A Glimpse into the Bureaucratic Hell of Denying Health Insurance Claims
splinternews.com
splinternews.com
The list of conditions for which insurance outside the ACA will be denied is long and opaque. The story makes it sound as if they're looking for reliably diagnosed conditions like diabetes. No. They're looking for indicators of a long list of potential conditions. If you or your spouse has a functioning female reproductive system, the chance of your family being denied is high, even without a diagnosed or treated condition. We were denied for something like that, and also because my daughter had an unexplained seizure when she was 4 (she's now 16 and just fine). To get insurance for the first couple years of Matasano, my wife had to take a crappy full-time job with group coverage.
Without insurance, a typical working family is one major medical incident away from zeroing themselves out. My daughter has never met a pickleball net that didn't break her ankle (she has met one pickleball net). Even with insurance, the cost of that injury was high single-digit thousands of dollars. Without it? The cost of a pretty decent car. Find a friend who's had an appendectomy some time and try to find out how much the insurance company was (nominally) billed for it. A down payment on a house.
If you work in this industry, intend ever to start your own business and potentially have a family at the same time, you should be extremely alarmed at the prospect of guaranteed issue regulated health insurance (the ACA) being replaced.
People have a bad habit of blaming the ACA for insurance prices. The ACA failed at its goal of making individual health insurance affordable, that is true. But it didn't cause that problem, and it did something extremely important to mitigate it.
Another thing-- the data on prices are a flat out LIE, the government is also making massive payments to the insurance companies directly -- their prices don't reflect their actual costs.
No matter what you think about prices, though, the most important thing the ACA did was create a nationwide requirement for guaranteed-issue insurance. However expensive you think insurance is, it's more expensive to be flatly and irrevocably restricted from buying your own insurance at all, which was the status quo ante of the ACA.
Stating "YoY" gives the false impression that this is the average increase over some number of years. However, this was simply the projection for 2018 and the article provides the reason:
"The price increases are fuelled by market uncertainty and the elimination of key federal payments to insurers."
https://www.cnbc.com/2017/10/17/decision-to-kill-obamacare-p...
That price increase was engineered by the GOP by cutting the payments from the budget followed by the Trump Administration's "finding" that they had no authority to spend the money.
I genuinely hope your posts are just virtue signaling created by a desire to appear as one of the faithful.
https://www.forbes.com/sites/theapothecary/2016/07/28/overwh...
I know ACA is good for some, but goodness did it remove my interest in remaining insured. I’m sure you can cite data that tells a different story, but my experience, as well as that of my peers, says ACA has been very bad for those actually paying the bill unsubsidized. I fully blame ACA for this.
Rising insurance premiums aren't good for anyone. The ACA set out to fix the problem of rising insurance premiums and (I think) pretty much failed. But it didn't create that problem; 5-digit annual premiums for a family of four were a reality prior to the ACA --- or, at least, they were in Chicago on the small group market.
The subtext to these discussions though is whether we'd be better off without the ACA. No, we would not be. We would lose guaranteed-issue insurance, so a sizable fraction of families wouldn't be able to get insurance at all, and, from the available evidence, we would at least have the same rate problems we have now, and (according to some studies) have worse rates. Obviously, this subtext is about the GOP's health care rhetoric, and I'm not wild about opening up a political salient in this thread, but let's at least be clear: the idea that you can repeal the ACA, do nothing else, and get lower health insurance premiums for real coverage is sleight of hand.
The net bill was over $110k if I hadn't had insurance and wanted to go to one of two ankle specialists in the city I live in. With insurance, $5k-ish.
Before, we had the (very poor) demand elasticity of people paying everything they had and then maxing out every credit source, and predictably prices rose to around that point. Now, we have no demand elasticity at all, and prices can be expected to rise well above the average person's net worth + credit access.
If you look at any microeconomic equilibrium chart, you'll see that the price is held in a balance between people buying and people holding off due to price. When the good is healthcare, the human cost of "holding off" is very high, and usually involves inability to pay. Unfortunately our economic system tends to fly off the rails if this balance is disrupted, no matter how noble or urgent the cause.
Elsewhere it has been said: choosing between bankruptcy for your family or cancer care for your child isn't an actual choice, it's two loaded guns pointed at your skull. One held by the hospital, the other by the insurance company.
The reason first world countries choose universal healthcare is that healthcare is a human right. Full stop. It is not an economic issue. If you want to get economic about it though you'll lose because as it turns out a healthy educated populace is more productive than one that loses productive families here and there to lances of bankruptcy from the unpredictable nest of human disease.
We were literally using lives as an economic mechanism, but now that we're not doing that we need to use something else in their place. The price of healthcare will continue to skyrocket unless we find something a little less horrifying than other people's lives to use as a balancing weight; although I won't claim to know whether it would be more possible to design a working market system or socialize it successfully.
Priority 1, stop making Soylent Green out of people. Priority 2, re-establish the food supply in a better way, because we need to eat.
Humanity survived just fine without real healthcare and healthcare is not essential to a fair balance of power b/t the government and its citizenry.
Universal healthcare needs to be argued on the economics of the issue because that is the only practical way to make it sustainable. The "feel good" stuff about it being a human right will fail when stress is applied to America and stress is coming. The US, frankly, has peaked and it is all downhill from here.
I suspect that the current UN rights council may be an example of this in action. See: the track record of the members on negative rights, the number of positive rights on their list of rights.
Frankly a single payer system is simpler and faster. But this is an area where American politics and market rhetoric just lead to terrible outcomes.
You have no right to "life, liberty and the pursuit of happiness", you have a duty to not interfere with other people's life, liberty or their pursuit of their happiness. But even that is a negative duty. Positive duties, like paying tax, are more like the right to healthcare.
So this should be looked on in similar fashion. Do you have a right to healthcare ? Well, answer the question : do you have the duty to take care of others' health problems, completely irrespective of how it affects you personally (for instance, what if it takes up 90% of your time, while still not doing much more than slightly prolonging a miserable short life for them ?).
These questions are not so simple and knee-jerk statements like "right to healthcare, period" are not helpful and will do nothing but get us into a lot of trouble.
