The 1-HR nurse visits that cost $15B to Medicare | Hacker News Reader

The 1-HR nurse visits that cost $15B to Medicare

wsj.com

If Medicare reimbursement rates actually mirrored market prices, this wouldn't be necessary. Doctors and especially hospitals rely on private markets to fill the gap that Medicare refuses to pay.

https://www.aha.org/2024-01-10-infographic-medicare-signific...

https://www.cancernetwork.com/view/rising-prices-and-lower-m...

Cost-shifting from Medicare to private coverage has been roundly debunked many times over. Citing the AHA is laughable.

Call it whatever you'd like but it's a fact that medicare reimbursements are absolutely terrible and the government keeps _reducing_ reimbursements in real value, forget about even keeping pace with inflation.

https://www.kff.org/medicare/issue-brief/what-to-know-about-...

https://www.reuters.com/markets/us/us-health-insurers-slide-...

Utter nonsense. The AMA and AHA absolutely love that people buy their propaganda though

You are bringing nothing to this discussion while I've given you numerous sources.

Because like I said this is a widely debunked myth that the industry has been slapping down over and over again for a long time. I've been in this industry working on these problems for 20+ years. You are trying to sell alchemy to a chemist

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160596/ https://www.coloradohealthinstitute.org/research/cost-shift-... https://www.healthcaredive.com/news/myth-diagnosis-do-hospit... https://washingtonmonthly.com/2023/06/19/dont-blame-medicare...

I read a few of your articles and just have some parting statements.

If the article on Healthcare Dive, the conclusion includes the statement: > Grundling said there has to be a breaking point somewhere so long as government rates fail to keep up with medical inflation

So regardless if cost-shifting is occurring or not, reimbursement rates are not doing the job.

The article in Washington Monthly seems to operate under the assumption that Medicare reimbursement rates are the "fair" value and anything above that is driven by greed. Instead it primarily blames monopolistic power as the cause of high prices, which is a power granted to them by.... the government.

So excuse my hesitation when I have a strong disbelief that more government intervention will solve this problem, given the above statements.

The provider side skates by with very little scrutiny in the US, when they make more than anywhere else in the world while also crying poverty and whining about Medicare/caid reimbursements. They're gonna have to figure out how to make it work with those rates because commercial spending levels are unsustainable, and the rate of medical inflation is unsustainable.

I haven't said anything about "more government intervention". Hospitals, doctors, and device makers are making bank, and are still greedy for more. They are the ones causing medical inflation higher than general inflation, it is not a fact of nature. It's on them to figure it out and to learn to live within a smaller budget.

You lost me at greedy.

Why is it greedy for doctors to seek reimbursement for a career that included hundreds of thousands of school debt, living off junk food at odd times, and losing your best years trapped in monolithic buildings with poor ventilation ? And then getting calls from patients are 10pm on a saturday night for the rest of their life because patients are anxious about an article they read online ?

Sorry, doctors should be making as much as they are now and then some, if the govt insists on having lamborghini healthcare standards in the US.

How we pay for it is another story, but how we got here is certainly not the doctor's fault. (or insurers, for that matter).

Or lets bring it close to home since this is HN. Is anyone calling developers greedy? Last I checked, US devs make more than a mid-level in the US, with zero sacrifices. Are devs greedy ?

The reality is that older generations and their representatives in congress got us in that mess, and shifting blame to others that are providing valuable service is a copout from actually putting your finger on the wart that is bureaucrat-managed lamborghini healthcare.

Yes, greedy. Spare me the noble sacrifice theme when they are all choosing high-paying specialties and not primary care. And no sympathy for the debt when they chose the profession willingly and then make 250k+ once they start working. It is nuts to me to say they should make this much or even more when our spending is completely unsustainable. We can't continue to outpace general inflation.

And it's not just the docs themselves, it is the entire provider side. "Non-profit" hospital just means a bunch of execs keep the profits. Playing games with ER/urgent care to squeeze both payers and the patients. They are the bureaucrats managing the lamborghini healthcare, because they want to charge a lot of money for it.

You are conflating too many things and casting a wide net. You are right in that there's too many specialists, but again, they are behaving like rational actors in a game that is rigged against them. Why not understand how the rigged game came to be instead ?

Do you know the history of why hospitals are nonprofits ? Do you know the history of socialized medicine ? Hint: its not pretty, at all. What other industries you see outpacing inflation ? Hint: its not cell phones, cars, or airplane tickets.

