Hospitals Block ‘Surprise Billing’ Measure
californiahealthline.org
californiahealthline.org
Medical facilities are forced to artificially inflate bills. Insurance then artificially gets a discount back to a sane price. This helps insurance look like they're "doing something" even when they aren't e.g. High Deductible when you pay 100% up to the deductible ("at least I got the insurance rate!").
Out of network also suffers from this. The networks themselves are discount networks and prices for uncovered patients are artificially high.
If you banned insurance discounts and insurance had to pay the same dollar to dollar cash price (without kickbacks/incentives), it would help the uninsured, it would help re-align patient/insurer motivations (i.e. both demanding low cash prices), it would make price transparency actually meaningful, and it would eliminate insurance networks.
But ideas like this, and removing employer provided healthcare (e.g. everyone on an open health insurance exchange) are politically impossible in the US because no politician can get elected for "taking people's employer insurance and taking their discounts." Even if they're the right thing to do to simplify, reduce costs, align goals, and force insurers to compete again.
It wouldn't. Insurers would still need to approve providers' prices, and those negotiations would have other levers that could be pulled.
But broadly speaking, yes--requiring insurers pay the same price that is advertised and available to the uninsured public is basic price-transparency policy.
Right now insurance either do cover something or they don't. That in itself is problematic. If insurance would cover a procedure up to e.g. $500 at one medical clinic why do they cover up to $0 at another? Shouldn't it be $500 here or $500 there?
Networks inherently pit you against both the insurer and healthcare provider. Instead you and your insurer should be on the same "side" against healthcare providers.
That's vastly oversimplifying. Insurance often covers part of something.
Single payer has proven in pretty much every western country to be massively less expensive than the insurance system in the USA.
US voters haven’t had the option for single payer, but they did have options for removing employer sponsored healthcare.
The only way to dodge that is to subsidize it, whether by reducing the budget elsewhere (cough cough the F-35 program cough cough) or raising taxes (cough cough on the ultra-rich cough cough).
Insurance pushes the price of care up by about 5 to 6 times in my estimation, single payer would fix it.
It never occurred to me before that this is an option. That sounds like a good idea.
I also wonder why health insurance should be allowed as an employee benefit. How does it make any sense to tie my access to healthcare with my employment status?
I work for a Fortune 500 and my daughter has probably cost the insurance $1m. No big deal rates didn’t even raise.
Before I worked for a contractor and we cost THEM a million bucks, and they had to get rid of the low deductible plan, and boost insurance rates by $50 per WEEK per employee. We single-handedly destroyed their risk pool from three months of NICU stay, making it so they could no longer offer affordable insurance. Rather than accept the new rates we got cheaper plans on the Marketplace. Unfortunately though those aren’t tax deductible but we still came out ahead.
It’d make far more sense to just have a marketplace for everyone and make the risk pool the entire US population, rather than let giant corps get good rates while small companies get devastated when an employee or their children get sick.
Was this a large group insurance plan (usually 50+ or 100+ employees depending on the state)? If it were a small group insurance plan I don't believe your utilization would increase the rates, since AFAIK all the small groups in one state/region and insurance provider are combined.
If the employer was large enough to have a large group insurance plan, but still fairly small, I suppose one person's utilization could noticeably increase rates at the next plan negotiation. I believe this is why some companies that are too big for small group insurance plans utilize "professional employer organizations" to participate in a larger risk pool.
WWII wage-price controls:
https://www.npr.org/templates/story/story.php?storyId=114045...
How does this make sense, though?
> "The war economy is an entirely different ballgame," Thomasson says. The government rationed goods even as factories ramped up production and needed to attract workers. Factory owners needed a way to lure employees. She explains that the owners turned to fringe benefits, offering more and more generous health plans.
Why is a healthy plan better for employers than paying cash and letting employees buy their own health care / insurance?
The 1943 IRS ruling that health insurance is tax free, and the legislature failing to correct that, is more of a problem. This blatant failure isn't an "accident", it's bad lawmaking that biases toward business, against people.
Wage-price controls prohibited that.
and letting employees buy their own health care / insurance?
Risk-pooling, information asymmetries, "shoe-leather" frictions (having to shop around, individually, for everyone), bargaining power.
Healthcare markets poorly.
How a big part of the reason the US healthcare system sucks is just a weird fluke of history!
The NYT has a nice overview [1], the relevant passages below. Wikipedia’s coverage [2] is excellent as well.
“In 1942, with so many eligible workers diverted to military service, the nation was facing a severe labor shortage. Economists feared that businesses would keep raising salaries to compete for workers, and that inflation would spiral out of control as the country came out of the Depression. To prevent this, President Roosevelt signed Executive Order 9250, establishing the Office of Economic Stabilization.
This froze wages. Businesses were not allowed to raise pay to attract workers.
Businesses were smart, though, and instead they began to use benefits to compete. Specifically, to offer more, and more generous, health care insurance.
