The Company Behind Many Surprise Emergency Room Bills
nytimes.com
nytimes.com
This is ludicrous! I have insurance, & still this will completely drain me financially. I'm at the point where I almost think it would be easier to declare bankruptcy and start over!
This is exactly why Congress should not be exempt from any health care legislation. They need to go through this also, so it can be fixed.
(the Gold plans are closest to other federal government provided health insurance...)
Of course, many members of Congress are quite wealthy and wouldn't be much more than annoyed by a bill in the tens of thousands of dollars.
Also, if you read your insurer's fine print, you'll find that they will only pay out-of-network providers to some limit that they and the provider agreed to. Even in an emergency situation, you will foot the bill for the delta.
The out of network doctors were resolved the fastest for us, and the longest was the hospital stay itself, which our insurance didn't agree to pay until 8 months after the stay. It was a seriously draining experience, and luckily my wife doesn't work so I didn't have to take time off for all the phone calls and following up that was required.
I don't fault our insurer. The hospital charged more for our one night stay than another slightly further hospital recently charged us for three nights stay. It was completely ridiculous. But completely out of our hands.
I've had to deal with that and more in the last couple years. In my experience there are no "good" or "bad" guys in this fight. It's a bunch of individually rational entities that when taken as a whole are completely fucking over the rest of us.
This.
This is so horrifically true, it takes call after call after call (and emails, and faxes, and snail-mail claims forms that take "30 days" to "process") to get anything changed, and by then you have collections companies harassing you and your credit goes down the drain. Meanwhile you must keep working and taking care of family and dealing with the actual illness/issue that led to the medical visit in the first place. It is insane.
He fractures his pelvis into 14 pieces, and broke another dozen major bones including both femurs.
The surgeries are still ongoing although he is mostly himself again. But even two years later, he is facing a daily barrage of calls, being put on hold, no callbacks, paper shuffling, records from hospital to hospital, faxing permission sheets, fighting with the insurance company (who has threatened to drop his insurance multiple times) and on top of it all, his landlord is trying to evict him.
It's been horrible to watch. It's like the insurance company is trying to kill him with stress.
A health insurance company, no less.
Is it a 'won't happen to me' sentiment? Preferring the freedom of literally landing on the streets with one accident since you're presumably fully in charge? I do not understand, though there must be an understandable reason.
I think the only reason anyone can think it's OK is (1) they haven't had a major medical expense yet and (2) their political tribe tells them capitalism is the answer for everything.
Honestly, healthcare in the US is so broken I don't see how we avoid a crisis in the next few years because of it. Maybe it will somehow pop like a real estate bubble (sad when that's the most optimistic thing you can hope for).
That sounds horrific. What sport was this?
If you take an ambulance to the emergency department, see a doctor, they order a scan, the scan shows appendicitis, and your appendix is subsequently removed, this can easily lead to six different bills:
- Ambulance
- Facility
- ED doctor
- Radiologist
- Surgeon
- Anesthesiologist
So, yes, if you refuse to be transparent in your billing and you extort money from your patients by refusing them treatment unless they agree to pay literally anything for service, you are a "bad" person.
Sounds like dental care in Canada.
I'm told this came about because historically more people had to pay for dental services out of pocket, so dental offices were used to having standard fees that they could just look up.
Apropos of outliers, this type of attitude is problematic and emblematic of issues in the US.
"Needing healthcare" is not "abusing medical insurance".
There are of course shitty doctors, but playing devil's advocate for a minute: you were arguing about theoretical billing scenarios while there were other patients in line waiting to be seen. So it's not exactly surprising that he got fed up and kicked you out.
Apparently, states are unable to restrict entry into state benefit programs such as healthcare. They can't set up a waiting period for people moving into the state before they are eligible; that was declared unconstitutional by a previous Supreme Court. So if states were to do their own single payer system, in theory sick people could move into the state and immediately gain free healthcare simply by virtue of being a resident. Conversely, they could then move back to their home state that doesn't charge higher taxes.
So it wouldn't be feasible on a state-by-state basis unless a future SCOTUS reverses their precedent. This is unlikely in the short term, given the current Court's make up.
Which isn't to say that single payer wouldn't be an improvement on the current system. Just don't get your hopes up for how much money it'll save.
No, we don't. Medicare is not single payer, though it has (for a subset of the services covered by Medicare) a default public option; it also has private, partially-public-subsidized pland; Medicaid, at least in many states, is not single-payer, either, even at the state level, even before considering overlap with Medicare and other insurance.
The cost side works in every other developed nation? Surely you're aware of how much more expensive health care costs are in the US, so what might you be referring to?
There are other effects as well - nobody is getting away with billing $600 for a 5 minute visit, for instance.
Government programs set maximum reimbursement rates and also mandate cost accounting mechanisms to assure that actual reimbursement is not merely within pre-set rates but also justified by actual provider costs. The government isn't buying services with no advance information about what the charges may be.
Private insurers impose similar controls.
So single payer (or even universal coverage through private insurers) eliminates the particular kind of “robbery” from undisclosed charges being discussed.
There's no free market in healthcare. They are selling services without providing prices... it completely breaks any market that might exist.
And it takes a state license for them to operate. The state could require them to provide an accurate and up-to-date price menu in order to remain in business.
I think the problem is also related to the opaque negotiated prices that "in network" providers negotiate with insurance companies, driving up the cost for uninsured or "out of network" consumers.
There are perfectly rational solutions short of single-payer.
Curious, can you perhaps provide evidence of this? Seems like a good thing to know.
> Call an attorney.
This is itself a cost, and maybe only makes sense if you owe ≥ $10k but for procedures billed as $1k when they should be $400 I don't think warrants the cost and time of an attorney; what other recourse is there except to pay?
I agree that an attorney only makes sense if you're facing a significant bill. On a smaller bill I would go to the hospital billing department and negotiate.
You can of course negotiate as well.
If someone bought a car or house, they knew their obligations exactly. If they declare bankruptcy, I would lay some fault with them, if not all.
But with medical billing, you cannot get a straight answer. If they cannot tell you what a simple procedure would cost you, then you don't owe them anything.
Also hopefully if enough people don't pay surprise bills, then medical industry would have motivation to simplify their systems.
I agree, I do, which is why I tried making my statement as much a question as possible. I am unaware that attorney's would fight for cases like this, if they are more common and do not lead to lawsuits.
I don't get this statement. Not protecting your credit score can cost you real money. Yeah, the whole thing is a racket, and I frickin' hate it, but, pretending like you can ignore your credit score without impact seems counterproductive.
I would really rather see this whole racket of a medical billing system held to account versus advocating that we allow them to punish us in any way for not playing their fraudulent game.
Despite this, I have been able to get a car loan, I got a VA loan for a house, I have opened two credit cards (which I use responsibly) since then, and also was able to get a personal loan for an emergency six years ago. It is absolutely possible to do "normal" things. It's just been a matter of explaining the situation.
Clearing errors involves a byzantine maze and way too much time in an era when everything is digital. There should be stringent regulation around accuracy and we should all have free year-round, real-time access to our credit scores.
But, my point here is not that you can't live a normal life with a few credit dings. It's that those dings represent punishment that can impact you. For instance, you may not have gotten the best interest rate available on your subsequent credit. So, we should be advocating an end to these fraudulent medical billing practices vs accepting punishment from them, then trying to live with it.
BTW, I predict Verizon will soon be the target of some hefty class-action. They are very shady when it comes to contracts. They also have periods wherein substantial numbers of customers report mysterious, frequently dramatic data overages for a time [0] that suddenly disappear. But, they refuse to acknowledge any issues.
And they specialize in making it extremely difficult to achieve resolution, with multiple phone calls, etc.
[0] https://www.wirelessweek.com/news/2016/09/thousands-verizon-...
My perception is that the problem is typically framed as a lack of insurance problem for financially challenged people, but the "abuse" on the billing side to me seems like at least as big of a problem. And if this is being conveniently ignored, it feeds my conspiracy thinking that the Democrats are actually largely indistinguishable from Republicans - they may wear a different mask, but their actions are only slightly different, in this case altering who is getting robbed.
Public option is a great solution, because it does not prevent the people who prefer (and can afford) to pay for private services from doing so.
And that is counting Lieberman as a D; a person who backed McCain for president and who later personally killed the public option.
I do think we will get to the public option at some point. It just makes too much sense not to and would strengthen the healthcare as a whole while allowing people more choice.
And then watched it get blown away by next congress as soon as the GOP gained 51 seats to do whatever they want. Blowing away the fillibuster is an awful, terrible, no good idea and there is almost no legislative agenda which would validate it.
And to be clear, the GOP senators were and still are slimey bastards for basically everything they did leading up to Gorsuch. It should have never been done. They will almost certainly regret it as soon as they lose the senate.
Source: http://voices.washingtonpost.com/ezra-klein/2009/12/the_deat...
By contrast, Lieberman single-handedly killed the public option.
But that's not always the case - Neil Gorsuch was confirmed by a vote to suspend the 60 vote rule. So the rule is available for things that a strong party consensus.
https://www.nytimes.com/2017/04/06/us/politics/neil-gorsuch-...
No, as your source accurately states, he was confirmed after a vote to abolish the rule for Supreme Court nominations.
Both sorts of actions decrease the power of individual senators. If anything, abolishing for a whole category reduces senator's power more - if you also read the article, the basic point is the action indeed altered the power dynamic, what those considering individual senator power are worried about.
However, it remains the case that in 2009, 59 senators were ready to vote for a public option, but there was no 60th. By contrast, there were nowhere close to even 50 votes for removing the filibuster and changing to a 50 vote threshold.
Please do not miss the fact that Lieberman had no rational justification for opposing the public option and that one of the keenest observers at the time accused him of being "driven more by a pathological dislike of the liberals who dogged him in 2006 than by any remotely rational policy judgment." http://voices.washingtonpost.com/ezra-klein/2009/12/lieberma...
Those are the facts. You are laying emphasis on the one person who wouldn't vote and I'm laying emphasis on the 51+ wouldn't take take stronger action.
I think it's reasonable to give my emphasis given the way the Democratic Party has behaved over time.
I suppose that voters could have hypothetically had a positive reaction to the public option once actually set up, and rewarded Democrats for it in subsequent elections. But I doubt it. Although Medicare already exists, the public option would represent a significant expansion which would probably come with serious growing pains - plenty of material for Republicans to make horror stories out of. Probably fewer actual cases of huge premiums (which are already not that common), but it's not like statistics have ever been much barrier to politicians and their preconceived narratives. I guess the GOP wouldn't have been able to weaken the law through a constitutional challenge, as they did with Medicaid expansion - after all, the public option can't be unconstitutional unless Medicare is. But the Supreme Court is highly political, and I wouldn't be surprised if the law ended up being weakened some other way by a 5-4 majority...
But politically, Republicans would have a stronger alternative to offer: ACA without the public option. Y'know, the thing they currently portray as the root of all evil; I think they'd have ended up seeing it as a good conservative compromise, that preserved universal coverage availability without requiring the government to be involved directly. Arch-conservatives might not like that outcome (then again, they might) - but they'd likely accept it as an intermediate step, that still accomplished the substantive change of repealing a huge government program (the public option). It would be much easier to get consensus on than the repeal-in-name-only bills they're tossing around in the real world.
I suppose I'm getting way too speculative; the last two paragraphs aren't even directly related to the nuclear option, although they're meant to question the upside of Democrats hypothetically having deployed it. There would've been serious downsides, not just in health care; it's quite possible the 60 vote rule would end up being killed entirely rather than only for 'special' bills, so Republicans in the current Congress would've been able to pass a wide variety of their priorities, and repeal a wide variety of Democrats'. (For all I know you might support the Republicans on their other priorities, but the Democrats whose votes we're talking about certainly didn't.)
