Olympics if it's mostly slagging. Otherwise healthcare.
Healthcare, b/c I don't know anything about the olympics except that I keep having vague ideas of signing up for cable this week.
Worthiness for health care as determined by Olympic-difficulty tests of strength!
GHAweGAJS:KLglsdabnjlwsjk
I mean, health care.
Healthcare. I'd be impressed if you could work them both into the same post though.
The Olympics -- because I will be there, at least for a bit.
Everyone root for G/eorgia G/ould and S/arah H/ammer!
Let's talk about Olympics of the Mind! Or whatever it is called now! Let us talk of trademark violations brought against diners by the Olympics Board.
Or Pindar's 1st Olympian! Is water the finest thing?
4: As in, not being able to do any actual activity?
Speaking of which, I believe today is the first time yet that I've gone to the weight room and not felt achey hours later. Even though I really didn't slack off. Progress?
After the first 10 comments, the score is
Health care 4
Olympics 1
Satan 5
Okay, let's tally up the votes, you dangling chads!
4 clear votes for health care.
1 clear vote for the Olympics.
1 I don't really know what slagging means
3 variations that are hard to interpret!
HEALTH CARE IT IS. STAY TUNED.
What's the 2008 equivalent to Eddie the Eagle or the Jamaican bobsled team ?
Bleh. Olympics, because I heard a story a short bit ago about the fact that many Olympic competitors are staying away from Beijing until the last minute in order to avoid coughing up a, uh, spitball and basically dying due to the pollution that's really bad already by 5 a.m., so we are really feeling badly for the triathletes whose event can't be rescheduled.
Oh, and spitting is illegal in Beijing.
Slagging would mean talking about how the Olympics suck. You should try to keep up with the way young people talk.
OK, you know what "suck" means, right?
Heebie, can we also have a penalty for wrongful denial of claims? 150% if they relent within 30 days, 200% within 60, 500% if they relent or are reversed thereafter?
The upshot would be that young, healthy people would buy coverage that didn't cover anything, for low premiums.
Older, sicker people would buy expensive coverage which covered things, if they could afford it.
You'd still end up with a lot of people who couldn't afford coverage being subsidized by health care providers charging those who can pay.
And you've still got all the incentives for cost shifting that so screw up the system today. (I'm sorry, if you'd read the master copy of your policy, which is only available in our offices in Elgin, you'd see that we clearly exclude coverage for conditions with 12 letters in their name, when the diagnosis is determined on a day whose calendar number divided by 13 is irrational)
The first law is that insurance companies must accept all applicants. The second law is that insurance companies must charge all customers the same rate.
Gah.
If the market is a shitty way to give basic health care, then we should just make a straightforward case for a "Medicare and/or VA style system for all" funded by the taxpayers. Letting the market do it, but dictating what they can charge is crap.
19: Yes. Yes we can. Effective retroactively.
If the market is a shitty way to give basic health care, ...
Yep. Single payor (and why does everyone but me want to say payer?)
day whose calendar number divided by 13 is irrational
An otiose condition.
The upshot would be that young, healthy people would buy coverage that didn't cover anything, for low premiums.
The answer I've heard to that is to have additional "catastrophic coverage", which just sounds insane. That's what insurance is for catastrophic shit you don't expect will happen but might.
One helpful suggestion I've heard is not to talk about it like insurance, since it's not like auto, or flood, or whatever insurance. But I don't remember the suggested term. Maybe just "coverage".
I have never seen the word "payor" in my life. is it some sort of Latin American herb?
My understanding is that one of the benefits of "universal" health care is that the healthy subsidize the unhealthy. Full coverage for a bunch of people who need full coverage will be expensive.
So I think that is a flaw in "someone"'s plan. Maybe a third law? If it works for robotics . . .
On preview, somewhat pwned.
Morph the VA into a single payer system. Increase funding for the VA. Find ways to increase the number of people with coverage through the VA (relatives of veterans, survivors of veterans, etc).
It's already has the best healthcare information management system in the world.
Heebie's policy proposals are pretty much old hat in the health policy world: "guaranteed issue" and "community rating" are the terms of art (the third concept is "insurer of last resort", "Medicare for all", or "lemon socialism", depending on your point of view).
Most UHC advocates favor some version of 1 and 2, and some will sign on for 3 as well.
