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Tags Affordable Care Act , AHCA , donald trump , health care issues , health insurance issues , obamacare , Trumpcare

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Old 3rd February 2017, 11:13 AM   #441
pgwenthold
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Originally Posted by Skeptic Ginger View Post
The latest lie told by some Congressman last night on the news: the increase in numbers of people covered was because of the improved economy and not because of the ACA.
Obviously. See, the improved economy mainly happened in those states where the governors accepted the medicaid expansion. Just a coincidence that they were far and away states led by democratic governors.

What's the lesson? That GOP governors were detrimental to economic improvement in their states.

Nice to see him admit that.

PS I thought the economy didn't actually improve all that much under Obama?
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Old 3rd February 2017, 01:22 PM   #442
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Originally Posted by xjx388 View Post
You seem to be brushing aside the idea that the USA is a different country with a different population makeup.
We're not Klingons mate. (I stole that line).

Originally Posted by xjx388 View Post
There is no guarantee that in the US, prevention+treatment for all = less money with better outcomes. And better outcomes is debateable. What criteria? This has been argued about in the literature for awhile now.
What literature? This isn't a gotcha, I just want to see the citations. If the literature is aimed at clinics, insurers or doctors, it might be biased.

Originally Posted by xjx388 View Post
How do you require people to attend these things? You can't find them or jail them obviously. So what if they don't go and don't listen?
Delicious pizza with a salad center and fat-free ranch? A doctor's order for paid hours off so they get out of work to attend? Change is often incremental. Years ago no one wore seat belts, now everyone does.

Originally Posted by xjx388 View Post
I don't see it as me stigmatizing anyone.
I know that.

Originally Posted by xjx388 View Post
Let's take smoking for example. It's a completely voluntary activity that everyone knows is very bad for your health.
Yes, and it ALREADY requires a higher premium so it's not the best example. It is based on the honor system BTW.

Originally Posted by xjx388 View Post
The sad fact is that any ill effects are indeed "your own damn fault." Same goes for the diets some people eat and other lifestyle choices that are bad for your health.
I recognize the personal responsibility thing, but I also see the interplay of many confounding factors. For one thing, obesity is a medical condition in itself. I have an uncle who got up to 400 pounds and developed Type 2 diabetes. When it became clear that lifestyle alone was not going to fully relieve his condition, maybe bariatric surgery would have been cheaper for all.

Originally Posted by xjx388 View Post
I don't find the "people are fallible" argument very convincing. How far should we take this argument?
All the way.

Originally Posted by xjx388 View Post
No need for lifestyle police. Answer a few questions, take some lab tests, get a physical. You'll still get insurance but you'll pay for your risks. Incentivize healthy lifestyles.
People who fell short would have a black mark on their record forever. The potential for abuse is enormous if we go back to the bad old days like Congress wants.

Originally Posted by xjx388 View Post
If you have more auto accidents or traffic tickets or if you drive certain types of risky car or if you are young, you pay more for auto insurance. If you smoke or don't pass a physical/lab tests you pay more for life insurance. If you make claims on your homeowners policy you pay more. You pay for your risk profile in the insurance industry.

Keep it simple. Risk.
Risk isn't simple. It's complicated. With health care, the top exposure is practically infinite - different than being burglarized or totaling a car. And it has historically been very difficult to get the information needed for an individual to assess risks. One factor is a pricing structure that nobody understands. In a pool? Appendectomy $7K. Uninsured? Appendectomy $35K. How do you budget for infinite risk? There is an actuary on this thread who questions some of your assumptions and has good data. Be open to that. You want to put it "in a nutshell." Not sure that works

Last edited by Minoosh; 3rd February 2017 at 02:28 PM. Reason: minor fix
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Old 3rd February 2017, 01:24 PM   #443
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Originally Posted by The Don View Post
b-b-b-b-but that would require an awareness of, and a care for, others
The wrong people might get health care and become healthy.
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Old 3rd February 2017, 01:42 PM   #444
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Originally Posted by Shalamar View Post
The wrong people might get health care and become healthy.
They haven't earned it. They deserve to be sick even if it costs me more money.
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Old 3rd February 2017, 01:59 PM   #445
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Originally Posted by 3point14 View Post
I recommend having the government pay for a massive number of scholarships for doctors that ensure the doctors can graduate without debt and contain a rider that they must work for a reasonable rate at a government hospital for, say, seven years after completing their residency.



