Health Insurance

[Beavah]

Yah, in da original thread on BSA v. Dale, BrentAllen started talkin' about health insurance cost increases, "Obamacare" and other things.

 

Seems like the topic of da economics of health care is in order, because it's a complimicated thing, and I reckon we all misunderstand it a bit.

 

As close as I can tell, da health care cost increases by private insurers are being driven by Medicare and by the uninsured. With da limits on payment for services by Medicare and the need to cover emergency services and other care for the uninsured, health care providers have to keep increasin' the fees on the private insurers.

 

On top of that, the billing overhead for private insurers, and the laws that mandate a lot of very expensive care for da terminally ill/aged, add to the unnecessary cost.

 

Da increases come from more people getting older and shifting to Medicare, resulting in increased fees to private insurers because of how Medicare underpays for its services. Yah, and there's also a liability insurance burden that matches our out of whack tort system.

 

And in general, da system also encourages expensive procedures and docs not spending time with patients, because the billing and payment is by the procedure/visit. So there's incentive to order procedures, and great incentive to be a "specialist" providing expensive procedures, whether needed or not.

 

If yeh want the costs to come down, you have to do a few things.

 

1. Yeh have to increase the pool of people who participate in insurance coverage, especially the younger, lower-risk folks. Simply put, yeh need da young people to pay for the old, and yeh don't want da burden of the uninsured increasing costs.

 

2. Yeh have to reduce the billing overhead, which is out of control. Single-payer does have its merits in this regard.

 

3. Yeh have to break da AMA's control of the supply side and open more medical schools. Supply and demand markets don't work if yeh allow monopoly control of the supply.

 

4. Yeh have to be willing to do the hard thing, and not authorize expensive treatment for the aged and terminally ill, unless they pay for it out of pocket or through some gold-plated private insurance.

 

5. Yeh have to be willing to limit civil liability for malpractice to something equivalent of willful neglect, not simple or gross negligence.

 

6. Yeh have to change da payment incentives to reduce the shift into procedure-based specialties.

 

Number four is the hard one, eh? In some ways, America has the best high end, research-driven health care just because we're willing to shell out so much money to give grandma another 4 months. But that also means that one of our scouts who is hurt at the camporee bankrupts his uninsured family tryin' to pay for his expensive treatment.

 

B

 

[Eagle92]

Very timely topic as I have just completed a lit search for some nurses who are doing a paper on the topic. haven't read everything, just glanced at it, but here are my thoughts.

 

1) having folks covered until they are 26 on their parents' plans doesn not help this problem

 

2)In reference to billing overhead, you are correct in that private insurance companies are subsidizing those on medicare/medicaid as well as the uninsured. don't get me started on that one.

 

 

3) I don't fault AMA and med schools, I fault the beauracracy of all the hoops physicians have to go through to get paid, as well as the malpractice insurance and all the other paperwork garbage they have to put up with. I cannot find the article now, but a recent survey from one medical journal asked recent docs if they knew what they know now, would they go through med school again, and over half, I want to say 54% btu don't quote me on that, said no.

 

Heck I met one doc who quit practicing and is a "consultant:" talking to docs and hospitals who have admitting and coding questions. And there are now companies hiring docs who provide those services.

 

To be honest I would not recommend anyone to be a doctor b/c of the garbage they have to put up with.

 

4) Not touching.

 

5) YES TORT REFORM! heck there was a case in MS in which a doctor, who was the son of a doctor and was a Jr., was sued by one of his dad's patients as his dad died several years prior to the lawsuit. lawyer knew it was the wrong physician, and still proceded withthe lawsuit!

 

6) yes you have to pay primary care physicians more, it's kinda sad when a plumber owning his own business has more take home pay than a primary care physician with their own practice.

 

With the new health care reform, be expecting longer waits, fewer doctors, and more use of PAs and NPs.

[GernBlansten]

Yeah, health reform was a joke.

