The fact that this is even a thing is mind boggling.
Note: I happen to have private healthcare with Cigna in a country with a reasonably good public health system (Spain, though it varies between different autonomous communities), happy to pay the taxes and will defend that public health systems are a staple of any modern country.
Small-time capitalism is quite good. Make a few millions, sure. I have no problem with that. But when the amounts concerned are in the billions? There needs to be massive oversight and regulation, regardless of the relevant field.
Totally agree with that.
https://en.wikipedia.org/wiki/Cigna#Cigna_Global_Health_Bene...
From their wiki entry:
"CGHB maintains its own, in-house international claims platform..."
Which may explain your positive experience, compared to their USA customers.
Further, wild speculation here, I'm guessing Spain does more to protect customers, not allowing CGHB to auto-deny claims en masse.
To be clear, we are talking about benefit to the patient; there's lots of reasons concierge doctors may not be the best benefit for society at large. But that's immaterial because this is just one example; if we hadn't gone for the worst possible way to scale private medicine, then there could be better examples.
But the point is that you can't seriously look at concierge doctors and say that public healthcare would be better for those patients! And therefore this refutes any claim that public healthcare is the best system overall.
I am an early adopter of concierge care. It's been tremendous.
I had a bone marrow transplant +30 years ago. Continuity of care has been an ongoing challenge.
From my reading and my own experience, having a patient advocate greatly improves outcomes. Someone who just keeps everything on track. Could be family member, friend, or a nurse / case worker. For me, it's now my concierge doctor. (Over the years, I've served as advocate for other patients many times.)
My current issue with concierge (patient advocates) is that it's rare. Everyone should have this. In times past, it was a family's doctor. But as everyone knows, that relationship is no longer stable, due to how healthcare in the USA has been commodified and "optimized".
Further, according to the research (like what Atul Gawanda has written about), specialty "wrap-around" practices greatly improve outcomes. Like for diabetes, cystic fibrosis, and other chronic life threatening conditions. Most all of a patient's care is done by these multidisciplinary primary clinics. One stop shopping. Instead of bouncing patients around, delegating the coordination and whatnot onto the patients themselves.
Again, thank you for this example. It's an interesting edge case. Today, I think most concierge arrangements are private. Whereas it should be the default, public or private.
FWIW, maybe about 10 years ago, Medicare and the VA had started to adopt the capitation model (preventative care vs fee-for-service). Now I'm curious what they (or any other large orgs) are doing wrt concierge (patient advocates).
It was private healthcare that backed public law forcing minimum coverage. Why? Because their pool was shrinking. They were getting sick people who needed care, but with premiums skyrocketing, what benefit is there for healthy people to buy in?
But I agree that the private for profit health care system is an abomination only made much worse by making it public law requiring we buy into it. Instead of Medicare for all.
Can you explain to me how the government telling you "you must do business with one of these insurers or else" is in any way a free market?
So a free market in health care is not possible because you can't consider your options and say "no thanks" when you need emergency treatment. Whatever the government does or does not do, you can't really get around the fact that at a moment of crisis health care providers have you in a coercive situation and could charge life changing amounts for care if they were permitted to.
That’s one of many many examples.
I'm also not sure what you mean when there's plenty of other examples. Examples of what? I'm still trying to figure out what the "what" is. Private health insurance companies in America ruthlessly deny claims, this is supposedly because of something about public administration of healthcare, and I'm still waiting for an explanation of how that works.
I suggested no such thing. Please don't ascribe your own ridiculous ideas to other people.
Not private hospitals/drug manufacturers - those are arguable - just insurance. What do they contribute?
They got bailed out in Covid, they take money out of the system in good times, they deny you care in the bad times.
Best I can tell they serve no usefull function
Dont exaggerate. I've lived in 3 European countries and Australia. My American healthcare is easily better than those. Sure I'm lucky to have a good job that pays for it, but you can't say its terrible without looking at how those public systems are really struggling right now.
Everything is fine everyone, no need to worry.