Just, in the parlance of my US friends, spitballing, really.
We do this already. The Feds have the National Health Service Corp where if you agree to up to 4 years of service, they will pay for up to 4 years of med school. Or you can apply for up to $50,000 in loan forgiveness for 2 years of service. There's also a program where if you work for the government (Fed, state, local, tribal) and make 120 payments towards your loans, they will forgive the rest.
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Old 3rd February 2017, 02:55 PM   #446
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Originally Posted by xjx388 View Post
We do this already. The Feds have the National Health Service Corp where if you agree to up to 4 years of service, they will pay for up to 4 years of med school. Or you can apply for up to $50,000 in loan forgiveness for 2 years of service. There's also a program where if you work for the government (Fed, state, local, tribal) and make 120 payments towards your loans, they will forgive the rest.
Yep, the problem is the bottleneck of only allowing a certain number of graduates become doctors by limiting the number of residencies.

Lawyers only wish we could limit the number of people who passed a bar exam in the same way.
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Old 3rd February 2017, 03:05 PM   #447
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BTW I'm not sure the huge billing discrepancies are still legal. The point is many patients have no reasonable baseline for comparison of hospital costs.

ETA: It's ironic that the politician who I think could accomplish UHC might be Trump, if he weren't so combative. Reform is a massive business deal. Properly structuring the transition would be yuge. If he really has the business chops.

Last edited by Minoosh; 3rd February 2017 at 03:20 PM.
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Old 3rd February 2017, 03:07 PM   #448
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Originally Posted by Dr. Keith View Post
Yep, the problem is the bottleneck of only allowing a certain number of graduates become doctors by limiting the number of residencies.

Lawyers only wish we could limit the number of people who passed a bar exam in the same way.
Can't you?
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Old 3rd February 2017, 03:26 PM   #449
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Originally Posted by Dr. Keith View Post
Yep, the problem is the bottleneck of only allowing a certain number of graduates become doctors by limiting the number of residencies.

Lawyers only wish we could limit the number of people who passed a bar exam in the same way.
Wait a minute. Are you saying there are graduates of medical schools who can't become doctors (excluding the ones who choose to do research or management instead of patient care) because there aren't enough residencies? How can that be? Residents are cheap labor. Most hospitals would want as many as they could get. I suspect the real bottleneck is the number of places in med schools; that's why Americans go off to the Caribbean and other foreign schools.
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Old 3rd February 2017, 03:49 PM   #450
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Originally Posted by xjx388 View Post
Quote:
But it’s important to remember that overall, the contribution of genes to obesity risk is small, while the contribution of our toxic food and activity environment is huge. As one scientist wrote, “Genes may co-determine who becomes obese, but our environment determines how many become obese.” (20) That’s why obesity prevention efforts must focus on changing our environment to make healthy choices easier choices, for all.
This is still not saying fat people should be charged more. Instead of genes as destiny, it's "our toxic food and activity environment" as destiny. We were born into an unprecedented global glut of food, coupled with an unprecedented degree of convenience. It's larger than an individual's willpower, so I would rather not penalize individuals.

This is a crude comparison, but to me blaming a person for being fat is about as useful as blaming a dog for being fat.
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Old 3rd February 2017, 05:39 PM   #451
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Originally Posted by Bob001 View Post
Wait a minute. Are you saying there are graduates of medical schools who can't become doctors (excluding the ones who choose to do research or management instead of patient care) because there aren't enough residencies? How can that be? Residents are cheap labor. Most hospitals would want as many as they could get. I suspect the real bottleneck is the number of places in med schools; that's why Americans go off to the Caribbean and other foreign schools.
Nah. They go to Baby Doc Haitian Medical School because they couldn't get into an accredited program onshore.