A suspension is both procedurally (or textually) more complicated (it either requires changing the rules twice, changing the rules to add a suspension provision and then acting separately to exercise it, or changing the rules to include a tailored exception that applied only to the case at issue) and more politically fraught (rather than publicly defending the case that the general rule is outdated, it requires legislators to defend that the rule is generally valid but should not be applied to the immediate case.) It's very much not the same thing as abolishing the filibuster for a well-defined class of cases.
This is particularly true in the Gorsuch case where the recent Democratic action to remove the filibuster from other Presidential appointees made applying the “nuclear option” to Supreme Court justices much less “nuclear” than it had seemed previously when it been considered.
1) Indian Health Service - the US agency tasked with providing and paying for Native American health care on reservations or "health service areas". http://www.richheape.com/american-indian-healthcare.htm
How does single payer fix that? If the hospital gives you a bill and won't negotiate down, how does the government "fix" this? Which is kind of what my question is: were specifics given in the ACA on how that problem will be fixed?
On national health insurance (monthly cost depends on your salary but for an average person it is a few hundred bucks per month) the hospital pays 70% and patient pays 30%.
It means basic visits to the doctor or dentist are very cheap here. Like $20 for consultation + medicine. ER+X-rays and MRI (appendicitis, sigh) was a little bit over $100.
If anything, the billing abuse is a much, much larger problem than lack of insurance. At least, that has generally been true since the ACA/"Obamacare" changes passed.
Socializing this theft turns it into Just Another Crisis among the hundreds of others the US has.
The "true" purpose of the ACA was to do something about spiraling health care costs. What was passed was a "compromise" where the people pushing for a public option got nothing and the most onerous restrictions on the monied interests were rolled back. This has not been an effective solution in many senses. I decline to further characterize the issue, however; this is extremely close to a political discussion, and those are ban-worthy here.
I would not put too much weight on conspiracy theories though. The healthcare system is massively complex. It will take multiple reforms to eat this elephant.
My thought experiment for some of this. Suppose the US government had a rider on every insurance policy in the US that said the government would pick up the tab for any amount over say $100,000 (think catastrophe insurance). Now, you would make the assumption that looking at the actuarial tables this would reduce the cost of health insurance because no insurance company is on the hook over $100,000 (thus no need to worry about the million $ payout).
I am more and more convinced that hospitals would screw this up with over billing for every damn thing and every visit requiring a stay would get jacked to > $100,000.
We have a solution. It is called "make it a personal criminal liability". Go after individuals. No matter how low they are on a totem pole and no matter how high they are on a totem pole. Committing such fraud should lead to bankruptcy ( all assets wiped out ) and jail time.
You would be amazed how quick those "accidents" and "mistakes" stop happening.
Unfortunately, as the society we do not want to throw Suzi the billing clerk into the slammer, which means that Mike, the Billing Manager, does not get a slap on the wrist, which in turn means that Jack, the VP of Billing Revenue Optimization, does not get Jackie his wife go bananas on him when their bank accounts, house and kids college fund is seized which means that Jack is represented by the public defender and ends up in a slammer together with Suzi, who actually pushed the buttons, Mike, who told Suzi to do it, and Jack, who came up with this wonderful idea.
The provider must set a high sticker price so that they can give the insurer the expected 60-80% discount to get in-network (and still tolerate underpayment and other shenanigans). The consumer is either intentionally misled or confused (usually both) about basically everything cost-related, and often won't learn the true out-of-pocket cost of a service until ~1 year after receiving it, when the billing process has (mostly) finished.
Example: just yesterday I got a new bill for a routine lab test I received in December. It says that the insurance discount applied, but they never sent a payment, and thus I owe a balance of over $200 to the lab company. Now I have to call the insurer to figure out why they denied payment, which is sometimes due to an administrative error, sometimes a paperwork thing like signing a document that verifies there is no other possible insurance carrier whom may have been responsible for the bill, etc.
Obamacare is thus anything but up front, because honestly working to fix the American medical system would involve excising market-breaking, paper-pushing leeches from the marketplace, but Obamacare props up this destructive apparatus by forcing every American to pay in or get fined.
Almost any economist will say this is one of the largest problems with US health care costs and employment mobility.
Every employer outside of the health insurance and drug industries should be furious at the price they pay to pay their employees health benefits. Besides having a distraction that operating businesses in other nations don't have, they're likely paying more than double than what they need to in this area to maintain competitiveness against other nations. It's even worse for startups.
It also probably should have used subsidies instead of Medicaid expansion. Expensive, but a bunch of healthy people would have been good for the exchanges (Medicaid expansion almost by definition was for healthy working people).
http://www.cnbc.com/2015/11/20/obamacare-architect-high-dedu...
The previous administration was working to move to different payment models to try to address it (it's not clear that the different models will have much long term impact):
http://www.reuters.com/article/us-usa-healthcare-reform-idUS...
Any number of effective cost-saving measures could be passed that would have the effect of increasing your premiums.
As for the increase premiums are up 25% in 2017 alone. At the same time deductibles are also rising, its much more money for much less coverage if you are unlucky enough to make over 50k a year or so.
http://fortune.com/2016/10/25/obamacare-insurance-premiums-2...
https://www.brookings.edu/wp-content/uploads/2016/07/Fall201...
It's remarkable that premiums didn't rise more under the ACA, despite how many new previously-uninsurable people were covered.
If you're paying for your own insurance, you're in the individual market, which is significantly more expensive, and what you're seeing is, in part, the market absorbing the cost of guaranteed issue, something we decisively did not have before the ACA, when health insurers could lock people out of coverage on suspicion of a medical condition, and later rescind care. Pre-ACA and post-ACA insurance is for that reason also not an apples-apples comparison.
Regardless of the cause, it's extremely frustrating to be hit with such a large monthly bill for rather poor coverage. I'm not quite as bad off as 0xbear, but we're at $1550/mo for a family of three for much crappier coverage than we had a few years back.
Here in Phoenix we've seen double digit increases every year for years, and are down to a single provider on the individual market.
Paying $18k/yr before you even use a plan is insane. Use it at all and you're looking at $20 or 25k total, with coverage limits not really kicking in to stop the bleeding until you've shelled out 30k or so.
Somebody making $80k/yr just hits the subsidy payout and is spending 20-40% of income on health care. Unsustainable.
Argue the whys all you want, these sky high rates have to change.
If you don't argue the whys, you're mostly providing a lot of noise that is convenient cover for the next attempt to bilk insured people.
Yes, premiums are way too high. They are not high "because ACA", though. In fact, they'll rise at a much faster rate if we get rid of ACA. (The latest bill had an annual rise of $11.4K for a single male adult >62 years, with an annual income of $12K.)
There's no question ACA is broken, and we need to fix it. But we need to know and understand what is broken to fix it. A repeal won't do that.
There's a good argument to be made that e.g. enforcing cost transparency would do that. (Right now, you have no idea what insane cost your provider will charge you - they make shit up as they go). Single payer is one possible way to do that. Not the only one.
There's another good argument to be made that we need to talk about the right to die. Numerous patients are kept alive at insane costs, even though they would rather live out the last few quiet moments at home, with their family.
There's another good argument that for a decent risk pool, everybody needs to be insured. (This is an argument that stands little chance until being insured is actually somewhat affordable)
There's a good argument to be made that Medicare should be allowed to actually get competitive bids. (Right now it's rejected to "pilot projects" and "test markets").
There's a good argument to be made we need to focus much harder on preventative care. Follow-up costs from acute episodes are much higher than a decent investment in preventative care.
There's a good argument to be made we should talk about our test and prescription obsession. The amount of stuff unnecessarily prescribed "just in case" is ludicrous.
None of these will immediately lower rates. But each day we spend wasting on the theatre that is the junk the current GOP tries to ram down everybody's throats is a day they rise. And should this pass, they'll rise tremendously.
If we don't all inform ourselves as to the why's and then hold our representatives feet to the fire using well-formed arguments, so they can't weasel out, we're stuck with a shitshow. So, while I understand the frustration - I've got health care bills too, after all - an attitude of demanding change without informing ourselves what change to ask for leads to an even worse disaster.
And that feet-to-the-fire thing applies to all parties, in case you were thinking I have a particular partisan view. But it needs to be an informed roasting, or we'll merely end up with the loudest guy making the good sounding promises.
I'm ranting against those who continually tell me "it's not that bad", "suck it up", "you're lucky you have insurance" or some variation of the above.
The first step in fixing the problem is to recognize the problem, and there's many I've talked with that reflexively reject the premise that there is a problem in the first place because of what that means for the ACA.
The foundational issue is that we're stuck in an uncanny valley between single payer and private insurance. Either single payer or private could be viable, but not the unholy menagerie we have now.
The high costs, over prescription and under prevention that are bloating the system all driven by that issue and could be solved with a single arbiter that gets the bill, whether that be the government or the citizen.
The best proposal I've seen is a two-tier system like Germany has, with public healthcare for all and private healthcare available for the rich. That tends to rub Americans the wrong way because fairness, but really solves most of the problems because it gets universal coverage to spread the risk pool while accepting the natural impulse to want to pay for better care if you can rather than rejecting that option out of hand like some single payer systems do.
I lol'ed. Because... we already have private healthcare for the rich, we just don't have public healthcare for all. Because fairness ;)
And I'm very much enamored with the German system as well, but then, I'm biased. I'm from there. (And currently pondering going back there, because as much as I love what the US could be, I hate what it currently is)
Is the actuarial and outcomes data corpus of the health insurance industry so bad that it makes actuarial sense to segment the markets to individual, medium group, large group, etc.? I've always wondered what the explanation is for so many cohorts.
Are state insurance regulations preventing medical insurance providers using more sophisticated risk modeling to create larger pools, or co-marketing with life insurance companies that gather pretty detailed data on individuals before underwriting?
Especially post-ACA, there are very strict limits on what factors can be used to set premiums. Risk-based assessments are basically outlawed except for a few defined variables like age and smoking habits.
The NHS costs about £3,500 a year per person.
Without adjusting for inflation, this growth is ~60% growth in 6 years, or a doubling time of ~9 years. After adjusting, it's more like 40% over the same 6 years or a doubling time of ~12 years.
That's why factcheck should not be used to check... facts. Just as they claim the RNC have twisted this and that to make themselves looks better factcheck is twisting things here as well, to make someone else look better. Health insurance providers had raised premiums in anticipation of the vote and the legislation passing. So it's specifically important to look not at 2010 when it was signed into law but a few years below when there was this uncertainty about it. One way market deal with uncertainty is to hedge their bets. "Not sure what will happen, but this might pass, and why don't we just raise the rate now" kind of idea.
I've heard this directly from the health insurance representative who came and told us told us, "sorry but rates are going up sharply because we anticipate this new legislation".
But they did during 2009. By July, a number of bills were already approved by committees in the House. And the Fall is usually when the companies get prices for the next year. So it went up sharply then. Then in again in 2010. Price is not always comparable because the level of coverage had also changed. We had to get new plans and while they covered some mandatory free procedures and didn't have lifetime maximum, they had also bigger deductibles and a reduction in options and procedures covered.
That doesn't mean we'll find a larger jump there, I found it for my self, but the KFF study shows there wasn't in general. However discarding date legislation has passed is also dishonest as factcheck did. Companies which are affected by regulations monitor them closely and adjust to them correspondingly.
So you could have the impression that you had "cheap insurance" as long as you never need to have significant healthcare paid for.
