RIP off in healthcare

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glxpass said:   Dshibb, just because you make an assertion doesn't make it true. You've spent much time and energy criticizing what I've said. Simply calling it BS doesn't make it so. Constructive criticism is fine, but you haven't done that. I've provided links, given examples of places using an integrated approach, tried to provide alternative ways of looking at the problem, and so on. You"ve discounted the information I've provided, but replaced it not with facts, but with gross generalizations and opinions.

When you are ready to have a real discussion about these matters, let me know; otherwise I see no point in responding further to your posts.


glxpass, I'm not calling it BS(which I actually didn't but whatever) because I disagree. Instead I've pointed out that you haven't offered anything on increasing patient responsibility post diagnosis which you haven't, yet you claim you're after an 'integrated approach'(integrated obviously meaning that patient responsibility is a part of the equation). And I did say that you're bull$hitting about actually believing in an integrated approach if you don't offer up anything to address one side of it(except to make it worse).


I'm not discounting anything. I've asked for one and only one thing and that is something/any ideas you have to increase the patient responsibility part of an integrated approach.

You've talked about 3 things:
1) Provided articles about the doctors and hospitals taking more responsibility. Fine that is one part of the 'integrated approach' and I'm in 100% agreement with a lot of the solutions they've put out, but it's not anything on the other side of the coin and that is patient responsibility.
2) Talked about education to get people to focus more on healthy lifestyles so that they are a lower risk of getting sick. But we've been talking about post diagnosis and this is pre-diagnosis. It's not an idea to actually addressed the topic at hand and one you said you were after(integrated approach)
3) Lowering deductibles to zero and co-pays to $10 to $100. So not only do you run in the opposite direction, but you offer up zero to even replace that reduction in responsibility let alone increase it.

So I don't know how any of these 3 things correspond to increasing patient responsibility to fit with your 'integrated approach'. None of them do. You can feel fee to explain how reducing it is actually increasing it or how focusing on providers stepping in is actually patients stepping in or you can tell me how focusing on pre-diagnosis healthy living is going to change peoples decisions to rush for quality and quantity whenever they do get diagnosed, but I don't know how your going to do that because it so basic common sense that even a 10 year old could figure out that those 3 things aren't going to increase patient responsibility towards the money spent on their behalf and in actuality would only decrease it.

So please provide any idea you have that actually increases patient responsibility *towards the money that is spent on their behalf* and then we can talk.

Or you can choose not to provide any even though you claim to agree that some increased patient responsibility is a good thing and leave us scratching our heads.

dshibb said:   ryeny3 said:   When I suggested a very HDHP plan, I was assuming that Medicaid would continue to serve the poor. One alternative to the traditional Medicaid model is a HDHP with co-pays based on income bands. Using BostonOne's example, people at 1X the poverty line would have co-pays at $0, 1x to 2x at 75%, and 2x-3x at 75%. Although copays based on income and an FSA accomplish the same thing, the copay skips the "rebate" process.

Interesting! I assume you mean a lower percentage for 1x-2x than you do for 2x-3x.


You know I'll go ahead and share my ideas on the subject matter. Now again I'm not particularly wedded to them they're just what I've so far thought up as the best I've been able to come up with.


The first place I look is to what best practice is for those that are financially secure and then seek to re-duplicate that for those that aren't.

So how would the financially secure approach this from an ideal standpoint. They would have:
1) At least a decent sized cash or liquid invested position largely earmarked for deductibles and co-pays if tragedy was to strike. Let's say they probably have zero to worry about if that number is let's say around ~4 times their maximum out of pocket for a given year because if a chronic situation occurred they would have several years of self funding.
2) And they would also have reserves to pay health insurance premiums in the event that they lost work or received a drastic pay cut(went on disability for example at an amount substantially less than their current income).
3) They have a high deductible, high co-pay plan because if something were to happen to them they would have the means to pay for it.
4) I think we could safely say that if it was possible to duplicate that is in some fashion for the masses not only would we have a stable healthcare marketplace with costs contained, but also one where capacity to pay wouldn't be as much of an issue.

Now the problem with the HSA + HDHP today(even though it's a step in the right direction) is that people need excess discretionary funds in order to fund which means that it isn't beneficial to the poor. It's really only a cost containment mechanism on the overall market by influencing the behavior of the upper income half of the country. Furthermore, it requires voluntary responsible behavior of which the problem was never really located in the voluntarily responsible.