The major controversy that heebie's "plan" elides is the issue of mandates: will the young and healthy be required to pay into the health financing system somehow, or can they play the odds until they get sick, at which point an insurer would be required to take them on at the same rate as members who have been paying premiums all along.
The policy debate is controversial enough, but once you start considering the necessity of winning 60 votes in the Senate, heebie's plan is a non-starter without either (A) a coverage mandate; or (B) a government reinsurance program that would take the liability for the sickest patients out of the private insurance pool.
Also, I should mention that the health insurers are clever enough to selectively deter bad health risks even under conditions of guaranteed issue and community rating. The classic tricks are things like offering reimbursement for health club memberships (ostensibly to improve member health, but really to attract a younger and more athletic customer segment) and requiring that new customers stop by in person to fill out forms at the insurer's office, located on the third floor of a building with no elevator.
the healthy subsidize the unhealthy
Elegantly captured by Roast Beef's phrase, "the living buy bread from the already dead".
Regardless of policy preferences, this much is clear: heebie has a crush on Ezra and is trying to lure him over.
I have a crush on trying to do my part to make Unfogged the very best little Unfogged Site it can be, Stanley.
I thought that the two parties to a check were the payor and the payee.
You also need a no-cancellation requirement. Presently, as I understand it, an insurance company can terminate an entire group, when that group becomes too old and sick and stops being profitable. This leaves people uninsurale.
Guaranteed acceptance to any group doesn't do it, because if the only group that covers your condition charges $15,000 per mnth, you're kinda screwed.
33: I'm recovering from a near-fatal bee sting with a less-than-ideal health-care system in place. Clearly, I can't post at a time like this, and I wholeheartedly endorse your efforts.
35: I'll have you know I'm really lazy. Yet I manage to push through the pain.
Find ways to increase the number of people with coverage through the VA (relatives of veterans, survivors of veterans, etc).
Every American, whether man, woman, or child, is a veteran, or a future veteran, or a would-be veteran, of the War on Terror. I'm sure this could be reduced to a pithy slogan that could fit on a bumper sticker.
Seriously, I think you're on the right track. The private health insurance industry is huge, and apparently hugely profitable, but it's also hugely unnecessary, not to mention completely incompatible with the goal of socialized health care for all. A government agency can do it better, and much, much cheaper (what with the elimination of the profit motive and etc.).
For the record, I totally agree with 38 and all the other socialized medicine pushers. I'm just saying, I have no idea how to get from here to there, and I thought this was interesting. By that I mean interesting to me. And ultimately I must answer to the face in the mirror. Thank you.
How about we make the age for Medical eligibility somewhere around 24?
I guess I don't know why the insurance industry's political maneuvers have been so successful. Most everyone likes Medicare, most everyone hates insurance companies - yet most voters can't bear the thought of those poor widdle orphan insurance companies being put out of business.
crap. Medicare. not Medical. That'll teach me not to use a spell checker when I can't remember how to spell sucessful.
You also need a no-cancellation requirement. Presently, as I understand it, an insurance company can terminate an entire group, when that group becomes too old and sick and stops being profitable.
It's not quite that simple, but it works out the same way. To varying degrees, state insurance regulations limit the ability of insurers to terminate a group policy outright. To get around that, the insurers simply stop writing new policies in that group. Without an influx of younger, healthier members, the group's actuarial cost (which determines the permissible premium) spirals up, thus driving the healthier group members into cheaper alternatives and leaving only the sickest members. At that point, the premium becomes unaffordable to anyone, and the group collapses. Insurers call it "putting a plan into a death spiral", and it's an open secret in the industry that they do it deliberately, though never obviously enough to invite an enforcement action.
42 - right. That's wht I meant to say. That's what's happenning to the Blue Cross plan I'm in, and there's no way I'm getting any other non-pool coverage. Just the application for the cheaper form (identify everything any doctor has said to you in the last 50 years - and remember that if you forget anything we'll deny coverage) is impossible.
In other words, I'm screwed.
and remember that if you forget anything we'll deny coverage go ahead and write the policy and take your premium checks, but we'll deny the claim and cancel your policy if you ever get sick and we go digging into your medical history.
How about we make the age for Medical eligibility somewhere around 24?
The political logic is unassailable. The main problem is that Medicare, as currently structured, is financially unsustainable even with the current restricted eligibility, and will become more so if you let in all the uninsurable under-65's.
