[kenberg]

luke warm, on Sep 24 2010, 05:20 PM, said:

kenberg, on Sep 24 2010, 07:29 AM, said:

~~Maybe they will send a bill. Maybe they won't. Maybe it was all paid for. Maybe we have been reported to some credit agency as deadbeats. Who knows? ~~

assuming your doctor: 1) takes medicare and 2) is in your other carrier's network, probably it was all paid for... your doctor will only be paid the contracted rate from both medicare and your supplemental... medicare will pay 80% of their fee schedule... the amount that is left will be paid at 80% of your supplemental's fee schedule (max), after deductible... but if the amount paid by medicare totals more than or as much as 80% of your supplemental's fee schedule, there is nothing due

the provider has to accept that payment (if in network) so you'd owe nothing

Yes, that is the expected outcome. Usually we get something explaining who has been paid what for what. This time, the answer seems to be just blowing in the wind.
So I expect that I owe nothing. I would like the usual documentation saying that this is so. Of course I'll live without it but I prefer them to act as if they know what they are doing.


Here is a more recent issue. Everything was fine but it goes to (the lack of) market forces. Apologies in advance for the gross details.
I was at the ophthalmologist for my usual exam. I had developed what I guess is called a skin tag above my eye. I am not all that vain but it was sort of ugly.
Doc: Would you like me to remove that?
Me: You can:
Doc: Yes.
Me:OK

Including the the injection by the nurse of something to numb it, the time for removal with a pair of snips totaled maybe three minutes. Maybe less.


As you note, the doc must accept the limitation imposed by medicare and the insurance so he had to settle for the limited amount of $710. If I were paying it I might have a. first asked the price and b. shopped around.


Added: As mentioned earlier, I am ok with some of my tax dollars helping a sick kid from a poor family. If my tax dollars are helping poor people get surgery that I really regard as elective, I am not so happy. At a different time of my life, I would not have considered $700, or for that matter $100, for such a procedure. Maybe $10. It's not what you call life threatening. Now I can afford it, and if I choose to blow $700 in that way, it's my business. Providing it's my $700.

[awm]

There are a lot of problems with privately run health insurance. Some of them:

(1) Each insurer has their own policies, paperwork, and their own bureaucracy to handle claims. This is pretty inefficient and causes problems for both doctors and patients. Obviously things would be much simpler if there was a single unified system.

(2) Insurance works mostly via economies of scale. Lots of people chip in a small amount of money, and then the few people who get seriously sick can be covered. This applies both to public and private medical systems. However, the obvious point here is that a large health insurance organization has quite a bit more leverage than a small one. The insurance company also typically negotiates with hospitals and doctors, and again a large company (which controls a lot of paying patients by deciding which doctors/hospitals to allow its customers to visit in network) has a lot of leverage. The upshot is that a government system with everyone involved has maximum size and thus more leverage than any private insurer. The situation also means that it's almost impossible for a new "small insurance business" with good ideas to enter the marketplace (very different from other endeavors where small companies with good ideas "taking over" is a big part of the efficiency of a free market). Note that in many areas in the USA there is effectively a single private insurer anyway for this reason.

(3) Insurance companies make money by insuring healthy people and not insuring sick people. This means it's cost-efficient for them to kick people off the insurance as soon as they get sick, which obviously is horrible for anyone who does get sick. Of course, they can't just do this arbitrarily (breach of contract etc) but they find that it's often more efficient to hire bureaucrats who can find loopholes allowing them to deny claims (i.e. someone filled out a form wrong, didn't disclose having the flu as a kid, etc) rather than actually pay the claims.

(4) Health insurance is really quite complicated, and a lot of people don't really understand what they are getting when they sign up for insurance. This creates a big market inefficiency when people purchase "junk insurance" by accident by not reading the small print. A single-payer system obviously doesn't have this issue.

(5) It's not the case that people who get sick and don't have health care or sufficient money to pay for care just die off. No one wants this to happen, and doctors/hospitals are legally obligated to help people in need even when they are unable to pay. The upshot is (especially for young healthy people) that it's more efficient to refuse to buy insurance and hope to get lucky, then fall back on the hospitals which "can't refuse emergency care" if they get sick. A government program can simply require these people to pay some money for insurance (take it out of their taxes) so that everyone is insured.

(6) Because insurance in the USA is often local (insurers don't always have nationwide networks of doctors) and also primarily through the employer, it creates a disincentive for people to move from one state to another or to change jobs. For example, if I have a sick family member and switch jobs, my new insurer may refuse to take them (pre-existing condition). If I decide to start my own business I will lose my insurance (through employer) and insurance on the individual market is much more expensive (no economies of scale). These problems reduce mobility, and can potentially cost the USA economy billions of dollars because people are unable to move to "better jobs" because of health-insurance related issues.