So instead how do you get to a point where every person in the country has first of all sufficient cash reserves to meet any and all deductibles and co-pays? Because if we can do that then we don't need to have 100% unlimited demand in any area of the marketplace. Well the best I've been able to come up with is to stratify the accounts based on the specific purpose(similar to how responsible people earmark money) and then make sure that the important ones are sufficient in size.

Let's say we gave every new born and child in the country $10k in a locked account(HSA if you want to call it that). We allow that account grow over 18(or whatever) years of their life and then at age it becomes available for use exclusively as a deductible and co-pay account. It'll probably be at least be $20k by then.
For poor people:
-The government continues to contribute a small amount of money annually into the same account on a sliding basis(probably in the neighborhood of a few hundred dollars a year)
-You then subject the max out of pocket deductible for poor people at a ratio of that account balance. So let's say it's 4 times.
-If they don't use it, it continues to grow.
-If they do use some of it then they have to contribute a percentage of their income to refill it back up(in addition to what the government contributes).
-You then say that at maybe $50k(indexed to healthcare inflation) and any amount that overflows that amount you can withdraw so they have an incentive to not waste the money inside of the account on unnecessary health expenses.

You would then have the traditional HSA as we see it now as a more flexible account overlaid on top. That would primarily be used by people that wanted to put money aside for higher healthcare deductibles yet and for people that wanted to have an account to pay distributions for health insurance premiums, etc.

Then implement a sliding scale voucher(or tax credit) to buy insurance up the a certain level of the poverty line. Don't try to standardize those plans people will pick what is best for them ***which will be high deductible/high co-pay because all of them will have the means to pay for those deductibles and co-pays***

Then you basically have 2 different solutions for the high risk people. Either state guarantee fund or the government back stops insurer losses beyond a certain point for certain health classes allowing for pricing to stay easily within reach for high risk individuals.

For me this would solve the moral question of making sure that every American had access to the cash needed to pay for care, but allowed people to take more responsibility for healthcare spending causing overutilization to fall and finally creating a positive cycle of declining costs and premiums in healthcare(progressively making the whole situation easier and easier to deal with).


The bold part (Let's say we gave every new born and child in the country $10k in a locked account(HSA if you want to call it that)) would create the biggest illegal gold rush in America the way the 14th Amendment in the Constitution is set up now.

MilleniumBuc said:   dshibb said:   ryeny3 said:   When I suggested a very HDHP plan, I was assuming that Medicaid would continue to serve the poor. One alternative to the traditional Medicaid model is a HDHP with co-pays based on income bands. Using BostonOne's example, people at 1X the poverty line would have co-pays at $0, 1x to 2x at 75%, and 2x-3x at 75%. Although copays based on income and an FSA accomplish the same thing, the copay skips the "rebate" process.

Interesting! I assume you mean a lower percentage for 1x-2x than you do for 2x-3x.


You know I'll go ahead and share my ideas on the subject matter. Now again I'm not particularly wedded to them they're just what I've so far thought up as the best I've been able to come up with.


The first place I look is to what best practice is for those that are financially secure and then seek to re-duplicate that for those that aren't.

So how would the financially secure approach this from an ideal standpoint. They would have:
1) At least a decent sized cash or liquid invested position largely earmarked for deductibles and co-pays if tragedy was to strike. Let's say they probably have zero to worry about if that number is let's say around ~4 times their maximum out of pocket for a given year because if a chronic situation occurred they would have several years of self funding.
2) And they would also have reserves to pay health insurance premiums in the event that they lost work or received a drastic pay cut(went on disability for example at an amount substantially less than their current income).
3) They have a high deductible, high co-pay plan because if something were to happen to them they would have the means to pay for it.
4) I think we could safely say that if it was possible to duplicate that is in some fashion for the masses not only would we have a stable healthcare marketplace with costs contained, but also one where capacity to pay wouldn't be as much of an issue.

Now the problem with the HSA + HDHP today(even though it's a step in the right direction) is that people need excess discretionary funds in order to fund which means that it isn't beneficial to the poor. It's really only a cost containment mechanism on the overall market by influencing the behavior of the upper income half of the country. Furthermore, it requires voluntary responsible behavior of which the problem was never really located in the voluntarily responsible.

So instead how do you get to a point where every person in the country has first of all sufficient cash reserves to meet any and all deductibles and co-pays? Because if we can do that then we don't need to have 100% unlimited demand in any area of the marketplace. Well the best I've been able to come up with is to stratify the accounts based on the specific purpose(similar to how responsible people earmark money) and then make sure that the important ones are sufficient in size.