My personal pet idea is to offer a more actuarially sustainable version of Medicare (i.e. with better cost controls) to younger citizens, but with the stipulation that they have to stay in the plan past age 65. That way, the government could correct some of the long-term financial imbalances in the over 65 program without the political uproar that would come from reducing benefits for current recipients.
dictating what they can charge is crap.
This isn't dictating what they can charge, though; it's dictating that they charge everyone the same price.
Think of it this way: if you walk into a store to buy an apple, they don't eyeball you (or rely on finely-grained statistics) and say, "hm, white guy, cop uniform, I bet he won't pay much for that apple" and then turn around and see Heebie and say, "young woman, athletic, I bet she's willing to pay a premium for healthy food."
44: you are just more articulate than me (can I say that?). That's what I meant.
My partner turned up with breast cancer on a routine mammogram shortly after getting a new Blue Cross policy. According to her, while she was in the hospital after the mastectomy, on a morphine drip, a Blue Cross representative stopped by and wanted to know if she'd noticed any lumps before the mammogram.
Obviously, if she'd said yes, they'd have denied coverage because it was an undisclosed condition for which she should have sought treatment at the time she was accepted into the new policy group. She said no, which was the truth, much to the disappointment of Blue Cross.
I'm just saying, I have no idea how to get from here to there,
Yeah, I hear you. I have no idea either. What with the power of the health insurance lobby, and the lack of a social democratic political party with enough power to, if not get its members elected in sufficient numbers to actually form a government, at least help push the agenda somewhat leftward, probably incremental change and stealth-like movement in the direction of universal health care is the only way to go.
physicians are a problem now too. It's a lot easier to convince someone they need to be making $450k/year than it is to convince them to take 2-300k cut. Even if malpractice is made sane, along with other bits and pieces that dig into that.
I've heard some pretty sickening stuff from private practice people about billing and the insurance codes. Which is undeniably reducing the standard of care for some procedures through a combination of the insurance industries inability to keep up with technology and private practice people getting addicted to easy money codes.
dictating what they can charge is crap
I got news for you: state insurance commissions already dictate (or at least regulate) the premiums that insurers can charge. To a greater or lesser degree, every state mandates certain minimum benefits, prohibits certain marketing practices, restricts the freedom of insurers to deny coverage and/or renewal, and caps the amount of premium that can be charged as function of the actuarial medical claims ratio.
So we're really talking about a change in degree, not of one of kind. And we're talking about a consistent nationwide standard rather than a patchwork of state regulations.
I'm just saying, I have no idea how to get from here to there
I'm pretty much convinced that the US system will continue to fall behind (ironic, isn't it?) until the insurance industry is largely or completely taken out of the game.
She said no, which was the truth, much to the disappointment of Blue Cross.
Subrogation, the practice of trying to find another responsible party to hang the costs on, is an incredible growth business in the health care sector. Basically, you have service providers who will take ever claim above a certain threshold and try to get the patient to acknowledge that the condition was either work related, covered by another insurance policy (e.g. a spouse's), or the fault of someone else who can be sued.
I had an interesting experience with a subrogration contractor concerning an injury that they were bending over backwards to characterize as a worker's comp claim.
All it takes is one asshole who knows what he's talking about to kill a health care policy thread.
52: Yep.
That's the big lesson companies have learned. The way to big profits is not to invent a better mousetrap. The best way is to capture all revenue while ducking all costs. Risk shifting.
That's why the answer has to be a single payor (or payer) system.
a more actuarially sustainable version of Medicare (i.e. with better cost controls)
Say more. What elements of cost control can you imagine?
What is the objection to allowing companies to vary their rates by age? So all customers the same age are charged the same rate but you can charge the old more than the young.
55
"Say more. What elements of cost control can you imagine?"
No coverage of any drug which is still on patent.
Say more. What elements of cost control can you imagine?
I'm just spouting off here, so this comes with no warranty, but....
1. something like a public sector version of Medicare Advantage (the Medicare HMO option that is presently administered by private insurers at significantly higher cost than the classic fee-for-service version of Medicare
2. An alternative, non-HMO model that compensates doctors for health outcomes rather than procedures (especially important for the treatment of chronic illnesses such as cardiovascular disease and diabetes)
3. A VA-style national electronic patient information management system
4. A more comprehensive offering of hospice-style options for end-of-life care, to provide a humane environment for patients who don't want aggressive medical intervention
5. Brass-knuckles negotiations with pharma companies over drug prices in the Part D program.
There are structural factors (aging population, advances in technology, rise in obesity) that are going to drive up Medicare costs no matter what we do, so I'm resigned to the fact that we're looking at a couple more points of GDP devoted to that program, but I don't think we're completely helpless to slow its growth.