I'd recommend looking deeper into those 3 if you really want to understand the causes and the philosophy that is driving spending in lamborghini healthcare. Because what you are advocating is going to literally break patient service. We are already seeing a version of that disaster in the UK, and more recently, in CAN.

Its lovely to waive the "they are too greedy" index finger. Its simple. It is comforting because it is binary and assigns blame. Yet the world is more complicated than that.

But who's not greedy ? Are you not greedy as a dev with 250K ? Who are these angels that are not greedy? Where do these angels live ? Its funny that its always the other person that is greedy, its never the one saying the word.

If medicare increases payouts then the payoff to this sort of behavior only increases.

Fair enough. However, I still think with better aligned incentives you could drive down undesirable behavior.

Friend of mine works for the "daycare" for elderly. Medicare fraud is rampant. People finding all kinds of ways trick the system for easy money. Recently her employer got a visit from law enforcement for fraud investigation and few other places around run into similar issues.

Elderly care is the new fraud.

It used to be opiod rehab back in the 2010s. There were companies that went from 2M operations to ~100M in about 3 years. That's unheard of in the services industry. I would almost call it ARR because people were getting sucked right back into recovery and govt would still pay.

Crazy times.

It's astoundingly clear we need a single payer system in the US (like every other developed country). We simply pay more for the same (or worse) quality as other developed countries.

Having lived in a number of European countries with single payer systems some of which are in a state of collapse, that's not even remotely true. I would characterize the level of care I receive in the US (fully paid by my employer) as absolutely top notch.

> fully paid by my employer

A privilege not everyone enjoys

> privilege not everyone enjoys

55% of Americans [1], and, I’d guess, a commanding majority of likely voters.

[1] https://www.census.gov/library/publications/2020/demo/p60-27...

I don't see anything in that link about "fully paid" so the number of people with employer-provided health insurance fully paid by the employer is probably much lower.

> In 2019, the percentage of people with employer-provided coverage at the time of interview was slightly higher than in 2018, from 55.2 percent in 2018 to 55.4 percent in 2019

> don't see anything in that link about "fully paid" so the number of people with employer-provided health insurance fully paid by the employer is probably much lower

You’re right. Tough to find statistics, in part because “fully paid” is ambiguous. (Saw this [1].)

The figure I should have referred to is 72% of Americans being happy with their own healthcare [2]. You’re not going to get single payer without convincing them they’re trading up.

[1] https://www.peoplekeep.com/blog/what-percent-of-health-insur...

[2] https://news.gallup.com/poll/468176/americans-sour-healthcar...

In my city (Pittsburgh) over half of the workers who work at our largest healthcare provider surveyed have some kind of debt to that same entity. My own mother is one of those people and she has been climbing for years. Funny how that works.

https://www.beckershospitalreview.com/finance/union-raises-c...

I am included in that 55% but my deductible and OOP max are too high for my salary so i still can’t go to the doctor because i don’t have an extra $8k per year to spend on it.

You can't go to the doctor for your free annual visit because your OOP max is too high?

What is the point of limiting the scope of discussion to a single visit per year? Am I missing some context from the article that makes this relevant to things like the expense of follow-up visits to confirm/treat complex diagnoses such as secondary hypoaldosteronism, discussed in the article?

In my case, I have multiple conditions that require expensive monthly or annual visits, which I’ve severely lapsed on.

I'm counted in that group but still pay several thousand a year out-of-pocket.

So 45% do not, and that’s ok?

Or the huge percentage of that 55% where their coverage is high deductible, so it’s functionally just a “you won’t be instantly bankrupted if you have a heart attack” not basic healthcare?

The bizarrely antisocial and frankly sociopathic “I’ve got mine, other people can get fucked” attitude people like you have is sickening.

You are very hostile in this thread. The GP didn't say anywhere that it was ok for people to be uninsured. Neither did they say they were among the 55% figure.

Secondly, it's easy to find some official figures - [0]

From January through June 2023, among people of all ages, 7.4% were uninsured, 40.7% had public coverage, and 60.8% had private coverage at the time of interview

And:

The percentage of adults who were uninsured decreased from 14.7% in 2019 to 10.7% in the first 6 months of 2023. Public coverage increased from 2019 (20.4%) through the first 6 months of 2023 (23.6%). No significant trend in private coverage was observed between 2019 (66.8%) and the first 6 months of 2023 (67.7%)

In other words, the majority of people in the US (> 90%) have insurance -- private, public, or both.

