RyanCare/TrumpCare

[Pointedstick]

I'm not convinced the practice of charging Mexicans less than Americans is a bad thing. Mexicans get a life-saving drug that they might not otherwise be able to afford, and the drug companies still get properly remunerated for years of research.

Why do Americans have to do everything? Why do we have to be the ones paying for the rest of the world's medical research? And defense, and...


Related to what Maddy posted, the New York Times ran a very relevant article yesterday:

https://www.nytimes.com/2017/03/29/maga ... -much.html

What a nightmare. Upfront pricing would do so much to fix this insanity.

[Jack Jones]

I'm not convinced the practice of charging Mexicans less than Americans is a bad thing. Mexicans get a life-saving drug that they might not otherwise be able to afford, and the drug companies still get properly remunerated for years of research.

Why do Americans have to do everything? Why do we have to be the ones paying for the rest of the world's medical research? And defense, and...

Hmm, I wouldn't lump medical research and defense into the same category here. The medical research is being done (at least partially) by private entities, where in the case of defense, it truly is American citizens paying to defend the rest of the world.

So back to your question...why do Americans have to do everything? We don't! Some of us choose to develop new drugs because we believe we can profit from doing so. My concern is that if we restrict those profits, fewer will choose to develop new drugs and instead spend their time developing apps to share cat photos.

[Maddy]

What a travesty it would be if the $600 Epipen had never been invented and consumers had to go back to using a $10 vial and syringe. How tragic it would be if all those diabetics I see stuffing their face with every sugary dessert on the table had to actually think about what it's doing to their glucose levels.

Maybe it's time to rethink whether all that research is giving us a worthwhile bang for the buck--especially in light of WiseOne's earlier comments in another thread about how shoddy much of medical research has become.

[Maddy]

The issue for me isn't whether charity toward third-world countries is a good or necessary thing. But let's be honest and transparent about it.

Redistribution in the form of cost-shifting is essentially dishonest. If the people of this country want to subsidize the medical systems of other countries, there are far more direct and vastly less expensive ways of doing that without engaging in elaborate cost-shifting fictions that distort the entire market for health care. It seems to me that there is only one reason that can adequately explain this government's insistence upon utilizing cost-shifting mechanisms to carry out its charitable purposes. It's to hide the true cost of this country's "generosity." If the actual tab were clearly visible to the population, there would be a revolt.

[WiseOne]

Maddy, thanks for that pointer to the NY Times article. There is a lot of truth in it, but it's mixing up several different issues.

I've talked about billing/coding in prior threads. It is sheer overhead cost with no parallel in any other health system on the planet, and a natural response to the byzantine rules set up by Medicare that are just an invitation to gamesmanship. The Times article tried to pin the blame on the AMA, but for once it's not their fault. The private insurance companies are simply following Medicare's lead.

The 25% overhead cited in the article counts only a small part of the cost of this, namely the salaries of billing & coding staff & (I presume) charges by billing/coding companies. There's also the cost of EHRs whose main purpose is to facilitate the billing/coding games, physician time dealing with all these coding requirements, "training", extra documentation etc, and of course the extra charges that result from all the upcoding.

I don't know a single doctor who wouldn't be thrilled to pieces to have this whole billing/coding system done away with and replaced with something more sensible. I just have no idea how it could be done, given how far along the path we've traveled.

[Pointedstick]

I don't know a single doctor who wouldn't be thrilled to pieces to have this whole billing/coding system done away with and replaced with something more sensible. I just have no idea how it could be done, given how far along the path we've traveled.

Cash-based practice, presumably. Don't accept Medicare, Medicaid, or insurance. Be like a dental practice: one doctor and one receptionist, with clear cash prices.

[Maddy]

I don't know a single doctor who wouldn't be thrilled to pieces to have this whole billing/coding system done away with and replaced with something more sensible. I just have no idea how it could be done, given how far along the path we've traveled.