Then, in 1943, the Internal Revenue Service decided that employer-based health insurance should be exempt from taxation. This made it cheaper to get health insurance through a job than by other means.”
[1]https://www.nytimes.com/2017/09/05/upshot/the-real-reason-th...
[2] https://en.m.wikipedia.org/wiki/Health_insurance_in_the_Unit...
It's an excellent way of reducing worker mobility.
The reason often cited for employer-based coverage is that it avoids some self-selection problems, but that's a different and complex topic.
>> A company signing up lots of their employees doesn't increase the size of the pool -- it just adds an intermediary.
I'm not exactly sure what you mean by that. For large group insurance plans, rates are determined by the risk (calculated by the insurance provider, with certain legal restrictions) of your individual employees. If you have 100 employees and 10 of them get a chronic illness, your rates will go up. Similarly, an employer with older employees will have higher rates than an employer with younger employees. The pricing is per group (employer), not based on the entire pool of the insurance provider's customers.
For very large employers, I believe it's common to self-insure, i.e. make a deal with an insurance provider to provide care to your employees at the rates negotiated between the insurance provider and health care providers, but the employer just pays out the total cost of delivered care rather than premiums. Then you get into stop-loss insurance and other interesting complications.
Economically speaking a 20-something will have fewer responsibilities than say a 40-something with a family and children.
So many startups have been funded by 20-somethings having the ability to couch surf and live off their parents health insurance -- likely because they're the only ones that can afford the risk.
The preponderance of a given condition is not a function of having insurance (though complications thereof can certainly be increased by NOT having insurance). And has already been factored in by actuaries into policy pricing.
The biggest issue is that we see health insurance AS insurance, not amortized healthcare costing.
> There has to be some way that the insurance company can make money on the odds.
That's the thing, they see an opportunity to increase profit.
A few comments on that, as someone who has worked in the industry of developing software for health insurance claims management and benefit processing:
1) insurers are incentivized to deny claims, often talking about how "unfair" it might be for "them" to have to pay for a treatment. The irony is that "they" are not paying for anything - the risk pool is. Those premiums were calculated based on actuarial assessment, plus insurer overhead calculated in. What they mean by "them" having to pay out is that we cut into their profits, as they don't refund money to risk pools if the entirety of the pool is not used - they keep it, in addition to the admin overhead.
2) insurers have been known to be outright unethical, if not illegal in denying claims. Some prurient examples: denying Heli EMS for car accident victims from the scene to a trauma center because of "lack of pre-approval" (sorry, as a paramedic I am not "hold[ing] for a nurse consult" as I call an insurer to decide whether they are going to deign to pay for this patient's transport, and retroactively canceling coverage for "failure to disclose a pre-existing condition" that was actually unknown at the time of disclosure, i.e. "You were seeing a physician for maladies X, Y and Z. You had not been diagnosed with anything at that point, but later were, and maladies X, Y and Z were symptomatic of that. Ergo, you had that condition at that time, though you did not have a formal diagnosis, and failed to disclose that you had it. Accordingly we are voiding your coverage for breach of contract".
It should be illegal to drop a person's coverage if a clear diagnosis was not made prior to an incident that required medical intervention and cemented a diagnosis on paper.
Not sure these are "prurient". You may mean salient.
Employers now document their insurance costs for each employee on their W-2 forms, in case you want to see how much yours is paying for you.
For 1, it's just completely insane that all medical expenses aren't automatically tax-deductible. It's silly that it's advantageous to have my employer pay $200 a month for my insurance plan rather than just pay me an extra $200 and let me use that on whatever plan I want.
For 2, that may be a little trickier politically. Group insurance gets more efficient the larger the group, assuming there's a mechanism to prevent adverse selection. So obviously, we want to increase group size. That was one of the claimed justifications for the individual mandate.
If you're paying for insurance with after-tax dollars, you can deduct it as long as you're a) itemizing, and b) have total medical + premium expenses >7.5% of AGI, but given that people who pay for insurance with pre-tax dollars get that benefit regardless of those criteria, it seems like it'd only be sane to relax the rules so that people paying with post-tax dollars get the same break.
Are they? Or are they allowed to get away with it?
The question becomes how to break out of the loop.
(GOTO considered essential?)
If we try that, I'd expect medical expenses keep going up and confused_pikachu.gif until people figured out that hospitals were never on their side. If this takes long enough, "bring back insurance companies" will be the solution, and then it won't work, and then we're back in an infinite loop with a longer cycle.
Hospitals need countervailing price pressure, and anyone who doesn't accept that is liable to vote for catastrophically bad policy.
http://sites.gsu.edu/us-constipedia/standard-oil-co-of-new-j...
They remain a massive concern with monopolies today.
I don’t think it forces them. I would say it gives them an excuse to do so.
The hospital, a for-profit business in the United States, isn't voluntarily going to give up profit, so they "hack" the system by raising prices. If InsuranceCo says they'll payback 20% of list price, but it costs the hospital $100 to run the test (including some nominal profit; hospitals aren't non-profits, for better or worse), the hospital must charge $500 for the test, just to break even on InsuranceCo's patients.