Let's say we gave every new born and child in the country $10k in a locked account(HSA if you want to call it that). We allow that account grow over 18(or whatever) years of their life and then at age it becomes available for use exclusively as a deductible and co-pay account. It'll probably be at least be $20k by then.
For poor people:
-The government continues to contribute a small amount of money annually into the same account on a sliding basis(probably in the neighborhood of a few hundred dollars a year)
-You then subject the max out of pocket deductible for poor people at a ratio of that account balance. So let's say it's 4 times.
-If they don't use it, it continues to grow.
-If they do use some of it then they have to contribute a percentage of their income to refill it back up(in addition to what the government contributes).
-You then say that at maybe $50k(indexed to healthcare inflation) and any amount that overflows that amount you can withdraw so they have an incentive to not waste the money inside of the account on unnecessary health expenses.

You would then have the traditional HSA as we see it now as a more flexible account overlaid on top. That would primarily be used by people that wanted to put money aside for higher healthcare deductibles yet and for people that wanted to have an account to pay distributions for health insurance premiums, etc.

Then implement a sliding scale voucher(or tax credit) to buy insurance up the a certain level of the poverty line. Don't try to standardize those plans people will pick what is best for them ***which will be high deductible/high co-pay because all of them will have the means to pay for those deductibles and co-pays***

Then you basically have 2 different solutions for the high risk people. Either state guarantee fund or the government back stops insurer losses beyond a certain point for certain health classes allowing for pricing to stay easily within reach for high risk individuals.

For me this would solve the moral question of making sure that every American had access to the cash needed to pay for care, but allowed people to take more responsibility for healthcare spending causing overutilization to fall and finally creating a positive cycle of declining costs and premiums in healthcare(progressively making the whole situation easier and easier to deal with).


The bold part (Let's say we gave every new born and child in the country $10k in a locked account(HSA if you want to call it that)) would create the biggest illegal gold rush in America the way the 14th Amendment in the Constitution is set up now.


Now it wouldn't. A) It's a pittance relative to the value citizenship is for one's career prospects(i.e. that is substantially larger). B) It's minuscule relative to any entitlement in the system. C) They can't even spend it on anything they want until it caps out and starts to overflow. It's stuck in that account locked down and a lot of people are coming from countries that have government insurance programs.

So not only would it not 'lead to a gold rush for citizenship' it would actually be a completely non factor. Welfare, food stamps, SCHIP, Medicaid, Unemployment insurance, and In-State tuition are hold true lures. A locked account you can't touch except for medical expenses wouldn't matter at all.

Watch this guys.
Remember when arguing healthy vs unhealthy that even though u r healthy now, it could be you in hospital tommorrow.

See this..
http://www.cnn.com/video/?/video/us/2013/02/21/ac-kth-griffin-hi...

ggmon said:   Watch this guys.
Remember when arguing healthy vs unhealthy that even though u r healthy now, it could be you in hospital tommorrow.

See this..
http://www.cnn.com/video/?/video/us/2013/02/21/ac-kth-griffin-hi...


That's why you don't get some $hitty health insurance policy. Especially when you don't have any control over services given and have to accept their chargemaster prices.

By the way how does the chargemaster prices get determined? They get determined by a common practice of hospitals that whenever they're facing a loss for the year they'll jack the chargemaster rates because they can't raise Medicare and they're likely locked into an agreement with most insurance companies on different things. So they have limited levers to pull so often times it's the chargemaster book that gets an across the board percentage increase. Some of the items are way too expensive so they look to create new things to charge for so that the price of other things aren't too outrageous. It becomes the situation of do you charge an even more insane amount for xyz machine use or do you create a new category to charge for Kleenex to save your hospital.


DrDubious said:   Figured I'd throw this out there:

http://well.blogs.nytimes.com/2013/02/21/getting-patients-to-thi...


Megagreen, thanks for sharing!

glxpass, read that once! That is the story that goes on every single day in thousands of doctors offices around the country and the fact that patients in those focus groups were 100% in unison that they don't want cost to even be a remote factor in treatment decisions is all you need to see.


Some highlights I found common, but nicely crystalized:
Article said: When my colleague finally invoked cost – telling the woman that while an M.R.I. might ferret out rare causes, it didn’t make sense to spend the enormous fee on something of such marginal benefit – the woman became belligerent. “She yelled that this was her head we were talking about,” he recalled. “And expensive tests like this were the reason she had health insurance.”

Article said: The researchers conducted more than 20 patient focus groups and asked the participants to imagine themselves with various symptoms and a choice of diagnostic and treatment options that varied only slightly in effectiveness but significantly in cost.

