Affordable and Quality Health Care

[rmnka447]

The underlying problem is at least twofold. People can't afford the hospital bill because they are poor. Also, patients can't afford hospital bills padded with an obscene amount of overhead. We in the industry call this ridiculous bidding. Hospitals have not been required to clean up their cost accounting structure--this is the true root cause; therefore, they have no earthly idea how much services should cost in an allegedly competitive marketplace.

 

This is why the average patient must vehemently negotiate against the hospital's FIRST BILLING OFFER. Treat it like a buying a car from a car dealer...everything is negotiable. The hospital bill is just a starting point.

 

For example, if I stay at a hospital and am not attached to any expensive equipment, I should not be billed $550/night for a room. I have stayed at the Ritz Carlton with 24/7 room service cheaper! Toothbrushes do not cost $10.00. In general, hospitals have not been required to have TRUTH IN BILLING PRACTICES; thus, they don't know how much their services really cost the patient so they apply all of their costs to overhead and are not compelled to track down inefficiency, waste, fraud, abuse, and poor inventory control.

 

Any hospital worth its weight should be on activity based cost accounting structures. Anything less is simply uncivilized and undisciplined.

 

See http://www.beckershospitalreview.com/lists/average-cost-per-inpatient-day-across-50-states-in-2010.html for crazy inpatient rates!

It's been years since I heard this but as I recall.....hospital bills are inflated for a business reason and are not a reflection of real costs. Most hospitals are businesses and to make the balance sheet look reasonable bills are inflated. They then fall into the category of Accounts Receivable until they are paid. Accounts Receivable is an asset, so the larger it is the more it offsets items on the Liability side of the balance sheet. I'm sort of foggy on what those Liabilites are, but for good reason they're pretty high for all hospitals. So to keep the hospitals viable and open, the fiction of overinflated bills is allowed and maintained.

 

If you are without insurance and huge medical bills come to you, a lawyer would tell you to not pay anything. Ultimately, a negotiation goes on with the hospital, doctors, and services that brings the total down closer to what insurance companies pay.

 

If you've ever seen a hospital bill with your medical insurance applied, you'd see that many items are reduced by significant amounts to get what the insurance and you have to pay. That write off is really reducing the bill to a more honest reflection of the cost of services rendered.

[rmnka447]

https://obamacarefacts.com/costof-obamacare/

 

Never did look up this web site. It answers a lot of questions about Obamacare. Says the average plan after subsidies is $82 a month for all plans but that sounds very low. Hmmm.

The average subsidy is something like $300/month. So in rough numbers, we're probably talking something like a total $5000/yr for each individual policy.

[RedSpawn]

It's been years since I heard this but as I recall.....hospital bills are inflated for a business reason and are not a reflection of real costs. Most hospitals are businesses and to make the balance sheet look reasonable bills are inflated. They then fall into the category of Accounts Receivable until they are paid. Accounts Receivable is an asset, so the larger it is the more it offsets items on the Liability side of the balance sheet. I'm sort of foggy on what those Liabilites are, but for good reason they're pretty high for all hospitals. So to keep the hospitals viable and open, the fiction of overinflated bills is allowed and maintained.

 

If you are without insurance and huge medical bills come to you, a lawyer would tell you to not pay anything. Ultimately, a negotiation goes on with the hospital, doctors, and services that brings the total down closer to what insurance companies pay.

 

If you've ever seen a hospital bill with your medical insurance applied, you'd see that many items are reduced by significant amounts to get what the insurance and you have to pay. That write off is really reducing the bill to a more honest reflection of the cost of services rendered.

Agreed.

 

Accounts Receivable and Patient Revenue is first set. Then Direct Cost, Indirect Cost, Direct Materials, Overhead Applied and Cost of Services Rendered is 2nd Set. Problem is 2nd set where overhead applications and indirect cost applications are huge cost pools relative to individual services rendered and creates unjustifiable bills.