No country has "right to healthcare, period". That does not exist. For the obvious reason that it simply isn't feasible. Providing a named (but finite) list of treatments and medicine free of charge if diagnosed by a licensed physician is the furthest any country goes. In some cases that list is pretty short.
Capitation brings the insurance industry's incentives (ie. only work with healthy people) away from insurance companies and onto doctors. What is a diabetic to do when doctors just directly refuse to treat them directly (or delay, or ...). And before you say it won't happen because of hippocratic oath, we both know this rule will force doctors to do that for 90% of their time.
For such doctors and facilities getting people with longstanding illnesses that are just going to come in time after time after time and need expensive drugs and treatment, like MS patients (multiple sclerose), is going to be financially debilitating. That's not reasonable and absolutely not what we want.
As for replacing doctors with "workers" (presumably he means not even nurses), I feel like shouting at him. Doctor's salaries are high, but don't represent a decent fraction of expenses. You could give everyone in medicine a 100% raise and the cost would be in the low single digit percentages (2-3%). Let's face it, this is not what we need to save on. And if we are to save on it, let's PLEASE do it the right way: by subsidizing the training of more doctors, not by replacing doctors with idots.
What I keep hearing about US medicine is that 2 things are necessary:
1) legal changes limiting legal liability of doctors (doctors pay 5 digits per month in insurance in some places, money that is paid by patients but is definitely not going to better care). Something like the European system where a doctor can only be sued before a judge if he's found by the local ethics/hospital/national medical/... board (staffed with exclusively other doctors) to have gone overboard.
2) limit the cost of medicine and increase choices (e.g. mandatory licensing, importing of generic drugs, or just outright force the use of a generic alternative if available like a lot of European countries are doing)
This is the only point I agree with Mr. Sachs.
and for a bonus (just for bringing sanity into the system):
3) Outlaw any and all advertising for anything medicinal (something like if it requires a prescription, advertising it = jail time)
“Universal right” is simply that which people feel all people ought to have.
> Humanity survived just fine without real healthcare and healthcare
“Universal healthcare” as a right is simply the right to a certain minimal level which is dependent on technology and resources. The fact that their have in the course of human history been times when no real healthcare by the standards of the early 21st century isn't material to that one way or the other.
> healthcare is not essential to a fair balance of power b/t the government and its citizenry.
That's quite arguably not the case; “government” is an a abstraction than the ultimately boils down to the subset of the citizenry with the most power in allocating resources, and it's quite arguable that that floors for allocation of resources in several domains, including healthcare, are essential for fair balance of power between that subset and the rest of the body of the citizenry.
Further, your implicit argument that a “universal human right” must either be something that prehistoric humans could not survive without or relate to balance of power between people and government is simply a statement of your political values, not a boundary on the what “makes sense” as a universal right.
> Universal healthcare needs to be argued on the economics of the issue because that is the only practical way to make it sustainable.
The actual concrete floor at any given time must be, but then again since every OECD country which guarantees universal healthcare, regardlesa of the details of the system, does it for less total (measured by absolute expenditures, per capita, or per GDP) than the US does spends on healthcare (and some don it for less by all three measures than the US spends in the. smaller public portion of its system alone, let alone the private expenditures), the economics aren't really an issue when you are talking about the US system.
I'm sure they said that in soviet Russia too. It's all good to say X,Y or Z is a right until you actually cash in on that right.
I mean you don't even have to look to the soviet union, what is goinig on with the VA? Obama was working to fix that smaller universal healthcare system from actually just waiting years for people to die but I haven't heard any good news comming out of there recently.
The rest of your claims are just nonsensical in this context since your just assuming universal healthcare works because the government decrees it to be universal.
I can probably predict the response but on the chance I'll be surprised - why can't America solve the problem when Taiwan, Switzerland, Sweden, France, Germany, the UK, Canada, Finland, Norway, etc etc etc have or nearly have?
(I have received healthcare in several of these countries and an readily prepared with counterpoints to the inaccurate "healthcare isn't good / lines are long in those countries" arguments, fair warning)
Healthcare is a non typical market and the cost of a persons health is irrationally high to that person.
Everyone on a boat has twenty dollars and absolutely needs an EpiPen to live. You have a supply of EpiPens and want to get as much of their money as possible. There's zero elasticity between 0 and 20 dollars, but you better not charge $21!
Now, imagine that there was only one person who needed an EpiPen, but everyone else was willing to pitch in as much as it took to help them out. If the supplier of the medicine was perfectly evil, the price would be $20 times the number of people.
Perfect self-interest is a pretty good model of any industry, including pharma, so I think this is a good picture of the situation. The ACA was careful to keep something like a market system in place, which is why we're faced with a problem that can be understood with microeconomics.
Healthcare is known to be a market which has non standard policy imperatives
The cheapest, simplest and most effective system is single payer with everyone in a single pool.
Every major first world power achieves better outcomes for lower costs than America.
Your theoretical premise would have merit if this was only theoretical, and we had no real world evidence that this was a bad idea.
I really feel like this discussion is suffering from false-dichotomy-itis: I've actually been very careful to avoid saying anything beyond my point, about (say) whether or not single payer is a good idea for the US.
This might be the case if hospitals had to actually show their prices rather than sending bills after the fact for a price you aren't allowed to know when you consent to treatment. It might also help if competition were allowed, but for hospitals it is pretty much not in a lot of states. To open a new hospital in many states, you need a "certificate of need", which is basically a document demonstrating that you won't be competing with the existing hospitals. So much for "free market health care".
Later, after some health issues <cough> first child diagnosed with T1D <cough> we were grandfathered into the private plans and the premiums did not change but the deductible was pretty high and the network was not great.
Later, and this was still pre-ACA - California had guarantee issue health insurance with little or no rating factor adjustment (surcharge) for companies with 2-50 employees. So I hired my wife and we switched to one of those plans. Premiums around $800/mo and $2k deductibles. That was about the time when our 2nd child was diagnosed with T1D.
