Gyroscopic Investing

Desert wrote:My favorite Trump quote during this process: "Nobody knew that health care could be so complicated."

OMG

It all starts to make sense once you realize we have a uniparty government that doesn't actually want to repeal Obamacare.

Simonjester wrote:

Libertarian666 wrote:

flyingpylon wrote:It all starts to make sense once you realize we have a uniparty government that doesn't actually want to repeal Obamacare.

Or if you realize that Trump is a master negotiator, and this bill would have been a disaster.

he is certainly proving masterful at ducking the nooses that the uniparty and their co-conspirators keep trying to get around his neck..

Um... didn't he want this bill? Wasn't it the "freedom caucus" that tanked it?

flyingpylon wrote:It all starts to make sense once you realize we have a uniparty government that doesn't actually want to repeal Obamacare.

What do you think they want? To me, a health amount of Repubs in congress don't want Obamacare... slightly less than they don't want to be seen as taking healthcare away from folks.

Of course, they'll suffer it, because their insurance company donors can still profit handsomely.

moda0306 wrote:To me, a health amount of Repubs in congress don't want Obamacare... slightly less than they don't want to be seen as taking healthcare away from folks.

When things cool down, the bipolar dynamic makes me really wish someone would legitimately pitch MediumTexCare in Congress. Universal coverage for everything over $50k/year, and a truly free market under that threshold for people who want to buy insurance for that high deductible. They can even offer assistance for low income people to purchase that insurance so that nobody is left out, as because of the cap it wouldn't even be that expensive anymore.

Think about it -- moderates and even many Dems would crow about universal coverage for all with nobody bankrupted by a major health event, and the Freedom Caucus would still get the chance to talk about free markets, individual responsibility, and doing what they can to actually bring down healthcare expenses. Everybody wins -- even citizens for once.

Tyler wrote:

moda0306 wrote:To me, a health amount of Repubs in congress don't want Obamacare... slightly less than they don't want to be seen as taking healthcare away from folks.

When things cool down, the bipolar dynamic makes me really wish someone would legitimately pitch MediumTexCare in Congress. Universal coverage for everything over $50k/year, and a truly free market under that threshold for people who want to buy insurance for that high deductible. They can even offer assistance for low income people to purchase that insurance so that nobody is left out, as because of the cap it wouldn't even be that expensive anymore.

Think about it -- moderates and even many Dems would crow about universal coverage for all with nobody bankrupted by a major health event, and the Freedom Caucus would still get the chance to talk about free markets, individual responsibility, and doing what they can to actually bring down healthcare expenses. Everybody wins -- even citizens for once.

Almost anything would be better than the current disaster, and MediumTexCare is no exception to that. It sounds considerably better than the piece of crap that just got defeated.

I'm convinced that nothing meaningful will change until the lawmakers acknowledge that the problem is not coverage, it's price.

Here, finally, is a concrete proposal that aims to address the government-sponsored monopoly that is the fundamental cause of the "price" problem. It's being floated by Karl Denninger of the Market Ticker, who's not on my list of favorite people, but who is nonetheless 100% on target when it comes this issue. His contention is that if EXISTING antitrust legislation were enforced against the insurance/medical/pharmaceutical industry, prices would fall to a mere fraction of what they are now and there would be no need for insurance other than minimal, catastrophic, coverage.
https://market-ticker.org/akcs-www?post=231949

Maddy wrote:I'm convinced that nothing meaningful will change until the lawmakers acknowledge that the problem is not coverage, it's price.

Here, finally, is a concrete proposal that aims to address the government-sponsored monopoly that is the fundamental cause of the "price" problem. It's being floated by Karl Denninger of the Market Ticker, who's not on my list of favorite people, but who is nonetheless 100% on target when it comes this issue. His contention is that if EXISTING antitrust legislation were enforced against the insurance/medical/pharmaceutical industry, prices would fall to a mere fraction of what they are now and there would be no need for insurance other than minimal, catastrophic, coverage.
https://market-ticker.org/akcs-www?post=231949

I stopped reading Karl a while ago, too negative for me. However, he always has had good ideas on healthcare, and continually states that no one, even on the right, will give him the time of day when it comes to this issue. So to expect such smart, grand sweeping changes like he proposes seems impossible for now, unfortunately.

Maddy wrote:His contention is that if EXISTING antitrust legislation were enforced against the insurance/medical/pharmaceutical industry, prices would fall to a mere fraction of what they are now and there would be no need for insurance other than minimal, catastrophic, coverage.
https://market-ticker.org/akcs-www?post=231949

Regarding the pharmaceutical industry, if we regulate drug prices too much we'll see fewer drugs being developed. I'm curious what he has to say...reproduced below (and emboldened by me) :

Wholesale drug pricing in the United States must be on a "most-favored nation" basis. The impact of this would be to force a level price across all nations for drugs produced by any pharmaceutical company marketing both in the US and anywhere else in the world. Violations, including attempts to "offshore" via subsidiaries to evade this requirement are deemed criminal and civil acts. The civil penalty shall be 300% of the difference paid to the customer who got screwed, and another 300% for each instance of a prescription filled at an inflated price paid as a fine to the government. This would drive drug prices down by at least half in the United States and for many drugs by 90% or more. It would instantly and permanently end, for example, the practice of charging someone $100,000 for scorpion antivenom in Arizona when the same drug from the same company is $200 for the same quantity 40 miles to the south and across the Mexican border. Since all prices must be posted at the retail consumer level for both goods and services controlling the drug pricing problem at a wholesale level is both simpler and sufficient since competition will already exist at the retail pharmacy level.

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.

Good, short article on how drugs are priced:

http://www.npr.org/2016/02/05/465748256 ... rug-prices

Jack Jones wrote: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.

Pointedstick wrote:

Jack Jones wrote: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.

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.

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.

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.

WiseOne wrote: 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.

WiseOne wrote: 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.

Maddy wrote:

WiseOne wrote: 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?

WiseOne wrote: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.

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.

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

Pointedstick wrote:

Maddy wrote:

WiseOne wrote: 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?

WiseOne wrote: 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?

Maddy wrote:

WiseOne wrote: 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.

Maddy wrote:

WiseOne wrote: 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.