this post was submitted on 19 Feb 2024
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It's funny you mention restaurants, in that case I don't particularly care when they bill me because the menu says precisely what I'll pay (counter order vs table service doesn't matter as much as cost and quality). If it's market rate (steak or seafood), they'll tell me what the day's rate is and what cuts they have.
I don't get that with health care, even getting a range in a quote is like pulling teeth. I pushed back a ton when my daughter needed a surgery, and after several calls I still didn't get a clear answer, and this was for a routine surgery. The quality and speed of service was great, billing was not.
One of the benefits of socialized medicine is not having to worry about billing, but you also often get delays in care. I don't think we need to go to socialized medicine to solve the unexpected costs issue, we can expect care providers to absorb some of the variability.
I agree, the current profit motives are misaligned, and pushes like the ACA to further expand the number of people with insurance further entrench these practices.
The profit motive should be attracting customers who otherwise would go without. But since pricing isn't transparent, cash payers don't have the same leverage to get a fair price. Many care providers have an informal "cash discount," but that's just not the same.
If the system works well for cash customers, insurance would need to earn customers' business, but when most people have insurance, the patient is no longer the customer, the employer is, so they'll charge individual customers more than employers with group plans. If we separate the insurance from the employer, they would need to cater to patients.
Removing private insurance is one option, but that's also quite disruptive and has potential for other issues (e.g. why would Medicare bother with good customer service if it's the only option?).
That wasn't my experience. We had two options for a surgery with different risks and costs, and after several calls, we couldn't get any numbers, just A costs more than B. That's why I'm so interested and "it depends on your insurance" blah blah blah. That's why I'm so interested in this. And this wasn't some podunk hospital, it was the premier children's hospital in the state, run by the premier public university in the state, and services kids outside the state.
I should be able to get quotes on a procedure from multiple care givers for a non-urgent procedure (like the one we had).
Patients should be able to switch insurance if they don't like the one they have. Right now, you either use the insurance you have or pay out the nose by giving up company cost share and ACA subsidies.
If my company offers a crappy plan, I should be able to take what they would've contributed and pick my own plan. If that was the case, insurance companies would try harder to make their service more convenient, just like auto insurance does (not a gold standard, but much better), and HR orgs would probably try harder to pick better plans.
If you're wealthy, you don't need much from your insurance. End of life care could be self funded, and insurance is there for the other surprises that could ruin your retirement. It would be totally acceptable for an insurance company to require some kind of down payment to cover EOL care, or a minimum number of years for coverage (if you die before the end of the contract, it counts as debt the estate needs to pay back).
I've run the numbers and can get a similar price (within 10% or so) for similar coverage without ACA subsidies, but I need to factor in how much they'd contribute to their own plan. Add to that couples who both work, your options are: have separate plans (less efficient) or give up the employer subsidy.
No, they'd just adjust rates to compensate. If there's something insurance companies are good at, it's averaging costs and holding a surplus. So a company that's better able to estimate this should get more customers and stay in business longer.
If they offer a 10-year or longer plan, they just need to average costs across their target demographic over those years to come up with a premium. Term life insurance companies do this, so why not health insurance?
Especially for homeless people. Which is a huge part of why I'm a fan of government funded ER. That's a huge risk factor for insurance companies and hospitals, and it's also a huge complexity for visitors and whatnot, so it should just be provided. If the paramedic thinks you need emergency care, it should be 100% free. However, hospitals should be empowered to deny care (and charge for wasting ER capacity) for non-emergencies.
But any extended care once you're stabilized should be covered by insurance instead, because you have actual choices in your care (and could theoretically walk out if you choose not to accept further care).
We were talking about service, not cost...... Like if they ran your card for every individual item, as soon as you ordered it. "I'd like to start with a coke to drink" takes out card to charge. "Then I'd like a starter" takes out card.
This is what i mean by bad service.
This is likely because you called before a prior authorization was completed, meaning that you most likely were utilizing private insurance. If you were utilizing Medicaid, which doesn't require pre authorization, then it would be really simple to tell you.
