patrick.net

The doctors are the easy fall guys for the crimes of the hospitals, the insurance companies and the government.

The doctors interface directly face to face with the patients. The hospital administrators and insurance sharks never see the patients, and aren't even identified as being involved with the system even if they do, so they know that the patients will lash out at the first thing in their line of sight, the providers. The admins and insurance companies work hard to keep it that way by trying to keep all the patients blaming the providers for everything while the admins and bureaucrats get away with murder.

Blame shifting, cost shifting, creating bureaucratic nightmares and always being a changing, moving target are the insurance companies' lingua franca.

Pharmaceutical companies, as well. They've done pretty well fleecing the insurance system.

turtledove says

I will never understand why that shit wasn't the primary focus of the effort to make healthcare affordable.

Well, they don't want to cut prices to what it's really worth: revenues in the healthcare sector would be cut in half and a lot jobs would be destroyed.
Armies of lobbyists fighting it out.
First step: stop its progress.

turtledove says

single payer

What's wrong with a single payer system? Single payer literally means that there is one transaction clearing house that performs all payments thus both streamlining billing and accounting, which eliminates billions of dollars of waste, and establishes the same price for the same procedure by the same provider for all patients. The later creates a health care market, which does not exist in any form in the current system. A health care market can only exist with transparent pricing, and that can only exist with single payer.

Single payer is not Medicare for all, which isn't a bad thing anyway. Medicare is a multipayer system in which many different health insurance providers still control payments and pricing is never transparent or consistent. Single payer is an essential reform. Without it our health care system can never be fixed.

Dan8267 says

What's wrong with a single payer system? Single payer literally means that there is one transaction clearing house that performs all payments thus both streamlining billing and accounting, which eliminates billions of dollars of waste, and establishes the same price for the same procedure by the same provider for all patients.

Yah - run by the government. They are AWESOME at streamlining and efficiency with those high union wages and pensions!

Private health insurance margins are about 5% on average. Huge volume for sure, but does anyone really think our massive government bureaucracy can run ANYTHING at 5 cents on the dollar?

socal2 says

They are AWESOME at streamlining and efficiency with those high union wages and pensions!

They have unions in other countries too, and the bottom line is that healthcare costs there are generally around half what your AWESOME, streamlined, efficient capitalists are extorting from you.

Of course it never helps to have a more corrupted government. But that's a different question.

turtledove says

will never understand why that shit wasn't the primary focus of the effort to make healthcare affordable

Because Democrats don't know how to control costs.

Heraclitusstudent says

Healthcare is a simple business (or should be). The question is how do you keep costs in check.

In a capitalist system there is only one thing that does that: competition.

But as far as healthcare is concerned there are good reasons why competition won't work:

- because no one shops around different hospital to see what cares cost.

- because insurances have little incentives to question the cares provided, rather than just passing it on to you.

- because when you choose an insurance, you're best bet is always to pick an expensive good coverage. The last thing you want is to have to sell the house to save your life.

So how do you keep costs down?

Upfront pricing. It works in LASIK. You see pricing advertised. If people could shop around for MRI's and other things that aren't time sensitive the pricing on that stuff would drop like the proverbial rock.

socal2 says

Dan8267 says

What's wrong with a single payer system? Single payer literally means that there is one transaction clearing house that performs all payments thus both streamlining billing and accounting, which eliminates billions of dollars of waste, and establishes the same price for the same procedure by the same provider for all patients.

Yah - run by the government.

Should be, but not necessarily. In any case, a single payer system can and should be a completely automated system. It's run by computers, not politicians.

And government is as good or as bad as the people in it. If you don't want bad government, don't vote Republicans. Conservatives cannot run a government effectively. They've proven that time and time again.

socal2 says

Private health insurance margins are about 5% on average. Huge volume for sure, but does anyone really think our massive government bureaucracy can run ANYTHING at 5 cents on the dollar?

The Truth About Health Insurance Company Profits: They're Excessive

One penny of the health care dollar is worth $347 billion over 10 years ending in 2019. That one penny would pay for more than one-third of the entire cost of the health reform program.

In response to a memo that Health Care for America Now (HCAN) sent to news outlets yesterday, AHIP attacked HCAN for pointing out the insurance industry's misleading use of statistics.