 

Hospitals have been so top-line focused that they have not paid attention to cost control in the indirect cost and overhead applications. The billing gets more outrageous with outpatient services because the hospital can't hide all of that uncontrolled overhead cost inside a service where the patient doesn't stay overnight. Plus, as more hospital services are rendered on an outpatient basis, there are fewer inpatient services to apply that huge uncontrolled overhead to 😏. Very vicious cycle.

 

It's time hospitals pull back the curtain on their overhead cost pools and focus on controlling their bottom line as well. Hospitals can't artificially grow themselves out of this overhead problem through acquisition of other hospitals. Economies of scale isn't the solution..... managing the overhead cost is an ugly, inescapable responsibility.

 

http://www.beckershospitalreview.com/finance/10-reasons-why-hospitals-are-shifting-to-advanced-cost-accounting.html

 

Then you got power play bosses like in this article====>An Art of the Deal move.

http://www.beckershospitalreview.com/finance/health-system-ceo-pulls-out-6m-check-to-pay-debts-during-budget-hearing.html

[Winstonm]

I heard again from some Republican Congressman or Senator (can't remember who) the argument that health service is always available for someone who goes to a hospital emergency room, which is true. The Republicans have never had a problem with this model, never vowed to dismantle this model, or even said much about it other than to defend their own policies, yet, if anyone can obtain healthcare services then universal healthcare is already our norm without question, debate, or argument. The only thing left to do is determine how best to provide that universal healthcare that we have already agreed upon.

[rmnka447]

I heard again from some Republican Congressman or Senator (can't remember who) the argument that health service is always available for someone who goes to a hospital emergency room, which is true. The Republicans have never had a problem with this model, never vowed to dismantle this model, or even said much about it other than to defend their own policies, yet, if anyone can obtain healthcare services then universal healthcare is already our norm without question, debate, or argument. The only thing left to do is determine how best to provide that universal healthcare that we have already agreed upon.

Yes, that is the critical question. The problem is that Obamacare provided access to "insurance coverage", but not necessarily access to "health care".

 

One of the big reasons why that is the case is the deductible. If an individual has an insurance policy that has a high deductible than they have "insurance coverage", but they don't have access to healthcare because the deductible acts as a barrier to getting care. Now if you're wealthy enough the deductible really doesn't pose much of a problem. But if you're a middle class person who's struggling to get by, than a large deductible is an insurmountable barrier to getting "health care". And, if those individuals go to the emergency room, they're going to get stuck for the whole bill unlike indigent people who essentially get those services free. If the bill were a few hundred dollars, it might be a tolerable problem, but a $5000+ bill can be catastrophic to a middle class person living paycheck to paycheck. I believe it's been reported that the deductibles have risen to an average of something like $9000/yr on Obamacare policies.

[PassedOut]

I believe it's been reported that the deductibles have risen to an average of something like $9000/yr on Obamacare policies.

Reported where?

 

Report: Average Obamacare Deductible Will Jump 20% in 2017

 

The average deductible for a silver plan through the Affordable Care Act, one of the law's most popular health insurance plans, is projected to jump 20 percent to $3,703, according to a report from Avalere Health.

 

Rep. Tom Price (R., Ga.), the nominee to lead the Department of Health and Human Services, said at his confirmation hearing that while many individuals have coverage through Obamacare, some of them are not getting the care they need because they cannot afford their deductible.

I'd be interested in seeing a link to the report you mentioned.

 

The problem with eliminating the mandate, while allowing freeloaders to get expensive emergency care for nothing, is that the rest of us have to pay for it. The attorneys-general for a number of republican states asked the US Supreme Court to find that citizens have a constitutional right to such freeloading, but Justice Roberts joined with four others to reject that request.

[Winstonm]

Yes, that is the critical question. The problem is that Obamacare provided access to "insurance coverage", but not necessarily access to "health care".