Some Americans do get excellent care with a minimum of grief. Others think their insurance is fine while they're healthy and only discover later that it doesn't really cover what they imagine it does. And the difference is entirely arbitrary.
The fundamental problem of health insurance is that you cannot know what you will need, and there is no way to make an informed consumer choice, but your need when you have it is absolute. It's pathologically pessimal as a free market. And you usually don't know until it's too late.
Maybe because it's a politicized topic? How can you smugly dismiss their point like that?
Because "it's fine if you're rich" is a shitty place to terminate the matter. It's not a useful counterargument in any sense. Of course it's fine if you're rich, that's why people want to be rich. What about, you know, the rest of the planet?
Actuaries know, in aggregate, what specific demographics will need. Insurance companies use those statistics to make profit. The view that consumers cannot make informed choices on healthcare needs is incompatible with the fact that risks are not perfectly and uniformly random. Unless, by “informed choice”, you mean one that is correct in hindsight, in which case, I agree.
A few examples for those wondering: * the total cost for over a week stay was a couple hundred dollars - very affordable! * certain painkillers banned in the USA were the first line of defense there * getting very strong pain killers was next to impossible - I think we probably only got it because we were family members of the anesthesiologist, and he knew we needed it. And it took nearly 24 hours of agonized pain before we could finally get them * nurses are not trained to put in IVs - we needed an MD for that. And the MD had a lot of things to do and we had to wait quite awhile even though there were many nurses around. In the USA, I think most people with the title of nurse can do that
I think some other places around the world use the title nurse for what may be a medical assistant in the US. (No clue about Germany though)
That's very odd. Nurses do that all the time in Norway.
It’s not so great for those in the middle.
There is no fun surprises like finding out that while your surgeon and hopsital were in-network your anaesthetist was out of network.
This practice has been outlawed this year.
When I was starting my career, I had to go to an ER that was out of network, I checked with my insurance and they said they would cover it. They decided after all not to honor their word and charged me 10’s of thousands of dollars.
Being young and independent, this was devastating, despite having a good job, good insurance, etc.
I largely credit this with my push to move to Europe, and have never looked back.
Sometimes knowing you can get any healthcare you need without it potentially a bankrupting you is it’s own reward.
That's the insanity here. You simply can't protect yourself reliably from overcharging. Hospitals and insurances do whatever they want and good luck to you fixing mistakes. I find it really hard to understand how people can be defending such a system.
If we divide up people into percentiles based on wealth, 25, 50, 75, 95, how do you think people fare in the different countries? How do you think they the median experience is in America?
The UK was amazing - no questions asked care for my health was a massive improvement over what I had in the US. Free access to a doctor at any time is more life changing that you can think - every health issue I had I could talk to a medical professional and get guidance. Even free mental health care.
Moved to Ireland last year, with a mixed public/private system, and my health is now slipping a bit. Going to a GP, trying to file for reimbursements, and knowing that every time I have a health concern, it will cost me money, is a powerful suppressing force. I miss the NHS.
If that's whats necessary to get decent health care in this country, then something isn't right.
So for an individual, it is roughly a $10k per year benefit to get it via employer and for a family of 4, $40k per year benefit.
Only thing that Carrie’s
Regardless of our personal experiences, the US spends so an enormous amount on healthcare and gets very little in return by basically all international measurements. Americans who think American healthcare seem to me too insecure to accept that their system is just plain bad. But yes Americans with a lot of money have access to better healthcare than average Americans. That said, this is essentially true in all countries so it's not that relevant really.
It’s astonishing how much market inefficiency we’re willing to tolerate.
That is not where you are lucky.
You are lucky to be healthy enough that you can hold on to that job. Once your health takes a bad turn, and you are unable to work, when you really need your healthcare, that's when you are better positioned to judge the quality of healthcare.
Not sure what is holding you back, but health should be a priority!
The trip to the EU, a vacation, and the MRI itself would be cheaper...
I was actually planning on getting it done on my next trip to China, which is about the same cost wise, and the doctors are good as they see so many people lol
So, yeah, go for it.
