As someone familiar with insurer, provider, and facility IT systems, I'd offer an alternate explanation -- the data is bad because healthcare IT is understaffed (and often incompetent).
These are businesses that have squeezed most costs out, and IT is definitely a cost.
Imagine banking... if there were much less competitive pressure and an inability to offer services across state lines without substantial additional effort.
They received a mandate.
They tried to respond in the way that required the least amount of effort.
From someone in the industry, it's entirely plausible this is the best they can do.
Which usually means it takes CMS threatening to drop them for them to launch a multi-year project to finally fix the issue (somewhat).
Dealing with them right now feels like dealing with the government might as well just have the government run it
This is the best they can do when all their incentives align so that being as opaque and disingenuous as possible about costs (and understaffing and often screwing it up helps with that!) helps them.
IMHO, best of both worlds would be the federal government taking over and centralizing the most core services (rates, interchange, data systems, etc) and allowing private insurance companies to build offerings on top of that (customer service, servicing, product mix, etc).
They are certainly very creative in making the system as expensive as possible. See Medicare Advantage.
"IMHO, best of both worlds would be the federal government taking over and centralizing the most core services (rates, interchange, data systems, etc) and allowing private insurance companies to build offerings on top of that (customer service, servicing, product mix, etc)."
This would be best. There is so much unnecessary bureaucracy at providers and insurers because the insurers have different setups. The medicare setup would be a good foundation .
In what way?
> especially on the operations side
If the US had national, universal health insurance, the operations would be much simpler.
(My qualifications to make this statement: 15 years in healthcare IT, including UHG/Optum, and 8 years as CTO of a large clinical organization that included primary through tertiary care, research, and an insurance operation.)
I certainly don’t have your credentials, but my experience in being an insured person doesn’t match this. I’m willing to believe you, but having filled out forms for UHC to get reimbursed for an out-of-network doctor, it sure feels like they kind of make it up based on how they feel that day. I’ve submitted what appear to me to be identical forms for reimbursement (like the super bill the doctor gives me has the same codes, duration, etc.), and the reimbursement differs for no reason I can discern (had long blown past my deductible, etc.). It feels like sometimes you get lucky and the person evaluating your form gives you a break, and sometimes you’re unlucky and they don’t.
On the other hand, malicious compliance does seem par for the course for these assholes. So what you say makes sense.
Sure, insurance companies ultimately know what they paid, but consider that these MRFs are almost certainly not being prepared by the people responsible for that knowledge. They were probably tasked to one or two data analysts who quickly banged them out in whatever BI/reporting tool they use and did nothing to verify correctness. It's not like they had an accountant audit these if they weren't absolutely required to (they weren't). Most healthcare analytics tools are complete junk drawers of data from numerous systems and getting these MRFs right was probably never a priority for anyone. Just a total "I have no idea if these are right but they sure are numbers" exercise.
I mean, how many times have you seen some Tableau report that's all screwed up because some of the MRNs aren't actually MRNs (even though someone named the model field community_mrn) but file numbers from the scheduling system, and now you've got duplicate patients? BI systems just breed that kind of problem unless you are extremely careful about managing them, and since they're "not systems of record" (these are scare quotes) few people are.
Maybe the problem IS the line items. You know the labor cost of tracking the fact a person was given Tylenol is way more than the cost of the pill? Just give people the incidentals and stop billing for them. Half your overhead might vanish.
BTW, yes every medication need to go on their chart. But it does not need to go through the entire finance system and to insurance.
> Sure, insurance companies ultimately know what they paid
It came to mind reading the above that a more accurate/useful perspective might be "The insurance companies' system knows what they are paid," but those system may comprise multiple software systems, none of which have data in compatible formats.
Ergo, even though the insurance company "knows" operationally (it can generate a number on request), it might be unable to generate a list of all numbers (effectively: every path through the system).
But that's why mandates work in insurance: if CMS pushes hard enough, eventually the insurers will develop the functionality.
Assuming this is true for the sake of argument, saying that this sort of thing isn't malicious compliance is a sad kind apologistics for bad behavior that seems to regularly appear on HN.
How can these kinds of companies optimize their charge codes to get the max for the procedures, optimize their taxes to pay the minimum possible, and then do a poor job on these existential crisis kinds of things? I think they know what they're doing in all cases.
It's not rocket science! But it is decades of code on top of decades of code. There's a reason they still pay COBOL programmers...
What's the cost of an X-ray? Did you know they used to do a FREE X-ray at the shoe store back in the day to check fit? Yeah, don't tell me they squeezed out most of the cost.
American healthcare not a free market.
That’s because their negotiating power is mainly due to the size of their buying power, not special knowledge or skills. Health “insurance” is basically the lamest, most economically perverted form of collective bargaining ever.
Brokers, medical billing staff, and other middlemen serve no purpose other than increasing cost (in order for an inefficient, openly colluding private cabal to invest premiums, deny claims, and collect profit) because everybody needs access to medical treatment.
On the other side my child's healthcare is amazing and all free. We get instant access to great services.
It’s not whether the cost is socialised or not that decides how long the wait will be.