The very year ACA took effect my health plan was canceled, my doctor went off-network, my new plan had 3x the annual premium and has grown 30% year over year, as have deductibles, and I fight tooth and nail every single charge to make sure it is in network and covered.
Yes, one anecdote is not data. But there is no more validity to the politician's lie that I can "keep my health plan, keep my doctor, and health care costs will go down."
Same here, and I hear the same exact story from most people I talk to. Plans dropped, premiums skyrocketing. Here in Phoenix we've got a single insurer left, and we'll see if we have anybody next year.
What I haven't seen is stories of average joes who were substantially helped by ACA. Sure, if you didn't have coverage before by cost or pre-existing condition, or get subsidies now, maybe you're happier. But the vast middle class, not so much.
So there's a face for you, 32 year old, healthy, middle class, white woman who likes cats, rides horses, and has a pet bearded dragon who she talks to in a baby voice can get regular cancer screenings because of ACA.
Post-ACA, I could once again buy health insurance.
I consider no longer being locked out of the US medical system a substantial help.
Consider also the not middle-class recipients of medicaid expansion.
Something like 80,000 Floridans lost that policy because it didn't carry the minimum services under ACA/Obamacare. But it wasn't just losing the policy, they were never able to afford the new blue cross blue sheild policies, having to purchase from a new insurer most of whom had reputations as fly by night operations (many not existing before ACA and shutting down 1 and 2 years in), and finally losing the good BCBS network.
Here is a copy of the actual letter sent out by BCBS when they had to cancel the policy: https://www.floridablue.com/blog/my-policy-being-canceled-no...
If that's the case, then the difference between Democrats and Republicans is that the Dems want to insure the poor while still ensuring high profits for the industry, while the Republicans want to screw the poor while ensuring high profits for the industry. They differ on one very important issue, but are still mostly the same.
Actually reducing medical costs requires a far more thorough overhaul of the system.
Also: this idea that the "Democrats are the party of the people" and the "Republicans are the party of corporations" is pretty silly.
The Republicans are a conservative political party. The Democrats are a coalition of blacks (~25%), latinos (~10%), women (+10% share), labor unions, and urban (but not suburban) college-educated whites. Liberals are an important component of the Democratic party (and have no home whatsoever in the GOP), but they don't run the table.
Republicans can't win the numbers game so they hammer home on right wing populism. Unfortunately, the last 30-40 years hasn't been kind to the "Main Street" centrist republicans of the past.
It hasn't been like this since LBJ. Both parties are completely driven by corporate lobbies. All that differ are the excuses why.
Probably the most important realization for the average American in the current political climate is how no party establishment represents you. Both have their sponsors, and none of them are the American people. Individual politicians might have more empathy than others and some might try to help the common man more than another, but they all still have their bosses and despite whatever rhetoric we throw around in almost every election (aside the scant few in contested states and counties) the people are not holding their leash, so they don't work for you.
It is like climate change. It doesn't matter how you want to argue about solving it, it is simply acknowledging the reality that has to happen first and moving on from there on a unified foundation of fact.
A lot of people forget that the GOP does not, as a political party, believe in universal coverage. Moving the country closer to universal coverage is not a GOP political objective. What is a GOP objective is minimizing federal interference and involvement with business. Health care is something like 15-20% of the entire economy, so the GOP's stated objectives run directly counter to universal coverage.
And yet, repeated efforts to eliminate the ACA have all retained policies built around universal coverage, including a massive federal expenditure in Medicaid (block granted or otherwise) and an extremely intrusive regulatory requirement for guaranteed issue insurance, something that only Ted Cruz has tried to push back on.
If that's not a win for the Democrats it's hard to imagine what plausible outcome would be. Nothing that involves 15-20% of the American economy will be simple, or will happen in one legislative session.
It only makes sense to at least postulate that the converse is true as well: if you find yourself stuck out-of-network, it's because these regulations created an environment where the insurance companies could do better by eliminating the providers it partners with. So it's reasonable, at a first approximation, to guess that this problem is the result of ACA.
We need a single payer system because, at the societal level, it makes sense for government to make sure people get their healthcare needs met for the same reason it makes sense for government to provide police and fire protection. But forcing all Americans to get private health insurance makes no sense and indicates a fundamental misunderstanding of what the insurance industry does.
Direct Primary Care, single payer and wellness programs all have a good track record of genuinely getting people healthier while bringing down costs. Obamacare cannot do any of those things and just runs expenses up.
Source/qualifications: Among other things, I worked in insurance for over five years. I have a certificate from a technical college in life and health insurance, paid for by my former employer.
Have you been watching anything that's been happening with the healthcare debate over the past, oh, 25 years? The Democrats have been trying with varying degrees of success to inch this country in the direction of a more sensible healthcare system and the Republicans have pitched a generation-long hissy fit about it.
It's been that way for decades.
On the coverage side, the two parties have contrasting stances.
Healthcare and Health Insurance are related but distinct topics.
I'm actually not sure the BHCA or AHCA or whatever it's called now has much in it besides slogans and major spending cuts which aren't aimed at making care less expensive -- they're aimed and reducing the overall amount of care provided by shifting costs to those less capable of bearing them.
That's a pretty big contrast.
Cost of healthcare, other than the occasional conversation about drug prices and definitions of necessary care (which continues to be abused by practitioners), continues to take a back seat.
For what it is worth, my personal opinion is that the medical professional lobby is a single issue voting constituency that is just as powerful as the NRA and the teachers unions.
Until then, I will continue to believe democrats and republicans serve the same master and only differ in language to provide an illusion of choice.
What a terrible industry.
The employees at an insurance company have an ethical responsibility to the company to deny any claims that do not perfectly align with the policy they sold. I don't think every insurance company is the antagonist in The Rainmaker or the car company in Fight Club, but insurance companies will try to reject as many claims as they can, straddling the line of losing reputation with consumers.
the health insurance industry shouldn't exist.
I am with Kaiser now and it is the most BS free medical experience I have ever had. To fix healthcare without single payer the government should just make a law that medical insurance can only be offered by hospital chains and the doctors and specialists cannot bill insurance separately, but must be paid by the hospitals. This is how Kaiser works. That way the hospitals can pay a fair market rate to doctors and not have them demanding a surprise emergency room rate from distressed patients.
If I had been on Blue Cross Blue Shield, I probably would've sucked it up given my super high deductible and navigating the in-network maze.
My biggest complaint about the medical industry is the cost of prescription drugs. It's ridiculous how much we pay for drugs in this country.
It's not terribly expensive either. I just started COBRA and it is $750 a month or so.
I'm glad I don't have an HMO, as I'm not organized, and tracking down referrals and such would be a nightmare for me. I've never found a doctor that isn't in my network, so I just figure out which doctor is closest to me and isn't a hack and schedule an appointment. I live a couple of miles from Northwestern University Medical, and Rush University Medical Center, and they've got almost any type of doctor you could possibly need to see.
I don't think my PPO is complicated, but I've never found technical documents that hard to understand. Most of the complications seem to be for emergency and urgent care, but office visits are as uncomplicated as I've made them seem. Some types of lab work might cost more, but I've never been charged for any diagnostic tests outside of cat scans and MRIs.
Since the ACA, there has been an emphasis on shifting from a fee-for-service model (FFS) to a value-based care model (VBC). Under a FFS model, doctors and hospitals are paid for each service they provide and make their profit from the margins built into the prices they charge for their services. In an ideal VBC world, doctors and hospitals are paid a certain amount for each patient they cover, and don't make additional revenue when they provide services to patients.
You can immediately see the incentives in each model. In a FFS world, doctors and hospitals are incentivized to give you the most care possible at the highest possible prices. For example, you could see how a doctor could be motivated to give a patient an unnecessary MRI. In a VBC world, the best-case scenario for the doctor is that he never sees you, and that you never enter the hospital. Each time you receive care, he spends time and money providing that care, but doesn't get paid any additional money for it. In other words, his margins decrease when he provides care (or, as those in the industry think about it, his medical loss ratio increases). When you become sick, the doctor would prefer that you seek care in a setting that is as low-cost as possible - via telemedicine, an urgent care center, or his office. That way, he keeps more of the monthly premium.
Practically, though, in the VBC world, the doctor probably wants to see you once or twice a year, to make sure you are healthy and that you are taking preventative measures to avoid becoming sick and utilizing healthcare. That investment of resources can help reduce your need for healthcare in the future, protecting his profit margin going forward.
So in a perfect VBC world, everyone's incentives line up. You spend as little time in the hospital or at the doctor as possible, and check in every once in a while to make sure you are healthy. Doctors and hospitals make more money when they don't have to treat you, and want to keep you out of the healthcare system.
The problem is, the current system is a mix of FFS and VBC. Most hospitals and doctors aren't compensated on a fully capitated basis (capitation is a concept that, in layman's terms, measures how close the system is to VBC vs FFS - more highly capitated = closer to VBC). Under FFS, doctors don't make much money providing preventative care, so there is no incentive to keep people away from the hospital. Unless you are a member of a system like Kaiser, you are most likely covered by a plan that is partially capitated - your insurer may share profits over a certain % with your doctor as a reward for keeping you healthy, but still pays for services on a FFS basis. Often, this profit sharing does not compare with the potential revenue from providing additional acute care services, so the old FFS incentives are still at play. (Hence the $600 1-minute consultation.)
Now, wouldn't it be great if every health system operated like Kaiser, where all the incentives are aligned and the objective is to keep people out of the healthcare system? Yes, but the answer is not as simple as requiring healthcare systems to provide insurance. In fact, Kaiser is one of the only success stories involving provider-sponsored health plans (Presbyterian in New Mexico is another).
The reason why many of these provider-sponsored health plans fail is twofold:
First, most healthcare in the US (70% I believe - but that is from memory) is provided by regional or community healthcare systems. These systems only serve certain communities (their primary service area, or PSA) and therefore certain populations. These populations are often not of significant enough size to provide adequate risk diversification for healthcare systems that provide insurance plans. One of the key reasons insurance works is risk diversification - but these hospitals can't diversify their coverage beyond their community's population. In fact, one of the most common criticisms of Kaiser from the investor community is that its membership is too concentrated in California - and Kaiser has over 10 million members on the East and West coasts.
Second, these systems often don't have the capability to price their insurance and healthcare services correctly to account for the levels of risk embedded in their insurance plans. Sometimes that is due to lack of actuarial experience, sometimes that is due to lack of risk diversification causing risk to exceed estimates, and sometimes that is due to existing healthcare prices driving up costs to a level beyond where they can reasonably charge premiums. Also, it is hard for these systems to predict who will enroll in their health plan, and what their overall risk level will be after enrollment season. There are companies dedicated to helping systems operate provider-sponsored health plans (e.g. Evolent), but this has proved to be a difficult problem. For examples of premier systems getting this wrong, look up Partners (they own Mass Gen), Catholic Health Initiatives, Northwell, Banner Health.
While this is a hard problem to solve, and I don't have the answer, you are right that the Kaiser model has in many ways proven to be more cost effective than FFS or other capitated models. It might be a good intermediate step for some of the larger systems. But there is still a lot of work to do to fix the system, and even solutions that sound good on paper have unintended consequences (for example, if you move to a single payer system to reduce prices, would lower drug prices disincentivize pharma R&D, hurting development in the US and the rest of the world? Would medical device companies making prosthetics go out of business if prices decreased below their cost levels? etc.).
Hopefully this was helpful to people who aren't as familiar with the way the system works. A less-than-perfect analogy I often use is:
The old FFS model is a "supermarket" model: the supermarket makes money by selling you as many gallons of milk as possible, and pricing the milk at a premium to their cost. The higher they can price the milk, or the more milk they can convince you to buy, the better off they are.
