Comment by inferiorhuman | Hacker News Reader

Comment by inferiorhuman | Hacker News Reader

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As a not doctor I don't understand this:

> It will likely strain these systems even further, as reimbursements from Medicaid/Medicaid are insufficient to run large health systems which depend on higher rates from private insurers

Time ran an article a few years ago about hospital billing and whatnot. One of the things that they pointed out was that Medicare reimbursement rates were based on the actual cost to provide the service. If the problem is that Medicare doesn't pay enough extra to subsidize indigent care then having medicare-for-all would address that as it would reduce the number of uninsured.

> In NYC even more physicians and group practices will try to go to alternate models such as cash-only. Try being on Medicaid or Medicare and finding an outpatient psychiatrist in NYC now as it is. This will extend to more PCPs, chronic disease specialists, etc.

As opposed to what's already happening? Keep in mind that the southeast part of San Francisco already has relatively poor access to health care. A few years ago Sutter decided to revamp Saint Luke's hospital in Bernal Heights. St. Luke's used to be a community hospital where you'd go for primary and emergency care. Sutter changed that all up and stocked the offices almost exclusively with specialists (because that's where the money is).

> The US healthcare system, if you have private insurance, is the best in the world already in terms of level of service and access to rapid specialty and high-end care.

I'm sorry, what? Back when I had Blue Cross/Shield I had to book an ultrasound something like three months in advance. In San Francisco. At the time I was seeing a fee-for-service GP. If I'd wanted to switch to an in-network GP the wait at UCSF was like nine months. Finding a GP that takes both new patients and insurance was not easy – in fact I didn't as my GP was amazing.

1. It’s just a fact that if all reimbursement was currently Medicare-level, the existing hospital systems in NYC would run a massive deficit and couldn’t provide the services they do now. They wouldn’t be in business barring massive reductions in staffing, hours, services, salaries, etc.

I don’t know what you read in the NYT but this is well-known in healthcare. Hospitals lose money on Medicaid/Medicare patients in general and make it up on private insurance (also in general) in order to hopefully pull in a surplus each year. Look up the idea of “payor mix.” Private insurance reimbursement varies widely but is typically a multiple of Medicare/Medicaid.

2. Yes - it is already happening. I think it would likely get worse. I don’t think single payer insurance is going to cause a renaissance of PCPs, especially if the overall reimbursement for that kind of service goes down. Probably the other direction. Maybe I’m wrong.

3. I’m not exactly sure what happened at UCSF with your ultrasound. Not familiar with SF really. But you can look up mean wait time for most elective procedures in the USA vs. Canada or USA vs. the UK. Or access to new therapies.

From my experience working at a private insurer, (1) is, unfortunately for the body politic, more complicated than meets the eye.

The payor mix narrative has attractive qualities: it makes the private insurance companies sound like they're subsidizing care, the logical implication is that if we made these atlases shrug with M4A, the local PCP would go bankrupt. In reality, the narrative is at best reductionist and at worst misleading. But it rhymes with the truth, so it has a lot of mileage.

Private insurance reimbursements are negotiated in multiples of medicare because insurers and hospital groups alike expend tremendous amounts of money each year in administrative costs to challenge claims back and forth.

A surprising proportion of private insurance payouts are never reimbursed at the negotiated price. But hospital groups are OK with this, because it allows them to deduct the difference as a loss. Accountants rejoice!

Medicare/Medicaid prices are "low" because (1) the government has a strong bargaining position, (2) the population served by those fees has confounding variables of age and disability which raises the relative price of care (3) the government does not play claim-challenging games anywhere close to the extent of private insurers.

Private insurance companies and big hospital groups benefit the most from the status quo, and have the most to lose from medicare for all. But it would not be doom and gloom.

Medicare can adjust their prices to match the new population and tax base, hospital groups can stop running mini debt collection agencies, etc. There are real cost savings in M4A.

I think what's most likely to happen is an expansion of medicare advantage, (ma4a?). Since it's a program that effectively nationalizes the existing regime of private insurance.

> I don’t know what you read in the NYT but this is well-known in healthcare.

Time Magazine, not the New York Times. I don't know what you think but it's commonly known that the chargemaster is indeed bloated to cover things like indigent, uninsured patients. Here's the thing, people without money use the emergency department for primary care because they cannot be turned away. That's expensive. Getting those folks covered and away from the ER absolutely reduces costs.

https://time.com/198/bitter-pill-why-medical-bills-are-killi...

> By law, Medicare’s payments approximate a hospital’s cost of providing a service, including overhead, equipment and salaries.

So I'm not sure what you're talking about. Obviously Medicare doesn't exist to guarantee a profit. Whatever fee schedule is negotiated with private insurance companies does not actually reflect the cost of providing a service – the negotiated rates include things like profit and taking care of patients who can't pay.

> I’m not exactly sure what happened at UCSF with your ultrasound. Not familiar with SF really. But you can look up mean wait time for most elective procedures in the USA vs. Canada or USA vs. the UK. Or access to new therapies.

Dunno what to tell you. My experience was back in the mid-00s, and I doubt anything's improved since then. It didn't then (and doesn't now) take much effort to find people struggling just to find a doctor that takes insurance. I couldn't tell you why UCSF was so short of ultrasound techs, but yeah I potentially could've found an outside (but still in-network) provider on shorter notice. But then I would've been on the hook to deal with insurance billing hell. Even (especially) with UCSF I was getting screwed by their chaotic billing. Labs that were part of an office visit were officially covered by my insurance but as they were billed separately they were not considered part of the office visit (and therefor not covered).

https://www.beckershospitalreview.com/hospital-physician-rel...

Average wait time for an appointment as a new patient 24 days, worst metro area was Boston at 52 days. 45 days to see a cardiologist in Boston, 51 days to see an ob-gyn in Philly. We're already rationing care (by financial means instead of need), and that's largely due to insurance.

While there was a multi-month waitlist for a GP that took new patients and insurance, the fee-for-service practice I used could typically schedule even new patients same day or same week at least. Hell, their rates weren't even obscene as their practice was almost entirely MDs and a single receptionist. They didn't have to fund an army of people to battle insurance bureaucracy. Over the years my GP went out on her own practice for a bit, and then as her circumstances changed she went back to a practice she'd been with years before. From a patient POV the biggest problem she had was finding competent non-degreed office staff.

I can't say for certain that single payer (or even just a dominant federal government run system) would crate a "renaissance of PCPs", but anything that reduces the administrative burden will reduce the cost of running a medical practice and by extension will reduce the urge to focus on specialties.

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