You can't give an accurate quote for private insurance because the individual plans are so personalized by their workplace or insurance brokers to lower cost and coverage that we literally don't know what your coverage until we submit if for authorization and equate for things like deductables and copay.
This authorization process requires not only a referral, but an itemized script, supporting notes, and a face to face with the provider. So unless they had the opportunity to complete these task, private insurance doesn't allow us to give you a quote.
Lol, you were just talking about a delay in care due to billing issues with private insurance. American private insurance also has the same exact delays in care, waiting weeks for prior auth, waiting months for people to meet their deductible, avoiding needed care because of cost, and just plain waiting for specialized care because we don't have enough specialty providers. Many specialty providers like neurologist or or rheumatologist have left the field specifically because of paperwork burnout. The authorization process for these expensive specialty practices is so scrutinized by insurance companies that it can take months of daily negotiation to even see a patient.
Lol, wrong again. The plans allowed on the aca marketplace had to follow aca guidelines, which included automating the billing process. These platinum, silver, and bronze plans are actually pretty easy to work with compared to those offered by people's workplaces. In the beginning we were actually pretty excited to see actual changes to the system, however since the removed mandate, and the subsequent deterioration of coverage in these plans, it's rare to see patient actually utilize there benefits.
What are you talking about about? Why would an insurance company want to attract uninsured people? The uninsured people of America are some of the most at risk communities in America. They are impoverished, underemployed, and are disproportionately likely to have long term health conditions. There is no wealth to extract from these people, and the longer they have been uninsured, the more likely they are to require excessive care once they are insured.
Lol, you have no idea the average cost of healthcare people accumulate during their lifetimes. One serious stint at an inpatient facility would bankrupt a wealthy person. As I said, there is no profit in healthcare that isn't created by denying healthcare.
Why exactly would it be quite disruptive? Also, Medicare is the only option for the people who have it..... If you qualify for Medicare for your primary insurance, private insurance automatically becomes your secondary. Medicare still offers more coverage than any other private plan. I don't think you quite understand that the people whom work in healthcare do so because they want to help people. Being a physician doesn't exactly mean you're making the big bucks anymore. There are plenty of fields that require a lot less schooling and pay way more.
As I said previously, this is an inherent problem created by private insurance. You can't just call and shop around on private insurance, the way they set up the prior authorization process is expressly made to prohibit this. The only way to do this is to call your insurance as a subscriber, and talk to your plans agent. They will direct you to their preferred network, where they have negotiated cost previously.
Again, insurance companies purposely create inefficient and archaic systems so their customers won't utilize their services as often. They make us do all the explaining and processing, so we get the blame.
I agree, and if your child was on Medicaid it would have been super easy..... You would have been told $0.00. Medicaid is an actual healthcare system, and because their goal is to actually improve their patients health it functions as intended.
Right, but who is preventing people from switching plans...... Oh yeah, private insurance. Because private insurance cannot afford to have patients switching insurance every time a patient has an operation. How are you going to remain solvent if a subscriber can just run up cost and then switch to a different insurance pool without contributing?
You are ignoring the fact that private insurance is a gamble. It's a company gambling that you as an individual will contribute more to the insurance pool than you take out before you turn 65. If a person can just switch insurance companies they could just change plans every year they needed an expensive operation. The same can be done with home/car insurance, but car/home insurance is allowed to charge people with prior history of heavy utilization with higher fees and deductible. This is not legal in healthcare, as it would automatically price out people with chronic illnesses.
And how many people are wealthy compared to the amount of people who are poor? Is your solution to build the entire country's healthcare system for 5% of the population? Also, why should your life savings be eaten up by healthcare cost if you already paid for life insurance your whole life? I just don't see why you are so ardent about paying more money for less coverage?
You are comparing individual self funded plans to those offered by your work? As someone who owns a company and works for a hospital..... I highly doubt that. I'm still utilizing my hospital insurance because the self funded ones offered to small companies were quite a bit higher when factoring in deductible and copays. If you were talking about individually funded plans, I would urge you too re examine the coverage.