My insurance premiums are increasing now at the same rate as they were when Bush ignored the problem.

Should have gotten medicare for all.

[evmori]

Here's what gets me. If you are a self-pay, those $5,000 MRI's and $4,000 CAT scans cost about half. Why? Why do these tests have to be billed at double or triple the actual cost to get reimburssed for the actual cost?

[OldGreyEagle]

Ed, Hospitals don't get paid "cost" they get paid from a Fee Schedule or from the DRG based on the discharge diagnosis. What hospitals charge and what they get reimbursed is pretty much vaporware

 

see

 

http://www.cms.gov/apps/ama/license.asp?file=/hospitaloutpatientpps/downloads/2010October_AddB.zip

 

Hit accept at the bottom of the page and open the spreadsheet

 

download Addendum B, this lists what hopsitals get paid per CPT code, thats the Procedure code, for example, a Head CT without Contrast pays the hospital a National amount of $194.60, less depending on the geographical area

 

A head MRA reimburses a National amount of $348.68

 

What hospitals charge and what they get are not related

 

I know this is complicated, its what I do every day. if you want more info PM Me

 

(This message has been edited by OldGreyEagle)

[OldGreyEagle]

In reference to the above, the totals given are for outpatient procedures, inpatient procedures are paid differently. Medicare pays for inpatient care based the discharge diagnosis. if you have a total hip replacement, and covered by Medicare, the hospital gets the hip replacement amount, no more, no less. Doesnt matter what they do, it pays the same. There are mitigating factors, but the care provided has little to do with the reimbursement recevied

[The Blancmange]

Beavah, some interesting and pragmatic thoughts. Some of my serious as well as tongue in cheek thoughts:

If yeh want the costs to come down, you have to do a few things.

1. Yeh have to increase the pool of people who participate in insurance coverage, especially the younger, lower-risk folks. Simply put, yeh need da young people to pay for the old, and yeh don't want da burden of the uninsured increasing costs. Mandatory coverage?

2. Yeh have to reduce the billing overhead, which is out of control. Single-payer does have its merits in this regard. Agreed. Will never fly in the current political climate.

3. Yeh have to break da AMA's control of the supply side and open more medical schools. Supply and demand markets don't work if yeh allow monopoly control of the supply. Sounds good at first blush, but the less pessimistic view says they also provide a valuable service in terms of standards and quality.

4. Yeh have to be willing to do the hard thing, and not authorize expensive treatment for the aged and terminally ill, unless they pay for it out of pocket or through some gold-plated private insurance. Death panels? Pull the plug on granny? Good luck with that one.

5. Yeh have to be willing to limit civil liability for malpractice to something equivalent of willful neglect, not simple or gross negligence. Why? Are the patient's damages any less based on the level of fault? Who is in the best position to bear the burden of the damages caused by a serious medical mistake. If they aren't borne by the provider, the most seriously injured will become public burdens. Malpractice judgments are a very small piece of the pie and experience in states that have limited awards shows that it doesn't lower premiums.

6. Yeh have to change da payment incentives to reduce the shift into procedure-based specialties. Agreed. Very few med students want to go into family practice or internal medicine. This might have an effect on #3 as well.

[vol_scouter]

The AMA is a small organization that represents a minority of physicians in this country. The federal government estimates that there are 954,000 practicing physicians in the US. From Wikipedia: "MedPage Today estimates that the AMA only represents 135,300 "real, practicing physicians" as of 2005 (15.0% of the United States practicing physicians)". After the AMA's support of the health care bill, that number is likely smaller. The AMA can provide opinions on health care issues that state and federal governments might use in decision making. However, the AMA DOES NOT SPEAK FOR ALL PHYSICIANS, AMA MEMBERSHIP HAS NOTHING TO DO WITH LICENSURE, THE AMA DOES NOT HAVE ANYTHING TO DO WITH MEDICAL SCHOOL CLASS SIZE! The federal government controls MD medical school class size. Therefore, the physician shortage is entirely due to the poor management of the federal government.