The current model is a "Costco" model: you pay a recurring membership fee to Costco, and can buy their products at a lower price, but (let's assume) you still pay a slight margin on those products to Costco. So, Costco would love to have as many members as possible paying membership fees - and, in fact, could offer its products close to cost if there were enough members who didn't use the store. But, they would still prefer that members use the store as much as possible, and buy as much product as possible at the highest allowable margin for Costco.
The "ideal" VBC model is a "Netflix" model: you pay a recurring membership fee to Netflix, and can stream any of their videos for free. Netflix starts out the month with its $10 of revenue from your membership, and each video you stream causes them to incur streaming costs and royalty payments, reducing their margin on your $10 throughout the month. From a pure profit perspective, Netflix would love to have millions of members who never used the service, allowing Netflix to keep 100% of their membership fees. However, in order to grow and be successful, Netflix needs members to use and love the service, so it "invests" some of its membership fee by streaming videos to users. If users are going to stream, Netflix would prefer that users stream its proprietary content, which is lower-cost for them to provide. (That last part of the analogy is stretching it a bit, but meant to demonstrate that for the health of the system, some utilization is required, and the provider would prefer that utilization to be as low-cost as possible.)
Mind me asking what kind of work your investment bank does with the healthcare industry?
I am in the opposite camp and don't have the time to write out my position to the extent you did. However, I'd just like to take a moment to point out the ludicrousness of calling something that isn't Fee For Service "Value Based", as if there's anything in the world more "value based" than paying someone for the value rendered in a specific service.
I agree that "value based care" is probably not the best name for a fully capitated system. (Population health might be closer, but still not perfect.) By definition the "value" of something is whatever someone is willing to pay for it. A doctor's reimbursement rate is negotiated with the insurer, so there is an explicit agreement to pay that rate for that service. And by being a member of that health plan, the patient explicitly agrees to pay whatever deductible or copay is required by the plan, based on the rate the insurer negotiated with the doctor. So in a FFS system everyone has actually agreed to pay the price that is charged.
The problem is that as a patient, it is hard to tell how much a medical service will cost before receiving it. In a grocery store, you can look at the price of milk and decide whether it is worth buying. But there are all sorts of reasons why price consciousness is harder with healthcare (for example: emergency care, lack of price transparency, agency issues). And so the idea of value is harder to measure from the patient's perspective, which is why value and price paid may not exactly match.
Then you get to sit in an "emergency room" for hours, when you're physically unable to move, and with your phone dead so you can't even let anyone know where you are. When you're finally wheeled to where you need to be, you're basically dumped in a hallway facing a wall for half an hour, and you're in a wheelchair and so weak that you can't even turn to face anything interesting. I paid about $1000 for that luxury. At that price I'd expect a decent waiting room...
Yes I just needed to vent about that situation. It sucked, especially for a college student. I was hounded for months afterward to pay those bills, because of course when you're throwing up you can pick which ambulance gives you a ride.
Most importantly, most states have laws mandating insurers use in network rates for certain instances of using out of network providers, including in factual instances like you described (i.e. in network hostitals and out of network providers). Seperately, most states have statutes awarding attorneys fees to the insured when claims have been denied in bad faith, like refusing to adjust bills to in network rates when mandated by law.
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My state's bad ass Insurance Commissioner is trying to mitigate this problem:
Surprise billing legislation passes state House of Representatives
https://www.insurance.wa.gov/news/surprise-billing-legislati...
Be sure to call and voice support. Public pressure matters.
Long-term fix is single payer, universal coverage. Remove the (worst) profiteering from our healthcare system (racket).
Please elaborate. How did that happen?
I worked in insurance for over five years. Not this kind of insurance, but it was a kind of health insurance.
a) Get a letter of "medical necessity" drafted by your primary care physician.
b) Call the insurance company and ask about the policies concerning emergency treatment. Don't accuse them of anything. They get cussed out all the time and it will not help you. Be nice and start from the assumption that there must be some mistake.
c) If you make no progress with that, have a lawyer send the insurance company a letter requesting a copy of your records. This sometimes makes them look very carefully at the bill and sometimes is enough to get you whatever benefits you are legally due. Which may not be your wildest dreams of avarice, but may stave off your desire to declare bankruptcy.
If you do have a lawyer request your medical records, expect the insurance company to come back with a form letter stating they need a third party auth. Yes, a lawyer will need a third party authorization to get your medical records, but I wouldn't bother supplying them with one at the start. Just make the request without it and supply it if you really need to. If you get your bill paid because a lawyer wrote them, your lawyer doesn't really need your records. The initial inquiry sometimes gets the claim looked over more thoroughly. I am basically recommending this as a scare tactic.
There are actually a lot of errors made in paying complex medical bills at insurance companies for the simple reason that the claims processor may not see an 8 day hospital stay all that often and may have about 10 minutes in which to look your bill over and decide what is payable before moving on. I had to process 60 claims a day to keep my job. This meant I had minutes to decide what the benefits were and people who were very fast were actively rewarded for it. I often cleaned up their messes and, no, this did not get me promoted or anything, even though it sometimes kept the company out of court because the people were threatening to lawyer up.
Best.
https://nextshark.com/youll-love-what-this-startup-does-with...
Here are some thoughts:
Fixed takes a percentage of the dollar value of tickets that get dismissed and you pay nothing for the service if it is not fixed.
Trying to get money out of an insurance company is sort of the opposite problem, though it gets monetized essentially the same way. Independent adjusters monetize by taking a cut of claims paid. This is basically the same monetization scheme that lawyers use for things like suing someone over an accident: They take a cut of cases they win, and you pay nothing if they lose. As far as I know, independent adjusters only work on real estate related claims, not health claims.
Last I checked, the only people legally entitled to talk to the insurance company on your behalf are your insurance agent of record, a lawyer or an independent adjuster. So, in practice, you would be talking about independent adjusters for the health insurance space. I am not clear that would even fly, legally.
Health insurance is a pain in part because it is very highly regulated. It has to comply with both federal and state laws in all jurisdictions in which it operates and laws for both health companies and financial services companies. Thus, it is subject to both HIPAA (Health Insurance Portability and Accountability Act) and The Gramm–Leach–Bliley Act (GLBA), also known as the Financial Services Modernization Act of 1999. I got annual training in Gramm-Leach-Bliley when I had an insurance job. Furthermore, claims must be reviewed and paid in accordance with various state laws. The company where I worked kept a database of "state exceptions." If you don't know those state exceptions yourself, good luck arguing the matter with an insurance company.
You are talking about a very challenging problem space.
I have had it cross my mind to offer a service helping people file claims with the company I once worked for. Although I haven't worked there in a while and some things have no doubt changed, I probably could help some people get more money out of their policy. But I have never gotten past the idle thought stage in part because insurance is such a pain of an industry, and in part for other reasons.
I went to the ER for a broken hand a couple years ago, got a $450 bill in the mail when I should have just had a co-pay. Called the hospital, they said I had to pay. Called my insurance, insurance company said I didn't have to pay. Got in a three way call with the insurance company and the hospital... The billing specialist at the hospital literally said "Sorry, that's a known billing error!"
I'm generally not a conspiracy theorist, but I've never heard of a medical billing error that was in favor of the patient... If you see something alarmingly high or out of whack (especially if you've done your due diligence, read and understood your policy, and researched covered hospitals) you'd be silly not to fight it.
When US citizens en mass realise they pay three times as much as a country for healthcare that other western countries do, maybe it will change.
Is this considered normal? I honestly think I'll take my chances than pay that much per minute. Of course I'm thinking in ₹ and my current salary in ₹, which must be vastly lower in absolute terms than the average American.
And those in the lower echelon of society economically are those least able to have the time or money to march or lobby for change.
With copays and out of network stuff a lot of people will go bankrupt in case of a serious illness.
By law, those are capped for people with insurance. The maximum that you will have to pay out-of-pocket can be no more than about $7,000, and many private plans set the cap at a lot less.
$7,000 is a non-trivial amount, but it's not a large number of people that both are insured and can't afford their out-of-pocket maximum without bankruptcy.
This is the equivalent of a car payment for the rest of my working life.
It doesn't matter, because that's still capped.
The bills themselves aren't capped. The amount they are obligated to pay is. Insurers make up some of the difference, and the rest is forgotten about. (It's not written down in the accounting sense, because the hospital doesn't necessarily actually treat the entire billed amount as receivable.)
I explained in a top-level comment how this works and why it works this way.
Also worth mentioning, it's been broken for a while (e.g.: ACA is not even broken in yet).
Even with a vanishing middle class, the middle and upper class that remains still have largely great healthcare and healthcare plans, it's the poor who are largely being screwed. Even then, they don't support universal healthcare (it's mostly us hipsters or whatever) because they are still weary of the government and we're still dealing with post-mccarthyism where any sort of government service for the public benefit is socialism.
This is absolutely not true [1]
That's only saying that you'll have bills you can't pay, not that you'll go bankrupt from it. Most (if not all) insurance plans have a maximum out-of-pocket expense amount that's like $10k. Yes, that's more than some middle-class Americans can afford to pay in a year, but it's not enough to go bankrupt over. They just defer paying it until they can afford to.
It's more like $6800 for 2016 and $7100 for 2017. That's the federally-mandated cap; many private plans set their cap even lower.
This is one of the things Obama-care addressed, because before that most bankruptcy's in America where caused by medical bills. I'll see if I can find the article. [1] But with Obama-care going away/being changed this might be a thing again.
[1] "A study done at Harvard University indicates that this is the biggest cause of bankruptcy, representing 62% of all personal bankruptcies. One of the interesting caveats of this study shows that 78% of filers had some form of health insurance, thus bucking the myth that medical bills affect only the uninsured.
Rare or serious diseases or injuries can easily result in hundreds of thousands of dollars in medical bills - bills that can quickly wipe out savings and retirement accounts, college education funds and home equity. Once these have been exhausted, bankruptcy may be the only shelter left, regardless of whether the patient or his or her family was able to apply health coverage to a portion of the bill or not. (Find out what you can do to avoid a financial meltdown when there's a medical emergency. " http://www.investopedia.com/slide-show/top-5-reasons-why-peo...
If I didn't have a comfy software engineer salary, and instead lived paycheck to paycheck, this would've been devastating, even with insurance.
You're right. Of course the private insurance premiums have a negative expected value. Aside from insurance always having a negative expected cash value by definition, private insurance premiums are literally used to subsidize care of Medicare, Medicaid, and uninsured patients.
Insurance was billed ~10k, with coinsurance I had to pay $1,400. This is after the hospital billing in multiple rounds and forgetting to bill insurance on one of them and also forgetting to send the bill to me (which if I hadn't been proactive about following up with would have led to it getting sent over to collections).
I'm assuming I have better health insurance than a decent percentage of the population and I can afford the bill but how the hell can most people? What a terrible, terrible choice for someone to have to make between getting care when they're at their most desperate and avoiding financial ruin
I see USA as a country where, if the car crash didn't kill you, the medical bills certainly will.
http://time.com/4829103/mitch-mcconnell-protest-senate-healt...
This last Saturday, there was a peaceful protest of around 200 people held in DC in front of Congress. One of my friends attended this protest. Around 150 of them were arrested, and then given bullshit charges, like crowding, obstructing, incommoding, or resisting arrest (of what charge were they being arrested for, angering Trump...).*
When you try to "peacably protest", and "redress the government for a redress of grievances" and are arrested, detained for 6 hours, and then given a $25 citation of 'crowding' - what else do you do? Molotov Cocktails? AR-15's?
The answer, unfortunately, is nothing. You keep your job, eat decent food, and live a life under whomever the current 'king' is. And hope to the gods that nothing knocks you down to a lower socioeconomic ladder rung.