If given the fiat, a reasonable budget of $1 billion, and 3 years, I personally could establish a single payer system that eliminates the waste of overhead, establishes a transparent health care market, and protects the rights of patients and doctors. And the savings would be orders of magnitude more than the costs of the status quo. The problem is political, not technical.

turtledove says

1) After all the withholding was taken out of the paycheck, we were left with about 40% to live off of (housing, food, and gas made CA look cheap -- don't forget VAT on everything, so Ireland isn't exactly an inexpensive place to live).

What withholding drove the tax rate up to 60%? Especially since the rate is 20% up to something like 60k euro for a married couple then 40% after that. It's a PAYE system so what could possibly be withheld beyond that?

zzyzzx says

Upfront pricing. It works in LASIK. You see pricing advertised. If people could shop around for MRI's and other things that aren't time sensitive the pricing on that stuff would drop like the proverbial rock.

People don't pay for MRI. The insurance pays. People will not pay less for insurance if they spend time and energy shopping around.
See, all the normal capitalist incentives do not apply because of the way the system is designed, and because people simply do not have the medical knowledge to know how to make trade-offs between some cares/risks and the associated price.

zzyzzx says

Upfront pricing. It works in LASIK. You see pricing advertised. If people could shop around for MRI's and other things that aren't time sensitive the pricing on that stuff would drop like the proverbial rock.

This has been discredited many times on patnet already but people keep posting it anyway. .

Dan8267 says

What's wrong with a single payer system?

As long as patients pay up front and handle the government claims filing themselves, you would probably see more support from the medical community, at least. I am so sick and tired of having to hire people to do nothing but chase down bills with insurance companies. When we first started our practice, we literally went months making zero money despite the fact that we were busy. It's not right to put doctors in the position of performing a service and then waiting months to get paid. No other industry would put up with that. We have bills, too.

As for support from the general population, the government could start by showing that it is capable of self audit among the services it currently mismanages. They could try demonstrating how they run a tight ship on a program that's already been forced down our throats. You must admit it's a little difficult to trust our government with such a big job when we have the VA as a shining example of government-healthcare-gone-wrong. I don't want to read about how our new US Health Administration is found paying $800 for replacement CPAP tubing or some other such nonsense. I don't want to read about how we have heads of departments making 20 times the median income and getting perks that would shame a guy like Trump... all the while people are dropping dead because they cannot get treatments authorized before the cancer metastasizes. If the powers that be want to increase everyone's taxes to cover such a venture, they have to prove that they are capable of managing the taxpayer's money. Every time they have been given this responsibility, they seem to fail miserably. I don't want to read about another broken, bloated program that I pay for.

turtledove says

As long as patients pay up front and handle the government claims filing themselves

Single payer would make medical default far less costly for three reasons.
1. The emergency room would not be used for non-emergency situations savings billions of dollars a year.
2. People will be able to compare prices and choose affordable care. Medical providers will have to compete for the first time in history.
3. Tracking defaults will be centralized and more effective.

Has anybody ever wondered in the insurance companies contract with labs and facilities they wholly or partially own via subsidiaries or whatever?

bob2356 says

zzyzzx says

Upfront pricing. It works in LASIK. You see pricing advertised. If people could shop around for MRI's and other things that aren't time sensitive the pricing on that stuff would drop like the proverbial rock.

This has been discredited many times on patnet already but people keep posting it anyway. .

What? This is a fact, nothing to discredit here. You can argue if and how it would work equally well with different procedures, but there's no doubt about the fact that these procedures are much cheaper because of the free market, same goes for invisalign. In fact centers for imaging not affiliated with doctors or their interpretation have been increasing in numbers and they are usually much cheaper than going to a doctor or hospital. Pocket ultrasound machines will likely be so affordable in a couple of years that doctors, skilled nurses or technicians could offer open market services where they come to your place for smaller routine ultrasounds for the total price of today's copay! That is, if regulation and cronyism will not block innovation. Shetty has been doing heart surgery in India for less than 2k for a while now with similar outcomes.

thunderlips11 says

Has anybody ever wondered in the insurance companies contract with labs and facilities they wholly or partially own via subsidiaries or whatever?