It is a joke.
Heck, WITH insurance you can expect it to cost up to around $1000 depending on coverage.
Though sometimes the price the consumer pays isn't reflective of the true cost.
Sometimes the public health system does buy/subsidize the machine for the provider and a private client isn't charged some chunk of the amortized cost of the machine because the public system (rightly) assumes that 99% of the work is going to be for their residents. The clinic can profitably just charge for their professional/office use.
Here's a Bucharest Romania MRI clinic with tariffs:
https://rmntineretului.ro/tarife/
It's about 3 Lei to a USD, or US$200-US$500 for an MRI.
The real kicker is that you generally can't even find out this price until you have the procedure and receive the bill. It's become almost akin to a legal mafia cartel. In my area, a majority of the urologists have become part of a medical group that now dictates pricing for related procedures. Most of the major insurance carriers don't want to pay this pricing so this group is not a covered provider, so finding a urologist that is covered entails sometimes waits of months for an appointment.
It's the worst parts of socialized and for-profit health care assembled into one system.
I find the American healthcare system pretty atrocious, but I've never had issues getting upfront costs when scheduling non-emergency procedures using cash. Then again it's probably been a good 8+ years since I've done that in the US.
Doesn't help if you are stuck in the hospital. But, it's an option otherwise.
Don't get one in the hospital if you can help it. They charge 1-2k because they have a full set of people who can't go anywhere else.
If this is the case, then it is no wonder the insurer has no particular care for them. It is the power of the consumer to change provider which gives them influence over the provider.
My opinion is that providing healthcare as a benefit should be banned. Employees who have healthcare today should be provided the amount the employer would have spent on health care in wages/salary. The fine details are hard to work out, but I think it is a good starting point.
I don't think that's the problem so much as 1) IIRC you simply can't use them for premiums in the first place and 2) you need a high deductible plan to be eligible for an HSA in the first place
No matter what society you live, the advice is the same: try not to get sick.
those are all there because the people that created the system did not think paying for it was good enough. it doesn't have to be that way. and even with wait times being long you still eventually get it. in the privatized system if you are poor and have bad health care you don't get it at all.
So I guess it depends on where (city/state) you live and also what type of insurance you have.
Where I live I have access to a SOTA network of hospitals with great technology and some practices amount the best in the world (people come here from other states and even countries for treatment) and I use their own insurance, so it's been great so far, never dealt with any issues having medical care rejected.
I pay $350/month (self employed) and I have a very reasonable deductible, $60 copay to see specialists and many preventive procedures such as cancer and heart disease screenings (which I use), blood work and some PT sessions completely free.
I even get discounts on fitness centers and health tracking apps which helps offset part of the premium.
My shoulder was actually spared from a very invasive surgery thanks to a doctor top of his field (he sees olympic teams) who was able to treat me with only PT.
I don't think I paid more than $1000 out of pocket for everything including several MRIs and multiple visits to his practice, plus several sessions of PT and medications.
It could have been free back in my country, I guess, but I could have also been screwed for life due to an unnecessary surgery.
> without autonomy
This is an incredibly poor way to act given that doctors usually have unlimited personal liability, even if they are employees
Not everyone came to this nation due to capitalism. My parents partially came here to be free to say whatever they wanted and not disappear, for instance.
It doesn’t mean healthcare is done right; just as using TP to wipe one’s ass is 100 years backward.
I sometimes wish they stayed back, because my own life and theirs would’ve probably been much better in the long run.
No, I won’t be forced. I’ll just get shouted down by anonymous accounts just like the cancel culture of the left.
You think complacency is patriotism. I actually would prefer to improve my country.
> So it’s not unsurprising that your attempts at forcing others to pay for your things is met with hostility when you and others that share your views don’t even want to face those policies themselves.
“My attempts”? Your response is indeed hostile, but you have it backwards.
My family and I have been directly paying for and subsidizing for your own care and other Federal entitlements for decades.
Your response is also irrational to the core. We collectively pay for law enforcement, the military, highways, etc.
