The Health Care Cartels

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D1984
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Re: The Health Care Cartels

Post by D1984 » Wed Sep 12, 2018 10:37 pm

sophie wrote:
Wed Sep 12, 2018 9:51 pm
Actually, I don't like the $50K deductible plan, because the huge expensive structure that drives up the cost of routine office visits, tests, and meds would all remain in place. I would like to see those things removed from the arena of insurance entirely, and made all self-pay. Third party billing, EHR/PQRI/all the other crazy documentation requirements etc would all disappear. For people truly too poor to self-pay, there can be Medicaid clinics staffed by residents at teaching hospitals, or volunteer-staffed free clinics - just exactly as they exist now. Insurance coverage should only be for hospitalizations and expensive outpatient treatments, such as cancer chemotherapy and dialysis.

Not to mention, if people are self-paying, a lot of non-compliant behavior and excessive testing, whether instigated by patients or physicians, would be instantly resolved. That stuff just wastes resources not to mention everybody's time.

What exactly would the cutoff in dollars be for what is considered "expensive hospitalization" and "expensive out patient treatment"? Unless said cutoff is income based (as a given percent of income) then you will have essentially made medical care unaffordable for millions of people; a $5000 procedure is nothing to a multimillionaire hedge fund manager, is barely a minor nuisance to a doctor or lawyer making $300K, is a major financial hit to a factory worker making $35K, and might as well be five billion dollars to someone making minimum wage because both amounts are so far beyond their ability to pay they will have to skip treatment the same either way. This is a non-starter unless massive expansions to Medicaid (and/or free clinics, etc) are funded, likely to the tune of several hundred billion $ a year (a rough estimate based on what is now spent on Medicaid and on the ACA to provide a even a bare minimum amount of coverage for poorer people) at a minimum.

For anyone making less than, say, 1.5X the poverty level expecting them to pay almost ANYTHING out of pocket is going to be a non-starter because they have to spend pretty much everything they make on food, shelter, payroll and income taxes, utilities, transportation, etc and thus have little or no discretionary income at that income level. If you wanted to keep a "self-pay" system for everyone you would (unless you provide the huge increases to Medicaid funding mentioned above) need to fund it with government HSA matching grants ranging from "free gratis money" to anyone under the poverty level to maybe 1:90 (for every cent the person kicks in up to a certain level/cap the government puts in 90 cents) for people at 150% of the poverty line and the matching grants would get much less generous as people moved up the income scale and would gradually disappear totally at or maybe a little above where ACA premium subsidies currently cut-off.

Oh, and while we are at it, do every single idea Dean Baker suggests (in his book Rigged....it's available free online as a PDF for anyone who wishes to read it) regarding having some actual competition in medical services, physician services, medical devices, pharmaceuticals, etc.

Even with all this you would probably still need to regulate prices if you want a system where cash-paying patients paying out of pocket can get truly affordable health care; if, say, an MRI (basic-no contrast imaging of head or abdomen) can be had in Japan for $98 or Switzerland for $140 there is NO WAY it should cost thousands of dollars here in the US; the same applies for drugs, doctor's office visits, surgeries, etc .... see https://www.vox.com/cards/health-prices ... are-prices and https://www.washingtonpost.com/news/won ... -ludicrous . How many nations have successfully kept medical prices low by "free markets" rather by directly or indirectly regulating prices (and/or by running the actual health system itself in addition to/in lieu of regulating prices)? As far as I am aware of....none.
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Maddy
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Re: The Health Care Cartels

Post by Maddy » Thu Sep 13, 2018 8:02 am

sophie wrote:
Wed Sep 12, 2018 9:51 pm
Actually, I don't like the $50K deductible plan, because the huge expensive structure that drives up the cost of routine office visits, tests, and meds would all remain in place. I would like to see those things removed from the arena of insurance entirely, and made all self-pay. Third party billing, EHR/PQRI/all the other crazy documentation requirements etc would all disappear. For people truly too poor to self-pay, there can be Medicaid clinics staffed by residents at teaching hospitals, or volunteer-staffed free clinics - just exactly as they exist now. Insurance coverage should only be for hospitalizations and expensive outpatient treatments, such as cancer chemotherapy and dialysis.