The amount they would have to raise rates exceeds their clients ability to pay..... You can't squeeze blood from a stone, and people are already struggling with their current cost. Raising the rate high enough to account for chronic disabilities isn't an option. This is why they fought so hard against the law that prevented them from rejecting coverage for people with conditions like type 1 diabetes, which isn't a disability that qualifies for Medicaid, but has a high cost.
That's just a bandaid who's only function is to protect insurance companies. If insurance companies are not good enough to cover emergent healthcare what's their point? If you can get free healthcare at emergency rooms instead of being insured, why not just go to the ER? This would just make the emergency room problem worse.
Why spend so much time coming up with worse work arounds when you haven't been able to tell me a single advantage private insurance brings to the table?
I'm not really following the point of the analogy.
If cost doesn't matter, I'd just give them my card and they can run it as often as they like. That's basically how it works on cruise lines, you set up a payment system and they scan your cruise card with each transaction. It's not an issue at all.
Right, and that's because the policy holder usually isn't the customer, the employer is.
Health insurance would likely be a lot simpler if the average policy holder could switch insurance, especially if there's no open enrollment period (like car insurance, I can shop rates anytime and understand what I'm buying pretty easily).
No, there was no delay in care. Once I picked the option, I got the procedure done in the next week or two.
The only delay was because I wanted the quote before picking the solution, and that's a totally artificial limitation that can be fixed by changing how insurance works (i.e. give me the cash price, and I'll figure in the deductible and whatnot).
You're right, the problem is paperwork, which is why we should give the insurance companies fewer options to reject claims. Eliminate or automate the authorization step. Care providers should never need to talk to anyone at the insurance company.
Higher risk just means higher costs. They can still collect some percentage of premiums, so why would they turn it down?
You're right, and those numbers are hard to come by since most studies/articles assume Medicare in retirement and focus on out of pocket costs. If I was proposing actual policy, I'd do my due diligence, but for this kind of discussion, I use what's readily available.
65+ insurance is indeed unique, hence why I mentioned an escrow system. Basically, you prepurchase insurance including end of life care. That amount of money buys you a certain guaranteed tier of end of life care, even if your individual costs exceed that. I'm guessing that escrow is something like $300-500k for basic EOL care, plus some extra for routine medical care. But I only have mediocre data to work from. If you have a good source, I'm interested.
I don't know how practical it is, it's just an idea for an alternative to Medicare for the wealthy. But honestly, just uncapping income for paying in and expanding Medicare a bit for poorer people is probably more reasonable.
Sure, and the same is true for education. And the problems with both are pretty similar:
In many areas, the government has a near monopoly on education, yet the problems persist. Why should we expect medicine to be much different? Once government has a near monopoly on something, it becomes very political.
Maybe something like the public option doesn't have as many tradeoffs, IDK, but socialized medicine certainly would. I'd only be in favor of a public option if care providers received the same amount from cash customers vs Medicare customers, and that amount is transparent and publicly auditable (i.e. if Medicare wants to fight high prices, that should benefit cash customers). That doesn't happen today with the privatized system, so that's where my focus is.
Privatized insurance isn't the goal here, privatized medicine is. If we want to subsidize that for the poorer end of the income range, I'm fine with that, but the majority should be expected to pay for a large portion of medical care, otherwise market forces don't work properly.
They do it because it doesn't cost them customers. I can't vote with my wallet and switch my insurance, I can only beg my HR department to offer something different. I am not the customer here.
Many customers are willing to pay a bit more in other industries to avoid BS, I don't see why that should be any different for health insurance.
The reason we have the system we do is because government incentivizes company-provided health insurance. We should instead encourage people to select their own plans. The ACA increases barriers to rejecting company insurance and doubles down on involving employers in health insurance decisions.
Either we need to completely put patients in control of their insurance or provide it as a public good. The current middle ground is worse than either extreme imo.
Auto insurance seems to work just fine with this. If I make lots of claims with one insurer, that slate won't just be wiped clean with the next one.