When ACA passed all CA guaranteed issue small business plans disappeared and everything switched over to marketplace. Silver plans for $2,000/mo for the family and $2,000 deductibles with $12,500 our of pocket max. Basically every spare penny went to healthcare, and then some, and we were slowly drowning in debt because of it.
Finally, I stepped off the treadmill, stopped taking a salary, and we switch to Medicaid. And went from spending $35,000/yr out-of-pocket after tax on healthcare to spending $0.
ACA unquestionably increased premiums and total cost for my family substantially, until I stopped taking a salary and went on Medicaid at which point ACA was a god-send due to Medicaid expansion / cost-sharing reductions.
For a healthy family of 4 ACA is horrifically expensive and acts as an extraordinary tax on middle class families who start earning too much for the subsidies. The marginal effective tax rates are so high, the CBO doesn’t have the guts to publish them with the ACA subsidy phase-out included in the calculations.
However, the fact remains that my health insurance options have generally been worse and more expensive since ACA passed. This year, thankfully, I am on employer healthcare plan instead. Because in my area, with the ACA, there is one provider only, and none of the plans are good, and they're all more expensive than before, and at least 2x what I was paying pre-ACA and with MUCH MUCH higher deductables.
Your options are fewer now because you have to be bigger to able to absorb the costs of the extremely high cost individuals such as those with anemia and premature babies and cancer patients.
Everything you’re experiencing is because more people are getting access to healthcare, and instead of everyone paying for it via higher taxes, we’re paying for it via higher premiums and deductibles.
Only way to bring relief is through more supply of healthcare, which means more doctors (they lobby against that) and more medicine (they lobby against that too).
One solution is to marry a doctor so you can take advantage of the situation.
e.g. the US as more doctors per capita than the UK and Canada - both of which have much lower healthcare costs than the US.
As I see it, the ACA was a very middle-of-the-road policy initiative. Building upon a Republican governor's program, namely Romney's in Massachusetts. It was meant to appeal to and help business as much as uninsured individuals. It was conservative in that it didn't throw out the existing system of insurance; rather, it brought new customers to the existing insurers. Insurers became enthusiastic about increased marketshare.
Law consists of two parts: 1) The law itself, and 2) Paying for it.
Republicans made very clear statements about their primary, number one goal (really, the primary goal of their party and their Federal legislative presence) being making Obama's presidency a one term presidency.
The ACA was passed, in spite of their opposition. But they used their subsequent control in Congress to not pay for an essential component. The law provided two years of compensation to insurance companies for excessive expenses resulting from ACA Marketplace plans. The idea was to provide a buffer -- government security -- while insurers caught up on the population's deferred medical expenses and built an actuarial understanding of the population.
When the insurers sought that compensation, I've been told by a professional working in the industry, they received about 15 cents on the dollar.
Premiums shot up. Companies dropped out. Republicans cited the "failure" that they helped create in the first place.
This isn't the only aspect of the situation, but it's a very significant one.
The ACA wasn't perfect. Work could have been done to improve it. Instead, a lot of political effort went into killing it.
Oh, and as tptacek mentioned, it did bring many costs under more control. Something that benefited group plans such as those provide by employers.
You don't hear so much about that, eh? Or the enormous profits that insurers are reaping, in spite of complaints about the ACA Marketplace plans.
P.S. As I've mentioned before, I'm someone who was denied coverage, at all, outright, prior to the ACA coming into full effect. I had a minor condition that a very well respected surgeon would not operate on, while I was still on a corporate group plan. Risk/benefit favored simply monitoring.
That didn't matter. No insurance for me!
(Fortunately, a professional and personal contact in the industry pulled some strings. Something NOT available to most people.)
P.P.S. I should add that some people think that some insurers may have underpriced their ACA plans a bit, initially, eager to maximize their portion of the increase in market size and relying on the temporary government security for protection. I don't know whether this is true. Even if it is, no law/program is perfect, and the two year timeframe placed an inherent limit on this behavior.
When the repayments came up so short (15 cents on the dollar), this might have magnified the corresponding premium increases somewhat.
But all this was accounted for by the ACA law, including limiting its effect. It just wasn't, subsequently, paid for by the Federal budget process.
And if it is true, it reveals insurer's enthusiasm about the ACA. They wanted the increased marketshare.
Instead of working with this momentum, it was thrown under the bus for political reasons. As I see it.
My mom pays half of what I pay and she gets family insurance while I get a single person insurance. Her pool is a large grocery store company.
(I just looked it up and, weirdly, average premiums on the large group market in 2017 were higher than those in the small group market; on the small market, they're around $17,000, and in the large market, $19,000).
I pay ~$220-ish a month for my family of three, the company pays $800+/mo. Boy am I glad to work for a company that pays such a large chunk of my benefits, many other places cover maybe 50% of your dependent costs.
https://www.medishare.com/blog/is-healthcare-sharing-tax-ded...
Health insurance prices are a nightmare. Please don't let me come off as sounding like I don't think they are. The goal of the ACA was fix that problem, and though it fixed some very important problems, it surely didn't fix that one.
Repealing really isn't an option (due to the near impossibility of repealing an entitlement) and the public doesn't want that either. I don't know how you would fix the issue that the loss ratios will be more skewed negative since the fact that sick people pay more attention than healthy people for insurance (even when you introduce tax penalties).
https://www.irs.gov/publications/p535#en_US_2017_publink1000...
Basically what I’m saying is the loss ratio for a bigger pool will be much lower than a smaller one. For insurance companies who charge premiums if you are in say a Bigcorp sized pool compared to a small business size pool the bigcorp pool will be larger and can have smaller premiums .
For a great many Americans, the figure you brush off as not particularly large is an unimaginable amount to come up with for insurance alone.
I agree, $18k for insurance, or $24k, is an enormous burden for most Americans. I was just trying to point out that that the ACA price the parent was calling an outrageous seemed completely inline with every other insurance policy I have ever had, ACA or not. Insurance in the US is just plain expensive, no doubt about it.
see eg https://www.healthforcalifornia.com/covered-california/incom...