 

One of the big reasons why that is the case is the deductible. If an individual has an insurance policy that has a high deductible than they have "insurance coverage", but they don't have access to healthcare because the deductible acts as a barrier to getting care. Now if you're wealthy enough the deductible really doesn't pose much of a problem. But if you're a middle class person who's struggling to get by, than a large deductible is an insurmountable barrier to getting "health care". And, if those individuals go to the emergency room, they're going to get stuck for the whole bill unlike indigent people who essentially get those services free. If the bill were a few hundred dollars, it might be a tolerable problem, but a $5000+ bill can be catastrophic to a middle class person living paycheck to paycheck. I believe it's been reported that the deductibles have risen to an average of something like $9000/yr on Obamacare policies.

 

No, the question is why aren't Republicans pushing for Medicare or Medicaid for everyone, as they have shown they believe a basic level of healthcare for everyone is a right.

 

Instead, they are pushing for a tax cut for the wealthiest Americans, paid for by decreasing access to healthcare for the poorest Americans.

[ldrews]

No, the question is why aren't Republicans pushing for Medicare or Medicaid for everyone, as they have shown they believe a basic level of healthcare for everyone is a right.

 

Instead, they are pushing for a tax cut for the wealthiest Americans, paid for by decreasing access to healthcare for the poorest Americans.

 

Good question. I wonder why the Democrats, when they had control, didn't push the same thing?

[Winstonm]

Good question. I wonder why the Democrats, when they had control, didn't push the same thing?

 

What, a tax cut for the wealthy? I guess because they don't believe in fiction.

[awm]

Good question. I wonder why the Democrats, when they had control, didn't push the same thing?

 

Democrats have pushed for a single-payer system for a long time, including Hillary Clinton's plan in the 1990s. When the ACA passed, there was an attempt to add a "public option" which was included in the bill that Nancy Pelosi passed in the house, but this was removed in the Senate version. And more recently Bernie Sanders and allies have proposed Medicare for all.

 

However, there are a few problems with single-payer which ended up being the reasons that not even a public option made it into the ACA:

 

1. Single payer (or even a public option) will put a lot of private insurance companies out of business, or at least cause them to downsize significantly. This means there's a pretty big lobby lined up against such a change! Further, making such a move will lead to a short-term bump in unemployment, perhaps a particularly bad idea when unemployment is already high (as it was in 2009-2010 when ACA was debated). In the longer term single payer will help reduce costs for many types of non-insurance businesses (employer-provided health care is a huge expense for many large companies) and may create job openings and spur entrepreneurship (easier to leave your job and start your own company if you know health insurance will be taken care of). But these are long-term effects and must be weighted against huge short-term upheaval.

 

2. Single payer is a big expansion of government. Despite conservative hostility to government, this is not necessarily a bad thing. The increased taxes for the new program will probably be less than the payments people are currently making to health insurance companies so most people/businesses end up ahead. And we already have health care rationing, but it's done by unelected commissions in private companies driven by the profit motive, rather than by government commissions. Nonetheless, there are plenty of congresspeople (including conservative Democrats) who oppose expansion of government for its own sake. And there are some constitutional issues that would have to be addressed to do this on the federal level.

 

3. The way the ACA was passed would have made single payer difficult. The initial idea was to get 60 senate votes (bypassing the filibuster). However, this required either Republican votes (and every single Republican held McConnell's line about opposing everything Obama wanted, despite the inclusion of many Republican amendments in the bill) or getting all 60 Democratic votes (difficult first because of the election situation in Minnesota, where it took a long time for recounts to resolve and let Al Franken be seated, and then because of the death of Ted Kennedy and his replacement by a Republican, and also because of very conservative Democrats from states like West Virginia and Nebraska). Eventually the strategy switched to using reconciliation to bypass the filibuster, but this tool is intended for budget bills that reduce the deficit, and it's not clear something like single payer could even be implemented in such a way.

 

Note that in Canada, single payer was organized on the provincial level (and is still managed that way). The ACA intentionally leaves open the possibility for states to implement a single-payer program of their own, and several states have in fact made efforts in that direction (most recently California). It's still possible this may happen, but it does require some cooperation from the federal government which the Trump administration is unlikely to provide.

[ldrews]

What, a tax cut for the wealthy? I guess because they don't believe in fiction.