If customers can easily switch, that should encourage insurance companies to lock in customers with longer term policies to spread out the risk.
And insurance isn't really a gamble, it's actually quite the opposite, a way to reduce risk. The insurance company doesn't expect any particular individual customer to be profitable, they just expect that their customers will be profitable on average. Individuals buy insurance knowing that they statistically don't get value from the insurance, they're merely getting it to reduce their own financial risk. For an insurance company, it's like buying an index fund instead of individual stocks, and for individuals it's like buying an annuity instead of stocks.
Yes. I'm comparing individual, non-subsidized ACA plans with those offered by my work. My work only offers high deductible plans with a premium and HSA contribution, and I'm comparing against ACA HSA plans with a similar deductible and max out of pocket. I've never had a copay, everything has been a relatively simple deductible.
Specific details certainly differ, but I think it gets me in the ballpark.
And this is for a reasonably large company. We have something like 3000 employees, so it should be big enough to benefit from collective bargaining. I haven't run the numbers for a couple years (I compared ACA when self-employed vs new company), so things could have changed. I like this method because costs are both transparent, and I actually estimate my costs (and subsidy) if i decide to stop working in a spreadsheet. I'm certainly no expert, but I do try to be reasonably thorough.
And yeah, I'll probably redo the numbers soon. I generally do this around tax season because I like to estimate my taxes to see how close I am (was really close last year), and I have a section to compare expected total costs of care for the two plans my company offers (only difference is deductible, premium, and max out of pocket) and a comparable ACA plan (those numbers are publicly available). Specific plan details vary, and it's not something I can get super accurate with (how do you put a price on a procedure I'm unlikely to need?), but hopefully it's close.
If you're interested, maybe I'll run the numbers this weekend and reply with the details. I'm not a medical or insurance expert, but I am very interested in personal finance and actually enjoy spending a few hours crunching numbers.
Maybe. But that's also assuming healthcare costs stay stagnant. If we drastically reduce the complexity of dealing with insurance, we also reduce the costs to insurance, which may be enough to offset an increase in claims.
All the paperwork is waste, and it's getting to be a massive problem, but it suffers from a prisoner's dilemma-type issue (an individual company is better off complicating the process in the short term, but if everyone does that, net costs go up) so the current setup won't resolve itself.
Insurance companies exist to cover extreme financial burdens, like developing cancer or other chronic conditions. Basically, things that could bankrupt you.
The issue with ER is that it often goes against your will, and getting financial consent could be the difference between life and death. What are you going to do if insurance rejects your claim? What if someone else calls an ambulance for you and you can't pay? What if you're a tourist and you don't understand the US medical system? There's just way too many weird cases to the point where we can't just expect insurance companies to take the hit here.
Publicly funded ER solves those problems and can protect emergency care providers from lawsuits and whatnot so they can focus on providing care. Once the patient is stabilized, they can make decisions for ongoing care, and that's where insurance should get involved.
In general, if something is involuntary or a natural monopoly, it should be publicly provided. That's absolutely the case for emergency care (I can't pick the ambulance company someone else calls for me). But routine and chronic care absolutely is voluntary and isn't a natural monopoly.
The ER would reject you and potentially fine you for nonemergency care. Just like calling 911 for non-emergencies.
Right.... But the point of this hypothetical is to explain how the billing process is detrimental to service. In this hypothetical, like with any time you visit a new Drs office, you have to go through a myriad of processes explicitly for billing. Hence why in this hypothetical the ordering process is specifically made to be labourus, so no, we won't hold on to your card. Please hand it to me for every item.
Wouldn't there be even more options if individuals chose their plans instead of large employers?
I already explained that's not economically viable.....
Your inability to choose an option is a a delay in care....... Any time between a prescribed written order and the fulfillment of that order is considered a delay in care.
My dude, you don't understand what the cash price represents. Nor do you understand that it is of no consequence to you if you already have insurance. The cash price is simply the Medicare allowable, minus whatever internal policy they have for discounts for people paying in cash.