I'm curious as to why you say "the ACA is horrendous" rather than "The income cutoffs for the ACA subsidies are way too low" - I mean, it seems obvious to me that if you make a median salary and have a family of four that you need some sort of health insurance subsidy, but I don't know where the ACA subsidy lines are, or even if they vary per state or not.
I personally am in favor of just expanding medicare or medicade so that everyone can use them to get minimal health care if they need it. I mean, sure, if you have money, you probably still want private insurance on top of that, just like retirees today, but we've got a reasonable system for giving everyone over 65 a minimal level of care, and healthcare for younger people is a lot cheaper than healthcare for old people, so it seems like a big rich country like ours should be able to cover that bill.
but I don't think that is politically possible. I think this last election was in some ways a referendum on the ACA, and I would interpret the results as saying that many, if not most Americans think that you should only get healthcare if you can pay for it. Which seems weird to me, because as you point out, if you make anything like average money, healthcare for a family for three or four is impossible to pay for without a subsidy.
>I'm seriously considering returning to wage employment for health care benefits.
In the days before the ACA, I'd just get a full time job every time COBRA and CAL-COBRA ran out, because I couldn't get a plan at all without. I mean, I was happy paying $6K/year just for me, and that's what I'd pay under COBRA or CAL-COBRA but, once that ran out, nobody would sell to me. Maybe I wasn't asking the right people, but it wasn't like they came back with high numbers, they just said they couldn't cover me. It was weird, because while I did have a chronic condition or two, none of them were particularly dangerous or unusual.
In 2016, I decided to take off from work and travel outside the US. I did what I thought was the responsible thing and purchased a travel insurance plan. In total, I was gone for a year...I had an amazing trip.
When I got home, I wanted to sign up for insurance again. But since it wasn't a life event, I wasn't eligible to enroll until the open enrollment period. And when that time rolled around, I wasn't eligible for the subsidized plans because I hadn't gotten a job yet and my monthly salary was $0/mo. Nevermind that I'd done enough contracting work during my trip such that if you divided my annual earnings by 12 to arrive at a monthly earning, it would've easily qualified me for a subsidy to stay on a plan that let me see my previous doctor. But I did eventually get signed up for Medicaid for the month between open enrollment and when I found a job, so...yay?
Then tax time rolls around and, it turns out, you need to be out of the country for 11 out of 12 calendar months to qualify as a non-resident. Since my trip didn't start on Jan 1st, despite being out of the country for an entire year, I didn't qualify as a non-resident for either 2016 or 2017 and had to pay the ACA penalty for the entire time I was gone because I didn't buy health coverage that would've only been useful in a country I wasn't present in. And adding insult to "please don't let me get injured", I had to pay a penalty for the time I was uninsured between when I got home and open enrollment.
In short, I feel like the ACA was rushed and they never seriously considered what was right for people not working a 9-5 job getting regular pay checks. By deciding to opt out of the workforce and do my own thing for a while, even doing it responsibly, the ACA cost me thousands because I somehow managed to find corner cases that were simply not considered or poorly handled by those writing the bill.
I think a lot of the bureaucratic issues might be the nature of insurance companies? My (pre-aca) experience was that any lapse in coverage and they don't let you back on. All this 'life event' stuff, I think, was part of how group plans worked back in the day, the rules about when you could change things and when they could kick you off.
I guess what I'm saying is that (aside from charging you the extra tax) I don't think it's worse than it used to be.
Unfortunately, the portion of the ACA requiring states to expand medicaid was ruled unconstitutional. As a result, 19 states have choosen not to expand medicaid, leaving a portion of the population to poor to qualify for ACA subsidies, but too rich to qualify for medicaid.
I should also point out, that the medicade expansion is 90% funded by the federal government starting from 2020 into perpetuity. Prior to then is a ramp up period where the federal government pays an even larger share.
https://www.prospectmagazine.co.uk/politics/which-uk-regions...
It’s been nice to see that a well designed system can help people take care of people so humanely.
And once you get a condition, you will get NO insurance without the ACA.
And we will all get a condition--it's called age.
Health care being tied to employment is anti-startup and anti-small business, full stop. In countries with single payer (or similar) systems you can change jobs without any impact to your coverage, you can start a business knowing your family's health and financial future won't be affected.
Center and center-right Democrats are pretty happy with the ACA as it was intended, although often not as it actually turns out in many states. Unsurprisingly, a lot of them take big contributions from insurers and pharmaceutical companies.
I think if single payer becomes widely accepted within the party, you probably will see the "helping entrepreneurs" angle as a big part of the messaging -- individual candidates do bring it up.
Many hospitals lose money on every Medicare and Medicaid patient. The only reason they survive is because they can charge private insurance companies more. So hospitals and health systems have been consolidating to strengthen their negotiating position against insurers
This article paints Medicare as the good guy, private insurance as evil, and hospitals as mixed. The reality is more complicated, and more regional, but overall healthcare is a zero sum game today between payers and providers fighting for dollars, and power comes largely from scale. In geographies where payers are bigger and stronger, they push hospitals and force many to consolidate or die. In areas where hospitals are stronger, they basically dictate price and rates can skyrocket
There's a lot of bad stuff happening on all sides, and it isn't clear that private insurance is always evil. If we become a single payer society, small providers that are struggling to survive will probably be the first to die, and providers will probably consolidate much more aggressively into massive national chains, like the Walmart of healthcare
The cause of a lot of healthcare issues is not one particular party (insurance, Medicare, hospitals) but a system that encourages monopoly seeking behavior without any good mechanism for regulating this
We should also better fund Medicare and Medicaid. Taxes should be apparent.
now look at EBITDA, a common metric representing cash flow. look at EBITDA / revenue, ie cash profit margin. this is around 20%, which is massive. this profitability is around the level of big tech and big pharma. however, most hospitals in the US have almost no profit. the profitability of large hospital companies is mostly due to their bargaining power. in fact, a decade ago, big hospital systems were some of the best private equity / LBO investments, bc they were massively profitabel, stable businesses that could take on a lot of debt. and this is before the ACA
before the ACA, this was even worse, especially for smaller hospitals. see [1], financial statements for Community Health Systems, a massive (but smaller than HCA) public hospital company, from 2009. for some hospitals this figure was 30% or higher
the problem is that not all hospitals are equal. the companies i mentioned are some of the biggest, most powerful hospital companies. however, many hospitals are completely different (often independent urban hospitals), and just bleed money. sometimes its because they have more under/uninsured pts, sometimes its because their contracted rates are lower, sometiems its bc they dont have enough commercial pts (instead having more medicare / medicaid). so a blanket law making hospitals eat more costs would just help the rich get richer and kill the little guys
i worked in investment banking and these big hospital systems were some of our best clients. a business that can write of 10-30% of its revenue as bad debt and still generate 20-25% profit margins is an incredible borrower, and we'd underwrite multi billion dollar bond issuances for these companies, so they could issue dividends to shareholders, and because they were so profitable they could afford tons of high yield debt without breaking a sweat
[0] https://www.sec.gov/Archives/edgar/data/860730/0001193125180...