56: Kind of cuts against the whole healthy-subsidize-the-sick thing, no?
59
"Kind of cuts against the whole healthy-subsidize-the-sick thing, no?"
I don't think so, if you look over lifetimes the healthy still subsidize the sick but everyone's payments more closely match actuarial risk.
59: But the whole point of healthcare finance is that matching payments to actuarial risk doesn't work.
General comment: it's not a bad thing that healthcare is expensive. It's valuable. We shouldn't flush so many healthcare dollars down the toilet, but even a more efficient system will still be expensive. But I would bet that the majority of American households spend more on transportation than they do on healthcare, and aside from whining about gas prices we're not too worked up about the cost of getting around.
Also, because I haven't been around much and don't want to cause needless offense, 53 was not intended to be taken seriously.
But I would bet that the majority of American households spend more on transportation than they do on healthcare, and aside from whining about gas prices we're not too worked up about the cost of getting around.
The minority that spend huge amounts of money on healthcare is large enough to require attention.
I'd also guess that if you include what the employer spends on health insurance premiums but doesn't show up on your pay stub, your statement may not hold true.
Finally, if you want the healthy to subsidize the sick, you'll generally need to force the healthy to do so. This isn't a bad thing, but pretending it doesn't have to happen is going to lead to heartache and failure.
60: The saying used to be that 90% of lifetime health care expenses are incurred within the last six months of life; older people are more likely to die, and more likely to die of something that costs a lot to treat.
63.1: No question. Catastrophic costs are manageable if spread across the whole population, but almost no one could pay those costs on their own.
63.2: That's the claim I'm making. I might be wrong, but around here the total cost of family coverage was somewhere in the neighborhood of $1000/month last time I looked, and two cars + insurance + gas + maintenance would run more than that for an awful lot of families.
63.3: Who's pretending?
65
"... but around here the total cost of family coverage was somewhere in the neighborhood of $1000/month last time I looked ..."
Isn't that going to go up if you charge children the same amount as adults?
Schneider rocked this thread. His 21 pretty much said what I was going to say -- there are a million selection games insurers can play if you try to fix charges but allow them to vary their coverage package.
The least you would have to do is require all insurers to give a few standardized policies defined by the government.
However, the Olympics is more interesting.
A guy I know was in Beijing a few weeks ago and said the pollution was so bad he had to wear a face mask, and even then within a day or two his throat was raw and he felt like he was choking. But that was right before the government made the steel plants shut down and they were all running at high intensity, so who knows.
Also, I just saw a documentary about Johnny Cash. I now feel silly for saying several times on this site that he was overrated.
$1000/month
Holy shit!
There's a lot of discussion about how to keep people in plans long enough for the numbers to work out, and how to ensure people don't only join at the last minute when sick, etc.
Just taking the money from everyone as taxation solves that. It solves almost all of the free-rider, sick-being-insufficiently-subsided-by-the-healthy problems.
Just taking the money from everyone as taxation
This is exactly it, nattarGcM. We're trying to figure how to get there.
The effect of these two laws would be that insurance companies can only distinguish themselves by the coverage they offer - bare bones coverage to extensive coverage.
In other words they can discriminate as much as they like, by playing around with the deductible and coverage. This is a Blame It On Fatty model and it's basically a non-starter.
"lemon socialism"
Quesque c'est? (No, I'm not going to google it; my phone won't open more than one window at a time, 'cause it's stupid like that Windows.)
"Lemon socialism" is privatised gain with socialised risk; the government bails out the lemons but the private sector absorbs all the profits.
64: For Big Telecom Corp., the current stats are that 20% of participants are 80% of the cost.
Also, pregnancy and childbirth are hugely expensive to cover, so please knock off all this procreating, you selfish parents.
If you were recommending one (or two or three) books on health care policy in the U.S. for someone with no prior knowledge of it and not much knowledge of economics, what would it/they be?
(Articles are ok, too, but I'm looking for something that includes a bit about the history of other attempts at health care, and that probably means more than article length.)