Which they aren't refuse, because those patients are a significant portion of the hospitals revenues, or due to laws, in some jurisdictions. ER's can't (legally) turn away people they don't like (Eg African Americans or immigrants).
I have never seen a real accounting of these costs so we can see whether they overcompensate. It’s the same with the high drug prices. They always say that other countries underpay and therefore the US has to pay more but you never see any real numbers.
And is been shown that doctors who belong to such are more than 2.8 times more likely to refer patients for imaging.
The dumb thing is, the bill won't hit my deductible cap for the year! (The procedure was done in 2018.) So, in any case, I will pay the full bill and the insurance company will pay nothing. But if the insurance company processes the bill, then I get the "discount".
This is mind-bogglingly stupid.
Honestly blue Cross blue shield is just like Facebook ..users are the product not the customer.
The number on the bill before the insurance discount is entirely imaginary, no one pays it.
There is always a built in cash discount for people without insurance.
For example, for a while I was having trouble getting insurance cards (stupid reasons) at a new position so I was paying out of pocket for prescriptions and office visits.
They were less expensive paying cash than with insurance pre-deductible.
Until they don't pay it. Then that entirely imaginary number becomes a very real debt that gets sold and reported.
I was all set to settle my bill actually, but the woman in billing (at the doctor's office) urged me to not give up and file another appeal. Apparently even she agrees that this is bullshit.
The whole experience has been surreal.
I ended up with the last laugh, though--eventually the insurance rejected it as billed too late, denied, drop it. Instead of collecting the negotiated rate they got $0.
To be fair, the current president ran partly on a platform to end surprise billing and has asked congress to deliver legislation to this effect
In the past, insurance just paid whatever the hospital charged it was called “usual and customary”. This came about because public plans were getting ripped off and gov’t said “no, you can’t charge us whatever”.
Cycle through a series of different reimbursement systems in order to get a grasp on costs and you end up where we are now - chargemaster rates are ridiculously high (because they aren’t allowed to charge more than that) and the payers negotiate rates down as best they can so you end up with massive gross-net differentials.
It’s really a complete mess.
https://en.m.wikipedia.org/wiki/Usual,_customary_and_reasona...
It works pretty well, though I've never had to use it. There is a private forum for members to discuss tactics on getting the biggest discounts. A member will typically ask for a self pay discount as we don't have "insurance". In many cases that knocks 25%-50% of the bill off right there. But you are still dealing with the normal hospital or clinic billing department at that rate.
If you continue to decline this "discounted" rate and push to be transferred (in person or over phone) to the billing department's higher ups, you might even be able to get the bill lowered even more... but you must reject these as well. Eventually you will be turned over to a collections company, and right before they file against your credit score you will actually have the most bargaining power. Typically you will be able to knock another 50% off of the bill.
There are many testimonies on the forum of people getting heart surgery or chemo and having bills in the $100k-$150k range and yet in the end, and after lots of phone calls and added stress... they walk away with paying only $20-30k.
So basically, "insurance" does this bargaining for you.
Overall I think a NHS is better.
"eye clinics were unable to keep pace with demand.... In four out of five cases, those affected had chronic conditions requiring long term follow up, meaning they are not covered by NHS targets." https://www.telegraph.co.uk/news/2018/06/06/hundreds-going-b...
While pathetic, it's not clear how it follows, as the DW asserts, "This is what will happen in America if Democrats get their way on 'Medicare for all.'" There are lots of countries with socialized medicine without the problem that NHS has. DW fails to mention that, possibly because of its bias. Private insurers in the US, in the meantime, are widely known to pick-and-choose what they will cover ... and will not.
Edit: here's a description of 'Medicare for All' from Forbes. https://www.forbes.com/sites/teresaghilarducci/2018/07/16/wh...
The US is already paying far more for healthcare than the UK, and that stays true even if we only consider government funding and ignore insurance. There's no reason something similar would happen in the US.
Also, that report mentions macular degeneration, and this is a problem mostly caused by terrible pharma practices.
Avastin and lucentis are very similar. Avastin is older, and is much cheaper than lucentis. They can both be used to treat AMD. The owner has licenced lucentis for use in AMD, and has chosen not to licence avantis for AMD. This means that doctors can use avastin "off label". The rights-holders decided to sue the NHS to prevent this off-label use.
https://www.bbc.co.uk/news/health-30138097
https://www.hsj.co.uk/finance-and-efficiency/breaking-nhs-wi...
The problem you identified is correct but the solution isn't right. You should let people be free to choose to freely associate with one another (or whatever insurance policy they prefer).
Instead, get rid of legislation that makes hospital bills something awful for unensured people. Many things are driven by the insurance companies but others are by hospitals or even just politicians with bad ideas. Remove the barrears of entries and things tend to get better too.