* https://www.washingtonpost.com/local/public-safety/police-ar...
If you are unable to enact the change you want from within the system it's because not enough people agree with the change you are proposing.
Welcome to the complexities of Society.
If you don't want to participate you don't have to. Abandon the laws of man and return to the laws of nature. Just remember the law of nature demands conflict be resolved in the favor of the more powerful will. I doubt very much you would fair well.
Because that's some bullshit.
Most of the great social and political progress in western nations has come from mass civil disobedience. You take that away and you begin to stagnate.
This StackExchange answer sums up it up succinctly: https://politics.stackexchange.com/a/16372. I find it immensely saddening; the same goes with the general population's attitude to education (in many countries) or providing housing.
For what it's worth I know a lot of people with private healthcare in the UK with the attitude that the NHS is complete trash (something I very much disagree with) - I fear this sort of mindset is spreading. "Pull the ladder up jack" as they say.
As a data point: the patient satisfaction scores for Original Medicare (government-run) are drastically lower than every single major provider of Medicare Advantage (privately-run).
As much as people dislike insurance companies, people in the US are even less happy with the government-run programs, compared to their private counterparts.
I didn't in my previous comment, because we were talking about the overall public perception, which may or may not be connected to the tangible metrics that we actually want a healthcare system to focus on.
As it turns out, though, Medicare Advantage also consistently outperforms Original Medicare on medical outcomes, and it comes in under-budget for identical coverage. Medicaid options vary much more (and they're different in every state, because Medicaid is administered at the state level), but the equivalent private plans for Medicaid coverage also typically perform much better than the public ones.
Hacker News readers aren't generally in the demographic for Medicare[0], but for anyone who is: there's really no reason to use Original Medicare. Every jurisdiction should have Medicare Advantage plans that cost you the same amount as Original Medicare does, and your experience (and overall care) will be vastly improved.
[0] people over the age of 65, or people of any age who are on dialysis for more than two years, etc.
I'd be interested to see these findings. Do you have links?
As far as Medicare Advantage is concerned, it's not the least bit surprising that patient satisfaction is higher. But I wouldn't go treating that as some kind of referendum on Government-run healthcare:
"Many private [Medicare] plans require no additional monthly premiums, yet the government pays an average of $849.90 in monthly subsidies to insurance companies for a person on Medicare Advantage, according to the Kaiser Family Foundation. That is about 14 percent more than the government spends on people with standard Medicare, according to the nonpartisan Medicare Payment Advisory Commission."
MA was supposed to demonstrate that private insurers could deliver care at lower costs than Medicare, and it hasn't done that. Basically, for every $1.00 the gov spends on a medicare patient, it pays $1.14 in subsidies for an MA patient, with the evidence indicating a lot of that goes straight into the pockets of insurers as profit [2]
[1] http://www.washingtonpost.com/wp-dyn/content/article/2009/10... [2] http://theincidentaleconomist.com/medicare-advantage-cuts-on...
That might be a reasonable comparison if Medicare's claims rates were self-sustaining, but they're not. As I explained in another comment on this thread, private insurers subsidize Original Medicare with their own payouts in claims, and that comes out a few orders of magnitude larger than 14% per Original Medicare patient.
- Try see your GP. Wait 2 weeks until your appointment.
- GP will give a cursory examination and recommend a dietary change, taking ibuprofen/paracetamol, and to come back if problem persists.
- Problem persists. Book in with your GP and wait another 2 weeks.
- GP will actually examine you this time. They may then refer you to the local hospital, and so you should await a letter.
- about 2 weeks later, the a will arrive saying that you should phone up to make an appointment.
- within 8 weeks you should get another letter telling you when your appointment is, which will be within 4 weeks.
At this point you have spent 20 weeks just to get seen by a specialist. And that's assuming everything goes ok. Admin may not update your details, so the letters go to an old (or wrong) address. They may just entirely forget to make an appointment for you. Probably if you try phone them they just won't pick up the phone.
There's a fetishisation of the NHS in this country that protects it from a lot of criticism. Some will say "well you should put up with that because it's free" or some similar rubbish, ignoring that it costs £2200 per person.
None of these issues are restricted to the NHS. Any large organisation will have such issues. But it's utterly frustrating stuff like this that makes me consider going private - I shouldn't have to spend hours on the phone figuring out why I haven't been assigned an appointment despite being referred 3 months ago.
1. Schedule with GP. Say I am in pain. Get in within 2 days.
2. Get a referral to Physical Therapy. Asked if I have any preference where to go. My doctor knows my network and gave me a number of choices that were within network (a number of which were within walking range of where I lived).
3. Call PT office. Schedule an appointment. They apologize that their next opening is a week away. Gladly accept.
Physical Therapy is interesting in that it is semi-free market and rather competitive, so it tends to work a bit better than some other scenarios.
> 1. Schedule with GP. Say I am in pain. Get in within 2 days.
> 2. Get a referral to Physical Therapy. Asked if I have any preference where to go. My doctor knows my network and gave me a number > of choices that were within network (a number of which were within walking range of where I lived).
> 3. Call PT office. Schedule an appointment. They apologize that their next opening is a week away. Gladly accept.
> Physical Therapy is interesting in that it is semi-free market and rather competitive, so it tends to work a bit better than some > other scenarios.
Speaking from recent experience, on Obamacare:
1. Live with pain for 6 months because you know you're not getting out of a specialist's office for less than $750.
2. Cave in when the pain becomes unbearable and see a specialist.
3. Make an appointment for PT with a provider who doesn't take insurance at all, because the transparent pricing means no surprises.
4. Pay out of pocket for PT appointments.
5. Spend the next 4 months getting bills for your one specialist visit. Half of these are coded wrong so insurance won't pay. Spend 2h every week on the phone trying to get it sorted out.
If you talk to whoever does the specialist's billing at any point, you'll find that they're totally unable to estimate the cost of services. You might as well not even try to figure out how much it costs in advance.
1. Schedule with GP, get appointment very quickly.
2. GP has no idea who is "in network" for you and doesn't seem to care very much. They also don't understand the different insurance plans so have no idea if you're covered for certain types of referral.
3. Schedule appointment with a specialist. Ask for up front cost estimate for consultation/procedure given your insurance plan. Unable to answer.
4. Go to appointment anyway as you don't have many other choices.
5. Receive astronomical bill for some obscure billing code that is not covered by your health plan.
6. Spend time calling doctors office and insurer to figure out the situation and try to avoid or reduce bill.
I've experienced the NHS too - for all its flaws, the peace of mind living in the UK from a health standpoint is worth every penny of the associated taxes IMO.
Chronic pain is an extremely tricky phenomena. A lot of US health care been "dealing" with it by handing out opioids and we can see the devastating effect of that. Even a given physical therapist may not be able to help a given patient (assuming some body of some sort could at all).
Similarly, a smart consumer may be able to find a massage therapist with skills in a bodywork subdiscipline that happens to really help them (I favor trigger point and Shiatsu massage after sample a bunch in my area). This is cost effective compared to just about everything and something I imagine someone in UK could find in the larger cities.
Tests are all same day.
It feels to me that we in the West are going ever faster backwards over fairness in issues like education, health and housing. I'm lucky to be well off & healthy enough to not (yet) be affected by a poor performing NHS but I wish we, as a country, would pull together on this - from top to bottom. Unfortunately, I just don't see it happening anytime soon, we seem to be increasingly more divided - religiously, economically, politically - than ever before.
Society feels increasingly like a "Mad Max" movie in operation. This is only going to end badly for everyone. There is way too much "me me me" from all levels. I find it emotionally exhausting to think about.
I don't begrudge anyone who has the means to get private health care from doing so (my girlfriend and many friends do) - so please don't think I am saying nobody should - I just wish there was a more proactive and pragmatic desire to fix the root issues. Of course, I realise I am living in cloud cuckoo land on that.
I should add that I can certainly empathise and can agree with your comment about chronic pain. My father is suffering from sciatica and it has been over a year to get an operation scheduled. This will involve him travelling from Northern Ireland to the Midlands because there is an even longer (multi year) wait to be seen in NI.
I agree with everything you say, except the part about cancer.
Even by European standards, the NHS is actually quite terrible at dealing with cancers - even "routine" cancers (like breast cancer and prostate cancer), let alone rare cancers. The five-year survival rate for prostate cancer in the UK is 55%, whereas in the US it's upwards of 90%. (Prostate cancer is an incredibly treatable form of cancer; for most people, as long as it's detected early and managed appropriately, they will die with prostate cancer as opposed to from it).
Of developed countries, only Japan, Portugal, and Denmark have worse five-year survival rates for prostate cancer.
Prostate cancer may be something of an outlier given the hesitation people have in discussing it. This is something that has only really recently been attempted to be addressed in the UK. Campaigns fronted by comics like Bill Bailey have tried to make it normal to talk about. The British as a society are still so reserved that I imagine thousands die of preventable cancers and diseases simply out of embarrassment.
Edit - I've just had a look at Cancer Research's figures[1], [2] and, using data from 2010/11 - prostate cancer had a UK survival rate of ~84% or so - i.e. nearly the same as the US.
[1] http://www.cancerresearchuk.org/health-professional/cancer-s...
[2] http://www.cancerresearchuk.org/health-professional/cancer-s...
It's looking at people with prostate cancer, regardless of insurance status.
> Prostate cancer may be something of an outlier given the hesitation people have in discussing it.
It's not limited to prostate cancer; for survival rates, the NHS does pretty terribly on almost every form of cancer compared to the US. I picked prostate cancer because it's something that's very treatable - the upper limit is close to 100% for five-year survival, which makes the UK's outcomes that much more unacceptable. But the story is the same for all other common cancers (let alone rare cancers, which the NHS is not optimized as a system to treat).
It's survival rate from point of diagnosis. Obviously, insurance and access will affect whether and when diagnosis occurs, but the effects aren't as simple as just limiting the scope to the insured or not.
https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...
I don't understand the point you're trying to make. [Treatable] cancer isn't the leading cause of death in any country[0], so no matter how good (or bad) a country is at treating cancer, you wouldn't expect that to be visible in the overall life expectancy rates.
[0] Ordinally, cancer is #2, but that includes untreatable cancers, and the tail is very long, so getting better at improving five-year survival rates for cancers won't budge your life expectancy at all, outside of the margin-of-error.
Such survival rates are from date of diagnosis; IIRC, because prostate cancer detected early usually doesn't have interventions that are less harmful than the cancer is likely to be, there's considerable debate about the utility of screening; there has been considerable argument that the US tends to overscreen and over-intervene for prostate cancer.
If the UK doesn't do that and tends to screen in a way that tends to catch less of the less-imminently-dangerous prostate cancers, it would have a lower 5-year survival rate simply by not diagnosing prostate cancer where the diagnosis isn't usefully actionable; this doesn't mean they are actually worse at dealing with it.
> Prostate cancer is an incredibly treatable form of cancer; for most people, as long as it's detected early and managed appropriately, they will die with prostate cancer as opposed to from it
Prostate cancer is very often an extremely non-aggressive cancer with interventions that can have significant negative impacts, which is why, even when it's diagnosed “watchful waiting” or “active surveillance” are often the preferred management approaches; quite a lot of people will die with, rather than from, prostate cancer with no active intervention.
Population-wide 5-year survival rates from diagnosis are probably not a good metric for comparing countries with different screening practices; mortality rates are a better comparison metric, but also don't tell the whole story.