So why do you suppose cash-based practices been so slow to catch on? With $6,000 deductibles, I'd think that patients would be lining up at the door. So far, I've seen several surgery centers go all-cash, but so far nothing with any other specialty. With the family docs, the concierge model seems to be taking hold, but that's just another cost-shifting scheme.

BTW, it was PointedStick who posted the NYT article.

[Pointedstick]

I don't know a single doctor who wouldn't be thrilled to pieces to have this whole billing/coding system done away with and replaced with something more sensible. I just have no idea how it could be done, given how far along the path we've traveled.

So why do you suppose cash-based practices been so slow to catch on? With $6,000 deductibles, I'd think that patients would be lining up at the door. So far, I've seen several surgery centers go all-cash, but so far nothing with any other specialty. With the family docs, the concierge model seems to be taking hold, but that's just another cost-shifting scheme.

A truly excellent question. Is this just a simple missed market opportunity, or is some regulatory nightmare preventing it?

[farjean2]

I've talked about billing/coding in prior threads. It is sheer overhead cost with no parallel in any other health system on the planet, and a natural response to the byzantine rules set up by Medicare that are just an invitation to gamesmanship. The Times article tried to pin the blame on the AMA, but for once it's not their fault. The private insurance companies are simply following Medicare's lead.

On the patient side I've been caught in Billing Code hell a couple of times and it's one of several reasons I have for staying as far away as I can from the medical system. The first time was when a doctor finally convinced me that I was 10 years overdue for my first colonoscopy at age 60. When the wrong code was input, it was determined that not only was it not covered by the preventative medicine provision of my policy but it wasn't even eligible to be paid out of my HSA. I ended paying the whole bill after several threatening collection letters and then had to work with the doctor's assistants to get the code changed so I could get my money refunded. Life is too short for hassles like that so that will be my very last colonoscopy.

Another time was when I made an appointment for my wife for routine biometric screening required by my company according to some provision of Obamacare. That one ended up costing me over $1000 due to billing codes and I gave up trying to get it straightened out because the doctor's staff would not work with me. Said it was my problem and not theirs.

[Maddy]

Just a guess, but it may be an irrational fear that a cash-only practice would attract a high proportion of riff-raff. I say that because of the reaction I get nearly 100 percent of the time when asked whether I have insurance and I answer "No, I'm paying out-of-pocket." It's that look that screams, "Oh. You're one of those." Honestly, a couple of times I've responded to that look by saying, "You know, the way I figure it, it's people like me who are the only ones in the whole damned system who are paying their own way." Almost inevitably, that elicits a smile and an acknowledgment that what I've said is true.

[dualstow]

We have catastrophic insurance only, so we're pretty much paying out of pocket...including the insurance.

[WiseOne]

I don't know a single doctor who wouldn't be thrilled to pieces to have this whole billing/coding system done away with and replaced with something more sensible. I just have no idea how it could be done, given how far along the path we've traveled.

So why do you suppose cash-based practices been so slow to catch on? With $6,000 deductibles, I'd think that patients would be lining up at the door. So far, I've seen several surgery centers go all-cash, but so far nothing with any other specialty. With the family docs, the concierge model seems to be taking hold, but that's just another cost-shifting scheme.

A truly excellent question. Is this just a simple missed market opportunity, or is some regulatory nightmare preventing it?

Regulatory nightmare. If you have a $6,000 deductible, that $6,000 has to be accepted by the insurance company. Cash payments for visits wouldn't count. So if you have insurance it doesn't make sense to go to a cash-only practice, unless the per-visit price is no more than your copay, and your copay doesn't count toward the deductible. That severely limits your patient population.

Maybe a version of MediumTex care where instead of a $50,000 deductible, the government end of the program covers hospital, diagnostic and drug costs for expensive conditions and leaves routine office visits completely to the private realm.

Or hey what about this for an idea: make an Obamacare option to exclude coverage for office visits as a variation of silver & bronze plans. I bet that would seriously drop the price, and instantly expand the pool of patients who are free to choose a cash-only practice. What do you think Pugchief?