An alternative approach would be to limit how much higher th e price could be compared to the median insurance re-imbursement for a particular procedure. If you set the limit low enough, then going out of network would not be much more expensive. And the total cost of having insurance and using them may be more than just paying out-of-pocket.
I went to an urgent care center and had a doctor perform a routine examination for a sinus infection. No special tools or materials were used. Before I went in I signed a form stating that I acknowledged that I was on the hook for whatever extra it cost if the situation required it. I was thinking along the lines of bloodwork, x-rays, etc. The doctor was very helpful in avoiding unnecessary expense as well.
A month after I paid and left I got a bill in the mail stating the that doctor had performed an 'extensive examination' and that cost an extra hundred dollars. They had all the information necessary to bill me this as I left the urgent care. Yet they chose to wait and send me a bill because it's a complete fraud.
I really wish I could find out the answer to how this works, but my guess is that there is some automated process that tacks on extra billing where possible as a way of boosting income. Ordinarily it's a 'victimless' crime in that it is paid for by an insurance company.
But ultimately we're fucked in this country with regards to healthcare. It is a disaster that keeps people sick, yet we need it because it's such a large part of our economy. Little by little this sector has inserted themselves into the literal lifeblood of the nation's finance and health and is holding everyone hostage.
Aside from that, (EDIT: More likely) it could also be that lots of billing actually takes place when a coder reviews the doctor's note of the encounter. This can be several days after the visit. This is a legitimate and very common practice. They might not have known the correct amount to charge until everything was properly coded.
[1] https://coder.aapc.com/cpt-codes-range/2869 [2] https://www.verywellhealth.com/what-is-upcoding-2615214
Why is it okay to tack on all these mysterious services rendered after the fact that may not have actually transpired and were instead 'upcoded' as the insurance company may cover it. This creates perverse incentives and allows physicians to bill the max rate and optimize for rendering the most lucrative number of services and they can reasonably get away with.
I've seen dentists do this time and time again if you come in with PPO and put the pressure on you for extra services if you have an HMO cause they are barely getting paid, recommending laser treatment for killing bacteria and a plethora of other scare tactics to get you to pay for their fancy equipment and hygienists, etc (confirmed this with a dentist relative).
I can understand when some complicated procedures can’t be correctly estimated until after, but there is no reason why routine procedures can’t be priced out ahead of time.
When my daughter had her tongue tie fixed at a dentist, they gave us the procedure codes ahead of time and I could ask insurance exactly what it would cost. It was beautiful.
It’s such a big problem now I’m surprised a hospital doesn’t use it as a selling point “we give you a guaranteed estimate and if we’re wrong, we eat any additional cost”. I know that would weigh pretty highly when I’m selecting a hospital.
It's billing code optimization. Doctors aren't specialists in billing/diagnosis codes, and their time is really valuable, so many of them tend to use a handful of fairly generic defaults they're most used to and then move onto the next patient. This is what you paid when you left.
There are really, really specific requirements for many billing/diagnostic codes, which will each have a fee defined against them. If a code requires a specific question to have been asked or a specific set of actions to have been performed by the doctor, if even the most minor component is missing it risks having the claim rejected[1]. Or more specifically, if it's missing _from the doctor's notes_[2], such that there's no documentation that it was done/asked, then it risks being rejected.
An asynchronous process got kicked off after your visit, where your visit details went into the queue for either a medical coder (either human or software) to review visit details, prognosis, and doctor notes. Then, based on their findings, they adjusted the code your doctor originally used (either changing it entirely, or adding supplemental codes). That's why you got an incremental bill at the end.
[1] This is in the case of insurance companies. If a medical practice wants to charge for a code, the insurance company demands the requisite documentation to justify the use of that code. I've never tried it, but you may have some success disputing the bill by _also_ requesting the specific diagnostic codes that led to the incremental bill, as well as the supporting documentation to justify the coding. Which is what an insurance company would do, too.
[2] This is one of the big benefits of an EHR to a practice. The EHR workflows can be set up to require a bunch of boilerplate information be collected and processes be followed, which generates very rich visit notes and provides a lot of opportunity (and documentation to justify) for upcoding a visit. Which usually makes administrators/practice managers happy, while mildly annoying physicians.
Different insurance companies have different tolerances, requirements, and denial tendencies for specific codes. So the definition of "reasonable" is highly contextual.
At least in this instance, the surprise bill was _only_ $100 from what sounds like a fairly standard medical coding practice. He could have just as easily been surprised with a several thousand dollar ER bill[1] if he had chosen a more financially creative urgent care facility.
[1] https://www.houstonchronicle.com/business/medical/article/Co...
Every hospital system does this, and it's a complete fucking racket.
I've gotten these "three months after you thought you were done with this shit" bills for anywhere between $300 and $1000. All were minor, single specialist visits or tests that lasted < 30 minutes.
