Health Insurance?

[old goat]

I agree health care should be non profit, but there are non profit health insurance companies and they're not any cheaper. I agree that hospital billing is outrageous, but Kaiser Health Plan (non profit) pays Kaiser Hospitals a fixed fee per member per year (no billing for $100 aspirins) and Kaiser is one of the more expensive health plans, at least in our area. (The Permanente Medical Group which contracts with Kaiser is for profit, but the docs are salaried, the group is paid a fixed fee per patient per year and the profit turns into a year end bonus that is usually about 5% or less of doctors' income.)

The point is that while there is greed, excessive profit taking, and poor incentives to save money in much of American health care, eliminate all that and it's still expensive.

[El Chupacabra]

Fuck standard healthcare. If you're just buying coverage for yourself, look into a Health Share program; I've got Zion Health but there are a bunch of legit options. As a 44 yr old, I pay $240/mo and it covers essentially everything with just a $1000 deductible / max out of pocket per event. Plus, there's no network which is pretty wonderful. I just had knee surgery and got to pick my doctor and post-op PT, which was quite refreshing compared to past history using standard health care plans.

On another note, self-pay (but I'm getting reimbursed after the fact) for providers allows them to offer ridiculous discounts. I paid $475 for an MRI, list price was $1200. I paid just over $5000 to the surgery facility, pre-discount was $9000+.

Add me to the list of responses cautioning against relying on health sharing ministries. It's not insurance. There's zero oversight. There's zero ability to dispute denial of claims or enforce any coverage in favor of the "insured."

It's very very very risky.

OTOH, if you have a lot of faith in God's will to provide you health care based on such a scheme, then go for it.

[J. Barron DeJong]

Another skeptic here.

Sure sounds like the shitty ‘insurance’ that was pervasive prior to ACA passing.

Fairly in depth report on health sharing:

https://www.commonwealthfund.org/pub...ing-ministries

[Cono Este]

Guess I should have put the /s on my post. With you 100% on the fact that it’s shouldn’t be profit driven. I’m easily in the $100k plus club, my main medication is $13k every 8 weeks. Luckily the Mrs is a teacher and we have good coverage to offset her subpar salary and shitty working conditions. I’m also very aware of how privileged we are to have that good coverage.

It pisses my off when people like CE act all pissed off about something we can easily change. Literally every other 1st world country has figured out how to provide medical coverage for their entire population but simps like him only support a political party that does everything they can to prevent that kind of progress.

All I ever hear is a solution to half the problem. Because you see, the NHS in the UK includes it’s own hospitals and providers. I have never heard any solution to why we’re paying 2-3x the price for routine surgery. Could
It be the scoundrels who own the hospitals?

I am also the biggest proponent of Original Medicare on this board. The same people critizing me for explain how it’s the greatest insurance we have are going with private medicare plans for free fitbit watches and gym memberships.

If you really want a UK type system, and I’d be fine with that, then start actually advocating for a UK type system with our own doctors and hospitals.

Disclaimer. I clean up bills for broke ass old lady’s whose doctors won’t see them because of $20 bucks.

[Cono Este]

Bernie had a solution

Again, he had no plans to give us a UK type system. No where in it was a plan to nationalize hospitals. Because there is no money for that and some might call that un constitutional.

He also had no plans to leave us with a private options. Yes, they still have private in Europe.

Why? Because his plan was nationalize the insurance part, ban private insurance, so the schmuck doctors and hospitals had no where else to go.

Fucking gangster.

[rod9301]

I live in France or of the year and here the doctors and hospitals are private.

System is similar to medicare in the us, part government insured and the balance private insurance

Yet a doctor visit us 25 dollars, drugs are very inexpensive, and waiting for an appointment is not any longer than in the us.

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[Bunion 2020]

Wait! You are saying that Health Care where it is socialized is as good as and cheaper than in the USA? Unpossible.