[1] https://www.sec.gov/Archives/edgar/data/1108109/000095012310...
My doctor was part of a medium sized practice that was swallowed up by a big regional system. Since that acquisition, they make the .gov that I work for look efficient and streamlined. They literally added 5-6 non-billable staff to an office that was staffed by 2. Per my doctor, that’s typical in most offices!
Negotiating good rates with payers is a top priority and a lot of strategy derives from that (which is another reason why they bought your doc: if they control all patient flow in and out of hospital, they have more leverage with payers)
how does your doc like working for a big health system?
My doc hates it — they built a good practice and did a lot of innovative stuff. Now it sounds like 10/10 on the awful bureaucracy scale.
The only happy doctor I know is an eye doctor who pays the fine to Medicare instead of putting in an EMR. He keeps the staff minimal and avoids overhead like IT. According to him, all of his colleagues with the big systems are miserable, working 80 hour weeks and probably 50% have alcohol or other substance problems.
Medicaid is like an ATM machine for providers in many states. There is usually little or no correlation between outcome and payment, and poor fraud controls. That’s why you always hear about providers in NYC and Miami who “visit” 900 patients a day. Additionally, you have the institutional racism aspect of Medicaid where services are unavailable in some red states.
IMO, the biggest issues in healthcare are for profit institutions and insurers and the trade guild practices associated with Doctors.
Single payer or regional systems supported by taxes are the way to go. Medicaid should be an institution that is replaced by something better.
"value based care" has many meanings. simply using patient satisfaction surveys can be considered value based care, while participating in a double sided risk sharing ACO also qualifies. as of 2016, only 36% of physiicans participated in ACOs, under 30% in patient centered medical homes, 31% in bundled payments (which only impact a subset of diseases). howver, 75% used patients satisfaction surveys, 55% used PQRS, and 64% achieved meaningful use [0]
so the reality is that outcomes based care is still the minority, and real risk-bearing (two-sided risk sharing, full capitation) arrangements are even less common. most care is still reimbursed as FFS. and even as value based care is becoming more common, cost of healthcare is still not decreasing
and yes, medicaid can be fraudulent in some cases, but not always
[0] https://physiciansfoundation.org/wp-content/uploads/2017/12/...
I think the solution would be to give citizens disease/disorder "endowments." i.e. a yearly health stipend account - it's money they can spend at doctors, but they can't spend on unrelated goods/services (i.e. food). On top of that, additional "stipends" for major life ailments. The trick would be in finding budgets for those stipends. Once individuals have money, though, they have the ability to do the relative value assessment for various treatments.
US healthcare (and education as well) are massively bloated with an abundance of low value-add administrators. These bubbles need to burst.
Private, for profit insurance is almost certainly always evil. Their margins are dictated by how much they can delay or avoid coverage. That pretty much defines evil.
Medicare is why hospitals exist, period. Private insurers make it as difficult as possible to stay in a hospital, because they are more expensive and usually result in worse outcomes.
Reimbursement rates are being squeezed because there is a glut of hospital beds. As a result, hospitals, designed to operate with higher overheads, are losing money.
There’s a whole web of bullshit where the lack of universal coverage and rational allocation of resources results in strange behaviors.
this is not true. check out the annual financial reports for the UC hospital system as an example [0]. the majority of revenue comes from commercial payers. looking at data from HCA (largest public hospital company in US) tells similar story [1]. this is despite the fact that medicare patients are more costly overall
the bigger issue, however, are the margins. in 2010, UCSF, UC Davis and UCI had 3.5% profit margin for medicare, -27% margin for medicaid, and 21.8% margin for commercial. for UCLA they had -30% profit for medicare, -36% for medicaid, and 34% margin for commercial. private insurance literally subsidizes public insurance here. without private insurance, those hospitals die [2]
looking at other hospitals id imagine it is similar, though dont have data offhand
as to the reimbursement rates being squeezed bc of glut of beds, i dont think that is true and have seen data in the past to refute it, though i dont have the sources offhand.
[0] http://regents.universityofcalifornia.edu/regmeet/nov13/a4at...
[1] https://www.sec.gov/Archives/edgar/data/860730/0001193125180...
I would love to see (and am hoping to build) solutions that give more power back to doctors and patients, and focus on patient experience and outcomes.
I know that a lot of consumers want to take their health decisions into their own hands, and I support that, but i think most people want help from an informed professional who is on their side (ie not controlled by a hospital or insurance company with competing interests)
Healthcare services (doctor salaries + facility overhead) is 80%+ of US healthcare spend. At first glance increasing supply of doctors seems reasonable. But how do you do that? Number of doctors (esp primary care and mental health) has been declining because of decreasing reimbursement / payment and increasing burnout. Being a doctor requires a decade or more of making no money, working long and unpredictable hours, and tremendous stress -- literally making life and death decisions. Can't just spin up supply overnight. To really increase supply you'd need to increase doctor salaries or decrease the cost of becoming a doctor. The former would not reduce costs, and the latter also is not ideal
One perhaps better way to increase supply is by rolling back consolidation. So same # of docs, but more independent practices. Another way is letting nurses / others practice at the top of their licenses, although I'll grant your point that physician societies sometimes make this hard. Also, one could argue that having more work done by low cost providers would encourage more volume and potentially unnecessary care
The main overarching issue though, even if it was as simple as increasing supply, the healthcare system in the US is not designed to optimize cost efficient care. It is designed to maximize profit and regulations arent optimized around this. So when hospitals view patients as numbers, the implication is that they will milk every last dollar out of a patient (30% of healthcare spend is unnecessary care). Insurance companies are incentivized to deny as much care as possible. No organization with any power in the system is incentivized to view and manage healthcare costs in an optimally cost efficient way
A few months ago, I woke up the next morning after eating some fast food and began vomiting. I couldn’t stop throwing up, and I couldn’t eat anything, for 2 straight days. I had a 101 degree fever at the worst point. At the beginning of day 3, when I vomited so hard that I passed out for a few seconds and fell on the floor, I went to the ER. They gave me IV fluids and anti-nausea medication, which worked.