I think the residency bottleneck is well documented. Keep in mind that as cheap as they are, they're still paid a lot of money (my wife's 5th year residency salary was $200K), need supervision, need to be insured.

Also: many positions are being filled by people who completed their medical degrees in other countries. They're very competitive.
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Old 3rd February 2017, 09:30 PM   #452
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Originally Posted by blutoski View Post
Nah. They go to Baby Doc Haitian Medical School because they couldn't get into an accredited program onshore.
....
That's why they go, but apparently many still turn out to be pretty good doctors who qualify to practice in the U.S., which might support the argument that U.S. medical schools are too small or too restrictive. I dunno what to do about residencies.
https://www.nytimes.com/2014/08/03/e...ed-school.html

Last edited by Bob001; 3rd February 2017 at 09:32 PM.
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Old 4th February 2017, 10:18 AM   #453
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Originally Posted by Minoosh View Post
<snip>

Change is often incremental. Years ago no one wore seat belts, now everyone does.

<snip>

States passing laws that made seat belt use mandatory kinda helped things along, though.

As did the Feds making seat belts required equipment in every car.
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Old 7th February 2017, 11:10 PM   #454
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Originally Posted by Minoosh View Post
Can't you?
No. I guess we could make the test harder, but they will just study more. We don't have a good way to limit the number entering like residences do.
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Old 9th February 2017, 09:41 AM   #455
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Originally Posted by Minoosh View Post
This is still not saying fat people should be charged more. Instead of genes as destiny, it's "our toxic food and activity environment" as destiny. We were born into an unprecedented global glut of food, coupled with an unprecedented degree of convenience. It's larger than an individual's willpower, so I would rather not penalize individuals.

This is a crude comparison, but to me blaming a person for being fat is about as useful as blaming a dog for being fat.
A dog can't choose it's food; they eat what's available. Dogs in the wild aren't fat and I don't think it's possible for wild dogs to get fat. Wild humans, on the other hand . . . well, we see where we are now. Humans have choices. We choose to make our lives easier so we don't have to move around much to get things done and we are capable of creating food that is tasty. Those are our choices. I don't read the way the article uses the word "environment" as meaning some natural habitat we have no choice but to succumb to. We do have choice, we just make bad ones.
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Old 12th February 2017, 02:24 AM   #456
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A case study of why U.S. health care costs are out of control:
Quote:
After his recent herniated-disk surgery, Peter Drier was ready for the $56,000 hospital charge, the $4,300 anesthesiologist bill, and the $133,000 fee for orthopedist. All were either in-network under his insurance or had been previously negotiated. But as Elisabeth Rosenthal recently explained in her great New York Times piece, he wasn't quite prepared for a $117,000 bill from an “assistant surgeon"—an out-of-network doctor that the hospital tacked on at the last minute.
https://www.theatlantic.com/health/a...l-debt/381163/
https://www.nytimes.com/2014/09/21/u...cal-bills.html
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Old 12th February 2017, 02:49 AM   #457
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Related to the above, the NY Times ran an extensive series about why health care costs vastly more in the U.S. than anywhere else in the world. Short answer: No regulations.
http://www.nytimes.com/2013/06/02/he...enditures.html
http://www.nytimes.com/2013/07/01/he...the-world.html
http://www.nytimes.com/2013/08/04/he...mple-math.html
http://www.nytimes.com/2013/10/13/us...le-breath.html
http://www.nytimes.com/2013/12/03/he...-tops-500.html
http://www.nytimes.com/2014/01/19/he...omes-soar.html
https://www.nytimes.com/2014/04/06/h...-in-bills.html
http://www.nytimes.com/2014/07/03/he...-It-Hurts.html
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Old 15th February 2017, 09:50 AM   #458
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There is now a lobbying campaign to bring back lifetime limits.

Quote:
Dye plans to come to Washington next month to lobby in favor of lifetime limits. He’ll target the delegation from South Carolina, his home state.

