Ok, no more teasing... Healthcare: The Real Reasons It Is Broken and How To Fix It

[RhythmDawg]

Just read this all the way through. Really interesting and interested. Unfortunately, I don't know that it would work for me in my condition now, but I can see it working for my wife and son. How does this work for women and their "types" of visits like breast screenings, pregnancies, and other stuff like that? Would they need an OB/Gyn separate from this group? As far as my situation or someone that has already developed a disease or diseases that have no cure, how would this model work? I still need the primary care model physician for bumps and bruises, etc..., but how would I incorporate the other care I need such as routine visits to cardiologists, pulmonary, GI, etc...?

Regarding the OB/GYN, if you aren't of childbearing age, do you really need one? OB/GYN is a specialty within Primary Care. If you are getting breast screening and paps, a primary care physician can do that.

For someone in your condition Dirty, my response would be...

This model allows each individual's costs to be proportional with their risk of consumption. If you are very healthy and a low utilizer, your costs will be much lower. If you have a chronic condition like diabetes, COPD, heart disease, cancer, etc., your healthcare costs will be proportionally higher, as it should be, because you are a high utilizer. Your healthcare costs more.

In your case, I would say to you, you need fully comprehensive health insurance coverage because your risk of utilization is extremely high. If I were trying to get into the white house, I would be saying...if the government wants to get involved in healthcare, subsidize end of life care, terminal illness, etc. by mandating/paying for catastrophic insurance coverage. Leave primary care and intermediate specialty care to us. The amount of money that would be available to care for you in your condition, and that could go to research, if the model was flipped would be unreal.

Everyone gets mad over the "everyone pay their fair share" tax argument. Its been happening in healthcare for decades. Everyone is dumped into the same pool and we all subsidize each other. Obamacare is taking it even a step further. This is no better illustrated in healthcare than group policies for businesses.

[Brian96]

RD, how is this going?

[RhythmDawg]

RD, how is this going?

Politicians have the only power to fix it and they aren't capable. Some are starting to listen though. Honestly, right now...if I can ignore the insane amount of money it will cost everyone and the massive regression of access to care...I'd rather keep the ACA in place and let the healthcare insurance industry collapse. The problem is the healthcare industry itself would fall apart. Hospitals would close all over the country. Technology and pharma companies would go out of business. People would stop going to medical school. But at this point everything needs to be wiped out and rebuilt.

Trying not to be pessimistic, but everything realistic that the government might do with healthcare is nothing more than shifting the degree to which the same problem exists.

Other than that it's going pretty well.

[DogsWin]

I'm surprised there has not been one comment in this thread about balance billing. The #1 cause of bankruptcy in the US is medical bills and allowing doctors to charge patients whatever they want to in emergency situations and insurance companies paying only to a certain point is what causes most of these bankruptcies.

For example, in 2008 on Thanksgiving Day I had to go to my Blue Cross Blue Shield in-network hospital due to severe abdominal pain. I had to have my gall bladder immediately removed per the ER doctor. Long story short- I was in the hospital for about 28 total hours and the entire cost of a routine gall bladder removal was ~$60,000! I had to pay out of pocket about $13,000. The ER doctor was not "in network" with the largest and arguably best health insurance provider in Texas. Why? Because he (and several other medical pros) REFUSE TO BE IN IT! They can make HUGE SUMS of money by not being limited by the insurance companies' agreed max payment amounts. The doctors, hospitals, etc just 'balance bill' the patient and this practice is illegal in several states. Also, hospitals negotiate with these "not in any network" doctors to give them exclusive rights to treat all emergency patients who arrive during their day on ER call. If a patient asks for an 'in network' doctor there will not be one, because he/she did not outbid the "not in network" doctor for the right to see ER patients for that day.

We are now repeating this same 'balance billing' process again with my son's ER visit which will cost at least $5,000 out of pocket (again with BCBS of Texas). Balance billing keeps coming up in many state legislatures to make this illegal in MEDICAL EMERGENCY situations where the patient has no choice to prequalify every entity to see if they are 'in network' or not. Every year the AMA lobbies to kill the bills that seek to kill balance billing.

Balance billing is a crooked and predatory practice that is destroying people financially. That is unless you are one of the doctors, hospitals, ambulatory service providers,... who are part of this activity.