 

I know that you are not that obtuse. So you must be deliberately misleading. The question is: Why did the Democrats, when they were in power, not institute a single payer system or expand medicare to be universal? It seems to be the obvious solution and was even back then.

[barmar]

I know that you are not that obtuse. So you must be deliberately misleading. The question is: Why did the Democrats, when they were in power, not institute a single payer system or expand medicare to be universal? It seems to be the obvious solution and was even back then.

I must be obtuse, too. I thought "the same thing" referred to "a tax cut for the wealthiest Americans, paid for by decreasing access to healthcare for the poorest Americans." The fiction is trickle-down economics, which is the usual Republican explanation for why reducing taxes on billionaires is a good thing for the country.

[Winstonm]

I know that you are not that obtuse. So you must be deliberately misleading. The question is: Why did the Democrats, when they were in power, not institute a single payer system or expand medicare to be universal? It seems to be the obvious solution and was even back then.

 

Adam's answered is more nuanced - I can only add the reason I think the Democrats failed to get a single payer system passed was the Southern Democrats would not support cutting off the insurance companies.

 

However, the compromise reached helped but was far from perfect. Why are Trump and the Republicans trying to generate a massive tax cut for the wealthiest Americans by eliminating healthcare coverage to millions of poorer Americans?

[ldrews]

Adam's answered is more nuanced - I can only add the reason I think the Democrats failed to get a single payer system passed was the Southern Democrats would not support cutting off the insurance companies.

 

However, the compromise reached helped but was far from perfect. Why are Trump and the Republicans trying to generate a massive tax cut for the wealthiest Americans by eliminating healthcare coverage to millions of poorer Americans?

 

To me the tax cut per se is a red herring. The current program is imploding, millions of people have access to healthcare insurance with premiums and decuctibles that they can't afford. Hence they have no effective health care. The situation seems destined to get even worse. Premiums continue to soar, deductibles continue to go up, insurance companies continue to bail out. Is this the program that you want to continue? If not, what is your solution to the problem? The liberals came up with this mess, now you want the Republicans/Trump to fix it? And you criticize the proffered solution? OK, then give us your solution.

[Winstonm]

To me the tax cut per se is a red herring. The current program is imploding, millions of people have access to healthcare insurance with premiums and decuctibles that they can't afford. Hence they have no effective health care. The situation seems destined to get even worse. Premiums continue to soar, deductibles continue to go up, insurance companies continue to bail out. Is this the program that you want to continue? If not, what is your solution to the problem? The liberals came up with this mess, now you want the Republicans/Trump to fix it? And you criticize the proffered solution? OK, then give us your solution.

 

No, I'd rather hear facts than regurgitation of Trump talking points.

[ldrews]

No, I'd rather hear facts than regurgitation of Trump talking points.

 

So you criticize but have nothing constructive to offer. Sounds about right.

 

I think the Republicans should just bag it. Not pass anything. Then when the situation becomes dire enough that the Representatives and Senators are getting heat from their constituents, then maybe they will work together and come up with something better. Until then, nothing much will probably happen.

[Winstonm]

So you criticize but have nothing constructive to offer. Sounds about right.

 

I think the Republicans should just bag it. Not pass anything. Then when the situation becomes dire enough that the Representatives and Senators are getting heat from their constituents, then maybe they will work together and come up with something better. Until then, nothing much will probably happen.

 

The Democrats already have a plan in place - it is imperfect and needs improvement. It is already much, much better than doing nothing.

 

Your solutions always seem to involve a fantasy portrayal of reality. There is no John Galt.

[jogs]

I have tried to do a bit of research on what the costs are for the proposed Health care plans.

 

The best rough numbers I could come up with so far are:

1) 8-11,000$ per couple

2) plus copayments and deductibles.

3) These numbers are expected(guess) to increase 10-15% per year.

 

Hopefully someone can come up with better estimates than my rough numbers.

 

I get the impression alot of people are voting for this right and feel this is so important we should all have it regardless of costs.

Gov Jerry Brown has proposed single payer for all Californians. $400B a year for 39 million residents.