Dye believes lifetime limits will allow insurers to offer more affordable plans, which would appeal to the low-income workers who typically use his company’s plans. He understands there will be trade-offs for families like the Morrisons, but, he says, that’s true with any policy debate.

“You cannot design something that is going to solve every individual’s problem or situation,” he said when asked about what would happen to those who especially intense medical needs. “It can’t be unlimited or else you will have a tragic circumstance; a child will circuit the math for everyone else that is trying to operate within actuarial parameters.”
Seems like you could these death panels.
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Old 15th February 2017, 10:02 AM   #459
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Originally Posted by Stacko View Post
There is now a lobbying campaign to bring back lifetime limits.



Seems like you could these death panels.
Of course. They are just appealing to the tyranny of the majority. The sell is that we get cheaper insurance, and MOST of us don't have to worry about maxing out. So they want most of the people to support it.

And what about those who will suffer? **** em. They are just a small fraction, so who cares what happens to them.

They are emboldened by the lack of compassion and common decency demonstrated by the American electorate.
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Old 15th February 2017, 11:17 AM   #460
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Originally Posted by Bob001 View Post
I would refuse to pay for the assistant surgeon if it wasn't clearly disclosed to me that he/she was out of network and why their services were even medically necessary. In any case, Medicare and most insurances pay an assistant surgeon at 16% of the regular surgeon. So, if it was medically necessary to have one and they disclosed to me that they would be present, I would negotiate a rate at 16% of what the surgeon got paid by my insurance. If they refused, I would tell my surgeon he either finds an assistant that is in network or I will find a surgery team that will work with my insurance.

It's also worth noting that the surgeon for a herniated disc surgery isn't getting paid anywhere near $116,000 by the insurance company. It's probably around 50 - 60% of that.

What happened in this case is abuse. It's like going to the grocery store and being told your grocery bill is almost double because they automatically added extra stuff at the end. We shouldn't tolerate it but we also have to be informed consumers.
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Old 15th February 2017, 11:21 AM   #461
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Originally Posted by pgwenthold View Post
And what about those who will suffer?

ER departments obliged to provide treatment with little to no hope of remuneration?
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Old 15th February 2017, 11:22 AM   #462
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Originally Posted by Bob001 View Post

Every single US healthcare invoice I see is negotiated down (increasing the number of heads that the healthcare industry has to pay for)

The discount? Between 20 and 80%. Some of the attempted charges are just plain scandalous.
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Old 15th February 2017, 11:36 AM   #463
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Originally Posted by xjx388 View Post
I would refuse to pay for the assistant surgeon if it wasn't clearly disclosed to me that he/she was out of network and why their services were even medically necessary. In any case, Medicare and most insurances pay an assistant surgeon at 16% of the regular surgeon. So, if it was medically necessary to have one and they disclosed to me that they would be present, I would negotiate a rate at 16% of what the surgeon got paid by my insurance. If they refused, I would tell my surgeon he either finds an assistant that is in network or I will find a surgery team that will work with my insurance.

It's also worth noting that the surgeon for a herniated disc surgery isn't getting paid anywhere near $116,000 by the insurance company. It's probably around 50 - 60% of that.

What happened in this case is abuse. It's like going to the grocery store and being told your grocery bill is almost double because they automatically added extra stuff at the end. We shouldn't tolerate it but we also have to be informed consumers.
Did you read the links? This is apparently a typical practice. The patient -- who, after all, is in the hospital because he's really sick -- gives unknowing permission for this stuff in the stack of papers he has to sign. We can't be informed consumers if the information we need is concealed. And unless you're terribly unlucky, you might have major surgery a couple times in your life. Hospitals deal with this every hour of every day. They are the experts, and they routinely sue people who don't pay up.

Unlike many consumer purchases, health care is an urgent necessity. A patient doesn't get to decide whether or not he needs cancer treatment or a heart bypass. The providers hold all the cards.

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Old 15th February 2017, 01:42 PM   #464
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Originally Posted by Stacko View Post
There is now a lobbying campaign to bring back lifetime limits.