By the way, bastards, wasn't it not so long ago that I was saying that Paris Hilton was very much underrated as a comic actress in the Doris Day mould? And you lot all said "no you're mad, etc". You realise it was only a matter of time before I was proved right, don't you?
Also, I should mention that the health insurers are clever enough to selectively deter bad health risks even under conditions of guaranteed issue and community rating. The classic tricks are things like offering reimbursement for health club memberships (ostensibly to improve member health, but really to attract a younger and more athletic customer segment)
Even in Massachusetts I've noticed this. Network health is onee of the Medicaid Managed Care Organizations, and they offer discounted health club memberships. It also happens to be that they are the lowest cost provider and are very stingy w/ mental health benefits--particularly for group therapy. Any psychiatric patient with sense is going to go to Neighborhood Health. People who used to owe no premiums now have to pay premiums which means that more people without illnesses will leave NHP for Network.
76: Jon Cohn's Sick is an engaging, non-technical introduction that traces the history of how we got here and also puts a human face on the tragic flaws of our system.
That's the claim I'm making. I might be wrong, but around here the total cost of family coverage was somewhere in the neighborhood of $1000/month last time I looked, and two cars + insurance + gas + maintenance would run more than that for an awful lot of families.
Alas, this example is misleading. Once you count 1. employer contributions; 2. Deductibles, copayments, and out of pocket contributions; 3. uninsured losses; and 4. government payments, the total cost of health care is approximately 2X the total cost of transportation in the economy (and that's counting ALL transportation, including the transportation component of the goods and services that people consume). And while the cost of transportation was in long-term decline until very recently (the real dollar cost per ton-mile declined almost continuously for over 20 years before it began to climb again), the cost of health care has been increasing faster than inflation over the same period, *and* the proportion of healthcare costs borne by individuals and families has increased faster than the overall rate of increase.
So yes, health care costs are on an unsustainable trajectory, whatever you believe about the positive value of health care consumption as a "luxury good" in the technical economic sense.
KR's right that there's a patchwork of state regulations, but there's also the massive Federal deregulation under ERISA. If your company/employer is big enough they are probably offering you health care coverage and not insurance in the state regulatable sense.
States can regulate insurance; they are not supposed to regulate employee benefits. If a company is big enough, it pays the claims itself and gets a company like United or Aetna to do the administration.
Medium sized companies can get around this by paying out the claims up to a certain point and then buying stop loss insurance to cover their losses beyond a certain point, but they're not buying health insurance, so it falls outside the purview of state regulation.
So, even if you live in a State like Massachusetts which has some degree of mental health parity, that may not apply. The department of Labor which regulates ERISA welfare plans does have certain rules about parity, and there are people trying to toughen them up. Lifetime limits on mental health care can't be lower than lifetime limits on other medical care, but there's a gaping hole in this protection which is that a company can simply refuse to offer coverage for mental health care with language like "no payment will be made to any psychiatrist or other professional treating any kind of mental or nervous condition."
Whole Foods does that which means that if your kid gets schizophrenia, you can't get him evaluated by a psychiatrist.
So the lesson is: don't shop at Whole Foods. In addition to being union busters, they also screw their employees on health care.
64: The saying used to be that 90% of lifetime health care expenses are incurred within the last six months of life; older people are more likely to die, and more likely to die of something that costs a lot to treat.
That seems high, but I am sure it is directionally correct. I do wonder what the fact the we have lost our way to death costs society.
81: Good point: ERISA pre-empts a lot of state regulation w/r/t employee benefit plans. It's a very complicated area of the law that I don't pretend to understand very well.
There are also significant federal protections for individuals under HIPAA, most notably the portability and nondiscrimination provisions.
84: I don't pretend to know it well, but I did take a class on it, and it is extremely complicated, and only about 1/4 to 1/3 of the course was devoted to welfare benefits issues. We barely covered the fiduciary duties aspects, since my professor had contributed the tax portions of the text book.
The supreme court is really sick of dealing with it, and it's not always clear what they're saying. Deciding whether something should count as insurance or not has been very tricky. Initially a lot of people thought that the states right to regulate insurance would only extend to things like loss ratios and reserves and that saying what sorts of benefits packages could be bought as insurance was preempted.
New York at one point (maybe it still does) had a law requiring insurance companies other than Blue Cross (then non-profit and a guaranteed issuer) to pay a surcharge to hospitals. Many people thought that this amounted to a regulation of benefit plans, but the S.C. said no.