Over-intervention and over-screening are two different problems, particularly for prostate cancer, where screening is low-cost and low-risk. In the US, most cases of prostate cancer do not require invasive intervention if detected early, but they will begin treatment, as well as more regular monitoring of the cancer. When screening costs are low, overscreening is not particularly problematic as long as it doesn't result in overtreatment (which is demonstrably true for prostate cancer in the US)
Again, this is not limited to prostate cancer. The difference is the most stark there because the screening costs and risks are both low, but the UK still does a much worse job at treating breast cancer, colorectal cancer, lymphoma and leukemia, which are the other deadly common cancers.
For all cancers, not just prostate cancer, the US over-screens a small amount, but the UK underscreens by a massive amount, resulting in many people detecting cancer when the window of optimal treatment has long passed. That's the reason that the UK is close to last place among developed countries for five-year cancer survival across all common forms of cancer, not just prostate cancer.
They are distinct but not unrelated, particularly in a system where treatment decisions are highly patient driven, especially for patients with financial means.
But my point is less about over screening than that differences in screening practices naturally produce difference in five-year survival statistics even in cases when they have no meaningful outcone in terms of disease progression, mortality, and quality of life, because more screening will detect more cases of disease earlier, even cases for which intervention would never be clinically indicated. If you do a lot better job at diagnosing cases for which there would never be intervention, you get a better 5-yesr survival rate but haven't done any better at dealing with the disease.
Note that I'm not arguing about whether the UK does deal with prostate cancer well, in fact what I've seen using mortality rates suggest they are a bit worse than the US, though much less bad then you'd think from 5-year survival rates. I'm just staying there 5-year survival rates aren't great metrics for systems that are different in conditions that lead to diagnosis.
I agree. That's why looking at all common cancers as well is important. Leukemia and lung cancer are the opposite end of the spectrum - early intervention is critical for leukemia and most lung cancers. And the UK does a much worse job at treating those than almost all other developed countries, and particularly the US.
So yes, some portion of the difference can be attributed to differences in screening practices, but screening practices are a relevant aspect of the entire system, and screening practices alone can't explain the UK's abysmal record for treating the more aggressive cancers which they do detect.
First: no, the England branch of the NHS is still larger than Original Medicare (~53 million in England compared to 46 million on Original Medicare).
And that might be a reasonable way to interpret the data, except that two-fifths of Medicare patients (and growing) are not on Original Medicare - they use Medicare Advantage, which is privately run. Coincidentally, Medicare Advantage outperforms Original Medicare on medical outcomes across the board, including cancer treatment.
So no, the fact that the US is drastically better at keeping prostate cancer patients alive cannot be explained by the claim that Original Medicare is so phenomenally better that it accounts for the difference.
It's very easy to draw conclusions from statistics. It's much harder to draw correct conclusions from them.
So... less than 1/3rd of what the US pays on a per capita basis? I'd be cool with that...
- Book a GP appointment. Generally get in the same day (costs $20-$80 depending on your GP. I have private insurance that pays up to $38) - GP orders blood tests, these are free. Clinic is on-demand, just show up. Wait times are around 30 minutes. Also prescribes ibuprofen ($5 for 100 tablets) and paracetamol (non-subsidised. $10 for 100 tablets). - GP will assess you and refer to a public or private specialist depending on your preference. In my case a public rheumatologist would have taken around a month to see, so I chose private. This cost $180 for the consultation and $120 for follow-up (insurance paid 80%). - Specialist refers more tests. For me this was an MRI. Public wait times were around 3 months because the machine needed replacement and they'd only pay for serious cases to go to the private clinic. I went private, this cost $1400 (insurance paid 80%). - Specialist orders more blood tests, still free.
And they still didn't find anything conclusive.
Personally I'd like GP visits to be free. They can be for people under a certain income level with the right GP. The public system also needs more funding, but in NZ we spend less per capita on socialised healthcare than the US, and the US has to add private insurance on top of that.
so it is a very hard sell to get more Federal involvement when we have constant stories of VA issues and more available just by searching. throw in rules that actively prevented insurers from making multi state offers and the system was bound to be a mess.
however one of the problems not discussed is that many receive their health insurance from their employers and while this has been going away slowly, this idea like income taxes, tends to remove the cost component from people's minds. you don't see the cost in whole or in large lump sums so its easy to not think about it.
the big hurdle will be convincing people there will be limits of what can be treated. the US infant mortality statistics are one area of exaggeration to the bad simply because to the extent money will be spent to save a newborn that many other system won't
http://www.econtalk.org/archives/2017/06/christy_ford_ch.htm...
The guest is an economic historian who details the historical forces which led us to where we are right now. She also describes a few different, more effective and rational models (not just single payer) which could potentially have existed, but which sadly are, for all practical purposes, impossible to get to now.
Once you have you'll quickly realise that the 'long wait times' narrative is complete propaganda FUD.
Anecdote time: My sister is anaphylactic, when she goes to the ER she is admitted, hooked up, and given epi almost immediately. When my aunt couldn't move her arm one day, she got an MRI, diagnosed brain cancer, and had brain surgery in the same week.
I'm glad to have a system that when you are waiting it's because there are people with more urgent needs, rather than because there are people who paid more.
> Once you have you'll quickly realise that the 'long wait times' narrative is complete propaganda FUD.
This is a decent example of the typical Canadian attitude I was referring to, blind refusal to even acknowledge any issues, such as the well documented long waiting times for non-emergency procedures, as well as the outright refusal to treat ailments deemed "not important enough" by your doctor.
Say I'm sitting around and I finally decide to get pain in my wrist looked at that I've had since I broke it ten years ago. I could see a specialist in less than a week. However, I probably would have had it looked at 7 or 8 years ago if I was in a single-payer system. Maybe I would have had to wait 6 months to see a doctor, but that still puts me about 7.5 years ahead of where I am now.
I know a lot of people who have bones that never healed right because an emergency room visit is going to cost you a fortune whether or not you are insured, so they don't go to the ER because it doesn't hurt 'that bad'. I imagine that is somewhat less prevalent in places with socialized healthcare.
It reminds me of an old joke about things that don't have a listed price: "If you have to ask, you can't afford it." I think that mentality is really prevalent in the US when it comes to healthcare, regardless of how expensive the procedure would actually be.
1. A friend of mine had severe back pains, all what he got from a family doctor was some painkillers and some stories that his back pain due to to weak muscles and he has to exercise more and wait a bit (3-6 months) before he can get some tests done. Anyways he moved to the US and week later made some tests to find that he has cancer in some serious stage. He started treatment but it was too late.
2. Another friend had spend 6 hours in ER with his eyelid cut in half (he got a branch into his eye while hiking).
3. I had some troubles with my daughter in Canada as well, don't want to go into details.
I eventually moved to the US and while healthcare here is outrageously and ridiculously expensive it is still years ahead of Canadian when you have a good insurance.
Anecdotes don't really do anything for us besides give us pointless things to argue about. You need to look at statistics like life expectancy, quality of life, average wait times, unnecessary deaths, etc.
The fact that you have to qualify your final statement with "when you have good insurance" is the whole problem. Before the ACA, that was far from a given, and even if you had good insurance it was too easy to lose. If Republicans have their way, we'll be back in that situation again.
I don't get it when people bring up situations like your #2. I'm sure it really, really sucked to wait six hours in the ER with an injury like that, but is it worse than staying home and trying to treat it yourself because you can't afford to visit the ER? Is it worse than dying from a simple condition because you can't afford to see a doctor?
Your doctor in Canada refusing to give you a referral to a specialist makes comparing these numbers not terribly useful.
> I don't get it when people bring up situations like your #2. I'm sure it really, really sucked to wait six hours in the ER with an injury like that, but is it worse than staying home and trying to treat it yourself because you can't afford to visit the ER? Is it worse than dying from a simple condition because you can't afford to see a doctor?
A system that allowed consumers to inject additional money into the system would increase the budget and managed properly(!), allow more total health care services to be provided to everyone.
Of course, "this will never work, all doctors will just move to the private sector" will be the refrain. Under our current society and so-called legal system perhaps, but put me in charge, I will put mandatory guidelines and levels of service in place, and then when doctors knowingly break the rules because based on history they well know they can do it without punishment, put a few of them in prison for 10 years, and watch compliance magically improve.
Surely even in the actual best in the world, waiting for something that is no urgent simply makes sense and is the only way it can function. Do you expect a hospital to have 5x as many beds and staff as is often required so you can have instant surgery on your non-urgent problem? (i.e. knee replacement)
Of course you wait a little bit while they schedule it in, otherwise it would cost an insane amount of money to have all those resources waiting around for your non-urgent problem.
My experience with "urgent" problems has always been instant in Canada - my broken nose, my brother's separated shoulder and broken legs. Even when I went in a week after being hit by a car I waited all of 5 minutes before a doctor saw me.
The idea that life is unfair and random is not accepted by america.
Black americans oppose any kind of social service that might benefit anybody but themselves including other black americans.
People are people and ignorance doesn't have a color. It has always been like this. Blaming one or the other doesn't actually fix anything and it is also why nobody brings it up any longer not because they are afraid to mention it.
We don't necessarily need socialized medicine. If we just went back to the way things were done in 1970 everything would be solved. The money the government currently spends on healthcare subsidies could buy free healthcare for everyone at 1970 prices.
Life expectancy was a bit shorter in 1970, but not by that much. And most of the increase is due to other factors than healthcare (e.g. the smoking rate has dropped a lot, cars are much safer, air pollution is reduced, etc.) And there have been studies done that show increased spending on health care doesn't really correlate with increased life expectancy.
I don't think that anybody really believes that the mess we've made of billing/paying-for services via insurance + government + hospital/doctor is a good idea. At least nobody who has dealt with it for more than 5 minutes, which is most people over 25.
The problem is that nobody can agree on how to fix it. One side wants to socialize the whole thing, the other side wants to do... something else, I guess. Regardless, neither side has enough power to just do what they want, so we're stuck with this bizarre Frankenstein's monster instead.
Meanwhile it's almost impossible to escape from the mess. You can't just have no insurance and pay for yourself, because they've made the prices for most things ludicrously high and then basically rebated them to the insurance companies.
Actually, it reminds me just a bit of that paraphrase of the Laws of Thermodynamics: you can't win, you can't break even, and you can't get out of the game.
The UK cried and moaned when the NHS was introduced but now (aside from Conservative efforts to "starve the beast" on it) most wouldn't go back for the world (though it could be improved, obviously).
The US has a mentality that it's the best in the world for everything. Even when it's objectively not true (like in healthcare) this colors the debate.
Fundamentalism, basically.
Or maybe fanaticism is a better word.
It's primarily lots of Byzantine rules in small print buried in long policies that few people read and even fewer memorize. If you are lucky and are conscious when you need to use a policy to visit a health care provider, you can bring your policy with you to ensure you follow it, but it's not always that easy. The health insurance company claims they told you how to follow the policy, but they don't make it any easier than they legally have to.
If you skip a rule (like calling your health insurance company before you visit an emergency room), that might violate your policy. If you visit an "out of network" hospital when you should have visited an "in network" hospital, you may be liable for the difference in cost (which is huge due to health insurance distortions in the medical market). If you try to go to a medical specialist without first going to your primary provider (as defined by your health insurance company), they likely won't cover it. There are usually dozens or hundreds of pages of these rules in booklets that you get when you join an insurance policy. If you don't know about / forget about a rule, you are responsible for the costs associated with the violation.
It's easy to unwittingly ask a health insurance question about your policy to the office manager at a doctor's office (who isn't qualified to speak about specific health insurance policies) and getting bad information that you then assume is good.
> Why aren't people marching in the streets?