Why is it suddenly taboo to consider whether we’d actually save money if we had a baseline?
Why is the worst of socialized medicine and the worst of market-based medicine an acceptable status quo?
Alternatively, I simply state that we both agree on law enforcement and military but not healthcare, so at a baseline you want to force others to pay for more things than I do.
I don't support the US healthcare system, but I won't support socialized healthcare because of that. The government can follow the rules it enforces onto private companies by operating its own healthcare service without forcing those that did not choose to use it to pay. Problem?
I specifically also mentioned highways. How does that fit into this narrative?
> Alternatively, I simply state that we both agree on law enforcement and military but not healthcare, so at a baseline you want to force others to pay for more things than I do.
I’m already paying for your care, so I’m paying for more than my fair share.
You have no idea how much I make, which your claim entirely depends on. You also don't seem to be reading very carefully, I'm stating what I believe should happen. I would like people to be forced to pay for less things. You would like people to be forced to pay for more things. Simple as that.
So you’d pay for law enforcement and a military, but without roads and highways they would be ineffective.
What is your proposal? Do police and soldiers have to pay money for its use?
> You have no idea how much I make, which your claim entirely depends on
And you have no idea whether I’m overpaying for healthcare to subsidize your care.
Those services you’re enjoying now and the professionals you’re relying on? Those are costs far beyond just the single treatment and whatever private insurance you’re paying for.
You made the claim, the burden of evidence is on you. All I said is that you wish people be forced to pay for things they don’t use and I do not, which you conveniently ignored after asking me to address every bit of your comment.
People like you always pull this “indirectly use” argument to justify making people pay for things they do not use. I don’t pay for the gym membership of the delivery guy, this is no different.
> The government already operates roads. Nothing would change.
Okay. So we established that you don’t mind if the government runs the roads as long as they pay for it (tolls, gas tax).
I’ll go out on a limb and say that until the Federal stepped in, our road system was haphazard and ineffective. Having standards and an interstate system was crucial, and only possible with government.
Now given that law enforcement and military can incur injuries, can we have an effective law enforcement without the medical support to get them back up when injured or sick?
Now for this portion: > So it’s not unsurprising that your attempts at forcing others to pay for your things is met with hostility when you and others that share your views don’t even want to face those policies themselves.
Why would you assume the worst ? This goes against Hacker News’ core principles.
> People like you always pull this “indirectly use” argument to justify making people pay for things they do not use. I don’t pay for the gym membership of the delivery guy, this is no different.
I help pay for all of infrastructure, the building safety codes that ensure the gym doesn’t collapse or electrocute me, that the machines aren’t death traps, etc.
It’s great that I don’t have to pay for a membership or other services if I don’t want it, but the foundation that makes these services even possible or reliable costs money.
Having these services on standby also costs money, even if you don’t use it. So yes, I’m already paying more than I’ve ever received in healthcare.
Back to healthcare. What I find frustrating is that your kneejerk reaction is neither unique nor uncommon, yet it never comes with a workable alternative and solution.
You realize we're discussing the US which has all this?
> beauracracy.
It's funny you mention this, because the US spends vastly more on bureaucracy in its health systems than other developed nations.
Health Care in the U.S. isn't just bad, its outright fucking brutal. An elderly friend of mine recently fell and went to an urgent care where they couldn't get him into the x-ray machine. They told him to go to an emergency room where he waited for _13_ fucking hours with a broken pelvis. I'm basically 100% sure that such emergency room bullshit literally kills people from stress or exposing them to other sick people. You can't even wait in your damn car and just have them text you - they just force you to sit in this horrible room with a ton of sick people for hours on end.
The U.S. Health Care system absolutely fucking blows.
If I was in a public system, I’d fear I’d be fighting for attention alongside the general public, so I’m not convinced it would be better.