Seems like you could these death panels.
Originally Posted by pgwenthold View Post
Of course. They are just appealing to the tyranny of the majority. The sell is that we get cheaper insurance, and MOST of us don't have to worry about maxing out. So they want most of the people to support it.

And what about those who will suffer? **** em. They are just a small fraction, so who cares what happens to them.

They are emboldened by the lack of compassion and common decency demonstrated by the American electorate.
Lifetime limits are more important for smaller insurance companies than for larger ones. The incidence rates are low, but if you don't have a large enough underlying pool of covered lives, they're potentially disastrous to the company. I know there's a tendency to cast insurance companies as evil money-grubbers, but at the end of the day if a small number of extremely large claims forces a company into insolvency, all of their policyholders are at risk of not being covered.

That said, the impact varies by state. *Most* states had pretty large minimums on lifetime maxes prior to ACA, so for *most* states, the impact of making them unlimited was marginal. Not negligible, but not nearly as large an impact on price as most of the other elements of ACA. For example, my states all had a minimum of $2,000,000 lifetime max. It's pretty hard to get to that level, and most of them are extension of terminal life situations - persistent life support for people who are otherwise dead. My personal view is that we should not extend life in that way int he first place... but that is my opinion, and is heavily based on my own beliefs of what constitutes compassion.

Aside form that blanket *most*, there were previously some states with extremely low lifetime limits for their individual market, where ACA's removal of those limits would have had a much more significant impact on price. I don't have as much sympathy for those states as they might like.

At the end of the day, this isn't a straightforward issue. It's not just cost, there are social implications as well. It intersects heavily with social views on end of life treatment and medical ethics. It's not black and white.
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Old 15th February 2017, 01:49 PM   #465
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Originally Posted by Bob001 View Post
Did you read the links? This is apparently a typical practice. The patient -- who, after all, is in the hospital because he's really sick -- gives unknowing permission for this stuff in the stack of papers he has to sign. We can't be informed consumers if the information we need is concealed. And unless you're terribly unlucky, you might have major surgery a couple times in your life. Hospitals deal with this every hour of every day. They are the experts, and they routinely sue people who don't pay up.

Unlike many consumer purchases, health care is an urgent necessity. A patient doesn't get to decide whether or not he needs cancer treatment or a heart bypass. The providers hold all the cards.
There have been a lot of cases lately that center around the anesthesiologist for surgeries. I believe there've even been some discussions of legislation on it.

Here's the basic situation: A policyholder schedules a surgery. They receive prior approval for the surgery, at a contracted hospital facility, with a contracted in-network surgeon. From the perspective of the policyholder, they've done all the right things and been as responsible as they should be expected to be. Post surgery, they find out that the anesthesiologist (who they did not choose and had no interaction with prior to the day of the surgery) was not contracted, and gets billed as out of network. Surprise!

It is my opinion that all ancillary practitioners involved in the service are the responsibility of the facility. If the patient does their part by making sure that both the surgeon and the facility are in-network, then the patient shouldn't be held responsible for the supporting practitioners that they had no say about, and in many cases no prior knowledge of. If the facility provides an out of network anesthesiologist or assistant surgeon, the financial impact of that should be on the facility.
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Old 15th February 2017, 02:23 PM   #466
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Originally Posted by Stacko View Post
A question here. What would be the impact on the health care industry if the federal government indemnified insurers against unlimited costs in exchange for controls on the prices providers could charge? Something like "We'll cover all the costs above $1 million ($2 million, whatever), provided that you do not pay providers more than the Medicare-approved fees (or some suitable percentage above them)." In other words, trade loss limits for price controls. This is not too different from what other countries do when their systems provide universal coverage through private insurers. Possible? Practical?
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Old 15th February 2017, 04:05 PM   #467
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Originally Posted by NoahFence View Post
I hear this term a lot and can't quite wrap my head around it. What's the cliffs notes version?
One version is mentioned in my signature.