This is literally extortion, you are on the hook when the artificially inflated bill arrives that insurance won't cover and you were duped into signing for just to be seen by a physician at their practice and your credit will take a hit when the debt collectors are hounding you for their cut if you don't pay up for these services that were upcoded after the fact.
They believe they can charge whatever they want even years after the service. You can never be sure if you are really done with them.
My insurance company calculated that the average cost of the surgery should be about 10k and that's what they were willing to pay. 6 months later I got a bill for $150,000 even for the surgery. First, what are the chances that a bill that large is perfectly even? It's an obvious scam that these places will literally try to charge as much as they think they can get away with. They ask for huge numbers hoping to settle above market rate. At no point during this process was I told anything other than you're covered and with a broken hand, it's not exactly easy to do research.
There are far too many such mistakes for it to be pure chance. Some of it certainly is carelessness but they don't care if they make such mistakes. (For example, once my wife got back to the exam room before it was realized that the appointment shouldn't have ever existed--she was sent home without anything being done. Many months later they bill for the co-pay for that visit. Obviously some auditing procedure noted the "visit" and the lack of a corresponding bill and "fixed" it.)
So...a week later, I get a bill, because their system knows I was there and didn't pay them. And I think about calling up and telling them it was supposed to be free, and then I ask myself if I really want to debate this with their billing department and I just paid it.
We went in the ER and I was admitted. The five day course of treatment on admission we were told would run in the vicinity of $20,000. Something I could afford given the extreme circumstances if insurance were to deny it (longer story there).
But the next day we were told that insurance would deny and the total would now end up around $100,000 for the full treatment. Not something we could afford. And I was not in the state of mind or ability to handle this smartly or know I could get a lawyer or try to start some negotiation with them as people might suggest.
So we had to be discharged without completing the treatment. A month later I had been relocated across country to change insurance to a provider that covered it and was able to start treatment. Now we could see that an insurance company was only paying $16,000 for the full course.
This effectively denied me treatment (amongst other things) and caused pretty significant harm.
(This is not ignoring that I am lucky to be in a position to afford a $16,000 treatment bill and many aren’t, but this is to say that when the hospital jacks up the price 7 fold in a situation like this they’re effectively saying “go away we won’t treat you”. They could’ve just as easily given me the real pricing and then I would’ve been able to be treated.)
This administrator (Cigna et al.) will have a bunch of policies for certain treatments and drug uses that define when they can be used. These operate like a firewall rule, being parsed, and if you don't match perfectly, you get denied. Sometimes they'll be more flexible, but some are known to be terrible (cough Cigna cough).
If you don't match this policy perfectly then your treatment gets classified as "experimental". At that point they point you to something called the "XYZ Company Handbook" which is something your employer maintained. This is a document that almost never exists in reality, but the gist is that "XYZ Company Handbook" will say experimental treatments are not covered.
(There was nothing really experimental about my treatment, it’s just high dose IVIG, with lots of patients on it and a half dozen of my doctors all supporting it. Experimental seems to be their euphemism for “expensive, so we don’t want to cover it”.)
So administrator points to employer, then you go to your employer, they point to the administrator. Then you go to a lawyer or your state insurance commission for help, and they say because it's a self funded health plan it is not technically an insurance product, and is regulated under federal law as an ERISA plan. This means years in court, and the maximum you can ever recoup is only the costs of the treatment. So you have to pay for treatment up front, then fight to get those costs reimbursed. And because there can be no punitive penalties there is no real incentive to act in good faith.
Your lawyer (or state insurance comission) will also point out that because the plan is self funded your employer is actually the ultimate authority and can approve or deny or make exceptions for any claim.
The appeals process can include something called an independent review, where an outside organization can review your case and recommend treatment or not. This is a time consuming process though. Also it doesn't always work out. And they tell you that they are not bound by the results of the IRO anyway.
In our case we were able to change from our employer's self funded plan to a legacy brokered plan, an old school type one where your premiums actually go to the insurance company and the insurance company pays for all treatments. These are regulated by state insurance commissions. This plan was actually provided by a not for profit Blue Cross/Blue Shield and they covered the treatment immediately because my case was pretty darn obvious that I needed it.
But here we are in California a self described progressive state, but the pols pull this?
Note, I’m not a progressive as I agree and disagree with many things and am politically all over the map but I think these are things that are good for all of us.
It's a principal as old as Life itself.
Increasing taxes raises the cost to the individual, but it also raises costs for all their neighbors, and results in community improvement (ideally).
Is investing an attack on your financial interests?
Insurance is worthwhile whether you get $0.80 or $1.25 back on the dollar. It's not necessary for people to have a positive expected value from it.
I propose a 2 part system. One system is government funded and pays for ambulances, ER visits, annual checkups/physicals, and maybe a few other basic services like dental cleaning. When you dial 911, the police and fire department both come for free, so why does the ambulance bill you a grand? Any sort of life or death situation would be covered by this. Abuse of the system can be monitored and the government has plenty of recourse.