[fastfred]

why are we bombarded with drug advertising
it's time to shut that down
oh wait its about money

[MagnificentUnicorn]

Bernie had a solution

Again, he had no plans to give us a UK type system. No where in it was a plan to nationalize hospitals. Because there is no money for that and some might call that un constitutional.

He also had no plans to leave us with a private options. Yes, they still have private in Europe.

Why? Because his plan was nationalize the insurance part, ban private insurance, so the schmuck doctors and hospitals had no where else to go.

Fucking gangster.

So you’re saying that the doctors and hospitals are responsible for the high cost of healthcare?


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[m2711c]

Not all the doctors, some of them give you a deal…

[MagnificentUnicorn]

The healthcare system in France is only socialized in a way, because the insurance companies and fees for service and timely reimbursement are regulated by the government. The insurance companies have to be creative and compete for patients. Premiums are regulated. Reimbursement must be payed to the provider within 48 hours iirc. Every person in France has a card vitale, your portal for medical records, insurance coverage and reimbursement for providers. In most ways the healthcare in France is less socialized than the US. Medicare/Medicaid is the largest socialized healthcare system in the world.

If you want a better understanding of first world healthcare systems read The Healing of America.

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[Conundrum]

So you’re saying that the doctors and hospitals are responsible for the high cost of healthcare?


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I’ll say it. Yes, doctors and hospitals are responsible for the high cost of healthcare. Insurance companies are responsible for the high cost of financing that care and are definitely taking their cut. Insurance companies deliver zero patient care. Just a financial aggregator to pay for something people used to be able to afford without pooling funds.

A couple of thoughts. Why is it that neither the medical care groups, pharmaceutical groups, nor insurance groups lobby for a single payer? Who is to blame when a person needs a surgery but doesn’t receive it because the insurance company won’t authorize it? The insurance company can only decide to pay for it or not. The surgeon and hospital can still do the surgery but are choosing not to because they are not getting the money they want for doing it. Only one of those sides can deliver the actual care and is basing that decision on a payment the patient can clearly not afford on their own.

[MagnificentUnicorn]

So hospitals and doctors should provide care for free? Fwiw, not for profit healthcare systems are required to provide a certain percentage of charity care per CMS.

Do you have any idea how expensive it is to run a hospital? Most insurance is now reimbursing at Medicare rates. It’s basically a break even for most healthcare systems. Larger academic institutions only survive because endowments and grants. Our system in the US is at a breaking point with most running losses, especially after Covid


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[oldnew_guy]

One of the big challenges for getting doctors on board with single payer and lower salaries is going to be some sort of income/retirement solution. They have a huge amount of time invested into education and training by the time they are getting an actual doctors salary all while incurring large debts and deferring income.

What’s strange is that I don’t really know any docs that aren’t for a single payer system yet the professional organizations lobby against it?

Seems like a hugely complicated issue to try to pin on one or two groups.

On the hospital and insurance front: Oregon just had to inject $25 million of taxpayer money into the system to help hire traveling nurses to assist with the respiratory illness surge.

[Conundrum]

I’m not saying hospitals should deliver free care. My entire point was it’s hard to have a conversation on fixing the cost of healthcare when one of the culpable parties delivers healthcare and the other doesn’t.

Look, I’m not picking on hospitals. Yes, I do know how expensive it is to run a hospital. In fact, if anyone is curious, you can pull the 990 of any non-profit hospital and see for yourself how expensive it is to run a hospital. I also know that the hospitals in my area spend about 50% of total cost on labor and that cost is up about 30-35% YOY.

No, most insurance companies are not reimbursing at Medicare rates. If that were the case, why wouldn’t everyone just support going single payer?

Insco contracts are typically 25-75% higher than Medicare reimbursements. In our region, both major systems just went back to the largest private payer and got 5% more on top of the 5% more they got last year to stay in network.