Article said: When it came to their own treatment, “patients for the most part did not want cost to play any role in decision-making,”...

Most did not want their doctors to take expenditures into account, and many made it clear that they would ask for the significantly more expensive medications, procedures or diagnostic studies, even if those options were only slightly better than the cheaper alternatives. “That puts doctors, whose primary responsibility is to their individual patients, in a very difficult position.”


Article said: A majority of the participants refused to consider the expenses borne by insurers or by society as a whole when making their choices. Some doubted that one individual’s efforts would have any real overall impact and so gave up considering cost-savings altogether. Others said they would go out of their way to choose the more expensive options, viewing such decisions as acts of defiance and a kind of well-deserved “payback” after years of paying insurance premiums.

Article said: Even when the focus group leaders reminded participants that the differences between proposed options were nearly negligible, participants continued to choose the more expensive options as if it were beyond question that they must be more efficacious or foolproof.


I'll tell you right now even given what I know my responses would be the same. "I'm not going to make a difference on the overall system so give me the most expensive option and bill my carrier" would be my response as well. Well you have perverted incentives so much that a smart person who get's all this and that they're only adding to the problem would say the same thing than you've effectively destroyed any functioning cost containment in the system.

glxpass said:   I realize that there are people who abuse the current healthcare system and will do their best to do the same for any healthcare system. Some questions and thoughts:

* How prevalent is this and what portion of overutilization costs are attributable to patients abusing the system?

* If everyone has health insurance or is subject to paying a fine if they don't have insurance and require healthcare, and If medical records were available to all providers by looking up a UPI (universal patient identifier -- I know there are privacy concerns about this), could that be used to identify and figure out ways to mitigate the abuse?

* Regardless of patient intent, we need to reduce the frequency of ER visits and make ER visits less expensive. Ways to do this might include providing more access and increased pre-screening by one's PCP, expanding the number of urgent care clinics (which should be less costly than ERs and from which truly critical cases that need further treatment are referred to ERs), increased use of PA's (physician assistants, etc.


I can't give you numbers on how prevalent the abuse is, but I can tell you it's something I deal with on a more or less daily basis. I don't think anyone could give a realistic number for what the costs are systemically, because defining and detecting whatever you decide to be abuse would be very difficult, subjective, and riddled with errors. For example, you will never really know if the addict with an exacerbation of chronic back pain REALLY needs that extra shot of morphine, or how long it will be before he can walk again. And you will never really know if he needs to be on disability, either, which is a whole 'nother conversation.

I don't think a universal EMR would help that much for much of the abuse we see. The Munchausen patients who roll through every hospital in the state trying to convince someone to do exploratory abdominal surgery exist, but not in the numbers that would justify a universal EMR by themselves. Although it would make life a lot easier for MDs in other ways, the EMR wouldn't be able to tell you that someone is lying about having tearing chest pain so they can hide out from their bookie for a few days until their next paycheck comes through. And it definitely wouldn't do anything to convince the lady arguing for the MRI in the NYT article I linked that a CT scan would be just fine for her.

What it really comes down to is that our society is going to crumble under the excessive costs of healthcare or healthcare in this country is going to falter so badly that only the very rich will get any decent sort of care. Nobody wants to pay for anything and expects their problems to be someone elses fault.

DrDubious said:   Figured I'd throw this out there:

http://well.blogs.nytimes.com/2013/02/21/getting-patients-to-thi...


Btw I thought I should mention that MRIs shouldn't be that costly and the the primary issue I have with that article is that it implies you can't get a low cost MRI... In my area, in a 5 mile radius, MRIs cost between $10,000 and $250. Maybe the insurance companies should say we'll pay up to this amount for an MRI, anything more and you pay out of pocket for it. Didn't insurance companies use to do this or did they get in trouble for it by the public? I also wish there was some sort of incentive for patients to choose the cheaper method like they get a bonus if they choose the cheaper option to bill to the insurance company.

goku2 said:   DrDubious said:   Figured I'd throw this out there:

http://well.blogs.nytimes.com/2013/02/21/getting-patients-to-thi...


Btw I thought I should mention that MRIs shouldn't be that costly and the the primary issue I have with that article is that it implies you can't get a low cost MRI... In my area, in a 5 mile radius, MRIs cost between $10,000 and $250. Maybe the insurance companies should say we'll pay up to this amount for an MRI, anything more and you pay out of pocket for it. Didn't insurance companies use to do this or did they get in trouble for it by the public? I also wish there was some sort of incentive for patients to choose the cheaper method like they get a bonus if they choose the cheaper option to bill to the insurance company.
Since most patients aren't concerned with the actual cost of a procedure, hospitals and many doctor's offices aren't used to providing prices upfront. Even knowing the correct billing or CPT codes doesn't guarantee that the estimate will match the bill.