[Winstonm]

I cannot imagine how it would not MONSTROUSLY lower the overhead costs of health care administration if eveyone who walked through the door was automatically known to be covered and there was only one source to bill (single payer).

[PassedOut]

Winstonm, on Sep 24 2010, 07:49 PM, said:

I cannot imagine how it would not MONSTROUSLY lower the overhead costs of health care administration if eveyone who walked through the door was automatically known to be covered and there was only one source to bill (single payer).

True, but that is much too sensible to get through congress.

[mike777]

AGain no one brings up innovation......cheap is good......but lets have incentives for progress...no one is happy with 1990 levels of medicine.........as justice.........equality.....


but that is the discussion........

[kenberg]

Regarding this issue of uninsured and emergency roo treatment, let me pose a problem. I start with my childhood.

When I was 5, I became ill, I wasn't getting better, my mother called the doc. He came to the house, diagnosed pneumonia, treated me, made a couple more visits, I got well. No insurance, charges were within the budget of my not particularly well off parents.

On to today. A poor kid gets sick. The illness has not yet been diagnosed. Maybe serious, maybe not. No insurance. If the parents take him to the emergency room, what is the legal obligation of the hospital? I understand they cannot turn away someone who is bleeding to death, but where is the line? Suppose the kid, instead of an illness, has a so-so case of poison ivy. Must the hospital treat it even if the patient cannot pay? I assume not, but I don't know.

I would like to understand what the situation is now, and what it will be under the new law. Adam, in his post above, says insurance is complicated and often not understood. He has that right, I could give many examples. But it's not just insurance. I really have no clear idea of what the law now requires hospitals to treat if an uninsured patient cannot pay, and I have no clear idea of what will be subsidized under the new law.

[luke warm]

awm, on Sep 24 2010, 07:01 PM, said:

~~ For example, if I have a sick family member and switch jobs, my new insurer may refuse to take them (pre-existing condition). ~~

they can't be refused, and there is no preX so long as the 'new' insurance is obtained within 63 days of the old's termination... aside from that, i agree that a single payer system is (or could be, depending on how efficient the gov't runs it) workable... perhaps expand medicare to include everyone with a job... charge a payroll tax (fairest, same % for everyone) or a set monthly premium to everyone and have it payroll deducted

you could also write into law that the system cannot, is not allowed, to run a deficit... the danger is quality of care if or when specialists decide to leave, because such a system cannot work unless it is mandated that *all* providers and facilities accept be in network

kenberg, on Sep 25 2010, 07:46 AM, said:

On to today. A poor kid gets sick. The illness has not yet been diagnosed. Maybe serious, maybe not. No insurance. If the parents take him to the emergency room, what is the legal obligation of the hospital? I understand they cannot turn away someone who is bleeding to death, but where is the line? Suppose the kid, instead of an illness, has a so-so case of poison ivy. Must the hospital  treat it even if the patient cannot pay? I assume not, but I don't know.

the hospital is required to stabilize the patient and then transport, or have transported, to a charity or state-run facility, unless to move him would be a threat to life or limb... if s/he can't be moved, and if s/he can't pay, the hospital eats the loss (defined as, we with insurance pay the costs in the form of higher premiums)... in the case of poison ivy, the kid would be given some salve and sent on his way

[blackshoe]

I remember reading about an incident in Chicago some years ago. Some gang member got shot, and somebody dumped him on the sidewalk outside the emergency room of Ravenswood Hospital. The hospital took the position that if he could make it to ER on his own, they'd treat him, otherwise not. So no one went out to treat him or bring him inside. I remember thinking that things in that part of Chicago must have changed quite a bit since I was born in that hospital.

[kenberg]

The times they are a changin

[kenberg]

luke warm, on Sep 25 2010, 07:47 AM, said:

kenberg, on Sep 25 2010, 07:46 AM, said:

On to today. A poor kid gets sick. The illness has not yet been diagnosed. Maybe serious, maybe not. No insurance. If the parents take him to the emergency room, what is the legal obligation of the hospital? I understand they cannot turn away someone who is bleeding to death, but where is the line? Suppose the kid, instead of an illness, has a so-so case of poison ivy. Must the hospital  treat it even if the patient cannot pay? I assume not, but I don't know.

the hospital is required to stabilize the patient and then transport, or have transported, to a charity or state-run facility, unless to move him would be a threat to life or limb... if s/he can't be moved, and if s/he can't pay, the hospital eats the loss (defined as, we with insurance pay the costs in the form of higher premiums)... in the case of poison ivy, the kid would be given some salve and sent on his way

I am left with some unknowns here.