Don't know but it is certainly possible that this is going on. However functional docs that don't take insurance but do more elaborate testing for people who want to figure out infections and deficiencies have partnered with labs to basically get huge discount on testing because they bring in more business so that although the patient has to pay for the visit in full (and may only get up to 20% back from their insurance after submitting the superbill) they almost come out equal because they save a lot of money on the testing (the labs still bill the insurance but with cheaper prices) and get better diagnostic services, esp. if they want to tackle the root cause of their symptoms and not just cover up the symptoms with quick medication.

bob2356 says

What withholding drove the tax rate up to 60%? Especially since the rate is 20% up to something like 60k euro for a married couple then 40% after that. It's a PAYE system so what could possibly be withheld beyond that?

Levies that were instituted after the meltdown. Also permanent health insurance... and some pension thing that we had no choice about. It might have been a little less than 60%, but it was close. I'd have to pull an old pay stub to tell you an exact amount.

Heraclitusstudent says

But hey... they get the job done for a fraction of the costs here. I think that's what most people want.

there it is again - thinking for other people. indians should be called native americans - it's what they want, and so it will be.

the hallmark of a liberal.

turtledove says

bob2356 says

What withholding drove the tax rate up to 60%? Especially since the rate is 20% up to something like 60k euro for a married couple then 40% after that. It's a PAYE system so what could possibly be withheld beyond that?

Levies that were instituted after the meltdown. Also permanent health insurance... and some pension thing that we had no choice about. It might have been a little less than 60%, but it was close. I'd have to pull an old pay stub to tell you an exact amount.

Levies of 40% up to 60k then 20% after that? What was that? Health contribution is 4%, PRSI is 4% but you have a big exemption before you take it out so the rate is much lower. There is also tax credits, what we call deductions on the gross.

turtledove says

JMHO, but if you are going to lodge a verbal assault against CIC, you should remove him from ignore so that he has the opportunity to respond. In the spirit of fair play.... and I'm kind of bored and could use the entertainment. Cheers!

Evidently CIC was very upset at this. He threw a little tantrum. He's so easy to emotionally manipulate.

http://www.theamericanmirror.com/mook-spooked-hillary-manager-predicts-trump-will-win-presidency-if-nominated/

Hillary manager predicts Trump will win presidency if nominated!

Hillary Clinton’s campaign manager predicts in an email that Donald Trump will become president if he wins the Republican nomination.

“If Donald Trump takes the Republican nomination, our party will lose more than the presidency,” Robby Mook writes to supporters.

It's hard to tell whether or not The American Mirror is a conservative newspaper or an absurd parody of one. And that says everything you need to know about conservative media.

bob2356 says

Levies of 40% up to 60k then 20% after that? What was that? Health contribution is 4%, PRSI is 4% but you have a big exemption before you take it out so the rate is much lower. There is also tax credits, what we call deductions on the gross.

That is incorrect. They passed emergency levies to bail out their banks. I know. I was there. Our paycheck was cut overnight. These were additional levies that were instituted after the meltdown. Levies in addition to the base tax rate.

Also, the "permanent health insurance" isn't what it sounds like. It's not "health insurance" as we think of it. It's disability insurance to put it in our terms. That contribution was in addition to the regular tax rate and the emergency levies...

turtledove says

That is incorrect. They passed emergency levies to bail out their banks. I know. I was there. Our paycheck was cut overnight.

So you should have no trouble telling us how the tax rate was 60%. I know the ins and outs of the tax system in every country i've lived in as well as a number of countries I haven't since I worked as a liason for an international recruiter and had to compare tax systems for people. I've never heard of anyone actually paying 60%. Even sweden, the highest tax country in the world, with a 48% nominal rate has a lower effective rate after deductions.

turtledove says

Generalists in this country are lucky to make $175k

Aren't those numbers based on surveys where physicians self report? Or is there some other way they come up with the averages.

How do they come up with these numbers. Every time I've discussed this with my relatives who are primary care physicians, they are nearly all at the 0.1% of their field in earnings and it is quite a bit higher than 175K except for one relative in Massachusetts. The other 3 reported making over 400K-1 million.

bob2356 says

This has been discredited

How has it been discredited?

mell says

Don't know but it is certainly possible that this is going on. However functional docs that don't take insurance but do more elaborate testing for people who want to figure out infections and deficiencies have partnered with labs to basically get huge discount on testing because they bring in more business so that although the patient has to pay for the visit in full (and may only get up to 20% back from their insurance after submitting the superbill)

But this has been 'discredited' without ever citing a single link ever

mell says

Shetty has been doing heart surgery in India for less than 2k for a while now with similar outcomes.

except they don't properly test their blood used in transfusions for presence of the HIV virus. Other than that the surgeons he employs are more skilled by 40 than their average 60 year old counterpart in the United States.

bob2356 says

So you should have no trouble telling us how the tax rate was 60%.