[CalicoPenn]

1. Yeh have to increase the pool of people who participate in insurance coverage, especially the younger, lower-risk folks. Simply put, yeh need da young people to pay for the old, and yeh don't want da burden of the uninsured increasing costs.

 

2. Yeh have to reduce the billing overhead, which is out of control. Single-payer does have its merits in this regard.

 

3. Yeh have to break da AMA's control of the supply side and open more medical schools. Supply and demand markets don't work if yeh allow monopoly control of the supply.

 

4. Yeh have to be willing to do the hard thing, and not authorize expensive treatment for the aged and terminally ill, unless they pay for it out of pocket or through some gold-plated private insurance. .

 

 

 

[vol_scouter]

5. Yeh have to be willing to limit civil liability for malpractice to something equivalent of willful neglect, not simple or gross negligence. Why? Are the patient's damages any less based on the level of fault? Who is in the best position to bear the burden of the damages caused by a serious medical mistake. If they aren't borne by the provider, the most seriously injured will become public burdens. Malpractice judgments are a very small piece of the pie and experience in states that have limited awards shows that it doesn't lower premiums.

 

Massachusetts Medical Society First-of-its-kind Survey of Physicians Shows Extent and Cost of the Practice of Defensive Medicine and its Multiple Effects of Health Care on the State "The physicians group says such defensive practices, conservatively estimated to cost a minimum of $1.4 billion, also reduce access to care and may be unsafe for patients." Massachusetts is not a large state so fear of lawsuits has a significant impact on the cost of medical care.

 

As a professional, a liability claim that exceeds one's insurance coverage can result in the physician being forced to sell property and pay the remainder. An internist in my general area was sued because a patient was told to have a procedure and did not. The patient later had a large stroke. Because the physician had not repeatedly called and written to the patient telling the patient that it was important to have the study (it was not disputed that the patient was informed at the initial contact), the physician was found guilty and the plaintiff was awarded $20,000,000. The physician had a typical policy that covered $1,000,00 per occurrence and $3,000,000 lifetime of the policy. The physician thus owed $17,000,000 to be paid personally. Internists in this area make on the order of $150,00 - $200,000 so the math is clear. Is it right that the board of Ford weighed the costs of the Pinto's gas tank rupturing and incinerating people versus a cheap fix. They were in no way personally liable. Physicians are not the only ones held to such a standard (all licensed professionals in general) but it does add significantly to the cost of healthcare.

 

[GernBlansten]

That sounds more like a case of legal malpractice by the defending attorney than a case of medical malpractice.

Should the same courtesy be applied to the defending attorney?(This message has been edited by gernblansten)

[vol_scouter]

Gern,

 

It goes back to a prior poster who said: "Who is in the best position to bear the burden of the damages caused by a serious medical mistake. If they aren't borne by the provider, the most seriously injured will become public burdens." The jury saw a family of very modest means with the plaintiff in quite poor condition and decided that the physician could and should pay. They did not feel that the patient had a responsibility to followup from the initial instructions but that the 'nanny state' mentality should prevail and that the physician should have made multiple documented contacts. It is advisable to keep patients in the hospital until all tests have been done and all potentially critical results are back.

[GernBlansten]

Vol,

Is it not better to have a system where grievances are heard and decided than a system where grievances are stifled? Which system supports the idea of freedom and liberty?

[vol_scouter]

Gern,

 

I agree with you there. That said, awards should be made because of negligence resulting in lasting harm - not because the accused is "able to pay". The awards should reflect the damages. Finally, as long as I and my family can lose essentially everything for an honest mistake or even worse - for a bad outcome, physicians will order extra tests and extend hospital stays so that there is ample evidence that everything was done.

[GernBlansten]

What would be the alternative Vol?

Limiting the freedom for me to sue a hack for butchering my child?