That translates to $3.4T for the entire USA. That would be about 80% of the US budget.

70% of Americans already has better health coverage than single payer. 30% have far better coverage.

There must be a better and cheaper way to provide health coverage for the 30% who do not have coverage from

their employer, medicare, or medicaid.

 

The individual insurance market makes no economic sense.

There are only two types of customers. Insurers love the healthy one who are over paying for services.

Insurers don't want those with pre-existing conditions. Insurers lose money with every customers.

 

Those with pre-existing conditions must be insured by the FED govt. Only the FED can afford to lose money.

[jogs]

The Democrats already have a plan in place - it is imperfect and needs improvement. It is already much, much better than doing nothing.

This is a lie perpetuated by the Democrats. Obamacare is in total collapse. Doing nothing is better.

[mike777]

Gov Jerry Brown has proposed single payer for all Californians. $400B a year for 39 million residents.

That translates to $3.4T for the entire USA. That would be about 80% of the US budget.

70% of Americans already has better health coverage than single payer. 30% have far better coverage.

There must be a better and cheaper way to provide health coverage for the 30% who do not have coverage from

their employer, medicare, or medicaid.

 

The individual insurance market makes no economic sense.

There are only two types of customers. Insurers love the healthy one who are over paying for services.

Insurers don't want those with pre-existing conditions. Insurers lose money with every customers.

 

Those with pre-existing conditions must be insured by the FED govt. Only the FED can afford to lose money.

 

OK but you seem unaware of the most important point.

 

the fed govt is YOU.

 

your post reflects the attitude of many posters here...the fed govt is someone else paying the bills...not you.

 

---------------

 

As for calif doing an experiment in single payer....it will be interesting.

 

I understand it is open to non legal residents as well

[Flem72]

No way I'm reading everything upthread, but wondering: Does it escape notice that this debate isn't about pricing health care, it is about pricing insurance? What if actual health care costs -- visits, procedures, tests, drugs -- were controlled, either by market forces, competition through advertising/cost comparison, or by some level of fiat (gulp -- not my cup of tea, really)? And if meaningful tort reform is part of the package, docs can use their common sense and medial experience in treatment and not have to fall back on the safest, by-the-numbers protocols -- OK, another MRI !! because if I don't do it, and the case falls into the small percentage where that could be made to look like it matters to a jury , I lose my shorts.

 

A friend who used to run hospitals tells me that in the 50s, 60s there was a book that priced procedures according to a regionally-based multiplier similar to a cost of living criterion. Base cost of an appendectomy = $X. In NYC, it's 1.9X, in Topeka, .7X. When was the last time any medical professional told you what something cost? when was the last time you asked?

[mike777]

No way I'm reading everything upthread, but wondering: Does it escape notice that this debate isn't about pricing health care, it is about pricing insurance? What if actual health care costs -- visits, procedures, tests, drugs -- were controlled, either by market forces, competition through advertising/cost comparison, or by some level of fiat (gulp -- not my cup of tea, really)? And if meaningful tort reform is part of the package, docs can use their common sense and medial experience in treatment and not have to fall back on the safest, by-the-numbers protocols -- OK, another MRI !! because if I don't do it, and the case falls into the small percentage where that could be made to look like it matters to a jury , I lose my shorts.

 

A friend who used to run hospitals tells me that in the 50s, 60s there was a book that priced procedures according to a regionally-based multiplier similar to a cost of living criterion. Base cost of an appendectomy = $X. In NYC, it's 1.9X, in Topeka, .7X. When was the last time any medical professional told you what something cost? when was the last time you asked?

 

The points you make are very important ones.

1) yes docs are deathly afraid of being sued. Even if they win the case it is a horrible and expensive experience.

2) So they order test after test after test

3) We the patient don't ask the cost. We do ask about the pain or hassle the test puts us through but not the cost.