[0] - https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202312....

In my experience in the US,”employer-provided” is not the same as “fully paid for by my employer.” Generally there is an employee-paid portion of the monthly premiums.

That is true. It's just not clear to me that we need a system where everyone has "free" (taxpayer-funded) healthcare.

Maybe you should ask the people who currently aren't covered if it's a good idea

So why not make everyone pay full economic cost? Ban employers from giving out insurance. Make everyone pay for their own fully.

I don't really follow European health-care policies, but the friends of mine who do seem to think public health care with a private-option (e.g. France) is better than single-payer.

I've also heard that the German system works reasonably well, which is also not a single-payer system.

I’d wager you have a copay, a deductible and a maximum amount your plan will cover. And if you are laid off you have nothing unless you sign up for COBRA which charges huge amounts monthly.

The European single payer systems are underfunded intentionally by “conservatives” who want to skim off the top by privatization and loath offering it to the poor & working class.

I don’t know, is Switzerland civilized country? We don’t have single payer. Neither are most of Europe (except Nordics).

Switzerland is paying 70% as much for healthcare as the US. They are #2 in the world on healthcare spending.

What they have is essentially Obamacare, that is, mandatory health insurance.

But insurance doesn't care about limiting healthcare costs. Increased healthcare costs just leads to increased premiums, which is really increased revenue for an insurance company.

There are no high-quality single payer systems that are currently functioning at or above American health care quality. This is doubly true if you're looking for a 300M+ person system.

It is true that other countries achieve their broken health systems at a lower cost than the US does.

What makes you think the US health system is of a superior quality to that of any other in the world?

Nope. The GP asserted something without evidence so I am engaging with that same standard.

What makes you think "every other developed nation" has higher quality (and single-payer) healthcare systems?

Again, every other developed nation has roughly the same outcomes as the US, but at a much lower cost per person. And a substantial portion of our population has no access to health care, which is not true in those other countries.

This is not a policy prescription or advocacy for anything, it's simply factually describing the situation.

In my opinion, more innovations (which the rest of the world’s public systems do benefit from), better customer service, better patient care (far fewer rude or abusive nurses and doctors), higher standards (quality of facilities and attention to detail and time spent with patient), flexibility (between providers, in scheduling, and even in the care/procedures you receive), etc. Oh and the ability to receive the care you are willing to pay for at all, instead of being denied. I do think there are lots of flaws too but feel they’re addressable with targeted legislation instead of some massive change.

This is not true. The US does not have better overall outcomes than the rest of the western world. We are better in some areas, worse in others, but overall outcomes are roughly the same, at a much higher cost per person

I do agree that US costs are much higher per person.

It is not true that countries with our scale (population) are at or above our healthcare quality (scale matters).

For reference, here are the countries I am talking about: India, China, Indonesia, Pakistan, Nigeria, Brazil, Bangladesh, Russia, Mexico.

Those are the Top-10 most populous countries (with US at number 3, after China). Mexico at #10 has 200M fewer persons, so calling that the same scale is generous.

I have no doubt that Norway or Singapore has better healthcare than the US.

Scale does not matter. If anything scale makes it easier. Those countries are not peers with the US when it comes to wealth and resources.

>scale does not matter

The actual data seems to indicate the exact opposite. Countries with large populations aren't able to provide inexpensive healthcare, while countries with smaller populations achieve better outcomes at a lower cost

edit: I've read some of your other comments on this post and I really enjoy the deep level of understanding you're bringing on the actual article's topic. I just think you're wrong about the specific scale thing that I'm talking about

I would argue that the quality of governance of those countries and the strength of their economies relative to the US dramatically outweigh looking at size alone. Size makes things easier. The more scale the more predictable the costs.

We have a single payer system for everyone 65+, because we had the political will to do it, and it remains funded and functional because it is an important and powerful political bloc. A lot of people make a lot of money from the dysfunction of the system for everyone else and they fight tooth and nail to keep that gravy train flowing.

I feel like it's apparent why comparing healthcare in the US with healthcare in, well, any of the aforementioned countries, is problematic. If you look at Western Europe (a bit less populous than the US) or the EU as a whole (a bit more population than the US) they have functional healthcare at much more reasonable rates than the US. Scale matters, but scale is also a matter of division. If a single system can't serve 300+ million people then it can be broken down into regional systems or state systems. That being said medicare already serves something like 60 million people. I'd argue that scaling a system to support 5x the number it currently serves is significantly more doable than scaling anything from zero.

