less money and had no insurance, I didn't just avoid care, I went without it entirely for years. We should avoid that as a society, it comes with high costs - the cost of more significant care later, the loss of labor force, and the loss of quality of life and family.
I hope to see the day when nobody avoids care - preventative and acute - due to cost. It costs lives, and in other cases diminishes lives. I avoid care myself, despite having health insurance and being relatively high income, because you can mysteriously get a $1250 "room fee" added onto a $300 bill to stick a camera up your nose for 5 seconds when an ENT casually suggests it, which actually happened to my partner during a simple consult recently (you can buy a similar camera to hook up to a smartphone display for $10). This sort of "surprise bill" and outsized costs for trivial diagnostics with almost no cost to the providers needs to end. When I made less money and had no insurance, I didn't just avoid care, I went without it entirely for years. We should avoid that as a society, it comes with high costs - the cost of more significant care later, the loss of labor force, and the loss of quality of life and family.
I were recently in the US for vacation. One of us had to go to the hospital (Thanksgiving - no doctor open). At the hospital, they just did a flut test. Positive result, got tamiflu.
We asked for a bill. They refused. Finally they somehow calculated it and said it was about 900$, we payed. BUT then they send another bill for 3000$ more (guess just for the registration at the hospital), on the bill we payed it was stated that it is not the final bill.
To be precise the insurance payed. But it is obviously a rip off.
We asked for a bill. They refused. Finally they somehow calculated it and said it was about 900$, we payed. BUT then they send another bill for 3000$ more (guess just for the registration at the hospital), on the bill we payed it was stated that it is not the final bill.
To be precise the insurance payed. But it is obviously a rip off.
/me laughs in Canadian
Seriously though, stop trying to patch a broken system... There's a better way...
Seriously though, stop trying to patch a broken system... There's a better way...
A friend once had a an emergency appendix removed and was hit with a $10000 bill because doctor was out of network.
Ridiculous.
Quite often it seems like laws only protect people wealthy enough to hire a lawyer to enforce them.
There have been a few times I got some surprise medic bills. At the time they went to soft collections before I was even notified and even then took 6 months for the first notification. I inquired a out the bill and the agency was firm. I literally told them "there is no fucking way I will ever pay this and I can wait out the 7 years" a couple times. They just disappeared into thin air faster than they appeared.
There is some policy I didn't agree to that allows them to bill me 6+ months later
My policy is your request for payment is denied. Damn the costs
There is some policy I didn't agree to that allows them to bill me 6+ months later
My policy is your request for payment is denied. Damn the costs
Jail time and asset forfeiture are the only real solutions to these problems. (For hospital and govt staff, of course.)
This is just a stop gap solution. Data collection so that the opposition party has less legs to stand on, until there is no further support for it.
The people behind many representatives don’t know or care enough.
This helps more of them know and care.
The people behind many representatives don’t know or care enough.
This helps more of them know and care.
From what I can gather.there is some sinister game hospitals and medical insurance play, but you would think that, oh, I don’t know, it would save time and money for them both to just come up with some agreed upon pricing and save some administrator overhead.