[Winstonm]

No way I'm reading everything upthread, but wondering: Does it escape notice that this debate isn't about pricing health care, it is about pricing insurance? What if actual health care costs -- visits, procedures, tests, drugs -- were controlled, either by market forces, competition through advertising/cost comparison, or by some level of fiat (gulp -- not my cup of tea, really)? And if meaningful tort reform is part of the package, docs can use their common sense and medial experience in treatment and not have to fall back on the safest, by-the-numbers protocols -- OK, another MRI !! because if I don't do it, and the case falls into the small percentage where that could be made to look like it matters to a jury , I lose my shorts.

 

A friend who used to run hospitals tells me that in the 50s, 60s there was a book that priced procedures according to a regionally-based multiplier similar to a cost of living criterion. Base cost of an appendectomy = $X. In NYC, it's 1.9X, in Topeka, .7X. When was the last time any medical professional told you what something cost? when was the last time you asked?

 

The problem with market=based approach is that when you are vomiting and doubled over in pain from appendicitis, asking how much it will cost to make the pain stop is not going to be a consideration - considering your options prior to occurrence of a problem is iffy, too, as you don't know where you will be when a health emergency occurs or if you will be able to answer questions at that time.

 

The basic question is actually simple: should some minimum standard of healthcare be provided for everyone or should healthcare be treated like a commodity, bought and sold to the highest bidders through a market-based approach.

 

An argument I have read for market-based is that a single payer system will devastate innovation and research, that the rest of the world is saved that cost by U.S. capitalism spending on development - the rest of the world gets to benefit from that research and thus can afford universal healthcare.

 

That, to me, seems a hollow argument as I lived during the time of "Ma Bell" and Bell Labs. The U.S. government made a deal with AT&T for them to monopolize telephone service but they had to forego all other business. This did not prevent them from spending millions on Bell Labs, although they could not benefit directly from the discoveries.

 

Even today, research and development is in a quest to find new drugs from chronic diseases - the most profitable drugs - and the development of new antibiotics is virtually non-existent. The market looks for profits - it is not equipped to care if most of the entire planet's inhabitants die off from a bacteria that is resistant to all treatment options.

 

Perhaps the best idea is a single payer system run by each state.

[mike777]

OK Winston you are against the markets making the decisions and prefer a King to make the decisions. However you are also in favor of crony capitalism working for the King to at least pay for health care.

[awm]

Obamacare has been pretty successful at what it sought to do, which is to reduce the number of uninsured and reduce the number of medical-related bankruptcies. The number of Americans with no insurance has gone down approximately by half (and it would be even better if Republican-run states had expanded medicaid). Of course, the cost of medical care has continued to increase, but the projections for Obamacare were that it would reduce the cost when compared to the prior status quo -- in other words, by reducing the rate of increase, not by causing an absolute decrease. This has happened! To the degree that exchanges are "collapsing" and insurers pulling out, there are a lot of reasons for this:

 

1. Uncertainty as to whether the premium support payments for low-income people will actually be paid by the feds. This uncertainty was created by the Trump administration, which has threatened multiple times to pull the payments.

2. Attempts to pressure the federal government to allow mergers of large insurance providers (for example Aetna has pulled out of several profitable markets for this reason).

3. Lack of young healthy people signing up for insurance (this would be helped by strengthening the individual mandate, rather than eliminating it as Republicans plan to do).

 

Anyway, Obamacare is basically working. What we need is some approach to actually lowering medical costs now that everyone has insurance. Some thoughts on this:

 

1. Get Republican states to accept medicaid expansion, so we don't all have to subsidize uninsured people getting medical care through the emergency room!

2. Demand more visibility into how hospitals price procedures.

3. Allow Medicare to negotiate directly with drug companies.

4. Some sort of price controls as a part of the deal when companies use the patent process to enforce a monopoly on a life-saving drug or procedure.

5. Some reworking of the medical lawsuit system.

6. Add a public option (medicare/medicaid buy-in)?

 

Thing is, the Republican bill is not really doing those things. They are just chopping money from premium supports and medicaid in order to give a big tax cut (mostly to the wealthy). There is no world where cutting federal spending on medical care reduces premiums or deductables!