The US is not comparable to W Europe or the EU on this topic, since neither of those are political units responsible for a healthcare system. However, that brings us to your next point

>scale is also a matter of division...

This is a great point. However, for whatever reason, we have never seen a successful single-payer system in a US state. Even very blue, wealthy states have not achieved this.

>scaling a system to support 5x...

Again, the data does not support this. I don't have a reason why, just observing that it's not supported by real life.

Hm, with regards to the difficulty of scaling these systems specifically and really the whole topic at hand more generally I don't know that there is sufficient domain specific data to justify a viewpoint either way. I mean how many examples of scaling a national healthcare system (public, private, or otherwise) to support 300+ million people do we have? Literally three, right? The US, China, and India. Each of which has such significantly different circumstances that comparing them is less apples to oranges than it is apples to giraffes to glaciers. That being the case I feel like it's only reasonable to draw upon non-domain specific data wherein so far as I'm aware and in my experience we see a pattern of scaling existing systems being simpler than originating new ones.

You're right that we only have a handful of countries operating at this scale (~150M+ populations) so it's not exactly "data" in the common tech-sense of that word.

I want to get back to my original point: it's not "astoundingly clear" that the US should have a single-payer system (not your words, I know). My own thoughts are that this is mostly a scale problem as well as an inability to properly assess the performance of other systems (e.g. I would call both Canada and UK healthcare broken, but others see those as successful).

I agree that the US system seems broken from both an "Outcomes vs Cost" and a "Cost over Time" perspective. I just disagree that nationalizing healthcare, either through a single-payer system or the current Obamacare system is the answer.

> We are better in some areas, worse in others, but overall outcomes are roughly the same, at a much higher cost per person

What if you limit yourself to Americans with health insurance?

First, it wouldn't be an apples to apples comparison because the Americans without insurance are not randomly selected, so you'd be carving out a population with other confounding variables. And second, if doing so showed better outcomes here than elsewhere, we'd be saying "we have the best care, but 10% of the country doesn't get to have it. Tough luck!". Third, our overall spending is so much higher, we'd be admitting that we spend way more money to not even cover everyone.

We also have an unhealthier society because we have different jobs, standards of living sedentary lifestyles, etc. For example we have more obesity. So depending on how you are measuring overall outcomes it could be that the US system is in fact better, but is just dealing with patients with a different initial health level.

I am not sure about this. Government healthcare has longer wait times, less flexibility, less quality due to reduced talent levels, and less incentive for innovation. I absolutely hate dealing with the government healthcare workers who think they’re above patients - some aren’t just rude but abusive, which I have direct knowledge of (at least in parts of Europe and Asia).

I do think the US healthcare system is expensive and sometimes fraudulent (overcharging for supplies, extra billing codes, etc). But we can fix these things with tweaks like forcing transparent pricing for healthy competition, creating transparency and consequences for billing or Medicare fraud, and other such ideas. I don’t think it requires as big a change as a single payer system.

Transparent pricing/competition is not going to move the needle. The overwhelming majority of costs come from a small percentage of people (80% of costs from 20% of people) whose overall medical spending is so high that they are far beyond any notion of shopping. Those people are well beyond their OOP Max and not even responsible for the costs anymore, and have serious conditions where any incentive to shop is basically non-existent anyway.

We also have gobs of data showing that people associate price with quality and often don't want to be price-conscious consumers in the first place (the classic "if your kid gets cancer are you going to the cheapest cancer treatment center, or looking for the best?" You will pay the same 10k OOP max either way). The types of health care that could be price-sensitive are a tiny percentage of overall spending.

Isn't medicare effectively a single payer, because the rates are mandated and can't be negotiated?

How much should it cost?

Maybe that cost is low. I don't know, but putting out a number with no context seems to be for shock value only, not realistics.

How much would it be if they met doctors?

A new high school in the US costs 100 million dollars. It seems they build 200 such schools per year. All of a sudden we have a spending of 20 billion on just new high schools each year. Is that too much or too little?

> How much should it cost?

Since the diagnoses are not followed up by treatments, nothing?

> Is that too much or too little?

It would be too much, if no students were admitted to those schools.

Do you mean they should treat even if there is no diagnosis?

This has nothing to do with treatment at all. Quite the opposite in fact, it is merely a diagnosis, for the sole purpose of increasing the risk score. If the person had been treated for the condition there would be no need for the diagnosis.