[Maddy]

Regulatory nightmare. If you have a $6,000 deductible, that $6,000 has to be accepted by the insurance company. Cash payments for visits wouldn't count. So if you have insurance it doesn't make sense to go to a cash-only practice, unless the per-visit price is no more than your copay, and your copay doesn't count toward the deductible. That severely limits your patient population.

I'm not sure I understand. If an insured person with a $6,000 yearly deductible pays cash for all the nickle-and-dime bills he incurs throughout the year, and there are no major catastrophes, he simply files away the cash receipts and moves on to the next year. If, on the other hand, he gets run over by a truck in late December, what's to prevent him from pulling out all the receipts he's accumulated during the past 12 months and submitting them to the insurance company in bulk as proof that he's met at least part of the deductible? Is there something in the policies nowadays that requires bills to be run through the insurance company concurrently with the service?

[Libertarian666]

Regulatory nightmare. If you have a $6,000 deductible, that $6,000 has to be accepted by the insurance company. Cash payments for visits wouldn't count. So if you have insurance it doesn't make sense to go to a cash-only practice, unless the per-visit price is no more than your copay, and your copay doesn't count toward the deductible. That severely limits your patient population.

I'm not sure I understand. If an insured person with a $6,000 yearly deductible pays cash for all the nickle-and-dime bills he incurs throughout the year, and there are no major catastrophes, he simply files away the cash receipts and moves on to the next year. If, on the other hand, he gets run over by a truck in late December, what's to prevent him from pulling out all the receipts he's accumulated during the past 12 months and submitting them to the insurance company in bulk as proof that he's met at least part of the deductible? Is there something in the policies nowadays that requires bills to be run through the insurance company concurrently with the service?

I can think of at least one thing that would prevent that.

[Xan]

Regulatory nightmare. If you have a $6,000 deductible, that $6,000 has to be accepted by the insurance company. Cash payments for visits wouldn't count. So if you have insurance it doesn't make sense to go to a cash-only practice, unless the per-visit price is no more than your copay, and your copay doesn't count toward the deductible. That severely limits your patient population.

I'm not sure I understand. If an insured person with a $6,000 yearly deductible pays cash for all the nickle-and-dime bills he incurs throughout the year, and there are no major catastrophes, he simply files away the cash receipts and moves on to the next year. If, on the other hand, he gets run over by a truck in late December, what's to prevent him from pulling out all the receipts he's accumulated during the past 12 months and submitting them to the insurance company in bulk as proof that he's met at least part of the deductible? Is there something in the policies nowadays that requires bills to be run through the insurance company concurrently with the service?

There certainly is. It's a deductible on covered claims against your insurance, not on any and all spending you do anywhere anyhow. Only things that are run through (and covered by) insurance count towards your deductible.

[Maddy]

I don't follow your logic. If annual physicals were dropped, all that would happen is less people would go annually if ever. In my practice, most insurance plans cover 2 exams/cleanings per year. The first thing that happens when people lose their insurance is they stop coming in for check ups. But as they avoid me for 3 years, the $200 filling caught early turns into a $2500 root canal and crown. How is that a good thing?

You're assuming that if a cash model prevailed for all but catastrophic expenses, out-of-pocket costs would remain the same. However, take away all the cost-shifting and administrative expenses, and prices could be expected to fall to a level where people could actually afford routine care. The fact that facilities such as the Oklahoma Surgery Center are able to offer the very same services as your local hospital for a mere fraction of the price suggests that the cash-based model works.

[Maddy]

Regulatory nightmare. If you have a $6,000 deductible, that $6,000 has to be accepted by the insurance company. Cash payments for visits wouldn't count. So if you have insurance it doesn't make sense to go to a cash-only practice, unless the per-visit price is no more than your copay, and your copay doesn't count toward the deductible. That severely limits your patient population.