I sometimes worry, in the short-term, about setting Federal standards, because if those standards aren't high enough, there will be a race to the bottom problem. Health Care for All MA posted information on a Republican bill (I don't think that the Dems would allow this) which was going to allow people in any state to buy health insurance from any other state. This would mean that young healthy people in MA and other guaranteed issue, community-rated states would flock to the cheap states and the mostly non-profit insurers in MA would go out of business, since nobody would be able to afford the premiums they would hav eto charge.
My understanding, Heebster, is that what you describe were key components of Edwards's, Obama's, and Clinton's plans (plus coverage minimums, mandates (Edwards and Clinton only), a government-run option, subsidies for those who can't afford, etc.).
From what I've read here and elsewhere, it's a piss-poor substitute for single-payer, but the health policy liberal elite (as represented in my mind by Ezra Klein) has decided it's the only thing that's politically feasible - single-payer would mean wiping out most of the health insurance industry, after all. Plus they've determined that people know the health care system is very messed up and requires change, but they also hate the idea of losing their current insurance for something unknown.
Despite all the weasel ways of the insurance companies, with good implementation, the current Democratic plans could still improve people's lot, and pave the way for single-payer in the future. (Specific mechanisms therefor: having the government-run option demonstrate its superiority and become predominant; publicly demonizing insurance companies for getting around the rules; etc.)
Is straight up single-payer really the best system? France's isn't, I don't think.
Also, much as I admire the Canadian system, they really need to include prescription drugs in the universal package.
85: Yes, this is one of the core planks of Republican health care policy: allow "association plans" to offer policies in all states under the regulations of the least restrictive jurisdiction they can find. They sell it politically by saying they want to allow "groups of small businesses and trade associations to bundle their purchasing power and get better rates", but this is, to use the technical term, an "overfilled crock of putrid shit". The real goal is to make state-level minimum standards impossible.
The danger of this plan is that it will actually work for a lot of people--conceivably even the majority of people--by making their premiums cheaper. It will achieve this by pushing all of the burden onto the minority of very sick or chronically ill people. In other words, it is intended to break up the risk pool.
The other planks of GOP health policy (health savings accounts, high deductible plans, and privatization of Medicare) are easier to understand once you grasp that the the fundamental ideological goal is to make health care a personal responsibility, rather than a collective one.
87: Maybe some countries with combinations of public and heavily-regulated private insurance (Germany? KR?) do well enough, but I don't see us getting our insurers cooperative and public-minded enough to make sure such a system works. Plus we have good experience with Medicare and the VA that can be applied (issues of future solvency aside).
Books I'd recommend:
Crisis of Abundance, Kling
Overtreated, Brownlee
For monographs, anything by Cutler or Pauly
87. Aren't you in danger of letting the best become the enemy of the good here? The French system isn't ideal, but it isn't actively pernicious either. And there are plenty of people who would sign up to the project of designing the best imaginable system because they would see it as guaranteeing that nothing would ever get done.
Does anyone know anything about Taiwan's healthcare system. I would guess that it would be one to look at since they changed from private to public more recently than the European countries. I keep meaning to look at what they did, but never quite get around to it.
Some more info showing that 61 is not only a unhelpful comparison but also wrong on the facts. These costs are for premiums alone and don't include co-pays, deductibles, plus things like credit card interest when having to charge medical services.
Between 2000 and 2007 alone, the average annual premium for job-based family health coverage rose from $6,351 to $12,106, an increase of more than 90 percent. During the same period, the average worker's share of annual family premiums rose from $1,656 to $3,281, an increase of more than 98 percent.
(From Families USA, a trustworthy org.)
As a general FYI, the Kaiser Family Foundation is also a good source of reliable information on health care.
90: Kling is a good recommendation to get a non-social democratic perspective on the issue. I have some pretty fundamental disagreements with Kling's analysis and prescriptions, but he is smart and honest, which cannot be said for a lot of people who hold similar views.
I haven't read the Brownlee book, but she has written some interesting stuff in the past on the distortions of the profit motive in our health care system. I would posit that a lot of lefties would concur with the argument that a lot of health care spending is wasted on low-value procedures and that the U.S. gets a poor bang for the buck. How we address that problem (by putting more burden on the individual so that they'll think twice about going to the doctor, as the consumer-directed care advocates want) or by a more dirigiste government intervention to allocate resources to high-impact uses (as lefties tend to prefer) is open to debate.
re: 93
Holy shit, again. As has been pointed out before, these numbers are high by international standards.