I agree that hospitals systems are at a breaking point. This was not the case until Covid though. Many consumers are also at a breaking point on affording either care or insurance. Pharma is very profitable. Insurance co’s are profitable but not like pharma.

I certainly don’t have a fix here.

Edit. Want to provide some sources here and it looks like I under estimated.

So hospitals and doctors should provide care for free? Fwiw, not for profit healthcare systems are required to provide a certain percentage of charity care per CMS.

Do you have any idea how expensive it is to run a hospital? Most insurance is now reimbursing at Medicare rates. It’s basically a break even for most healthcare systems. Larger academic institutions only survive because endowments and grants. Our system in the US is at a breaking point with most running losses, especially after Covid


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In 2020, across all hospital inpatient and outpatient services (including both facility and related professional charges), employers and private insurers paid 224 percent of what Medicare would have paid for the same services at the same facilities.

https://www.rand.org/pubs/research_r...RRA1144-1.html

In the contract awarded in September, the state set a ceiling of no more than 200% of Medicare rates for the amounts the Blue Cross plan would pay providers overall in its first year. The contract says Blue Cross will target reimbursing providers an overall rate of 180% of Medicare’s rates by year three of the agreement.

https://khn.org/news/article/montana...lic-employees/ Article goes on to talk about the Montana State program that paid a % above Medicare that still wasn't high enough. Inside baseball-certain hospitals would not deliver care to those on the state plan even though it was higher than Medicare.

You really want to look at fixing this, a uniform Medicare reimbursement schedule for hospitals like you’re are saying exists now (it doesn't). Private insurers can prove they add value and efficiency better than CMS and they can stay in business. Or, CMS takes it over. Hospitals can learn to deliver care on the Medicare fee schedule or they don't. Care suffers and Medicare is forced to work with their charge masters to keep hospitals in business. Providence system's CEO earned $10.5m last year. Blue Cross of Michigan's CEO pulled $11.5m. Aetna CEO $29m. HCA Hospital's CEO $20.5. These are regionals and large nationals. Please tell me this isn't about the money on either side.

Like I said earlier, AMA and AHA are both against any payer approaching Medicare reimbursement rates and a single payer system would do that. The blame isn't just on insurance companies. Big pharma is probably worth a thread of it's own.

[::: :::]

I just had an epidural cortisone shot this week.

The doc who did the procedure also owns the outpatient surgery ctr where it was performed. He also employs everyone in that clinic. (It would also not surprise me to learn he owned the building/property as well, but I don’t know that for sure.). Everyone in that clinic is billed separately from separate business entities. Each of those businesses charge for their overhead and admin. They all send bills to my insurance, and then send me the remainder per whatever policy responsibility I may have.

Fun fact: they made me sign a ownership disclosure form on arrival that acknowledged that I had a choice in where my procedure was performed. I was not happy about that surprise and gave the receptionist a polite but purposely awkward, drawn-out explanation about how not doing the procedure after waiting weeks wasn’t a choice I had any agency in. I signed “don’t like it” on the form.

My health insurance company also operates this way. They run the insurance as one entity. They run billing as one entity. They run hospitals. They run clinics. But all are “independent.” And all bill separately with overhead/admin/profit.

I was in the hospital a couple days in September. I received EOBs listing individuals who work at the hospital (scheduled, staffed and organized by the hospital) as if they were independent contractors. Some of the names were not familiar to me per my meeting caregivers in the hospital & roles/tasks were not identified beyond “office visit”: faceless folks reading charts or whatever for a couple minutes, certainly not “office visit”. When I called the insurance customer support to figure out who these randoms were and what they were billing for, Customer Service couldn’t tell me. They directed me to the Billing office. I asked “how can you approve the invoices against my plan if you don’t have records of what service was purportedly performed?” No answers. I called the Billing office. They said my Customer Service place should be able to explain the EOBs. ORLY? They then said they’d send a “detailed” invoice by mail only. No discussion on the phone of the various line items that I see on my EOB from the hospital visit. That detailed invoice had a lot of meds on it (all scanned each time off my wrist band: I wasn’t questioning those), but collapsed the staff tasks & time into a single line item that said Professional Services. Transparent billing, huh? No independent contracting entities listed.