The 2nd part of the system would cover short and long-term illnesses and conditions as well as prescriptions. Things like orthodontics could also be a part of it. Basically, it pays for any doctor that doesn't work in an ER. This way people who don't use these services a lot aren't burdened by those that do while at the same time eliminating the fear (and litigation) that comes with being bankrupted by a catastrophic accident
Pre-existing conditions are not defined by the average paid out in claims to a person.
It's normal to have a deductible that's over $5K and is not met in a typical year, and one or more pre-existing conditions. So it bewilders me how people keep debating as though the contrary were typical.
The question is not whether a person should have their predictable costs paid for through "insurance", but whether a person should be able to get insurance for catastrophic costs, if they are considered to have a non-quantifiable risk.
There is a fundamental inefficiency in a market that discriminates against sick people, not just a lack of "social justice" or whatever. If insurance companies are allowed to discriminate against pre-existing conditions, then they have to charge not just enough to cover the true risk of the high risk customers, but enough to cover the risk of being wrong about the risk - insurance against "unknown unknowns", adverse selection.
"Fairness" often costs more money.
Yes, it would! People always vote to raise taxes on the minority (the 'rich') to give money to the majority (the 'poor'). This is rule by tyranny, a common issue with democratic governments. It is one of the main reasons democracy is not the ultimate value of the United States governmental system.
Oregon passed significant housing reform this year - California failed (OR HB 2001 vs CA SB 50).
Lots of articles on this:
https://www.sfchronicle.com/opinion/article/San-Francisco-Ba...
https://marketurbanismreport.com/blog/the-disconnect-between...
And one on Oregon's bill: https://www.sightline.org/2019/06/30/oregon-just-voted-to-le...
California politics are not particularly progressive, and they look that way only if you compare us to Alabama, otherwise we're a solidly center-right state. We just don't do extreme right (GOP).
And in all honesty, it seems that 60% of the problem with modern insurance lies with these totally arbitrary delineations of what is in-network and what is not. The insurance company gains implicit power over where you get treated by making up these "networks". Why should an insurance company be the one certifying hospitals? Shouldn't that be done by, yknow, a government agency and not a profit-seeking insurance firm?
I mean, governments do certify hospitals. If you don't have gov't certification, you can't provide medical services.
With private insurance, your insurance contracts with some hospitals. If you go to a hospital that's not contracted, your insurance will pay what it deems "reasonable", and you have to pay the balance of whatever the hospital decides to charge you. With a law like this, the hospital would have to just take whatever the insurance company deemed to be the correct price. This would seem to incentivize insurance companies to have very low "reasonable" prices for out of network visits.
I live in Argentina, that's like being the most-dysfunctional and mentally challenged cousing in an already dysfunctional extended family (South & Central America).
We have lots of issues with health care here, _specially_ for those that work on our own (I don't exactly work on my own, but working for a foreign company is more or less the same).
There are lot of stories going around (some of them I know first hand because some relative's kid has a rather strange syndrome, and getting their health care org to cover that was an impossible task) but still, the "You broke your leg here's a 50K bill" kind of story I often get from the us is a total and utter madness.
I kind of enjoy in a bewildered amusement these public displays of lobbying, thought.
I had to go to the ER during the middle of the night. Saw the doctor for 10 mins total. A few months later, I got a bill from the physician on duty saying they were out of network; it was for a shade under $1000.
I called the insurance company, and they said, the hospital had a history of sending fraudulent bills, that they had already paid the physician AND previously had sued the hospital for sending these fraudulent bills and obtained a legal settlement enjoining them from doing it.
In another incident, my wife's OBGYN kept sending us small bills, $29, $74, etc. even though we have paid our co-pays. I called them up and asked what the bills were for, and they honestly couldn't tell me-- saying they would call us back. Which they never did. Which I assume meant, "you caught us lying."
You're better off borrowing money from the mafia than you are visiting most any emergency room in the US. The mafia has much more straightforward billing transparency, fewer surprises, and is generally more honest.
Also, know that the primary care givers (nurses mostly but also doctors) don't get paid as much as you think they might. The insurance companies are all for profit so the system is gamed this way.
[Edit] If you need non-emergent surgery and have an idea of what you need you can check out: https://surgerycenterok.com/pricing/
Disclaimer: I have no affiliation with this organization but I applaud them!
I've also paid cash at old specialists who don't accept Medicare, and traveled to Mexico for care. I've also gotten superb care while overseas. Single payer is probably the answer. If I need serious surgery some day I will likely do it in India. Your site there seems a reasonable alternative I would look into.
But this still leaves open the situations with a serious accident requiring immediate care which would surely bankrupt anyone. Insurance never covers whatever care is nearest to a random accident site, and this scheme is by design, along with the curious situation where each hospital and their staff are carefully partitioned out to different networks.