If you want to know the cash price, look up the medicare allowable for the procedure or item, then call the office and see if they offer cash discounts. If your office accepts Medicare, then it's against CMS guidelines to set billing codes for cash payers more or less than the Medicare allowable. You can apply discounts after using the Medicare allowable, but you must initially bill by coding guidelines.
However, if you already have private insurance then we have to bill for the specific pricing negotiated by the insurance and office. And like I said most of the times, unless it's a plan and operation the office does frequently, we won't know what your cost will be until we run a prior authorization.
These are private companies...... What right does the government have over private industry to moderate them so closely? They would argue that it would risk their solvency as an industry. They would proclaim the same propaganda that has so effectively captured your own loyalty so well.
Did you even read anything I wrote about this? You aren't legally allowed to raise prices of individual coverage based on use. This isn't car or home insurance. And if they raised prices for everyone any more than they already have......people might start getting a little more excited about things like Medicare for all.
No it's not......... It's all publicly available information on the CMS website. You can literally track where every single Medicare dollar goes, which is the benefit of socialized medicine, it's extremely transparent.
Lol, people barely have the competency to sign up for Medicaid, a free service. The average citizen isn't going to be able to have the funding or the ability to plan that long into their own future. I feel like you have some misconceptions about public health, and who it primarily serves.
Do you understand that the average person in my state would have to work 10 years to earn that kind of money? Just earn, not save. That's virtually impossible for the vast majority of Americans. That the average working male only contributes around 60k dollars to to Medicare in their entire lifetime?
Right but this was a response to the claim the providers were colluding with insurance companies to make more money, which is wildly false.
This is assuming the problem is inherent to government, and not the decades of declining funding, or the response of white communities to integration after the civil rights movement. Other governments do have a complete monopoly on education and they don't have these same issues. So I don't really think itakes much sense to just blame the government.
Because we already have a socialized healthcare network that treats the majority of healthcare needs, it's just being weakened by private insurance stealing funding away from the system, and is kept artificially unavailable to younger healthier patients for the sake of private profit. And even surrounded by these parasitic corporations Medicare continues being the highest standard in the industry. Offering more coverage for lower cost than any other insurer in the country.
Any evidence to support that statement, or even a theory on what kind of negative trade offs? You are speaking as if you are an authority on the subject, however based on prior statements you seem to have some great miscommunication about health care systems, billing systems, and the over all concept of insurance pools.
How is that even a possibility? The amount of people paying for their healthcare upfront in cash is so small that it's not even trackable. You are talking about cash payment as if it's a common occurrence. I've been working in the field for over a decade and I've probably had 1 maybe 2 patients pay in cash upfront.
You are also assuming your own ignorance of the subject is due to some sort of colluding shadow group of healthcare providers working against you. In reality you're just unfamiliar with the inner workings of our healthcare system, and instead of just reading the literature available on the CMS website you've done your own "research" on YouTube.
Literally every single one of the claims you've made has been inaccurate. I have no reason to lie to you, I get paid the same no matter what I bill, or how many patients I see. I work at a state run children's hospital, specializing in orthopedics and rehabilitation. If I wanted to make more money I could easily take a job at a private clinic.
You do not know what you are talking about, I don't know how to say that in any simpler terms. The assumptions you have made are not idiotic ones, in fact private insurance companies spend a lot of money (often An illegal amount) to spread this misinformation to you.
However, what would be idiotic is to assume that you know more about a system than someone who has worked with it every day for well over a decade. I assume you have some specialized knowledge or skill you utilize in your career? What would you think of the person who tried to lecture to you about your career after a couple hours or even days of "research"?
Again....... The medical system is not profitable. There are some aspects that are profitable, but those profits are required to be cycled back into the system to help support the rest of it. If you simply privatizes the only aspects of the system that were profitable and socialized the ones that weren't, it would raise the overall cost of insurance for everyone.
You can't just keep repeating the same inaccurate claims when you haven't acknowledged any of faults ive previously pointed out.