I'm not sure I understand. If an insured person with a $6,000 yearly deductible pays cash for all the nickle-and-dime bills he incurs throughout the year, and there are no major catastrophes, he simply files away the cash receipts and moves on to the next year. If, on the other hand, he gets run over by a truck in late December, what's to prevent him from pulling out all the receipts he's accumulated during the past 12 months and submitting them to the insurance company in bulk as proof that he's met at least part of the deductible? Is there something in the policies nowadays that requires bills to be run through the insurance company concurrently with the service?

There certainly is. It's a deductible on covered claims against your insurance, not on any and all spending you do anywhere anyhow. Only things that are run through (and covered by) insurance count towards your deductible.

Okay, but what's to prevent the patient himself from submitting the bills to his insurance company? The scenario I'm suggesting contemplates a physician who has opted out of the insurance system entirely, so there is no behind-the-scenes agreement that requires him to submit bills to the insurer. Assuming that the applicable policy covers the services of out-of-network physicians, exactly what in your run-of-the-mill policy would allow the insurer to reject the claim? I just don't understand the idea that cash payments "don't count." (The lawyer in me is muttering, "Like hell they don't.")

[Xan]

It's not that cash payments don't count, it's that unless the payment was made through an agreement with the insurance company, then the insurance company won't count it against the deductible.

[Pointedstick]

Perhaps, but you are assuming it is a given that prices would drop. Since 95% of my patients are on a PPO or HMO, I am currently receiving, on average, about 60% of my full fee. If we got rid of the insurance companies as middle men, the price would be less than my current full fee,but more than the ridiculously low negotiated fee I am contracted at now. So the net to the patient would be higher than what it is now. Perhaps if my costs dropped enough by not having to deal with insurance, I could get as low as what they pay now. Idk.

Does it even make sense that you have a "full fee" if 95% of your customers don't pay it? It seems like what would happen is that your new cash-based "full fee" would drop to the current negotiated rate instead. Also, since everyone would be paying cash, you would be exposed to price competition, and would be incentivized to lower your prices over time. This would probably have the effect of lowering the prices of your supplies and materials as you economized and started shopping around for better prices, same as your customers.

Or I could be totally wrong, I dunno. You're the one actually in the industry! But it seems weird that dentistry would be the one market not affected by transparency and competition.

[Pointedstick]

You are correct, it makes no sense. Back in the day, when only 50% of my practice was PPO, I actually did receive full fee half of the time.

Part of the problem is that you guys assume health care is a commodity. It is and it isn't. If you need a knee replacement, do you want the guy who does broken arms and legs and also does some knee and hip surgery? Or do you want the guy who does nothing but knees? Even if he charges twice the price?

Sure, but most medical care isn't a knee replacement. It's a lot more routine and low-level than that. And to the extent that there are a lot of invasive surgical procedures, I'm convinced that the root of the problem in the USA is how unhealthy the population is from eating garbage every day for years. Any resolution to this situation needs to start there. There was a bill in the New Mexico legislature this year to extend the sales tax to food deemed to have little to no nutritional value that died a fiery death after a thousand special interest groups howled bloody murder. What a shame.

[WiseOne]

Maybe things are different in dentistry, MangoMan, but here's a short list of tasks and expenses that could vanish with a switch to a cash-only practice:

- billing services (30% of all collected fees go to these guys and that doesn't count the internal billing center)
- the electronic medical record system that all of us curse every day and that cost our medical center $40 million...and then they realized it was unworkable so they're replacing it with a slightly better system at probably twice that amount. There are simpler and better systems out there, but Obamacare made most of them obsolete, which gave the top two EHR developers (allscripts, epic) a virtual monopoly.
- Periodic paperwork & online training programs to stay credentialed with all the local insurance companies & CMS
- The extensive documentation required by any third party payor in order to justify bills submitted directly or via the patient. Most office visits could be documented in about 30 seconds, but the extraneous requirements & convoluted entry systems inflate that to at least 30 minutes. It's why most practices now employ (i.e. pay) scribes to do this job.
- Coding & billing compliance services (or employees)

That overhead easily sucks up most of the office visit bill. Why not cut all that out, reduce the office visit fee, and then do something else productive with all the time that just got freed up? Or am I just being too simplistic?