I broke my ankle in a really bad way rock climbing two years ago. When I first broke it, my health insurance was Kaiser, an HMO, which is a decent example of how a government healthcare system might look like in other parts of the world (you cannot just go see a specialist and everything is controlled by referrals). I had major trauma in my ankle that required surgery, but Kaiser won't even let me see an orthopedic surgeon. Their policy was that since it was foot injury, I would only be able to see a Podiatrist, and I had no choice in that matter since I had no control over which kind of specialist I could or coudn't see. When I talked to my orthopedic surgeon friend about this referral to a Podiatrist, they thought it was crazy.
I went to see that Podiatrist and they basically told me that my ankle was screwed, there was not much they could do for me, and that I will spend the rest of my life in pain. I think in another country like Canada or Britain, that would probably be the end of the story.
I am pretty young, so I didn't want to give up just yet. I went and got a second, third, fourth, etc... opinion from other doctors, just paying in cash outside of my insurance. Eventually, I switched insurances to a PPO plan (just a regular Obamacare plan) and found my way to The Steadman Clinic in Vail, which is where a lot of pro sports players get orthopedic surgery. There, a surgeon recommended a procedure where they use stem cells during the surgery to rebuild dead tissue. I was able to have that procedure.
Two years later, my ankle is still pretty messed up, so I went to that doctor again, and he recommended a third surgery to clean up a bunch of dead tissue. From the time when I decided to see the doctor again to the time I had the surgery was 1.5 weeks!
All this is a great example of why the US system is bad overall, but actually good for the patient if you have money. I have seen like 10 orthopedic surgeons for this injury and have had 3 surgeries, all because I was motivated to try to get better and to try all options. I don't think I would have gotten nearly that much or that good of care under a government plan. The amazing thing about the US system is that if you have money, and you want to try stuff, you just can! There is noone telling you otherwise.
The ER doc would refer you to an orthopedic surgeon. You might spend some time in a boot waiting for a surgery slot since your injury isn't life threatening, but you would get surgery.
Anecdotally, our family have been Kaiser members for nearly 25 years, and we've NEVER been party to a billing dispute. Perhaps Kaiser fights with SF General or other ER providers, but they thankfully keep their members out of it.
Finally, my yearly cost to remain with Kaiser tends to be about 10% less than our company's other PPO options.
This just a few years after a 71% loss of operating income: https://www.beckershospitalreview.com/finance/cleveland-clin...
Maybe healthcare systems are in a pinch?
It's actually all laid out in your link.
Insurers (and the Cleveland Clinic) achieve income through both premiums charged and investment return on those premiums. Because premiums are a competitive market, more subscribers can be acquired by lowering premiums, possible by pursuing higher investment income. Which works until it doesn't.
Premiums and payouts are locked-in contractually, whilst currency valuation and investments float on the market. Stay on the right side of that and you're Life's Golden Child. Get on the wrong side and nothing can go right.
Curiously, the insurance (that is: risk-management industry) seems blind to the investment-side risk and keeps getting bit by that bug every decade or two.
Wikipedia's (very brief, incomplete) treatment:
>Global except north america
i.e. You go to war torn Sudan we've got your back but if you dare going anywhere near that bastion of freedom known as the US...you're on your own.
The fact that medical insurance companies are down with Sudan, North Korea and China...but not the US...that would suggest the need for some introspection frankly.
(Bit puzzled by the Canada inclusion though - any ideas?)
The wording is literally global except for.
There might be some gotcha in terms of "doesn't cover active warzones" that I'm not aware of, but my point stands. Insurers are fundamentally OK with the concept of global...but won't touch America. Makes sense - US medical system pulls numbers out of a hat so how do you insure against that as an outside non-US medical aid?
The claims I've filed in other African countries cleared without question. In fact I try to do my annual checkups there.
Edit...no can't link..its a custom policy...but i believe it to be reasonably close to market terms
Correct. Thanks for elaborating.
https://www.globaltravelinsurance.co.uk/single-trip
"GEOGRAPHICAL AREAS
1. United Kingdom
...
2. Europe
...
3. Worldwide
All countries outside of the above (except those within Area 4).
4. North America, Central America & The Caribbean
Due to the increasing unsustainable cost of medical treatment in this Area, we regret to confirm that we are no longer offing[sic] travel insurance under this product for trips to Area 4."
(Although note that the policy, like most, excludes areas where the Foreign Office has explicitly advised against travel, which I guess may well include Sudan.)
Nope. This is full blown global medical coverage (except NA).
For an affordable price too. Employer covers UK...I kick in an extra 600 USD per YEAR to make it global (except US).
...let that sink in...my surcharge for everything global for a year is less than even a trivial operation in the US.
600 a year to cover all my shenanigan on travels...I'll take it.
>excludes areas where the Foreign Office
Nope. As I said this isn't travel insurance.
No Sudan yet, but I've pushed a lot of Africa claims through this with zero questions asked. Never had anything denied thus far
> Choose your area
> Include the USA or exclude it. It’s that simple.