Say the kid has been unusually listless and has a mild fever.
Stabilization is not an issue. He is stable, but clearly he is not entirely healthy, and exactly how unhealthy is not immediately clear. The parents are uninsured and have no extra cash. Eg, they are as hard up as I was as a graduate student. What now?


Here is one of the things that I am trying to get at: There have often been two charges leveled at the health bill. One is that it will cost a lot of money. The other is that it is unneeded because the sick are already taken care of in emergency rooms. These two statements work against each other and I am trying a thought experiment to see which statement seems to apply with this sick kid. If we treat him under the current system then the cost need not increase with the health bill. If we do not treat him, well, then, there seems to be a need.


The poison ivy example is also intended to get at an issue. When I was 16 I had it so bad that eating was confined to sipping broth through a straw and I could barely do that (it was the result of another teenage stupidity, I'll skip the details). But usually when I got poison ivy, which I often did, I got some calamine lotion, applied it, and waited for it to go away. The cost was minimal. If the kid goes into an emergency room he may, as you say, be given some lotion and sent on his way. But at what cost to whom? If he can get a quick treatment at the ER then this is probably an excessive expense. But it's an expense that is perhaps already there.

[luke warm]

kenberg, on Sep 26 2010, 06:37 AM, said:

Say the kid has been unusually listless and has a mild fever.
Stabilization is not an issue. He is stable, but clearly he is not entirely healthy, and exactly how unhealthy is not immediately clear. The parents are uninsured and have no extra cash. Eg, they are as hard up as I was as a graduate student. What now?

in general, the er docs will decide whether or not it's safe to have the patient transported to a state hospital... if the diagnosis allows transport, that's the call... if not, s/he stays (and may even be admitted to the hospital until transport is feasible)

Quote

Here is one of the things that I am trying to get at: There have often been two charges leveled at the health bill. One is that it will cost a lot of money. The other is that it is unneeded because the sick are already taken care of in emergency rooms. These two statements work against each other and I am trying a thought experiment to see which statement seems to apply with this sick kid. If we treat him under the current system then the cost need not increase with the health bill. If we do not treat him, well, then, there seems to be a need.

it comes down to who bears the cost and whether that cost will increase, i imagine... presently, all those who pay for health care bear the cost... under this bill, all taxpayers (supposedly) will bear it... the cost increase is due to the projected numbers of those seeking care being much higher than at present... i understand that cbo projects that this bill will result in an eventual decrease in the deficit... some believe that, others don't

Quote

But usually when I got poison ivy, which I often did, I got some calamine lotion, applied it, and waited for it to go away. The cost was minimal. If the kid goes into an emergency room he may, as you say, be given some lotion and sent on his way. But at what cost to whom? If he can get a quick treatment at the ER then this is probably an excessive expense. But it's an expense that is perhaps already there.

yes, probably there are millions of instances where er treatment was not warranted but were performed... and yes, we with insurance paid for it down the line... those opposed to this bill believe, rightly imo, that the instances of er (and other, such as primary and/or specialist) visits will dramatically increase... the cost will be spread amongst a larger group, true, but the costs themselves will probably more than offset this

i'll give you just one example... all group plans aren't the same, but let's take a typical one where dependent children over 21 are not covered unless they are full time students... in the student cases, coverage continues until age 24... now, this plan does away with this provision by covering these children until age 26... even with a relatively small group, this results in a cost increase in the millions... couple this with the preX provision and costs soar

[PassedOut]

kenberg, on Sep 26 2010, 06:37 AM, said:

Here is one of the things that I am trying to get at: There have often been two charges leveled at the health bill. One is that it will cost a lot of money. The other is that it is unneeded because the sick are already taken care of in emergency rooms. These two statements work against each other and I am trying a thought experiment to see which statement seems to apply with this sick kid. If we treat him under the current system then the cost need not increase with the health bill. If we do not treat him, well, then, there seems to be a need.

Very plainly stated.

Health reform will bring millions of new people into the pool, and that will be bringing additional money into the system. The only way that extending coverage to these additional people will raise health care costs is (1) if it is not true that those folks already receive care and (2) if those unmet needs cost more than the new money coming in.

In my opinion, we need to focus on increasing efficiency in the healthcare system, on eliminating the need for unnecessary defensive medicine, and on doing away with excessive end-of-life expenditures. Not on saving money by denying folks the care they need.

[blackshoe]

PassedOut, on Sep 26 2010, 11:15 AM, said:

doing away with excessive end-of-life expenditures.

What, precisely, does this mean?

[PassedOut]

blackshoe, on Sep 26 2010, 10:20 AM, said:

PassedOut, on Sep 26 2010, 11:15 AM, said:

doing away with excessive end-of-life expenditures.

What, precisely, does this mean?

One fourth of all Medicare costs are for medical bills incurred during the last year of life.

