Socialized National Health Care DOESN'T WORK!*

[Haroki]

Well, for one, I'd be ok with providing healthcare for all, but not under our current system. Riser gives a few good reasons about the problems we face.

I've heard that in the US we throw a lot of technology at emergency room paitents. Is that true in general? I know from my own experience, going to my regular doctor is a pretty - shall we say - basic experience. But at no time do I feel like I'm not getting good care.

It seems like doing just that would lower my ins costs, something I think everyone could be ok with.

But to be selfish, what's the immediate payoff for me? Just to throw something out there, I'd be willing right now to vote for govt healthcare if I could get someting else. Like say, an end to welfare/unemployment, and convert it to something more productive like job training along with child care to get people to work, or back to work.

 

[Trader5287]

I've had a key employee out since July. The employee, the workers comp insurance carrier, and I all agree we'd give anything for a socialized system. Or anything other than this mess.

 

[riserburn]

My ex-wife first got me to look at alternatives. If you think about, our doctors are trained to do two things.....cut you or drug you. They have very little training in alternatives or in preventive medicine. Thank God for my HSA.

Indeed...... certain CAMs and HSAs are nice if you can afford it; particularly ones with focus on preventive regimens. Unfortunately, the out-of-pocket costs for a lot of people prove too much to bear. However, some insurers are starting to see the benefits ($$$) of "an ounce of prevention"; although on a limited scale presently.

 

[riserburn]

By the way, can anybody provide a reliable source that has a ballpark figure on how much it will cost the US treasury if universal healthcare was instituted in the US?

http://www.ahrq.gov/data/hcup/

Although you'll have to do some digging and statistical math, the figures are accurate and unbiased.

 

[riserburn]

Thanks for taking the time to respond, Riserburn.

No problem. I'm glad there are those that are actually interested in this issue. A lot of people have no idea how enormous and dire this problem really is much less want to even think about it. After all, its not nearly as "controversial" or "stimulating" as other points of discussion on this board.

Although I am a practitioner and not a quant or in the management end of the industry, I'll try to answer your questions the best I can. Possibly, there is someone else on this board that is more intimately versed on the financial and budgetary details of the issue could contribute?

bingo .... exactly....lesson over...

Hardly; the lessons are only starting. Consequently, its a "class" where the "teachers" don't even have a concrete set of answers to all the questions. Since you can't see fit to behave, you can join my ignore list with your bigot friend you quoted and go sniff glue somewhere else.

 

[tradermaji]

Thanks Riserburn.

 

[riserburn]

They are also forced to comply with regulatory standards that dictate what is and is not an acceptable level of quality of care. To top that all off, the federal and state agencies that provide funding for healthcare dictate what they will pay for, how much they will pay, and how it will be paid.
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This is only important if the cost of mandated care exceeds the reimbursement provided by Medicaid/Medicare. Is this the case?

First of all, Medicare/Medicaid hasn't kept up with the costs of inflation. Just last year in this NYT article on the Global Action for Aging website, Michael O. Leavitt, the Secretary of Health and Human Services, made several disturbing statements. Payments for services with this system is in a constant state of struggle and falls prey to budgetary cuts and balances every year.

Second of all, the Medicare/Medicaid payment structure is seriously flawed. basically, the government sets expectations within the system as to what they think will be spent on Medicare/Medicaid payments each year. The checks are written out according to that budget. If the balance of the debits exceed the amount in the budget (which it has consistently for quite some time), the system, Medicare/Medicaid, proportionately reduces its payment percentages for the following year. Wash, rinse, repeat; the cycle is continued into the following year.

Finally, to make matters even worse, the system has a mandated structure of what it will pay in a FIXED amount based on a "typical" scenario within a demographic of patients related to a certain illness or treatment regimen; NOT on a case by case basis. Its known as the Prospective Payment System and, if you aren't opposed to some "light" reading, you can find it here. Payment for other services not covered under PPS is loosely referred to as a "fee-for-service basis", but, in the end, turns out to be a FIXED amount dictated by another wonderful set of codes. You can find it here. THEN we throw into the mix Medicare Advantage Organizations. Its a wonderful extension of the Medicare + Choice program whereby HMOs and other for-profit managed care organizations are allowed to suckle off the government Medicare nipple for the low low price of tooting Ws new drug benefit program horn. You can read all about it here.

Yes, thats right. Instead of fixing a broken system, W adds to the mess and ensures that yet another special interest group gets to participate.

You can get all the juicy details you like at the CMS website:

http://www.cms.hhs.gov/

Its a plethora of bureaucratic knowledge about a broken system on a newly minted website.

If so, then the Government is surreptitiously coercing the insured to subsidize the uninsured by short changing HMO's and providers.

I really wish it was that easy and true. We could run them all out into the capitol lawn and lynch them for conflict of interest and other various charges. But no, in the end, they truly ARE THAT STUPID and their addiction to special interest money proves to be more gripping than heroin.

 

[riserburn]

IMO the costs of caring for the uninsured is THE single largest contributor to the high cost of healthcare.
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If the uninsured impose the largest cost on the system, then minimizing their burden under the current legislative climate of 'health care for all' would seem to be the first step in reducing costs.

Yes that would seem logical; in theory. BUT based off of what we know about governement tendencies towards inneptitude in spending as evident in my last post, can you really blame people for being skeptical about just what a socialized "healthcare for all" climate would be like? If they can't run a healthcare program for the elderly and disabled in an efficient manner, what makes anyone think they could for everyone else's healthcare needs? I mean really (for all you business owners out there, help me out here), if you wrote checks and balanced the budget the way this government does, how long could you stay in business?