> Area 1 – Worldwide
> Area 2 – Worldwide, excluding the USA
Adding the US nearly doubles the cost:
Foundation: £1,121.86 -> £2,042.96
(other policies omitted - difference is roughly proportional)
Prestige: £4,838.85 -> £8,707.48
Prestige + Dental: £5,208.19 -> £9,380.09
Prestige Plus: £5,856.55 -> £10,560.74
(basic quote - 1 person, ordinarily resident in the UK)
https://www.axaglobalhealthcare.com/en/international-health-...
Doesn't this bill completely undermine the insurance business? If a hospital can't charge more than the median value that in network patients are charged, why would you buy insurance? I must have misunderstood or misread something.
I would think this would make it substantially more difficult for insurance providers to make negotiations and cut deals with hospitals. I would imagine they would just pass off the cost to the consumers, as they typically do.
It always seems to me that these half way positions between universal health care and commercial end up being worse than either. From a very high level it sounds like a fantastic thing, preventing patients from getting screwed, but isn't the cost that those with insurance pay more? I would assume that there's far more people paying insurance than the number of people that get these surprise bills. Though I'll admit the whole system feels rigged at this point and is likely intentionally convoluted to make consumers uninformed (by level of difficulty).
You would buy health insurance for the same reason anyone buys any kind of insurance (above legal minimums).
Suppose a thousand people have a 1% chance of owing $10,000. Their EV is -$100.
If a company offers insurance for $120, the company benefits by making $20 * 1000 and the individuals benefit by removing variance from their life.
You can find affordable car insurance because your actual payout from your insurer is very likely zero this year.
If your actual payout this year is certainly 10-100k this year depending on what actually goes wrong this year how on earth do you affordably insure that individual. Remember also that sickness stunts family income.
Insurance only makes sense for large hard to predict expenses.
This is a popular thing to say, but the trouble with the logic is that the cost of preventative care, albeit small, is multiplied by everybody, while the cost of the large claims is multiplied by a small fraction of everybody.
So whether it is actually profitable to prevent problems is very sensitive to the cost of the prevention, and the likelihood of the consequences without prevention.
I think a lot of people are familiar with the scene in the movie Fight Club where the guy is talking about the cost-benefit equation for initiating an automotive recall. If prevention was automatically profitable, then that scene couldn't exist or make sense.
If you have no deductible, it's basically just your employer giving you a tax-exempt bonus, I think.
More like they offer you the insurance for $99.99 and make money by having $99.99 * num_customers sized chunk of money to play with (i.e. invest into things). But yeah, your general comment is correct.
Insurance is just there to offset risk, the risk being more (or massively more) medical bills than what you would pay if you paid out of pocket.
If your insurance company gets a lower or higher rate, really doesn't matter to you directly.
But it does indirectly because this influences the price of that insurance and how many networks your provider is part of. There's definitely a feedback loop here (network effect) where the larger the provider the better deals.
If my out of pocket is the same by having insurance and not having insurance, why get insurance? Or maybe why get a better plan (which I assume are more profitable)?
Good. I'm all for taking profit-by-default out of health care.
It always seems to me that these half way positions between universal health care and commercial end up being worse than either.
...
Though I'll admit the whole system feels rigged at this point and is likely intentionally convoluted to make consumers uninformed (by level of difficulty).
It's pretty damn bad right now so it's hard for me to imagine something worse. Let me give you my tangentially related anecdote. I don't currently carry insurance for a variety of reasons and I ended up in the ER earlier this year. Upon being discharged they left me with an estimated bill. The paramedics (SFFD) were very prompt about billing me (ouch). The hospital, part of a private chain, was not. Eventually I got inquiries from their patient outreach (or whatever) department — not billing, but a whole department dedicated to seeing if uninsured people qualify for a variety of government programs. Eventually I got an initial bill with a due date and three different "total due" dollar amounts (full price, their goodwill discount, and a further discount if I paid in full by the initial due date). So I navigated their ambiguous web site and paid it, and was prompted to take a survey asking how clear I thought the bill and payment system was (lol). Then I got a bill demanding the middle dollar value with a due date earlier than the initial bill (I'd already paid it well before both dates). Then I got another bill claiming I hadn't paid anything. I finally created an account to actually view my billing statements. The site claims that I owe the difference between the lowest and middle "total due" values from the initial bill.
As an added bonus because I'm not carrying insurance it's not like I can complain to the state insurance commissioner.
100% on board
>>It always seems to me that these half way positions between universal health care and commercial end up being worse than either.
> ...
It's an issue if consumers have to pay more. Those affected the most are those that have the most to lose. I'm all on board of getting money out of the business and making health care about people. But my worry is that these "small step" methods is just causing worse coverage at higher costs. I mean look at how Blue Cross is making record profits but coverage is going down (and they blame Obama Care the whole way).
Really I'm saying stop with the small steps and just get along with it. Sometimes small steps is the way, other times there's a chasm in-between and you have to make a leap to cross it. I feel our health care system is in the second category.