[RhythmDawg]

I'm surprised there has not been one comment in this thread about balance billing. The #1 cause of bankruptcy in the US is medical bills and allowing doctors to charge patients whatever they want to in emergency situations and insurance companies paying only to a certain point is what causes most of these bankruptcies.

For example, in 2008 on Thanksgiving Day I had to go to my Blue Cross Blue Shield in-network hospital due to severe abdominal pain. I had to have my gall bladder immediately removed per the ER doctor. Long story short- I was in the hospital for about 28 total hours and the entire cost of a routine gall bladder removal was ~$60,000! I had to pay out of pocket about $13,000. The ER doctor was not "in network" with the largest and arguably best health insurance provider in Texas. Why? Because he (and several other medical pros) REFUSE TO BE IN IT! They can make HUGE SUMS of money by not being limited by the insurance companies' agreed max payment amounts. The doctors, hospitals, etc just 'balance bill' the patient and this practice is illegal in several states. Also, hospitals negotiate with these "not in any network" doctors to give them exclusive rights to treat all emergency patients who arrive during their day on ER call. If a patient asks for an 'in network' doctor there will not be one, because he/she did not outbid the "not in network" doctor for the right to see ER patients for that day.

We are now repeating this same 'balance billing' process again with my son's ER visit which will cost at least $5,000 out of pocket (again with BCBS of Texas). Balance billing keeps coming up in many state legislatures to make this illegal in MEDICAL EMERGENCY situations where the patient has no choice to prequalify every entity to see if they are 'in network' or not. Every year the AMA lobbies to kill the bills that seek to kill balance billing.

Balance billing is a crooked and predatory practice that is destroying people financially. That is unless you are one of the doctors, hospitals, ambulatory service providers,... who are part of this activity.

The ER doctor removed your gall bladder???

In most ERs, the physicians fall under one of two categories...employed by the hospital or employed by an ER staffing company contracted by the hospital. In the first scenario, the hospital would bill globally and your services would have been provided in network. In the second circumstance, the hospital might, depending on their arrangement with the staffing company, either bill the same way and pay the ER staffing company, or bill technical components only and allow the staffing company to bill the professional component. In the second scenario, if the staffing company is not in network with the same insurances as the hospital, that is negligence in my opinion on the hospital. I do see it...in fact it happened not long ago in Ruston...and a hospital should never allow that. Similar scenarios happen with remote radiology, lab, and pathology services.

If your gall bladder was removed by an employed surgeon, it would have been billed globally...and should have been under an emergency situation. If the surgeon was not employed, he/she might also have billed pro fees themselves, and the same issue could apply.

Payment depends on both the patient's policy and the contract between a provider and the insurance company. The hospital or physician may set whatever price they want to...because in a contracted in network scenario, the price usually isn't going to matter for the patient. A payer will reimburse the hospital based on their contract with the hospital. They will require the patient to pay their portion based on the policy you purchased from them. They will contractually adjust the rest. Balance billing this contractual adjustment is insurance fraud. Any huge payments required by a payer of the patient is going to be determined by your policy you purchased toward a deductible.

Out of network payments and self pay is another ball game, because there are no contracts in place to govern these rules. In these cases, a provider can balance bill. I agree, it should not be allowed in these cases without an adjustment to the price because the price was artificially inflated for an in network arrangement. All hospitals should have a mechanism in place to deal with this. Patients also have a right to negotiate.

I have always wondered how much people would be willing to pay for a consulting/advocacy service in cases like this. I bet I could have gotten your fees at least cut in half. I've done it pro bono a few times for friends in the past, and even found major billing errors hospitals and physicians made that kept insurances from paying and the hospita/physicianl passed the responsibility on to the patient to pay...and they hospital/physician had no idea they made the error. The patient certainly couldn't have figured it out. But we got it rebelled and paid by the insurance.

[RhythmDawg]

A word on price inflation...