Other options are probably more appropriate for the US.
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OECD healthcare spending
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Every year since 1990 the US Public healthcare spending has been greater than the UK as a proportion of GDP. More US Tax goes to healthcare than the UK
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Old 15th February 2017, 05:28 PM   #468
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Originally Posted by Bob001 View Post
A question here. What would be the impact on the health care industry if the federal government indemnified insurers against unlimited costs in exchange for controls on the prices providers could charge? Something like "We'll cover all the costs above $1 million ($2 million, whatever), provided that you do not pay providers more than the Medicare-approved fees (or some suitable percentage above them)." In other words, trade loss limits for price controls. This is not too different from what other countries do when their systems provide universal coverage through private insurers. Possible? Practical?
The problem is getting the providers to agree.

As long as providers can simply say "no, I'm not going to accept that payment, and I won't contract with you for that low a rate", it won't work.

Now, if the government indemnified insurers for those excess costs*, AND also dictated payment rates that providers were obligated to accept, that would be peachy. Heck, if the government simply dictated the rates that providers were obligated to accept, there wouldn't necessarily be a need for that indemnification.

*FYI, there's actually a term for that: reinsurance. There's even a whole industry built around reinsurance - insurance for the excess risk that insurers take. It's kind of meta in a very geeky way.
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Old 15th February 2017, 05:32 PM   #469
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Originally Posted by Dr. Keith View Post
Yep, the problem is the bottleneck of only allowing a certain number of graduates become doctors by limiting the number of residencies.

Lawyers only wish we could limit the number of people who passed a bar exam in the same way.
Actuaries manage this by constantly tinkering with the exams. If the pass rate is too high, they make it harder the next round; if it's too low they make it a little bit easier. Keeps us in short supply and high demand. It's very lucrative for me!


ETA, I have no idea how I ended up bounced back several days for the post I was looking at.
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Old 15th February 2017, 09:09 PM   #470
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Originally Posted by Emily's Cat View Post
The problem is getting the providers to agree.

As long as providers can simply say "no, I'm not going to accept that payment, and I won't contract with you for that low a rate", it won't work.

Now, if the government indemnified insurers for those excess costs*, AND also dictated payment rates that providers were obligated to accept, that would be peachy. Heck, if the government simply dictated the rates that providers were obligated to accept, there wouldn't necessarily be a need for that indemnification.

*FYI, there's actually a term for that: reinsurance. There's even a whole industry built around reinsurance - insurance for the excess risk that insurers take. It's kind of meta in a very geeky way.
Well, a lot of providers take Medicare, which generally means accepting Medicare rates. Insurance companies could say they will only include in their networks the providers that will accept the established rates, which is basically what they do now, except the insurer sets the rates, not a government agency.