I think most people see this as a "free market" problem (since 60%+ are covered by their employer-sponsored health insurance), not a political one. ~20% of Americans are covered by Medicare (the retirement-aged national health coverage) or have military veteran benefits, which are generally considered pretty good (unless you listen to political arguments). How would "marching in the street" fix a problem that people have with the "free market"?
The remaining 20% are among the most politically apathetic. We are lucky to get 50% participation of the voting-eligible electorate, even in presidential elections (which have higher turnout than other elections).
I think lots of Americans pride themselves on being stubborn and pretending like painful things aren't painful, then trying to ignore them.
Lastly, I think most Americans simply don't think that marching works. Rural America doesn't march. Urban America only seems to march for generic social justice causes, not for specific policy improvements.
Americans seem to have always preferred so-called "freedom" to social solidarity. It's every man for himself over there in the land of the free.
Media outlets like to publish horror stories because it attracts eyeballs.
Yes they can happen and there are bad actors in the system. But most ER patients either don't pay a dime because they don't have a dime, or their insurance picks up the tab subject to deductible. "In Network" rules specifically don't apply in true emergencies under most plans. Of course if you go to the ER for a runny nose, there may be some pushback.
We have the resources to fix many of these problems. But we won't. The powers that be would prefer lower taxes.
For the rest who aren't, there's a simple reason: services operated by the government tend to suck (or are at least perceived to be so). It is an American tradition to stand in long lines at the Department of Motor Vehicles to renew your driver's license, or to get your vehicle inspected. The TSA exists to inconvenience travelers. Public schools are perceived to be failing (they are in some places; I was lucky enough to get a very good education in public schools) even if they are not necessarily. The Postal Service is not profitable (even if it doesn't need to be...) and there are always lines at post offices. And so on. (typing on mobile, could give more examples but I'm sure others have their own)
Whether these problems are real or not is irrelevant. Americans distrust the government, especially the federal one. You could call it indoctrination, to a degree. Those who benefit from the system are allowed to persuade the populace, even from birth, and are supported by both major parties. (Drug and other healthcare advertising is legal.)
It is also part of our history. The tradition of the US is a distrust of big government. Before the US Constitution was written, we had a federal government under the Articles of Confederation. It was meant to be permanent. The federal government was extremely weak, gave too much power to the states, and ultimately did not work. So the Founders had to go back and try a second time and gave the federal government more power. And that's where we are today...but that feeling of distrust has persisted through the centuries.
So to sum it up: many like the idea of private healthcare not because they have a choice, but because they believe that the government(s) will screw it up worse.
Everybody should know, the health insurance system in the US is fundamentally broken and has been almost since its inception in the early 20th century. The lack of adequate consumer protection, transparency, health systems and appropriate government regulation, in addition to organizational oversight, has lead to a situation where we have poor systems that can easily be exploited. And they are exploited.
What the third party care outsourcing/billing company mentioned in the article (Emcare) was doing sounds like upcoding. They bill the highest cost service they legitimately can to maximize profit. In this case, as a third party billing organization, they both want to maximize the profit for their customer (the hospital system), but also for themselves, as they surely take a cut as a middle man.
Likely, they were operating within the gray area where illegal upcoding has to be proven in a court of law. It is an expensive process, that requires review and comparison of huge amounts of medical records with claims to determine whether the more expensive procedure billed was medically necessary/appropriate, or if it was egregious. That legal process does pan out sometimes in the end, but it can take years and just adds even more overhead.
Coding correctly, fairly and getting reimbursed correctly and fairly is incredibly complex. There are an enormous number of combinations of services (usually represented by codes called HCPCs and CPT codes) and diagnoses (ICD-10... which has 100,000s of codes), as well as all different regulations and scenarios for settings of care (inpatient, outpatient, doctor's office, etc.).
Props go to the hospital system for taking back their coding after they realized what the third party was doing, but the reality is, it was probably financially benefiting the hospital system too.
Every technology that I know of has been tried to address these issues, such as data mining, machine learning, rule-based expert systems, etc. and none of them has addressed the root cause, which is the basic system is fundamentally flawed.
All the politics you see about US healthcare in the news are, in a way, representative of the root problem - how big and complex the systems are now, how much money they represent, and how many interests are involved. We have a tangled web.
I don't know the solution (and many have been proposed).
I doubt the hospital system got anything from it, physician groups usually keep all their revenue from professional services claims - the hospital gets paid whatever they do for their facility claim regardless of what the professional claim pays.
The reason I say that is the article points out another glaring issue - the shortage of ER docs that we are currently facing. I know this first-hand, as I have a family member who is one and is working harder than ever.
Some of these arrangements are to make up for the shortage, and the hospital systems and physician groups are often working in partnership... so it could be there was benefit for both since the hospital system needed coverage for their ER (due to physician shortages), and Emcare is providing the physicians. Without the physicians doing the services in the hospital, there would be no facility claim either...
This is true, and being a mere software developer I'm in the dark on the contents of any of the contracts my parent company has with facilities either.
> The reason I say that is the article points out another glaring issue - the shortage of ER docs that we are currently facing. I know this first-hand, as I have a family member who is one and is working harder than ever.
Insert my standard rant about restricted med-school/residency admissions and cost of tuition here.
Stalemate.
We need to go through Kurt Lewin's change model process - "unfreezing, change, and refreezing" and find something better. It's like, we need agile healthcare or something - fail fast and iterate faster... without costing people their lives or their savings. https://en.wikipedia.org/wiki/Kurt_Lewin#Change_process
There's no technology cure for the insatiable greed of a few. Sad reality.
I don't follow what you're saying. Are you proposing that the root of the problem is that it's a huge, expensive, complex industry, where a lot of people work?
I don't want to go so far as to say all huge institutions have problems like this, but I am thinking along those lines.
Some have proposed simplifying health insurance greatly by running a "single payor" system, where the emphasis is on a single health insurance entity that covers claims for every person in the US. While that might seem like a simplification in terms of process, procedure and organizations, it is very unlikely to happen in the US, and I'm not sure we could even administer that well either.
If you look at other countries that are closer to single payor, maybe say, the British NHS system - even in those countries, private insurance still exists and competes. The NHS does provide care for everyone and eliminates some issues by having a stricter control system, but the quality, availability and timeliness of that care is often called into question.
In the end, being able to dictate quality, access, and affordability (and preventing fraud) comes down to control vs. morals/ethics. Many are vying for control, for many different reasons and this often tears apart the basic industry, while morals/ethics are difficult to maintain.
For example the US Real estate market is 7.4 Trillion, about 2X the size of the health care market with many more players and much more predicable outcomes. Finance and insurance are about the same size as well and are not terribly broken.
[1]https://en.wikipedia.org/wiki/Economy_of_the_United_States#G...
Sarcasm aside: this problem is solved, and it's called insurance. Private entities sell it. The government does it too. It works. We just need to make sure everyone actually has it.
It's not that the patients don't have insurance, it's not even that they go to a hospital without an agreement in place with their insurer - it's that the ER has a number of people outside that insurance contract, you don't know who they are, you don't get to choose whether they treat you, you just get a bill at the end - despite being insured, and choosing a hospital recognised by your insurer.
Insurance is not the solution for this problem.
What really pisses me off is that the HSA max contribution has not kept up with family OOP max. I contribute the max every year and can't end up with $8,500 saved.
I had a decent insurance plan prior to Obamacare. Now it's 3x as much and a HDP. Don't even have dental insurance anymore; use the HSA for that. Work for a Fortune 100 Company too.
Your HR department is shit. I manage a 30 person company and our benefits are better than what you've mentioned.
Funny thing about HR directors is that they don't last more than 1 year before rotating out. Don't want them to become too attached to the people they are there to screw.
Honeywell; thermostats?
You're probably now paying the 'true' cost of healthcare. (Of course, inflated by the peculiarities of the American system.)
At that level a company that wants a good plan can demand no exclusions for pre-existing conditions (an issue prior to ACA), same-day partner additions, better drug tiers, lower copays, etc. Often they pay less per person than a 1,000 person company does for a much worse plan.
I know because I looked. Two employers ago we got acquired by a very large company (over 80k employees). They paid ~$800/mo for my family. When I moved to a startup, they were paying ~$1200/mo and the benefits were worse. I'm back at a large company again and it's back to ~900/mo for a better plan.
You are getting screwed because the company has decided to do so.
Ha ha, didn't have to tell me that! I bet my coworkers we won't have company health insurance in a few years. Gotta keep that stock high.
Crazy thing is, now that I'm middle age, and my 401k approaches 7 figures, I'm beginning to care more about fund performance to get me to retirement in 20 years than benefits. It's all coasting from now.
http://www.riverradiology.co.nz/diagnostic-solutions/price-l...
$500 NZ versus $11000 US - maybe there is something wrong with your health system.
Average price for a CT scan is probably between $1000 and $2000 though.
In Russia fully out-of-pocket (no insurance, no subsidy) CT scan will cost you $50-$200 (depending on body part).
So, this is likely around its prime cost. And the rest of your $(3000-200) is split and pocketed by hospital shareholders and insurance company.
People using an emergency room are not in a position to negotiate price or seek an alternative service. An unconcious accident victim can't say, "That price is crazy I am going to the hospital across town."
Single payer is the only viable solution.
That's not true. Plenty of European systems are not single payer and work fine.
Edit: a common thread among these systems is that the private payers are not for profit and highly regulated.
The public system premiums are a % of income. The private is a flat cost, so as you make more become much more attractive (even costing less in many cases).
Doctors are sometimes private only or have separate private insurance waiting rooms. Hospitals have separate public and private rooms/beds, etc.
It's a two-tier system that works pretty well, at least in comparison to the US system.
My info is a few years dated, but is based on having been a patient in both US and German hospitals. From friends, I've heard the English system is similar in some respects to the German.
Amazingly to me, the German system was instituted under Otto von Bismark in the 1800s.
https://en.wikipedia.org/wiki/Timeline_of_healthcare_in_Germ...
https://en.wikipedia.org/wiki/Healthcare_in_Switzerland
This ensures that the system works better than the US system, as the hospitals do not need to deal with having to treat uninsured patients who cannot pay. This is a major problem for the US healthcare system, and a critical threat to the solvency and continued operation of many hospitals, especially rural hospitals and clinics.
More to the point...is this the America we want to live in?
Turned out alright, I think. I'm still concerned I'll get an "oh by the way" bill in the mail.
I would say single payer, or a single regulatory arbiter of procedure and drug prices (within a multi payer context).
When you look at the healthcare costs GDP, the single payer systems still tend to come out ahead multi-payer + regulatory oversight (its one more level of abstraction you pay a complexity cost for...).
As someone who works for a medical billing agency either would make my life easier, having to juggle dozens of insurance contracts and rates stinks. France does the latter, insurance companies and the state plan negotiate and a single group - at the best this could make a good stepping stone to single payer in the US.
This statement is close to the fallacy "Something must be done. This is something. Therefore it must be done."
Consider counterexamples: http://marginalrevolution.com/marginalrevolution/2013/08/a-f...
If you're bleeding, and someone hands you a price quote, what are you going to do?
Or if you're unconscious, they can't even hand you a price quote. (I guess they could shove it in your pocket.)
I know the one time I needed to go to the ER, for emergency surgery, I'd have done it if they'd said it was a million billion dollars, because my life was literally on the line. I wasn't going to go shopping around, because leaving that ER would've meant death.
What's a price quote supposed to do in those situations?
We just need universal coverage, whether single payer or actually universal insurance.
I think you may be getting downvoted for your last sentence, but the points you're making are very real.
I spent 4+ hours before a small outpatient procedure at a local hospital trying to find out if the anesthesia group and surgeons were in-network. I never got a straight answer -- no one knew the answer and I was forced to roll the dice.