The Billing office said they could initiate an internal review of the tasks to determine if they were necessary. Guess what the response was from the self-examination of invoicing? “It’s all correct as coded.” And no evidence was provided for what any of it was…I stopped there having spent hours trying to understand it. I’m better off spending business hours earning money to pay the fucking premiums that have grown over 10x in 10yrs

^^^ this is the admin bloat that makes our healthcare stupid & expensive

And there is zero competition to provide an alternative because the industry is making a shitton of money despite the low medical staffing that we all read about


And they were happy to set up a payment plan…and there they are texting me now reminding me about it…their ears must be red

[rod9301]

One point:

In the us,i had a minor procedure, and there was a doctor, a nurse and another person in the room

In France, similar stuff, and just the doctor in the room, doing the procedure.

A medical practice in France had only one receptionist. In the medical group in Tahoe, receptionists, nurses, a lot more admin people.

Same with schools. In France, the small elementary school my daughter goes to has no admin personnel at all. The principal teaches as well

In the charter school in Tahoe, principal and 3 admin, about the same size school.

No wonder medical care and education is so much more expensive in the us

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[old goat]

As Rod points out, one of the big expenses in medical care is the expense of coding, billing, and collecting. If all providers are paid salaries, medical systems are paid capitation (they get so much per enrolled member per year), AND only working providers (not administrators with MD after their names) made decisions on what care is justified, we would see some savings. But we would still be more expensive than the rest of the world.

[jono]

I have an odd billing question for the insurance experts, hopefully not a repeat but I've never seen this: insurance trying to give me the Bobby Stainless Maggot Special.

My wife got an EOB from a fairly major procedure recently and about half of the many, many lines show that the providers billed less than our insurance is saying we have to pay. They're telling us that we have to pay the "Discounted rate" column no matter what, so, for example, $197 as "discounted" rather than the billed amount of $40.

Allegedly this is because the bill is based on max allowable (reasons unknown) so the insurance company is obligated to pay the max allowed amount whether it's billed or not--this despite the fact that "amt we paid" is zero, so they're not the one paying anyway.

To me it looks like someone just plugged in numbers until their total matched the providers' and the electronic system would pass it. The only person who calls back leans pretty hard on "this EOB was processed correctly," so it sounds like she agrees, but won't say so. The absurdity has passed annoying and it's kind of funny at this point. (Maybe that's the real purpose of HSA's.)

AITAH? Is there really a way that insurance contracts can raise the price and force the patient to pay it? Should we even be talking to insurance or just calling the hospital and proposing the most favorable number I can come up with and telling them to show their work if they want to object? So far everyone agrees that the EOB makes no sense, so it feels like they ought to be agreeable to something.

[El Chupacabra]

Google balance billing, and see if it's legal in your state.

[jono]

Google balance billing, and see if it's legal in your state.

No balance billing in this case, or so they claim. The insurance people just say they're making us pay the max allowable for each of those items.

There's a deductible to be hit somewhere in there, but it's mostly not their money, so maybe they're playing along. But it seems like the EOB should have to explain or what's the point? I may just ring the state insurance commission and see what they say.

[AK47bp]

Toss the EOB and wait for the actual bill.

[skaredshtles]

In today's installment of "How Fucking Stupid is the U.S. Healthcare System"...

[jono]

Toss the EOB and wait for the actual bill.

Tried that first, but the bill had the same number on it as the EOB‐-but only at the end. So my complaint might be that there's no valid explanation or it might be that there are discrepancies. I just have no way to know which.

[AK47bp]

Is this employer provider insurance? If so check if the company offers a Benefit Advocate service. They can research and dispute for you if needed.