And I understand the concept of reinsurance: Companies share the risks among themselves. But the costs are ultimately paid by the insurance companies. I'm talking about a system where the government would tell insurers "No patient will ever cost you more than X as long as you don't pay providers more than Y."
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Old 15th February 2017, 09:44 PM   #471
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It's actually pretty simple: make it illegal to add on extra services insurance doesn't cover without the patient's explicit consent. Since this practice is pretty much how Medicare defines fraud and abuse it isn't much of a stretch. For example, doctors and hospitals aren't allowed to bill patients for services they don't pay for unless the patient signs an Advance Beneficiary Notice form which spells out the cost and why Medicare won't cover it. We still have to bill it to Medicare with a code that tells Medicare that we notified the patient. They deny it and we can collect from the patient. If we fail to disclose with an ABN, it is fraud/abuse to bill the patient.
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Old 16th February 2017, 12:48 AM   #472
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Originally Posted by xjx388 View Post
It's actually pretty simple: make it illegal to add on extra services insurance doesn't cover without the patient's explicit consent. Since this practice is pretty much how Medicare defines fraud and abuse it isn't much of a stretch. For example, doctors and hospitals aren't allowed to bill patients for services they don't pay for unless the patient signs an Advance Beneficiary Notice form which spells out the cost and why Medicare won't cover it. We still have to bill it to Medicare with a code that tells Medicare that we notified the patient. They deny it and we can collect from the patient. If we fail to disclose with an ABN, it is fraud/abuse to bill the patient.
When a hospital patient is handed that form with other paperwork, particularly in an emergency, does he know what he's signing? And if he doesn't sign it, can the hospital refuse treatment? Does he also sign some kind of blanket form that says something like "I authorize such care and treatment as the hospital deems necessary?" It sounds like there's plenty of room for some shady business.
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Old 16th February 2017, 01:08 AM   #473
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Originally Posted by Bob001 View Post
When a hospital patient is handed that form with other paperwork, particularly in an emergency, does he know what he's signing? And if he doesn't sign it, can the hospital refuse treatment? Does he also sign some kind of blanket form that says something like "I authorize such care and treatment as the hospital deems necessary?" It sounds like there's plenty of room for some shady business.
When my cat needed emergency care I signed anything they put in front of me without reading it all carefully and getting on the phone to my solicitor to get her to check it over! If it was me or a relative or friend I'd sign anything to get the treatment needed, and worry about the bills afterwards - which seems to be what actually happens in the USA as well.
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Old 16th February 2017, 01:12 AM   #474
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Originally Posted by xjx388 View Post
It's actually pretty simple: make it illegal to add on extra services insurance doesn't cover without the patient's explicit consent. ...snip...
Your partner is giving birth, the care etc. is part of your insurance package so you are happy with the cost. Sadly during birth there are unforeseen life threatening complication for your partner and baby, are you really going to say that the hospital must immediately provide you with an agreement that covers what they will now do and indicate what won't be paid for your insurers so you can sign it before they try to save the lives of your partner and newborn?
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Old 16th February 2017, 01:31 AM   #475
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Originally Posted by Emily's Cat View Post
There have been a lot of cases lately that center around the anesthesiologist for surgeries. I believe there've even been some discussions of legislation on it.

Here's the basic situation: A policyholder schedules a surgery. They receive prior approval for the surgery, at a contracted hospital facility, with a contracted in-network surgeon. From the perspective of the policyholder, they've done all the right things and been as responsible as they should be expected to be. Post surgery, they find out that the anesthesiologist (who they did not choose and had no interaction with prior to the day of the surgery) was not contracted, and gets billed as out of network. Surprise!

It is my opinion that all ancillary practitioners involved in the service are the responsibility of the facility. If the patient does their part by making sure that both the surgeon and the facility are in-network, then the patient shouldn't be held responsible for the supporting practitioners that they had no say about, and in many cases no prior knowledge of. If the facility provides an out of network anesthesiologist or assistant surgeon, the financial impact of that should be on the facility.
To defend anaesthetists as they are called in the UK it is worth remembering it is they that make the surgery possible, they keep you alive whilst the surgeon is poking around (pretty literally in the case of neuro-surgery - not one of the most delicate specialities). You probably want to pay your anaesthetist pretty much what you pay your surgeon. i grant there are easy anaesthetics for easy ops in well people, but the you should not be paying a surgeon much either.
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Old 16th February 2017, 01:34 AM   #476
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Originally Posted by Bob001 View Post
Well, a lot of providers take Medicare, which generally means accepting Medicare rates. Insurance companies could say they will only include in their networks the providers that will accept the established rates, which is basically what they do now, except the insurer sets the rates, not a government agency.

And I understand the concept of reinsurance: Companies share the risks among themselves. But the costs are ultimately paid by the insurance companies. I'm talking about a system where the government would tell insurers "No patient will ever cost you more than X as long as you don't pay providers more than Y."
This is even an issue in the NHS. The NHS has local health providers, in a small population e.g. an island or rural area, a single expensive patient can bankrupt the provider, so they have to go to central government / national NHS to get special funds - a form of re-insurance.
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Old 16th February 2017, 01:51 AM   #477
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Originally Posted by Emily's Cat View Post
Lifetime limits are more important for smaller insurance companies than for larger ones. The incidence rates are low, but if you don't have a large enough underlying pool of covered lives, they're potentially disastrous to the company. I know there's a tendency to cast insurance companies as evil money-grubbers, but at the end of the day if a small number of extremely large claims forces a company into insolvency, all of their policyholders are at risk of not being covered.