I never said it was a 60% tax rate. I said that after everything was taken out of the paycheck, we were left with 40%. Then, I explained to you what those other items included. Whether it's a "tax" a "special levy" or "permanent health insurance," it's compulsory. The withholding affects one's net pay. When all was said and done, we were left with roughly 40%. You can split hairs all you want, but that's just a fact.

Aren't they the biggest, along with the pharmaceutical, hospital and medical device manufacturers

turtledove says

I am so sick and tired of having to hire people to do nothing but chase down bills with insurance companies.

The idea of taking insurance for anything other than catastrophic medical events is obnoxious. It's even more obnoxious that people expect to have low deductible insurance to get seen for a common cold.

The most obnoxious thing is having to see 30 patients a day because the reimbursements are low from government based insurance options; however you still have to spend as much time with a medicare or medicaid pt as you do with someone with private insurance.

Government based insurance might not be as much of a problem for an RE as it is for primary care though.

bob2356 says

discredited many times on patnet alread

Not easy but doable; easier for doctors in a DPC or concierge model to negotiate rates though.

http://www.forbes.com/sites/kateashford/2014/10/31/how-much-mri-cost/2/#317f07eb45a1

There's only one reform that counts: A mandatory set fee schedule for medical costs. Including for Rx. It's the only way to do it, price controls, revamped annually.

Otherwise it's too Opaque, and the more costly and serious the problem, the more opaque it will be.

MMR says

Government based insurance might not be as much of a problem for an RE as it is for primary care though.

Though RE services are typically covered only through diagnosis... If it goes the way of Quebec or some Euro countries, IVF coverage could be the way of the future if our country becomes concerned that the population is declining. It seems to be a go-to move when governments get worried that people aren't replacing themselves fast enough to cover the social services of the aging population. Social engineering reasons aside, there are some reasons why it should be covered, and I'm surprised that insurance companies haven't jumped on the bandwagon to manage costs. For example, we have a woman who has had five molar pregnancies over the last fourteen years. The last one required chemotherapy. She could have died. These people don't have the resources for IVF with genetic testing to select healthy males for transfer, thus removing the risk. We're talking almost $20,000. We sent letters to her insurance trying to get them to cover the treatment to help these people out. Denied, denied, denied... despite the fact that her insurance company has probably shelled out many, many thousands of dollars treating these molar pregnancies. Her insurance refuses to see the treatment as necessary. I was able to come up with a solution to help these folks. I got her story on a network TV show, so we were able to get all the parties to waive their fees in exchange for the national coverage. Obviously, it was easy for us to waive our fees, but we didn't have the power to waive fees for all the other cooks in the kitchen. But once they saw that they would get television coverage, they were very helpful. So, we got the embryology lab, the surgery center, and two genetics' labs to waive their fees as well. Now, I just have to make nice with some drug reps and we'll be all set. But these kinds of gymnastics shouldn't be necessary to help people like this when they pay good money every month for health insurance.

MMR says

The idea of taking insurance for anything other than catastrophic medical events is obnoxious. It's even more obnoxious that people expect to have low deductible insurance to get seen for a common cold.

The most obnoxious thing is having to see 30 patients a day because the reimbursements are low from government based insurance options; however you still have to spend as much time with a medicare or medicaid pt as you do with someone with private insurance.

I couldn't agree more. It's absurd that you have to pay a biller to chase $100 from an insurance company. All the letters, all the hours on hold.... It's such an unbelievable waste of resources, it isn't funny. And they just make up rules as we go along. Just today, I had a patient who supposedly has fertility coverage with Aetna. We requested a prior auth. several weeks before the cycle started. During that phone call, the Aetna person said that we weren't listed in their women's health directory. So, I took a screen shot that has us listed in the Aetna provider directory under RE. "That's funny, our name is listed right here under 'reproductive endocrinology.'" The Aetna person said that they would fix it and she would probably be able to get the prior authorization backdated if the cycle had to start before the authorization was official. So, I explained this to the patients and left it up to them whether they wanted to go ahead and start and hope that Aetna does what they say they are going to do.... or wait until they actually have a prior authorization. They decided to go forward with treatment. They went through their cycle and then the patients submitted their claim to the insurance company.