About 2 months later, I received a letter from my insurance company (Anthem). They had determined that my situation didn’t qualify as an “emergency,” and therefore they were denying the entire bill for this ER visit. I have appealed, and so far it has not been overturned. I am now on the hook for thousands of dollars, even though I had already covered my entire deductible for the year.
I thought that this had to simply be a mistake, but then I learned this is actually a new policy that insurance companies are implementing in the era of Obamacare [1]. Patients are expected to self-diagnose whether or not their situation meets their insurance company's definition of an “emergency,” and are rolling the dice as to whether or not an ER visit will be covered.
[1] https://www.vox.com/policy-and-politics/2018/1/29/16906558/a...
What does the policy has to do with Obamacare? Completely unfair denials obviously happened before the ACA (see: this article), and the idea that Anthem is doing this to stave off bankruptcy is laughable (just see their financials since the ACA was enacted).
Unfortunately, in capitalist economies, when you use the law to put the hurt on companies, they will pass that hurt onto unsuspecting consumers. The money will come from somewhere, and it's not coming out of executives' pockets. Perhaps this is why Nancy Pelosi urged lawmakers and the public not to read Affordable Care Act before it was passed it into law [1]. Had everyone read it, they would have known that problems like this would eventually arise.
It's getting to the point where I'm genuinely thinking there is some bad faith activity going on.
Anthem pulled out of my state altogether for 2018, so I also had to switch providers at the beginning of the year (this claim was from late 2017). I think that's another reason they are giving me issues with this claim - they simply don't care because they no longer have to deal with my state's insurance regulator. The new insurance provider (which was the only choice I had in my area, regardless of price) so far appears to be even worse and more expensive. Something has to be done about all of this. I don't pretend to have the answer, but the ACA was apparently not it.
The richest don't even understand what health insurance is as a concept. I mean, just look at what our own President Billionaire has to say: "Because you are basically saying from the moment the insurance, you're 21 years old, you start working and you're paying $12 a year for insurance, and by the time you're 70, you get a nice plan." [1] What does that even mean? Or our Speaker of the House: "The whole idea of Obamacare is...the people who are healthy pay for the...sick. It's not working, & that's why it's in a death spiral" [2]. That's literally the entire point of health insurance. This is what we're dealing with here.
[1] https://www.cnbc.com/2017/07/20/trump-thinks-young-people-pa... [2] https://www.washingtonpost.com/news/politics/wp/2017/03/09/e...
This is the whole point of health insurance! What a stupid idiot (I am overly nice to Paul Ryan. His budget plan was the most ridiculous thing I have ever read).
This bizarre obsession with using the phrase "insurance" and insisting on a product that is not at all insurance is probably why the US health-care system is so fucked.
Not true. Car liability insurance is very similar to health insurance. A lot of people never get anything out of it.
In a pure contract between equally informed parties, it's exactly how insurance would be priced.
Although I suppose if the singularity happens, that will also solve the health care crisis in this country. (sarcasm)
Why are they not allowed to do so? I think it's more likely that they don't want to so they can make up prices as they wish.
"Your EV from holding a car insurance plan is slightly lower than if you’d put that money in bonds. The benefit is that you can spread your risk across multiple parties. It’s entirely different from medical insurance, where your EV depends strongly on individual circumstances (and can be very negative)."
This is exactly the same as health insurance. Spread risk over many people. EV depends on individual circumstances (driving skills or health). If health insurance is healthy people subsidizing sick people, then car insurance is good drivers subsidizing bad drivers. I don't see the difference.
How does that make sense? If I knew I needed $5000 worth of medical treatment for asthma, and I pay an appropriate premium based on that, but then I get cancer..... well then someone else is going to have to pay for that, because my premiums certainly won't cover the cost of cancer treatment.
So then I get cancer, and the bill is more than I can afford. Where does the money come from? Not my premiums, because I've only been a subscriber for 3 months, and my premiums won't even cover the cost of treatment for a week of cancer treatment. If someone else isn't paying for me, and I'm not paying for me, who is paying for my treatment?
The people that are going to get cancer are unknown, but the whole group is willing to pay 0.5% of the cost of cancer treatment for a contract that covers 100% of the cost.
The 950 people that know they don't need expensive asthma treatment don't really want to pay for contracts that will cover expensive asthma treatment, so (in a pure insurance market) either the cost has to be included in the contracts for the 50 that do have it or the treatment can be excluded from the contracts.
If you do get cancer, the other 99% of folks who didn’t get it are covering your costs.
This is exactly my point, but it's this mechanism Paul Ryan said wasn't working. @powera claimed this is not the point of insurance. These things seem like exactly the same thing to me, so help me understand the nuance.
You’re not looking to insure against the chance you get asthma: You have asthma, and you’re looking for someone healthy to help pay for it. If too few healthy people sign up for Obamacare relative to the sick (and remember, all else equal, they have to be charged the same regardless of their health) those healthy folks will get an increasingly bad deal as their premiums are covering the costs of more and more sick enrollees and more and more healthy folk drop out of the exchanges. That’s the “death spiral”.
This is a serious misunderstanding of what insurance is. Insurance is a net benefit for society because it linearizes individual risk curves even if you have to pay in proportionally to your expected costs, not because it makes less risky people subsidize more risky people. Perhaps you should avoid calling people “stupid” for misunderstanding insurance.