Given that it is entirely unacceptable for there to be any such thing as a 'lifetime limit', I interpret the above as meaning that some insurance companies just can't afford to be in the healthcare business.
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Old 16th February 2017, 04:51 AM   #478
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Originally Posted by Planigale View Post
To defend anaesthetists as they are called in the UK it is worth remembering it is they that make the surgery possible, they keep you alive whilst the surgeon is poking around (pretty literally in the case of neuro-surgery - not one of the most delicate specialities). You probably want to pay your anaesthetist pretty much what you pay your surgeon. i grant there are easy anaesthetics for easy ops in well people, but the you should not be paying a surgeon much either.
The issue isn't the cost of the anesthesiologist, but who pays for it.

Here in the US we have private insurance, and most insurance companies have a "network". The network consists of people contracted by the insurance companies who agree to charge a certain amount to any patient using the insurance. When you submit a claim to the insurance companies, they will provide full reimbursement if you used an "in network" provider, the insurance company pays. If you use an "out of network" provider, you pay. (And like everything else in American health care, details vary widely. The point is that if you go out of network, you owe a lot more money out of pocket.)

So, a common problem is that you go to your doctor, who is in network, and get a test done. You pee in a cup, but the doctor doesn't do the test himself. He sends it to a lab. Well, the lab is out of network, and you pay the full bill for the lab work. You didn't choose the lab. You didn't know what lab was being used. No one asked you anything about labs. But you get a $400 bill in the mail, and you have to pay it out of pocket for something you thought was covered by insurance. If the doctor had chosen a different lab, it would have been.

The same thing can happen with the anesthesiologist. You go to an in network hospital using an in network surgeon. You're covered. Except that they use an out of network anesthesiologist, and those guys aren't cheap.
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Old 16th February 2017, 12:52 PM   #479
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Originally Posted by Bob001 View Post
Well, a lot of providers take Medicare, which generally means accepting Medicare rates. Insurance companies could say they will only include in their networks the providers that will accept the established rates, which is basically what they do now, except the insurer sets the rates, not a government agency.
Well, yes and no. Many providers take Medicare, but many don't. And of those that do take Medicare, most of them will only take a certain volume of patients at Medicare rates - they expect significantly higher rates for their commercial aged patients. There's a degree of cost-shifting that occurs in the US with respect to Medicare and Medicaid pricing.

Currently, the insurer's don't "set" the rates (if we did, they'd be a LOT lower than they are ). It's a negotiation. The providers, especially hospital-based groups, have a lot more negotiating power than you might realize. There are many regions where there is only one hospital in a given area. To be an insurer, you have to be able to prove geographically appropriate access to care... so there's not really a choice. If the insurer wants to be licensed to sell coverage in that area, they *must* have that hospital in their network. Then you get the really large provider organizations where hospitals and physicians have banded together under one umbrella - there are many cases where those provider organizations have near-monopoly power over the marketplace.
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Old 16th February 2017, 12:56 PM   #480
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Originally Posted by Planigale View Post
To defend anaesthetists as they are called in the UK it is worth remembering it is they that make the surgery possible, they keep you alive whilst the surgeon is poking around (pretty literally in the case of neuro-surgery - not one of the most delicate specialities). You probably want to pay your anaesthetist pretty much what you pay your surgeon. i grant there are easy anaesthetics for easy ops in well people, but the you should not be paying a surgeon much either.
I don't disagree with the importance of the anesthesiologist, not at all. It's the impact to the customer when the anesthesiologist is out of network (so the patient is responsible for virtually the entire billed cost) but the facility and the surgeon are in network (so the patient pays only a portion of the discounted cost). Especially since in many cases, the patient isn't able to select their anesthesiologist, and has no reasonable way to verify that they are in network.
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