Hospitals are currently more like co-working spaces where each room (ORs, radiology, etc.) is rented out. The support staff is included, but everyone else is their own small business.
I work for a medical billing company owned by a competitor to EmCare, we participate it a large number of insurance networks at each site we staff because it's the best way to get reimbursed - I'm rather shocked the hospital didn't investigate how their contracted providers handled insurance contracts and billing.
The problem with trying to provide quotes for emergency services is you don't know ahead of time what E&M code will apply to the visit, what labs will be run, what procedures may be required for treatment, and since physician and facility billing are separate the right hand doesn't know what the left is doing.
I also have some suspicions about the jump from 6% to 28% rates for billing what I assume is a 99285 (highest level non-trauma ED E&M code) and why it may explain the lack of their participation in insurance networks, but I don't want to tread into libel territory so I'll keep my mouth shut.
Disclaimer: I work for MedAmerica Billing Services, Inc. a subsidiary of CEP America - these views, opinions and statements are my own and don't necessarily reflect those of my employer.
I'm always one to call for legislation and price controls, because time and time again, without the legislation in place, situations like this arise. It's the sad reality. Regulating companies is apparently our only hope to keep people from constantly being stepped on.
$0 out of pocket, just showed my government issued card everywhere.
Couple of years ago my father was in an ICU for two weeks with Parkinson's related complications. That one had a $0 out of pocket bill as well. The ICU was in a world class university teaching hospital.
System works here. Sure people can cite edge cases, but they are relatively rare. The single payer, $0 out of pocket system also encourages pro-active care as opposed to waiting until the problem is severe, which in turn keeps costs down.
Wouldn't trade our single payer, socialized medicine for anything. There's reason why Tommy Douglas, the father of Canadian socialized medicare, was voted the greatest Canadian of all time by the public in a recent CBC poll.
(Shameless plug: software industry is booming in Toronto and there's lots of jobs. Just sayin'...)
$0 out of pocket for the hospital work, a small co-pay for the prescription.
He also spent a few months on a waiting list for surgery. Cataracts surgery. They fixed him, he can now see better. Out of pocket cost? $0.
The system works. If the trade-off for free life-saving treatment is waiting on non-critical surgery, it's a good trade-off. When you're ill, the last thing you want to weigh is whether you will put pay the heating bill, or the ER bill, or whether you should go to some other hospital, because this one will gouge you, even though you're in-network.
The whole point of health insurance is that the healthy pay for the sick. We will all eventually be sick.
Not sure these are just "edge cases"...
http://www.cbc.ca/news/canada/british-columbia/patients-live...
Total cost: $0, 9 stitches, and a lecture from the nurse on the dangers of drinking.
Large hospital systems accept patients who have a range of payers (Original Medicare, Medicare Advantage, various Medicaid plans, private insurance, and uninsured patients). On the aggregate, they want to make sure that their entire system is cashflow-positive - however, they do that in a rather roundabout way, because they only have the ability to negotiate with some of their payers, whereas the others are able to set their rates at whatever price they want.
Medicare and Medicaid set their reimbursement rates by fiat, and providers have essentially no ability to negotiate those. Except in critical access areas, Medicare actually reimburses much less than the marginal costs of care for its patients (7% in the aggregate)[0]. These rates are so low that Medicare actually has a separate program to pay extra money to hospitals that treat a lot of Medicare patients - otherwise, they would literally go under. The reason they provide this money as a separate program and don't count it in claims is entirely political.
As a result, providers present very large bills to everyone else (privately insured and uninsured patients) to make up for this loss - you can't stay in business if you're literally making a loss on every patient! Uninsured patients see the large bill and assume they have to pay the entire amount (they don't!), and private insurers end up negotiating that down to some multiple of what Medicare pays.
A typical insurer will negotiate an agreement like, "we'll pay 350% of what Medicare pays for this category of services".
[0] This is not looking at any markup that the hospital provides - we're talking about how much the hospital has to pay its suppliers. So, for a hypothetical vaccine that costs $100 wholesale, Medicare might reimburse $93, which doesn't even cover the cost of the equipment, let alone the entire hospital infrastructure (wages, etc.).
Except suppliers can engage in their own fiat prices, as the OP demonstrates.
But your narrative does show the basic situation - where you have an elaborate digraph of buyers and sellers, most of which have a more or less monopolistic position. These monopolistic suppliers initially/formally set their prices based on "what they could possibly imagine getting", expecting regulators/down-stream-buyer to be the ones who will push things back into sanity (or not).
American health care, of course, has bounced from regulatory regime to another, with all of the players having to adjust. And moreover, all the players are now adept at adjusting, able to switch gears to leverage whatever ad-hoc cost reductions might go with any new system (cautious enough to lay-low when the new system comes since they know the politicians need to point to gains but will move on - see the way Obamacare worker great for two years, etc, etc).
And with all the bouncing, the situation has gotten only broadly more catastrophic. Health care was ~18% of GDP a year or two ago and no doubt is higher still.
Not only does health care have a problem but the four or eight cycle of ad-hoc fixes to health care has itself broken. Which might relate to the general breakdown of the countries political system, and so-on. I assume when (part of) Rome fell apart, no had seen an empire disintegrate on quite those terms (where a lot of civilization still remained on higher terms than Rome's neighbors). Perhaps our descendants will look back on this era in similar terms.
Those aren't fiat prices by any stretch. Aside from the fact that there is a competitive market of providers, patients don't have the obligation to pay the entire billed price (a key point which this article does not mention). That's neither a monopsony nor a monopoly.
Medicare, on the other hand, is a legal monopsony over its patient population and does set its prices by fiat. (There is no competitive market; patients can opt to receive their Medicare benefits privately, but they cannot opt out of Original Medicare entirely. Similarly, most providers cannot legally opt out of accepting Medicare, in practice).
http://www.flexmonitoring.org/wp-content/uploads/2013/06/CAH...
(in high population areas it doesn't make sense to comply with the limits imposed by the program, for instance, only having 25 beds, that's why there aren't any in Connecticut and such)
(Just adding a bit of info, I think CAHs are pretty high jargon)
Notice here, in 2013, an article about how "For the very first time, the federal government is publicly releasing the "rate card" (the full charge before insurance company discounts) prices hospitals throughout the nation charge for the one hundred most common procedures and services." https://www.forbes.com/sites/rickungar/2013/05/08/the-great-...
Yet two years later, a CEO of a hospital cannot even get the costs at the hospital of which she is CEO: https://www.nytimes.com/2015/09/08/health/what-are-a-hospita...
Price discovery, the most basic element of a free market, is literally impossible, even for expert executives within their own organizations. Vast price discrepancies exist for procedures just a few towns apart. Discovery for consumers in advance is impossible, and of course absurd in the situation where you are being rushed to the nearest hospital in an emergency.
Do not let anyone get away with claiming that this is somehow a "Free Market" until reliable prices, and outcome rates (with case difficulty information) are as easily available as prices and reviews on Amazon.
I have a friend who had to have an emergency appendectomy this year. She paid $1500 for it after insurance. My father had knee surgery he says they tried to charge the insurance company $64k for it.
At this point I think the pricing is all arbitrary. It’s about them trying to charge what they think they can get away with and sticking you for the rest. Kind of like raising the price so you can offer a deep discount later on. I think the real price of the surgery (without insurance) was probably the $7.5k.
I can think of no other business where you agree to have work done without an agreed upon price. The insurance company will tell you it’s covered but the hospital you go to may decide to play games with you. At the very least I suppose they are just hopping you pay so they can collect interest on your money on it before sending it back.
You can't really compare this with other businesses. Unless you want the doctors to stop the moment they hit your negotiated price (like lets say a building constructor would).
However you should be able to get a rough quote for the procedure (assuming no unexpected complications).
And I agree with you in general, US health care is a total scam (very high-quality to be fair).
I've always thought that my informed consent should also apply to cost of procedure - I have a right to say "NO" to something in the medical establishment. And had I known the price and the success rate, I would have said "No".
Now, I'm not asking "What is my exact rate?", although that would indeed be nice. But given minimal complications, I should be able to get a range of what to expect.
Further, it shouldn't be necessary for people to be making financial decisions in the middle of medical emergencies, even if it was easy.
there are all sorts of folks using ERs for non-emergency issues, simply because ERs are required to treat everyone.
both of my trips to the ER (subluxed knee; particulate matter lodged in my eye) would've been amenable to at least a few moments of financial consideration, had any information been available to me.
They can't just ask about price while unconcious.
According to the article, ~50% of hospital admissions today go through the ER.
They also didn't understand why anyone would even ask the question. They kept saying, "for patients that can't afford to pay we usually work out a payment plan." They didn't understand that I could afford anything and that was the problem. I can write a seven figure check which is why I'm careful not to open myself up to that kind of liability.
It's ridiculous, and it should be illegal. At the time, my reason for visiting was a condition that required treatment, so not going to the doctors really wasn't an option. But the inability to even begin to determine what I'm going to pay is ridiculous.
(I did this after a prior visit to a different doctor stiff'd me something like $3k for the use of what amounts to glorified camera. A camera whose photos I never obtained, despite asking for them — to which the doctor replied "we've never had anyone ever ask for that" — i.e., for their medical records. I could understand that medical-grade cameras might not be cheap, but at $3k per use, my gut says money is raining from the sky.)
Seems like getting a hospital to think they treated someone who doesn't exist is a better bet and no more stressful than getting your insurance to cover things to the extent you are lead to believe they would be covered
So I switched to Kaiser which is slightly better from the billing side but feels pretty mediocre care-wise. I don't hear back from the GP about questions/tests ordered and I've waited literally all night just to get something for a bad cough.
Healthcare in America is truly and thoroughly fucked.
Im curious how many supporters of GOP's free market rhetoric would support regulations around these practices once they are hit with a surprise bill like that
These next two to four years are going to suck, though.
I am a New Jerseyan and the medical industry is going to fight tooth and nail on this. My district swung (!) and even the Democrat won't endorse single-player.
Hopefully we can effect change as the Boomer leaders die off, at the very latest.
This should be easy to answer and explain.
This is merely the tip of the iceberg for what for-profit healthcare is developing into. You cannot have sound medical decisions being made when money is so deeply intertwined in the process.
Congress could solve this issue overnight by passing a 1 line law:
If a patient is using services that is not covered by their insurance, or if they have no insurance, no medical service provider can change more than the official medicare standard rate for any services rendered.
Problem solved.
Imagine if you would, a small hospital. They probably don't see enough patients with diagnosis X to keep staff specialized for X busy year round. There is a doctor in town that specializes in X. This doctor needs a place to get their patients stabilized and where the doctor can see the patients periodically. When one of the patients needs hospitalization, the doctor can write an admission order telling the hospital to take care of a patient in a certain way. When somebody comes into the ER and the generalist/hospitalist discovers that person has condition X, then the hospital knows they can call on the doctor to consult with them on how to treat X.
A historical artifact of the hospital/physician relationship is that there are separate billing streams for each side. There is just enough information sharing so that the doctor's billing system knows who the patient is and it is up to the doctor to claim that certain actions were performed for a valid medical reason and documented.
The current state ranges from very arms length relationships to total economic integration, which is rare enough to have a term for it, Single Billing Office.
http://healthaffairs.org/blog/2016/05/09/the-tangled-hospita...
This surprised me, but I suppose it makes sense that cost have to be born by those of us that have the means to do so.
In theory, the high reimbursements are so out of network doctors can get paid market rates. There's also a fair amount of propaganda from insurance companies on this issue which makes the reality hard to discern. Yet they pay 10-20% on average of the bills they receive, so it's just another way to punish the patient while both the insurance company and doctor are taken care of.