I'll use hospitals as the example, but these things apply equally to all healthcare providers. Hospitals are required to charge everyone the same price for a service. But they negotiate...usually poorly...and contract with insurance companies for reimbursement rates. Rates are different from one payer to the next for the same service. Also, the same payer will pay differently to different hospitals for the same service. All payers will pay the hospital its price or its contracted rate, whichever is less. Thus, if I see a hospital getting paid 100% of their price, I recommend them to increase their price for that service because they lost money by getting paid the lesser of the two. Some payers will also pay a percentage of the price instead of a negotiated flat rate. Sometimes they put a cap on it, and sometimes they don't.

This all means that a hospital must assign a price that 1) is higher than every negotiated payment rate for that service, and 2) maxes our the caps for any percentage rate payments. This is what makes a piece of gauze cost $25 on your bill. Each payer pays their contracted rate...and requires you to pay your portion based on the policy you bought...and they contractually adjust the balance.

So. If BCBS pays $100 for a service...

Your hospital charges $125, you according to your policy pay a $15 copay, BCBS pays $85, and BCBS requires the hospital to contractually adjust $25. If your hospital charges $1000, same scenario and the contractual adjustment is $900.

If you do not have insurance, you get the same inflated bill. You have to understand how all this works and negotiate it. Usually a hospital will have a self pay discount...and often they make more on you than they would have from an insurance company because your self pay transaction is based on the inflated price influenced by all payment rates. The insurance transaction is based on a much lower contracted rate that you are not privy to.

All of this is also why prices are so different from one hospital/physician to the next. If you have insurance, and depending on your policy setup and if your provider is in network, price doesn't matter.

[dawg80]

All of that reeks of antitrust price fixing. Anyone so engaged should end up in federal prison.

[DogsWin]

The solution is pretty simple- MAKE BALANCE BILLING IN EMERGENCY SITUATIONS ILLEGAL IN ALL STATES!
There is a very good reason these bills keep getting written EVERY YEAR and there is a very good reason they keep being killed by (arguably corrupt) politicians in committee ($$$$$).

A $60,000 routine gall bladder removal, a $1,600+ out of pocket ambulance (just the patient's portion) expense,... These things have got to stop!

[RhythmDawg]

The solution is pretty simple- MAKE BALANCE BILLING IN EMERGENCY SITUATIONS ILLEGAL IN ALL STATES!
There is a very good reason these bills keep getting written EVERY YEAR and there is a very good reason they keep being killed by (arguably corrupt) politicians in committee ($$$$$).

A $60,000 routine gall bladder removal, a $1,600+ out of pocket ambulance (just the patient's portion) expense,... These things have got to stop!

Medicare pays $450 for an ambulance transport, all inclusive.

[RhythmDawg]

All of that reeks of antitrust price fixing. Anyone so engaged should end up in federal prison.

countless judges and lawyers disagree. But...it IS what is wrong with healthcare.

[Brian96]

Politicians have the only power to fix it and they aren't capable. Some are starting to listen though. Honestly, right now...if I can ignore the insane amount of money it will cost everyone and the massive regression of access to care...I'd rather keep the ACA in place and let the healthcare insurance industry collapse. The problem is the healthcare industry itself would fall apart. Hospitals would close all over the country. Technology and pharma companies would go out of business. People would stop going to medical school. But at this point everything needs to be wiped out and rebuilt.

Trying not to be pessimistic, but everything realistic that the government might do with healthcare is nothing more than shifting the degree to which the same problem exists.

Other than that it's going pretty well.

More specifically, how is the clinic in Ruston with the model you described working out? How does something like that fit into (or not) ACA?

[RhythmDawg]

More specifically, how is the clinic in Ruston with the model you described working out? How does something like that fit into (or not) ACA?

The ACA regulated it out of existence. We are currently running it at a Louisiana hospital through its multiple clinics, but it is slightly altered from the original.

There are now over 2500 of these clinics across the country. Ours was different because we addressed intermediate and catastrophic care and not just primary care. It required a catastrophic policy with a high deductible. The law (ACA) deemed a policy with a deductible greater than $2000 to be illegal...but the government is not enforcing it. Nevertheless...insurance companies are basically not writing those policies.

[Brian96]

I was afraid of that. When will we learn that health insurance does not equate to health?

Keep up the fight!

[TYLERTECHSAS]

In summary, greedy reedy doctors, lawyers, insurance and drug companies are the cause.

[PawDawg]

In summary, greedy reedy doctors, lawyers, insurance and drug companies are the cause.

Not a very good summary