It also doesn’t help that the private system is incentivised to undermine the ‘free’ system at every turn.
If care is free, aren’t you more likely to go than if you had to pay even a minimal cost?
New Zealand has an accident compensation system which pays for accidents (though there may be a small surcharge) but not most medical events. They split the hair finer that is sane. Swallow a foreign body? Medical problem. Swallow a foreign body as say ‘it feels scratched’? Accident. Insect bite? Medical. Mosquito bite? Accident (it’s a distant memory from when I billed these things but I’m fairly confident I’m right).
It’s all to do with cause and effect, and each must be identified.
The accident compensation scheme covers a portion of wages too. Medical problems cost, not US style but not free.
By competing on ... what? Can't be price (because "free" wins). The only other option is competing on quality.
Your statement doesn't sound correct.
I already asked what the ways are; why are you replying saying there are ways?
I literally asked "In what ways?" and you are replying "handwaving There Are Ways" ...
In case you really can't imagine alternatives: what if the private system spreads lies about the non-private system? What if they use their influence to change laws and regulations to prefer their system? What if they use their influence to make others with influence treat those using the non-private system worse?
None of these are competition in the sense you're asking for, and yet they are a natural consequence of private incentives.
It's hard to compare apples to oranges but with high doctors per capita, low wait times for speciality services, long lived citizens and a far lower percentage of GDP spent on health, I wonder if there are any serious holes to poke in Italy's system when compared to the U.S. or if they simply just beat us on every metric.
https://www.oecd-ilibrary.org//sites/242e3c8c-en/1/3/2/index...
https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?location...
$1500 on my HSA plan, which btw right now is returning 4.6% in a money market. How awesome is that?
Great deal. Worst pain ever.
The point is, the entire thing is broken nearly everywhere you look. I don’t know what a better alternative is, but we sure need one.
So you millage may vary.
Also, where I live there are five (?) Hospitals with ER within a ten minute drive... in suburbia. There just can't be that many people getting deathly ill sick.
I thought they do, in fact, and the bill expires if not sent out in time.
If you have a chainsaw accident and its serious, you arent going to wait 8 hours
US, and he's insured, and it's supposedly a pretty-good hospital.
I've been to the same ER within months of that, and it was empty and I was back in a room (well, cubby) within 15 minutes, with something just barely severe enough to merit an ER visit. Quick. Fucking expensive (think it was almost $3k by the time they were done sending bills, for 5 stitches and an x-ray—and that's with insurance), but quick.
It was mostly just timing and luck.
> My father's cancer treatment was not covered so the last year of his life cost him everything.
Sucks that it happens to anyone, but the final year(s) of healthcare finding a way to soak up every cent, before the end, is basically the norm here in the US. Everyone's retirement savings is just money the healthcare industry's lettings us hold temporarily.
The same dynamics play out with pension schemes. Declining birth rates play havoc with proposals that rely on a large, young employed base who's work supports a small, retired set of pensioners.
My own perspective is that healthcare is extremely limited on the provider side. Professional organizations have been limiting the supply of doctors / doctor equivalents for decades. Not to minimize the work a family medicine or general practitioner puts in, but many important health services/early interventiona can be safely and reliably provided by a nurse practitioner or physicians assistant (what a horrible name) on a much larger and affordable scale then exists today.
It's a perverted cross between escrow and welfare in which the population basically pays their own way in the long run plus supports all the people who make their living by being "administrative overhead" along the way.
There is enough (potential) money and incentive here that almost any system will be perverted eventually.
NHS is not known for speedy treatment, for instance.
It’s about ongoing oversight and a willingness and ability to cut through bullshit to fix things. That’s in short supply here and everywhere else.
The stories (first hand from relatives who use it) of blatant profiteering and abuse of the system in Medicare is mind boggling.
From what I understand (I am not a UK citizen, but me mum's mum spoke Scouse. My mother, on the other hand, spoke The Queen's English), everyone loves to hate on the NHS, but no politician in their right mind will touch it. It's a "third rail."
In the UK, it's from the voters.
In the US, it's from the Healthcare Industry.
They are allowed to spend as much as they want for votes due to their freedom of speech. Sure they can't directly vote but ever since like 2010 have a lot of human rights and I'm sure would love more. I would not be surprised if one day they could directly vote considering due to their rights. I hope though we can push back before then and change things.
https://www.brennancenter.org/our-work/research-reports/citi...
Most of Medicare is administered by middlemen and private companies.
t. licensed broker / agency owner
Now can you make a cogent argument for why more than one federal / national union should exist? Why does Europe allow multiple unions?
You should be able to go back to the hospital and say - based on the hospital public fee schedule , total FFS for CPT should be (very low number) . Therefore, my deductible payment is overstated, please reduce my bill dramatically.
A lawsuit would follow, which would make it very interesting. Chief argument:
The customer can clearly say its fraud - he/she looked at the public rate schedule and believed the charges would be based off the public rate schedule.
Ultimately, the disconnect between published rates and the EOB is going to come back to bite hospitals, once people shop around using the data.