But in your little group, there's still a 36% that no one will get cancer and that's offset by a small chance that multiple members of you group will get the disease. If even 4/20 members get cancer, that would now come pretty close to bankrupting everyone in the group. So what do you do? You increase the size of the group and lower the chances that no one will get cancer while also increasing the chances that only a proportional number of people (5%) in the group get the disease.
But then along comes Danny. We also know that Danny has a 10% chance of getting cancer. He also wants to join our group. If we just let him join, it won't be fair...after all he's twice as likely to need us all to pay for him. So we can either tell him to get lost, or we can just make sure that when the bills for someone's cancer show up, he pays twice as much as any other member. He's bringing twice the risk with him so he pays twice as much.
In poker, players learn to avoid being outcome-oriented when evaluating their decision making. Rather than looking at a decision they made and seeing whether they won or lost, it's more important to look at the decision and ask themselves if they'd made the same decision a million times, how many times would it lose and how many times would it win. Because any individual hand where a correct decision is made can still lose due to variance.
Insurance is the same concept. Actuaries use statistical analysis to determine an individual's risk so insurance companies can price that risk accordingly. Over a million lifetimes, your insurance premiums (less the insurance company's profits) would come very close to the overall insurance payouts. But since you've only got the one life, you'll be under- or over-paying. But you're still only paying for your own risk, you're not paying for anyone else's risk.
Where the ACA comes in is when Danny can't really afford the double stake. It forces us to let him join the group and pay less than double whenever someone gets cancer. That's a bad deal for all of us 5%ers, despite the fact that there's still a 90% chance that Danny doesn't get sick.
Now try to answer your question...do you see the difference between paying for your own portion of the risk pool vs lower risk individuals subsidizing higher risk individuals? If you were in one of those groups of 5%ers, would you just let Danny join without adjusting for his added risk or would you be looking for more 5%ers like yourself?
Health insurance in the US is not conducted in any way like the over simplified, text book example you provide. There exists no real world example of health insurance that functions as you describe.
There is the obvious problem that there is nowhere near that level of precision in anticipating the given level of risk for any individual getting a certain disease, especially as most populations are fairly heterogeneous when it comes to health risk profile.
The insurance companies use statistical tools to estimate the average risk of insuring a pool of people with some element of similarity, like a pre existing conditions. This is a far cry from being able to evaluate the risk profile of a given individual.
The complaints people have about being rejected for coverage based on a pre-exsisting condition, when they think that condition doesn’t really make them that risky reflect the imprecision of the actual tools.
This is also illustrated by these blanket denials: insurance companies are rejecting populations that the feel cannot be adequately evaluated for risk.
There is another aspect of such complaints (about blanket denial of coverage) which come from the issue that some people simply do have a health condition that they cannot cover the expected cost of.
This is a societal issue, and different socities deal with it differently. It inevitably involves some sharp elbows between the various interests involved.
In the US, for historical reasons, a big method of covering the costs of those who can’t afford the full premium was through the patchwork system of employee health plans, complementing government run plans like social security, Medicare, Medicade, local government programs, and charitable programs.
As imperfect as the system is, it remains the case that the health care coverage of high risk individuals, meaning those who can’t cover the full cost of a risk based premium, relies on what is known as “health insurance.”
This doesn’t matter at all, on account of the way variances from independent RVs add up. Look up the Bates distribution as an example. Variance over mean goes down as the square root of the number of independent RVs (insurees). That’s like half the point of insurance.
> was through the patchwork system of employee health plans,
These were the result of highly nonlinear tax policy during WWII, not the reasons you’re claiming.
Insurance is about lowering variance, not about subsidizing high risk. The ACA tries to make insurance affordable for everyone, and in the process, some people pay less than their actuarial cost and others pay more. That is not just insurance, it's forcing people with a lower actuarial risk to subsidize those with a higher risk.
Insurance is about taking the chance element out of something that is inherently probablistic because the rare event would be catastrophic. By pooling risk, you make things more predictable. But everyone is still paying for their own, individual share of the risk pool.
I'm not arguing that we shouldnt, as a society, ensure that everyone can afford health insurance, but we shouldn't pretend that "it's just insurance" because it's something entirely different.
The idea of extending an insurance program into a mechanism for subsidizing those who can’t pay the premium does not mean it magically transforms the program into a totally different thing.
In the limited definition, it is still the case that the healthy pay the cost of sick.
The extension of the concept of insurance fits semantically, because it is based on the idea that there is an element of chance inherent in who gets sick; getting sick includes many factors that are outside the source of an individual’s contol (as well as factors that are within an individual’s control).
The ACA included a “tax,” among other methods to socialize the cost of covering the “premiums” for those that couldn’t cover them on their own.
The whole system relied on the same actuarial principles as the previous system to smooth out variance in costs to individuals.
Paul Ryan sounds like an idiot here, because he is a mealy mouthed politician, who doesn’t have the courage of his convictions.
Ryan is libertarian minded tool, whose real opposition to the ACA is not that the healthy pay for the costs of the sick. His opposition is to the elements of the program that force wealthier members of society to cover the medical costs of the poorer members.
It's not "just insurance." That's not "what insurance is." We're talking about a form of socialized medicine, not insurance. That's the correct terminology. Anyone arguing for anything between Obamacare and Medicare For All (which includes me, BTW) needs to own up to that terminology or something to that effect and stop selling the notion that what they're arguing for is just insurance.
Insurance, as a concept, doesn't shift the burden for risk from people who can't afford to pay to people who can. It's something different and you don't get to alter definition of insurance just because the correct terminology has a stigma. So when the comment I replied to says,
> This is the whole point of health insurance!
No, it's not. That's the whole point of socialized medicine. Words have meaning and we should be using the correct ones.
Poorer members of the insurance pool have their premiums subsidized. From the insurance companies point of view, they are (theoretically) managing the pool and premiums using the same actuarial tools they used previously.
The rules about not being able to reject people for pre-existing conditions force them to broaden the set of (heterogeneous) members included.