Insurance companies got into trouble for using UCR estimates, that many believed were not usual,customary or reasonable.

If the co-pays for an ER visit are set too low, some patients may find that the ER is their cheapest out of pocket option. One common small group policy has $20 co-pays for doctor's visits and $50 co-pays for an ER visit.


Sprained ankle on Saturday:

1. Pharmacy: Buy reusable ice packs, compression bandages, "boot" and crutches. Cost is probably > $50. Add co-pays if decide to see a doctor later.

2. PCP on Monday: $20 co-pay plus the cost of all of the items in #1. will probably be referred to a specialist for an additional $20 co-pay.

3. Specialist on Monday (hopefully): $20 co-pay plus the cost of at least some of the items in #1.

4. ER on day of injury: $50 co-pay. All of the items in #1 included for no additional charge.

Depending on the time of day (Saturday nights seem to be the worst for the ER), it may take less waiting time in the ER than trying to get "worked in" at a doctor's office. For most people, a Saturday visit to the ER doesn't require time off work.

Good news for our discussion. Since the excellent article in the OP probably won't be read by most posters, I present to you the most recent episode of Planet Money that sums it up in a scant 19 minutes. They have the author of the article on and everything. Linky.

But if you have reading power, seriously read the article in the OP. It's 11 pages well spent.

MilleniumBuc said:   Wow. No wonder we are screwed. The sad reality from the following 2 paragraphs:

"Recchi’s bill and six others examined line by line for this article offer a closeup window into what happens when powerless buyers — whether they are people like Recchi or big health-insurance companies — meet sellers in what is the ultimate seller’s market."

"... the American health care market has transformed tax-exempt “nonprofit” hospitals into the towns’ most profitable businesses and largest employers, often presided over by the regions’ most richly compensated executives."



Might as well say it. Healthcare (Profit and Non-for-Profit) will push the price as high as you can for a very simple proposition: How much are you willing to pay to live without pain - or even further - to remain alive. I support capitalism, supply and demand, but there is a line that has to be drawn on the price of lives.

agree 100%

goku2 said:   DrDubious said:   Figured I'd throw this out there:

http://well.blogs.nytimes.com/2013/02/21/getting-patients-to-thi...


Btw I thought I should mention that MRIs shouldn't be that costly and the the primary issue I have with that article is that it implies you can't get a low cost MRI... In my area, in a 5 mile radius, MRIs cost between $10,000 and $250. Maybe the insurance companies should say we'll pay up to this amount for an MRI, anything more and you pay out of pocket for it. Didn't insurance companies use to do this or did they get in trouble for it by the public? I also wish there was some sort of incentive for patients to choose the cheaper method like they get a bonus if they choose the cheaper option to bill to the insurance company.

I think there is already a bonus. At least in my case I have co-insurance 10% even if I have taken the best coverage from my employer.
10,000 - my part $1000
250- my part $25

Please remember that 10,000 MRI is not same as 250 . Some might involve the 3D image reconstruction and hence costly.

cristinaaaron said:   There is so much fraud in medicare that they justify the reimbursement rates.

There is no way that it is possible the true cost of a chest xray is $21 when the process normally involves 30min of time for an xray technician with a loaded salary of $80k/year ($50k pay + $30k benefits), cost for device time, facility cost, and billing cost. The only way this reimbursement rate is feasible is if a high percentage of claims are fraudulent (which they are).

Sure, the normal cost for these procedures is inflated, but the medicare cost is artificially low because a huge percentage of procedures which medicare pays are in actuality not done.

30 mins for a chest xray? no wonder we don't question anything in life!

ryeny3 said:   BrodyInsurance said:   PhrugalPhan said:   BrodyInsurance said:   The IRS and Tresury considers a single day of coverage per month as a full month, so you would be exempt if you had coverage from January 1 to October 1 and no coverage for the rest of the year.

Go from January 31 to October 31st and we're down to 8 months of coverage.

Depending upon the rules and the PITA factor, one might only need coverage for 9 days.
You mean Jan 31 - Oct. 1, right?


Yes. And for "9 days", I was talking about just keeping insurance for one day a month in each of 9 months.
If the maximum gap is < 3 months, then it's 10 days. If <= 3 months then 9 days. Regardless, it's a clever idea.

Even better, January 31 to September 1st.



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