Levying a mandatory patient surcharge for non life threatening emergency room visits and imposing regular check ups for continued medicare coverage could be a start.

Hospitals and doctors already mail out bills to all those individuals with a mailing address. They just rarely get paid. The enormous costs in litigation is rarely justified by the amount owed, not to mention the negative press associated with enforcing civil penalties on people that are impoverished. As for imposing regular check ups for Medicare coverage, REMEMBER: the government dictates that. The very same politicians that run that mess are going to mandate those types of enforcement measures on all those registered voting Medicare beneficiaries? NOT A CHANCE.

The idea is to make the uninsured accountable.

AND/OR to get them insured. But how?

 

[riserburn]

Quote from riserburn:
They [HMOs] dictate what, how, and how they will pay or not pay.
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I am not sure I understand why this is important if providers are ultimately compensated for their gross costs.

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Quote from riserburn:
In turn providers raise the prices for what they can be compensated for.
They KNOW they aren't going to get full compensation, so the price is set to a level that offsets that which isn't reimbursed.
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Again, the net effect is a final price tage commensurate to its cost of provision. Nothing inherently nefarious about that.

Again, I am not sure I understand. How do HMO billing practices increase the ultimate cost paid by the insured?
From my understanding, HMO's are simply forcing providers to defer costs from unprofitable procedures to profitable ones. The gross cost charged by providers and compensated by HMO's should remain unchanged.
Am i wrong?

The best way to answer all your questions about managed care billing and reimbursement practices can be best described by detailing for you with examples and links to some issues that I am aware of. This will take some time to compile and its getting late here. I will continue tomorrow when I get in, and AFTER I set up the next day's trades (instead of getting sidetracked); after all, thats how I ended up on this site to begin with

 

[riserburn]

Before I go into the details on how managed care organizations and insurers fleece the system, it is necessary to give some a brief explanation of the payment schedule and reimbursement practices that are employed. A lot of people aren't aware of the details, but for those of you who are; I do not mean to insult your intelligence.

There are 3 primary methods of payment: capitation, fee-for-service, and salary. Hospitals, skilled nursing facilities, and other facilities are paid by the first 2 primarily. Physicians and other healthcare professionals under contract are paid with either one or some combination of all 3, which is usually the case. Within each of the first 2 methods exist a series of subdivisions and clauses that narrow down the specific reimbursements rates for specific services rendered. The ones most commonly used are referred to as "carve-out" clauses and "bundling".

Capitation, also known as per-member-per-month-payment (PMPM), is a fixed payment to cover specific services for a specific patient population. These payments are typically prepaid and are designed to transfer the operational risks from the payer to the payee. For example, a doctor or facility is paid a fixed amount by ABC HMO to delivery the babies of all their clients for a period of one month. If they don't deliver any babies that month, they simply pocket the cash. If they have to deliver more babies and its costs more operationally than the amount paid, then they are stuck with the loss. Usually, all it takes is one difficult delivery to eat up, or even exceed, the amount of the payments.

Fee-for-service is self-explanatory. They are paid for a fixed amount per service per patient.

Salaries only applies to lump-sum payments made to physicians and other professionals that have a contract with an HMO for one. Salaries can also be applied to professionals in group practices that receive lump-sum payments by contract and is then doled out to the group members on yet another contract that exists within the practice group itself.

Obviously, professionals and facilities prefer the last 2 of these 3 methods. However, it is rare that they would receive a lucrative contract for them without accepting some form of capitation schedule. The REAL gremlins that lurk in the system are the practices of "carve-out" and "bundling" clauses.

"Carve-outs" are clauses within the contracts that separate out very specific procedures, treatments and services into a separate payment schedule. "Bundling" is the practice of grouping more than one procedure, treatment, or service into a single payment schedule. Both of these methods are commonly used to take advantage of "hidden" discounts within the system for services that are rendered to patients that have more than one problem or patients with a problem that involves multiple conditions. For example, diabetes often leads to complications of heart disease, poor circulation, and, on occasion, vision problems. A doctor or facility treating such a patient is held to a standard of care that dictates they must treat all aspects of the disease. However, when they file for reimbursement they may find that the managed care group has "carved-out" specific service charges associated with an entirely different diagnosis (i.e. congestive heart failure or arteriosclerosis) and "bundled" them into a single payment schedule in order to take a discount on the originally filed diagnosis. There are literally thousands of these examples.

The final complex mix in this equation are bonuses and withholds. Some contracts contain bonuses that are doled out by insurers as incentives to practitioners and facilities for meeting certain criteria that save the insurers money (and the details can be very specific; like limiting the number of patients that are admitted or limiting the number of days certain demographics stay in the facility) or help to increase their client base. If the minimum goals are not met, some contracts actually contain clauses that withhold payments. Financial incentives are murky areas that I think deals more with practices that lead to a lower quality of care than the payment issues themselves. This issue is extremely controversial and many disagree on its impacts.

Well why don't the practitioners and facilities simply reject these contractual obligations and move on to a more lucrative offer? Because the market penetration and capitalistic practices of insurers makes it damn near impossible. I'll explain in more detail in a later post.

Aren't the practitioners and facilities aware of the details of the payment and reimbursement schedules before they sign the contract? Actually no; and they aren't even allowed to provide specific samples as proof of this practice as covered under antitrust laws. I'll explain that in detail as well in a later post.