Yeah....seems to be a problem inherent to privatized insurance, which is my point. The reason you can't do this is because the insurance companies can't afford to let you do this. It would make apparent that private insurance only achieves solvency via careful control over their insurance pool.
Because you have some inherent misconceptions about how insurance companies remain solvent, despite their cost exceeding their subscription fees. The only way insurance pools remain in solvency is by meeting a target subscription projection that would theoretically eventually cover their aging subscribers.
The way this projected growth is theoretically supposed to work is by adding multiple more young subscribers for every older subscriber they currently have. And for a while with the economic and population growth America has achieved in the past, this has been possible.
However, if the growth dwindles or if you get generations make less than their parents, the system starts to collapse. Which is why countries with disproportionately old populations have a hard time maintaining stable healthcare systems.
Wrong again..... The aca was simply a plan to get the uninsured rate down. They offered both incentives to companies and individuals to achieve this goal. Before the aca individual plans were not even offered by insurance companies. These individual plans were actually really robust, especially with medication cost, better than even my current private insurance. However, Republicans sponsored by the insurance lobbyist slowly ate away at the funding and requirements, making the individual plans basically useless, culminating with the abolishment of the mandate during the trump administration.
Are you a motorized vehicle? What makes you think insuring an entire population is similar to insuring a inanimate object? I've already pointed out that it is illegal to charge people a higher premium because of their preconditions or prior use. And if it was legal this would either lead to people being uninsurable, or would collapse the insurance pool.
A rebuttal that you have not acknowledged this entire discourse.
Do you not see the internal contradictions of "customers can easily switch" and "lock in customers with longer term policies"?
Which is not true with healthcare...... Not on a long enough timeline. Which is why insurance companies boot people to Medicaid or Medicare when they start to become a financial burden. If they are forced to provide coverage past the age of 65 then there is no possibility for a return. We all end up eventually receiving more healthcare than we pay for.
Again, you are ignorant of the fundamental differences of health insurance when compared to ensuring inanimate objects. At this point it seems like you are purposely being obtuse, so I'm assuming you lack the mental plasticity to change your mind regardless of any new information or perspective.
Aca self funded plans have significantly reduced their coverage and network size since the mandate went away. The original plans were actually a pretty decent deal, but they're pretty worthless by now.
Again, if you are going to be standardizing these private organizations to the point where you dictate their operating procedures, what's the point of privatizes healthcare?
Yes, it seems like every one of these "non profit" private insurance companies are prioritizing profit over service......Strange.
No, private insurance companies exist to extract public funds from the government at the expense of its citizenry. The entire point of a healthcare system, is to improve the health of the entire population, not individuals. Private health insurance damages the system, and does nothing to improve it.
Bahahaha, what? You don't have to take financial consent to treat someone at an ER. You don't need ID, or insurance paperwork, or even an address. What do you think we do with people who are unconscious upon arrival? We don't just stick them in the waiting room until they miraculously wake up.
As I said, you are making huge assumptions without a very basic understanding of healthcare. One of the reasons hospitals are inherently a natural monopoly nis because there is no choice often. You can't dictate where your ambulance goes, and we can't turn down a person in need.
Lol, insurance companies do not take the hit, we do. The cost is covered by the hospital, and its burden is redistributed via raising price of healthcare.
And again this would just lead to people using the ER more than they already so.
First of all, this is once again illegal. But more importantly bits highly immoral and violates the Hippocratic Oath. No ER provider is going to turn away a patient in need of emergency medicine.
And of course you will say, that they can turn away non emergent care. But this just proves you lack of understanding of the healthcare system in general. Minor ailments that go untreated will eventually turn into actual emergencies. So it doesn't matter if you turn them away, or worse fine them, they will eventually come back in worse condition.
The only way to lower emergent healthcare cost is to provide affordable/free preventative care and education . Take for example the diabetic shoe program, every diabetic with peripheral neuropathy in America is eligible for diabetic shoes and custom inserts. At one point as a cost saving measure they cut this service, which ended up costing them hundreds of millions of dollars in the long run due to the increased incidents of wound care and amputations.
It's a much more complicated system then you would like to assume.