This ~92% insured in 2020 includes:
- People subscribed to unusable ACA and private plans (eg: $9100 deductibles)
- People considered eligible for Medicaid by CMCS, including those who are denied coverage by state administration agencies
- Millions of people who were directly granted temporary Covid Medicaid coverage by CMCS (bypassing state agencies) - which expires in days
[1] FCC broadband maps consider an entire census tract served, as long as an ISP alleges just one house there can be served.
Are you not a part of the "general public"? If it is true that there is a class of people who don't have your advantages and therefore have worse medical care, is that a situation that you see as acceptable?
It always seems strange to me when people argue this about this issue from a hypothetical perspective, when we have a wealth of actual data that we can use to compare health outcomes. We can just look at the results and see what works better!
https://www.pgpf.org/blog/2022/07/how-does-the-us-healthcare...
(TLDR: the US spends much more per capita on healthcare, especially in administrative costs, and has worse health outcomes than most wealthy countries).
The answer is obviously yes, given that they don't want the "general public" to have the same level of access and make them potentially have to endure any longer waits. Their convenience is more important than the health of others.
I've waited less than an hour in New Jersey and Connecticut.
When I still lived in NYC, I resolved that if I needed a hospital but I wasn't in extremely bad shape, I would drive an hour into an adjacent state's ER rather than wait in NYC.
Coming in via an ambulance doesn't trigger some sort of re-prioritzation, if you're not suffering from something that is immediately life threatening.
In most NYC hospitals, you will end up in a secondary waiting area that lies just beyond the regular ER doors.
Good luck if it's a Saturday night.
https://projects.propublica.org/emergency/
Where I live, all in driving distance have an average wait time more than 2.5 hours.
"Wait" can be defined very differently. Wait time to get triaged by a nurse? An ECG for chest pains? Initial physician assessment? Entry-to-exit? Lab results? Time to X-Ray if needed?
Lots of directives may be in place too. In an efficient system, the nurse is empowered to "order" many procedures that screen out serious things that require immediate physician intervention. Or just to save time like ordering an X-Ray first instead of waiting to see a doctor to order it and then waiting again for it to come back to review.
Sincerely, if anyone can explain to me - how can we as a species both have figured out game theory, AND consider this as a position that is in any way acceptable?
The current situation is that the parent poster has preferential healthcare access, and other people that they do not care about do not. The alternative is equal treatment which might mean the same access, or worse access as they are forced to "fight for attention alongside the general public" as they so blithely put it.
Given the option between the status quo, or a change which can only ever be the same or worse for you personally (regardless of the broader impact), of course someone self-centered would choose the former.
It's people in the middle who are getting squeezed by HDHPs, mostly not the poor, who have access to Medicaid (exact qualifications vary by state) or Medicare (everyone 65+).
Contrast this with Europe, where I could get a doctor to make a house call at 3am for a reasonable fee.
Ah yes, how dare the plebs interfere with the path of the chosen ones.
This anecdotal evidence is garbage.
Are you basing this fear on any sort of facts or are you just afraid out of ignorance?
I live in Massachusetts. I would take a public system over what we have now, no questions asked.
It's a well-known trope (probably proven, but I don't know the studies) that insurance companies routinely delay healthcare to AIDS and other patients with terminal diseases, in the direct hope that the patient dies.
With AIDS patients, there's a big moral component to the diagnoses, and companies can "get away with it," because there's such stigma to the disease, but I have also heard of the same thing happening to cancer patients. In fact, it can sometimes be a matter of life and death. If a treatment is delayed enough, it can change the outcome.
I have been told (but don't know it for a fact) that this is actually the point of the delays, and that the delays are triggered by the diagnosis.
In many cases, delaying payment, also delays treatment. Most patients don't have an extra 500K, floating around, that they can pay the hospital for a procedure, in the hope they get reimbursed. No promise of payment, no treatment.
So that means that refusal to pay is the same as withholding treatment, and these companies know it.
I think that AI is likely to make this worse, as they will probably give these decisions to an AI, thus removing any hope that there may be a caring human in the process that could possibly feel shame.
As if Medicare didn't reject millions of claims too.
A number of physicians just don't accept Medicare because it's subpar.
Heh.