The plans are provided by “health insurance companies.” The product you buy from them is called “health insurance.” The imaginary, purist notion of what you are declaring to be “insurance” is like a simplified model of economic theory you might find in a textbook. It’s used to gain insight about how an insurance product works. There are no real world example of “health insurance” that conform to your simplified definition.
Health insurance in the US has long included coverage for routine care, which already falls outside of your model.
I’m of the theory that the meaning of words is defined by how they are used in everyday language, not how I think they should be defined.
That statement is true, but health "insurance" covers lots of non-chance things, because it covers lots of things that are not a result of "getting sick". Some examples:
* Birth control.
* Basic childhood vaccination.
* Well-child checkups.
* Annual health checkups for adults.
* Basic screening tests for adults (mammograms, colon cancer screens, that sort of thing).
All these things should be provided, imo; insurance is the wrong vehicle for providing them. Politically, I _think_ (hope?) there would be a lot more support for "provide all children with basic health checkups" than there is for the ACA. Of course there would be less support for the "birth control" item, which is why people like to bundle these all together, and with things like emergency medicine and end-of-life medicine. Which are _also_ quite different in terms of their risk profiles, tradeoffs, and elements of chance.
It also covers some things that in an ideal world would not be chance but are in practie (e.g. routine births with no complications; they are more chance than they should be because as a society we suck at birth control, on both the organizational and personal level).
I really wish we separated our "health care" a bit more along some of these axes, because I suspect that the "right" answer is to have single-payer for some aspects of it, an insurance scheme (private or public or both) for other aspects, and "you're on your own" for still others, with expensive and invasive end-of-life interventions heading this last list.
Surely you can see how that is different from (say) fire or auto insurance, where no one would expect to pay the same to insure two houses, only one of which is actually burning at the moment.
Regardless, the idea that under ACA “the healthy pay for the sick” as expressed by Ryan was certainly not an oblivious truism about the nature of insurance as it is being portrayed.
Remember with Obamacare about how there was a huge push to get young people to sign up for it, because without healthy young people paying too high premiums, the system would fall over with the costs of the elderly? Maybe that is why young people didn't want to sign up for the ACA, and they needed to enforce 'penalties' for not having health care.
If young people were actually charged a fair market rate for their health insurance, they would sign up in droves because it would be dirt cheap. But when you make them pay far more than is reasonable, because old people need health insurance too, then that is how you get a system where no one wants to sign up for it until they are legally forced to.
The ACA in this sense completely subverted the point of insurance. So, maybe the right doesn't understand insurance, but neither does the left.
Imagine a world where a 20 year old would be able to buy a 10-year term life insurance policy for the same amount that a 90 year old can. That is essentially what the ACA attempted to provide.
Instead of paying for other peoples health insurance and then other people pay for mine, why can't I just save the money that I would be paying in premiums above and beyond what the rational amount would be and then pay for my own health care when I get older(or, pay for the higher premiums when I get older)?
The young (and healthy) paying for the old (and sick) is a function that can only be provided by government, or bona fide charity. It's impossible for this to be provided by private companies because, in line with the denial behavior we're seeing, it's rational for any company to take on the overpaying low-cost customers, tell the underpaying high-cost customers to go elsewhere, and then pocket the surplus.
Having said that, I'm not personally a believer in single payer fixing everything. It certainly should be possible for routine care for financially able people to be provided completely on the open market. Immediate common-sense based reforms would go a long way. For example, hospitals/providers should be required to have one and only one price list for all payers, published months in advance. And the bundling of "insurance" with employment should be outright prohibited
Even though I don't like the ACA, I give Obama a lot of credit for trying. There is no political benefit to doing so.
As a nation we should try optimizing for a more moral, just system. As I see it that would be something like Medicare for all but I'm open to suggestions/solutions.
I started a company with my brother that is attempting to drastically lower costs for primary care. (https://scalpel.com) We build software that allows physicians to set up their own direct primary care clinics. Our beta clinic in South Carolina charges $49 / month for unlimited visits and charges people at cost for things like labs and procedures. So instead of dealing with a labyrinthine medical system people are just working directly with a doctor. We really only care about making money off our memberships which we charge what we believe is a reasonable amount.
https://www.cms.gov/Regulations-and-Guidance/Legislation/EMT...
From the link you provided:
Hospitals are then required to provide stabilizing treatment for patients with EMCs.
I often wonder why health insurance companies don't use a similar tactic.
Edit: Try finding a pediatrician in Berlin. (Seriously, I would love to hear recommendations)
Also Germany suffers from an ageing population which is why there aren't that many experienced professionals of any kind.
A country like the USA see this in the light of healthcare as a business, make as big a profit as you can, irrespective of the actual services that you provide. In other countries where the relevant governments provide universal service they allow private businesses to dictate the price that the government pays for the supplies required.
So, we have general commodities when supplied into the healthcare system being charged at 10x or greater for on item which, if not used in a healthcare environment, is charged a much lower price. This applied to things like computers, phones, chairs, tissues, matches, paper, toilet paper, gloves, etc,
The suppliers get away with this because of the perception that these goods are of a higher quality. These goods often come off the same production lines as those sold in a normal commercial market.
I have seen up to date medical equipment that cost a large fortune that looked pretty, but if you actually looked at the basic equipment was technology that was anything up to 10 years old and was superseded by stuff your could get commercially.
The amount of money charged for drugs is based on the amount of money spent of research, which if you actually looked at the figures thrown about were spent by the public purse not the private.
It is a captive market and those supplying into it want it that way to maximises their profits. Morality questions are not considered to be important unless it has regulatory considerations that will significant reduce your profit margins if you fail to live up to them.
The problems within the healthcare system (insurance included) will not be solved any time soon. Even if there was a revolution that changed the entire basis of how and when healthcare was supplied, it will soon return to what we see today as greed is the basic motivator for society as a whole.
To bring about real change requires people really changing and this will not happen because we are basically looking out for ourselves and our own. This occurs on the local level, on the regional level, on the state level and on the national world levels.
The healthcare system is an area that needs a complete overhaul worldwide. It is not going to happen since most people do not have the ability to see past their local situation.