For what it's worth, I'm aware of several practices in quaternary/tertiary care academic centers that have already gone to cash only. You can only do that if you're prepared to lose a chunk of your patient population, though.

[Libertarian666]

Maybe things are different in dentistry, MangoMan, but here's a short list of tasks and expenses that could vanish with a switch to a cash-only practice:

- billing services (30% of all collected fees go to these guys and that doesn't count the internal billing center)
- the electronic medical record system that all of us curse every day and that cost our medical center $40 million...and then they realized it was unworkable so they're replacing it with a slightly better system at probably twice that amount. There are simpler and better systems out there, but Obamacare made most of them obsolete, which gave the top two EHR developers (allscripts, epic) a virtual monopoly.
- Periodic paperwork & online training programs to stay credentialed with all the local insurance companies & CMS
- The extensive documentation required by any third party payor in order to justify bills submitted directly or via the patient. Most office visits could be documented in about 30 seconds, but the extraneous requirements & convoluted entry systems inflate that to at least 30 minutes. It's why most practices now employ (i.e. pay) scribes to do this job.
- Coding & billing compliance services (or employees)

That overhead easily sucks up most of the office visit bill. Why not cut all that out, reduce the office visit fee, and then do something else productive with all the time that just got freed up? Or am I just being too simplistic?

For what it's worth, I'm aware of several practices in quaternary/tertiary care academic centers that have already gone to cash only. You can only do that if you're prepared to lose a chunk of your patient population, though.

All of that would cut expenses to the point where routine office visits would be affordable for most people.

Let's see if "Obamacare repeal 2.0" makes a dent in this problem.

[Pointedstick]

All of that would cut expenses to the point where routine office visits would be affordable for most people.

Let's see if "Obamacare repeal 2.0" makes a dent in this problem.

Indeed. My wife went to a Walmart optometrist a few weeks ago. $70 cash price, clearly posted. After getting her perscription, she went online and bought some new glasses. Lots of bells and whistles and nice attractive frames. They should last for about 5 years. $65 total. No hassle, no insurance, no billing claims, no codes, no bureaucracy, no bullshit.

That's what medical care should be like everywhere. Yes, optometry isn't ever an emergency, but most medical care is also not an emergency. Shopping around for non-emergency care and paying cash works just fine.

Frankly I keep waiting for Walmart to open cash-based clinics in their larger stores. I'm sure they would be a smash hit. I wonder why they haven't.

[Xan]

Perhaps, but you are assuming it is a given that prices would drop. Since 95% of my patients are on a PPO or HMO, I am currently receiving, on average, about 60% of my full fee.

This is a huge part of the problem in general. The 60% number is the actual price, and the "full fee" is a made-up price that nobody actually is expected to pay.

Our insurance is grandfathered. (Unfortunately, that's finally going away, and of course at this point it's impossible to make any plans for replacing it because everything is changing unpredictably!) It doesn't cover maternity. When each of our boys were born, the sticker price for the hospital was some $25,000. But, oh, if you're doing doing insurance and are paying up-front, then they'd take ~$5,000.

That's great for us and all, but it really illustrates what a scam the whole system is. People who do pay for ridiculously fantastic insurance will say "I could never have afforded $25,000!", and never see that the *actual* price is something far less.

[Maddy]

The 60% number is the actual price, and the "full fee" is a made-up price that nobody actually is expected to pay.

I recall reading somewhere that by having a "full fee" that virtually nobody pays, hospitals take massive write-offs on their taxes for purely fictitious losses. I don't know whether this is true, but if so, it's quite the scam. Can anyone verify?