Not to mention, if people are self-paying, a lot of non-compliant behavior and excessive testing, whether instigated by patients or physicians, would be instantly resolved. That stuff just wastes resources not to mention everybody's time.
I thought that's what MediumTex had proposed. Memory has never been my strong point. Anyway, I agree with you completely, Sophie.

So with deductibles as high as they currently are, why has this model not taken greater hold? If you look at the directories of "cash only" or "independent" physicians, you find, for the most part, the very same cast of characters that have always operated outside the insurance structure: naturopaths, acupuncturists, cosmetic dermatologists, people with foreign names. I do, however, see an increase in "concierge" practices, but to me that's just another, albeit private, form of cost-shifting. The (rather high) monthly membership price is no bargain for those of us who rarely have need for a GP more than once every few years, but it makes it possible for concierge practices to promise the high-utilizers in their fold all the hand-patting in the world.
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sophie
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Re: The Health Care Cartels

Post by sophie » Sat Sep 15, 2018 8:26 am

The problem with concierge practices is that they still have to deal with the mountain of regulations that apply to documentation and billing. This is what is driving costs sky-high.

In an earlier post, I explained that if you remove these obstacles from the already low-margin world of outpatient medicine, the costs would drop to something that is congruent with other things that we all routinely pay for without a second thought: haircuts, movie tickets, grocery, cell phone, cable TV etc. The same people who are supposedly too poor to pay for outpatient visits all have cell phones, high speed internet, cable TV, and reasonably nice haircuts so I assume they go to salons. I think the barrier isn't so much "too poor" as "not wanting to go to see doctors, but they will if it's free." I personally think that's wrong-headed - if someone isn't motivated to go for care, they won't comply with the prescribed regimens and that just wastes time & resources.

I'd put all hospitalizations, outpatient procedures, some high-cost diagnostic studies, and high-cost medical treatments such as chemotherapy and dialysis, on the list of stuff to insure. No need for deductible or copays. For pharmaceutical coverage I was thinking a list of low cost drugs that are self-pay and the rest can be insured through a separate program with prices negotiated between Medicare and the pharm companies - because it's those costs that dwarf everything else in the world of outpatient medicine, and can be truly unaffordable for many. Practices will still need prior authorizations for these things, but a system of spot-checking would greatly lessen costs, compared to the current system of having to confirm every single such instance.
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Re: The Health Care Cartels

Post by Desert » Sat Sep 15, 2018 10:47 am

sophie wrote:
Sat Sep 15, 2018 8:26 am
The problem with concierge practices is that they still have to deal with the mountain of regulations that apply to documentation and billing. This is what is driving costs sky-high.

In an earlier post, I explained that if you remove these obstacles from the already low-margin world of outpatient medicine, the costs would drop to something that is congruent with other things that we all routinely pay for without a second thought: haircuts, movie tickets, grocery, cell phone, cable TV etc. The same people who are supposedly too poor to pay for outpatient visits all have cell phones, high speed internet, cable TV, and reasonably nice haircuts so I assume they go to salons. I think the barrier isn't so much "too poor" as "not wanting to go to see doctors, but they will if it's free." I personally think that's wrong-headed - if someone isn't motivated to go for care, they won't comply with the prescribed regimens and that just wastes time & resources.

I'd put all hospitalizations, outpatient procedures, some high-cost diagnostic studies, and high-cost medical treatments such as chemotherapy and dialysis, on the list of stuff to insure. No need for deductible or copays. For pharmaceutical coverage I was thinking a list of low cost drugs that are self-pay and the rest can be insured through a separate program with prices negotiated between Medicare and the pharm companies - because it's those costs that dwarf everything else in the world of outpatient medicine, and can be truly unaffordable for many. Practices will still need prior authorizations for these things, but a system of spot-checking would greatly lessen costs, compared to the current system of having to confirm every single such instance.
This sounds perfect, actually. I couldn't agree more with this entire post.
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