The couple got a letter back saying that it was denied because they never got a prior authorization. Here's the best part. Aetna sent a letter to the patient telling them that they (the patients) don't have to pay the bill. So, I wrote the patient back telling them that I authorize them NOT to pay their Aetna premiums. WTF! Does Aetna honestly think that we are obligated to provide services and not get paid? Of course, I collected up front from the patient and told them they could submit their bills directly to their insurance company for reimbursement... So, we're not out anything... but the very fact that Aetna inserted this idea in the patient's head that they didn't really have to pay even though the service had already been provided really pisses me off. It's not like I can repossess the embryos! The fact that they are acting like they need months to secure a prior authorization is ridiculous. For surgeries, I have instant authorizations. What's so special about IVF? I'll tell you. The insurance companies just don't want to pay for it even though they lure people in with a promise that they will. It's a trap. Just another example of hours wasted dealing with insurance companies.

turtledove says

For example, we have a woman who has had five molar pregnancies over the last fourteen years. The last one required chemotherapy. She could have died. These people don't have the resources for IVF with genetic testing to select healthy males for transfer, thus removing the risk. We're talking almost $20,000. We sent letters to her insurance trying to get them to cover the treatment to help these people out. Denied, denied, denied... despite the fact that her insurance company has probably shelled out many, many thousands of dollars treating these molar pregnancies

That is really mind-boggling. Did you guys ever manage to recover that money? PGD testing definitely costs money and set my wife and I back a substantial sum, but I feel like it is worth it. Makes me wonder if the previous two transfers were due to poor embryo quality.

Probably requires "creative diagnosis" to get reimbursed; molar pregnancies, on the other hand, are probably cut and dried ICD-10 diagnoses that most insurances cover since they are serious and potentially life-threatening and can greatly increase the risk of having choriocarcinoma.

turtledove says

The couple got a letter back saying that it was denied because they never got a prior authorization. Here's the best part. Aetna sent a letter to the patient telling them that they (the patients) don't have to pay the bill.

Prior authorizations, in general are difficult to obtain and frustrating. Collecting upfront is the best policy and the policy of most RE practices. I would only say that if insurance coverage ever becomes the norm, that RE docs should reduce the prices of procedures to get people in the door instead of relying on insurance.

turtledove says

It's not like I can repossess the embryos

exactly

turtledove says

What's so special about IVF? I'll tell you. The insurance companies just don't want to pay for it even though they lure people in with a promise that they will. It's a trap. Just another example of hours wasted dealing with insurance companies.

IVF is extremely expensive out of pocket; to the extent that you can bill patients upfront and have them send a claim to be reimbursed by their insurance companies, that's what should be done and it's what the majority of RE practices I have experienced do.

I would rather see more people have to do that. At least even if their insurance is paying 80%, the process of having to do that gives the patient some 'skin in the game'.

MMR says

Did you guys ever manage to recover that money?

No we gave up with the insurance company. We have worked with The Doctors in the past, so I pitched the idea to one of the producers and she thought it was a great story. Typically, when they do a story on you, the clinic involved gives the service away for free. But it's a fair trade, as you are featured on national television. I had to get the patient to go along with it. They are kind of shy... but it was the best solution I could offer to their problem. Obviously, they decided to just put it all out there for the chance at having a family.

The couple is in a holding pattern right now (BCPs) while we wait the four weeks for the results of the a genetic test on the mother. We want to do gene sequencing on her to see if she has a mutation/deletion at 19q13.42. If so, this could explain why she's been so predisposed to molar pregnancy. The good news if this turns out to be the case is that we could do PGD instead of PGS to look for a specific mutation on affected embryos, leaving open the possibility that she may have a female child. If she shows no deletion/mutation at the locus, at least we ruled that out... and we're left with just looking for 46xy embryos for transfer, which can be achieved with PGS. Either way, it's a reportable case, so we're excited about that aspect, as well. Her prognosis is quite good. This should have a very happy ending.

Hillary already paid off a ton of people for her nomination. The dog and pony show they call "Democratic nomination" is for gullible audience.

FortWayne says

Hillary already paid off a ton of people for her nomination. The dog and pony show they call "Democratic nomination" is for gullible audience.

That argument would be a lot more convincing if she hadn't done the same thing in 2008.