United Health Care and others have figured out that if you go to someone's home, dubiously diagnose them with a condition that Medicare has deemed expensive to cover, Medicare will send them more money to provide health insurance for that person, whether or not they actually have the condition or ever receive treatment for it.

ETA to make it explicit with an exaggerated example: UHC gets say 10K/year from the govt to give you health insurance. Then UHC sends a nurse to your house who shines a flashlight in your ear and says "you have diabetes". Now UHC gets 15k/year from the govt to give you health insurance.

right, but this has nothing to do with health care, nor nurses or patients

It is simply that bureaucrats have passed regulations where they do not understand the repercussions

Every domain that is bogged down by bureaucracy will have inefficiencies of various magnitudes.

This is fraud, not poor regulations. Insurance companies are misdiagnosing for the sole purpose of collecting more income. These people do not have these conditions. Many of these conditions are very rare and Medicare Advantage diagnosis rates are far above normal.

This is not bureaucracy, it is fraud. They sold it as a way to save the government money, claiming that private insurers could do it more efficiently than Medicare. And then what actually happened was it costs more, because they fraudulently gamed the system.

The $15B isn't the cost of the visits, it's the nurses adding on extra billable diagnosis to the patients to bill Medicare outside of their doctor's reviews/knowledge. This was largely just a way to collect higher payments from Medicare.

> Sixty percent of UnitedHealth home visits generated at least one new revenue-producing diagnosis of a condition no doctor was treating, the analysis showed.

I don't think you are understanding the mechanism here. This is not costing $15B because they are consuming $15B worth of health care.

Medicare calculates what it costs to cover an average beneficiary by region, age, etc, and then private insurance companies can sell Medicare Advantage (MA) plans to people in place of standard Medicare coverage, and Medicare reimburses them for providing that coverage. Medicare is essentially saying "it costs $10K/year to provide standard Medicare benefits, if you guys think you can do it cheaper we'll give you the $10K as long as you provide the exact same coverage".

What are they reimbursed is also risk-adjusted so that if any given plan covers a sicker than average population, they get reimbursed more.

What is happening here is these plans are adding superfluous and questionable medical diagnoses to drive up that risk score and get higher payments from Medicare. The theory behind it is if having condition X means you cost an average of 10% more than an average beneficiary, and every person who buys an MA plan from a given company has condition X, they get reimbursed 1.1X the average. They are adding these dubious diagnoses to drive that number ever higher.

What this has led to in practice is MA costs the government much more than standard Medicare. And this is despite the fact that MA plans tailor their offerings to attract a healthier than average population, but then they goose the risk score so the financial effect is the opposite.

I admit I don't understand the mechanism - but this just sounds like they created an a flawed system that has nothing to do with nurses or patient or even health care.

An improperly devised system that can be easily circumvented.

It is not relevant to the subject matter of health care, it is not different than corn subsidy or whatever.

It's not a flawed system, it simply needs to be managed and rules need to be enforced. It may very well be true that private insurers could provide coverage for cheaper than standard Medicare. I have personally worked with health insurers who were able to outperform benchmarks by implementing care management programs, reaching out to insureds to make sure they are taking medications and getting ongoing care from their physician, etc. They can also develop close relationships with local providers, and/or have their own captive providers like the HMO model. It's not all free market dogma that there is potential for savings there, because standard Medicare is somewhat of a convoluted mess that needs modernizing.

But instead of doing that, they realized that they could just pressure providers to up-code and goose the risk score and make more money.

MA is relatively new. We needed many years of experience to see how the market would play out. But now we've known for a decade or so that it is clearly costing way more than it should and offering no additional benefits to justify the cost. Unfortunately we have not yet had the political will to fix it, and the handful of massive companies making bank on it will fight tooth and nail to keep the gravy train rolling.

The lesson from MA is that people will figure out how to game the rules, so we need to be reactive and flexible and able to update the rules accordingly. But because health care is a complicated and personal subject, people are wary of change, and we have very little political will to fix this. This will get even harder with the recent Chevron decision, which will serve to make it even harder for CMS to fix the regulation of MA without new legislation.

> I admit I don't understand the mechanism

I'll simplify it for you: The government pays health care providers for providing healthcare. It is very easy to defraud the government by billing for fake work, so fraud is common and costly.

The actual details are irrelevant. There are some extra steps involved, but functionally it's the same as a nurse sending a bill that says "I treated patient X for condition Y" and the government going "Sounds good, here's some taxpayer money"

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