At the Mayo Clinic (in the interest of full disclosure, I should mention that I take my family members to the Mayo Clinic for any significant medical problems), doctors monitor geriatric patients closely and provide wonderful care, but avoid expensive treatments that offer little or no benefit to the patient. At other hospitals (UCLA Medical, for example) the philosophy is the opposite: try anything, no matter how expensive, to try to prolong a patient's life for even a short time.

Not surprisingly, it costs twice as much per patient to provide end-of-life care at UCLA than it does at Mayo. Using the Mayo approach across the board would save $700 billion dollars per year.

Not that all of the extra money spent at UCLA is a waste. Once in a while those expenditures produce some extra, good-quality life. More often they prolong the agony of dying person, sometimes against the wishes of that person.

In my opinion, Medicare recipients who want don't-let-me-die-no-matter-how-expensive care should have to buy a separate insurance policy to cover anything beyond the Mayo approach (or pay for it out-of-pocket).

[blackshoe]

Okay. What I don't want to see is a bureaucratic "we can't give you treatment X because our policy (or your insurer's policy) won't let us" approach.

[Winstonm]

blackshoe, on Sep 26 2010, 05:09 PM, said:

Okay. What I don't want to see is a bureaucratic "we can't give you treatment X because our policy (or your insurer's policy) won't let us" approach.

I'm uncertain as to why you would separate "government bureaucrat" from "insurance company bureaucrat" when considering denial of benefits.

When the motive for denial is profit rather than following regulatory procedure, the lure of malfeasance is significantly higher IMO.

[hrothgar]

blackshoe, on Sep 27 2010, 01:09 AM, said:

Okay. What I don't want to see is a bureaucratic "we can't give you treatment X because our policy (or your insurer's policy) won't let us" approach.

What is your alternative?

I hate to say it, but there is something to this whole "Death Panel" concept.

Its a natural consequence of, what are to me, a couple simple predicates:

1. There is an obligation for the state to provide health care for its citizens
2. Individuals can not control their demand for health care

Ultimately, the state needs to apply some kind of rationing systems regarding what policies it will/will not provide.

I've been trying to wrap my head around what might constitute a reasonable system for quite some time. The closest that I've been able to come is a system like the following:

1. The state provides comprehensive health coverage for all citizens up to some specified age limit. The age would be 65, 70, something like that. The age cut off needs to be low enough to exclude costly end of life choices for folks who make bad life style choice (smoking, obesity, etc.)

I wouldn't object to a system in which this age is pushed out for individuals who are able to demonstrate that they make good life style choice. (Keep your weight within the following band, demonstrate that you don't smoke / use the following substances and we'll give you an extra 5 years of health care)

2. The state continues to provide free preventative care as well as end of life services throughout an individual's life.

3. Individuals are responsible for their own catastrophic coverage from age X on... If you want to burn through your children's inheritance trying to beat lung cancer at age 85 you're welcome to do so...

[kenberg]

Those of us who are 65 or 70 or something like that probably will not be supporting this plan.

Added: For the most part, I don't think access to medical care should be withdrawn on the basis of age. It gets tricky. An 80 year old friend has been told he has a slow growing prostate cancer. He is not having an operation. But this is more a medical decision than a financial one. Most likely he will be dead from something else before the cancer becomes a huge problem. But take your lung cancer example. My mother died in 1963 from an aggressive cancer. The fact is that she was going to die, and soon, so the only issue was exactly when and how. She was short of being 65 but so what? I really don't think that the age of the patient should be a prominent feature in the financial, as opposed to the medical, aspects of the decision.

[luke warm]

kenberg, on Sep 26 2010, 09:24 PM, said:

I really don't think that the age of the patient should be a prominent feature in the financial, as opposed to the medical, aspects of the decision.

then this isn't the plan for you

[hrothgar]

kenberg, on Sep 27 2010, 05:24 AM, said:

Added: For the most part, I don't think access to medical care should be withdrawn on the basis of age. It gets tricky. An 80 year old friend has been told he has a slow growing prostate cancer. He is not having an operation. But this is more a medical decision than a financial one. Most likely he will be dead from something else before the cancer becomes a huge problem. But take your lung cancer example. My mother died in 1963 from an aggressive cancer. The fact is that she was going to die, and soon, so the only issue was exactly when and how. She was short of being 65 but so what? I really don't think that the age of the patient should be a prominent feature in the financial, as opposed to the medical, aspects of the decision.

I agree that the whole "Age" thing is a tricky one...

I would prefer to have a more accurate, yet still simple / objective standard. I haven't been able to come up with one. I welcome suggestions...

(Ultimately, I think that simplicity and transparency is probably more important that accuracy. This might be the root cause of some of my problems)