96: These numbers are insane by any standards. And, as you may already know, the U.S. ranks something like 37th in health care outcomes.
92: Taiwan is universal single-payer, with dedicated payroll taxes. There are some presentations here.
One more pointer: I find J@cob H@cker's description of what is more or less the Obama/Clinton/Edwards plan very helpful.
Also, much as I admire the Canadian system, they really need to include prescription drugs in the universal package.
The drugs are heavily subsidized. Much more affordable than they are here.
Health insurance may be the reason we move to Canada. We have crappy insurance for shivbunny at the moment; mine's covered through school, but once I finish, if I don't land a job, I can have crappy health insurance, too. Surprisingly, crappy health insurance doesn't cover pregnancy, and as we do want to have kids, it looks like immigrating to Canada would be cheaper than finding a plan for me here.
And remember, kids, those numbers? That's for health *insurance.* Not health care. $12,000 a year, if no one at all gets sick.
95: The reason I credit Kling with honesty is that he openly and straightforwardly says that Americans consume too much health care services with a low marginal utility, and that they do so because the incentives in our health financing system insulate the patient from the consequences of this decision.
Your average dishonest Republican, tries to frighten the public with horror scenarios about government-imposed rationing under UHC (there are waiting lists for hip replacements in Canada!) without acknowledging that their own preferred policies are premised on creating financial deterrants to seeking health care.
As it happens, Kling is also honest enough to concede that his consumer-directed utopia cannot deal with the problem of the sickest 20% (the severely and chronically ill who cause the majority of health care expenditures), so he advocates that the government step in to socialize the risk associated with these patients. Just to make that perfectly clear: on the single most important issue in the health care debate (from a liberal perspective), the conservative libertarian economist is acquiescing to the liberal solution.
Keep that in mind when you read Kling, eb.
we have lost our way to death
Very interesting (and lyrical) formulation. I definitely agree on many fronts -- not enough hospice care; illegality of assisted suicide; Terri Schiavo sorts of cases -- though I have a harder time drawing a line on when aggressive treatment should end.
re: 97
Well, yeah. The numbers on US healthcare [costs and outcomes] are transparently fucked up. Although on 'teh internets' there are zillion people prepared to argue that fact anyway.
The NHS is a favourite whipping boy for private healthcare advocates but on almost every measure [cost and outcome] it performs way above the US norm. And I don't think anyone seriously thinks the NHS system is the best out there.
It shouldn't need pointing out, but in case it does, the British NHS and other universal systems emphasise primary care over hospitalisation not just because it tends to lead to a healthier and happier population, but because it's more fucking cost effective.
government-imposed rationing under UHC (there are waiting lists for hip replacements in Canada!)
Can I rant about this? I want to know who the hell these Americans are, who call up their doctor and get into surgery the very next day. Every single person I have known in the U.S. who has had procedures like that has had to wait months, for availability, for insurance approvals, for referrals. These, of course, are the people with sufficient insurance to consider a hip replacement.
So who the fuck are these people, and why the fuck are we taking their experiences as normal?
(Plus, there is no rationing of hip replacements (calling to mind proud Canadians humbled in line-ups, hoping their number will be called so Tiny Tim can be handed a hip) or MRIS or knee replacements. When there are long delays, it's due to not having enough doctors and nurses, mostly. That's a significant problem, but it's surely not the government coming in and saying 'no more hips this year.')
I'm no big fan of the NHS, but one thing it has done successfully is control doctors incomes. A study by the McKinsey Global Institute (can't link to it because they block my work IP) showed that the major difference between the US and Germany was not in the number of procedures performed per patient, but in the labor cost of the procedures. Authors like Kling gloss over the fact that other countries (France, Germany) "overconsume" health care, too (because you have to take a certain amount of needless care into account if you're going to ensure that care is always provided when needed); it's just that the providers earn a lot less for each unnecessary procedure.
Further to 106: Before anyone says "but if you limit doctors' incomes, they will flee the profession and we'll be short of doctors, or we will get less capable doctors," save it.
The limited number of positions to study medicine in Germany is heavily oversubscribed every year (there's a waiting list!), and the medical faculties routinely fill their classes with students with the highest possible grade on the high school leaving exams.
The daughter of friends is a medical student. Her cohort aren't sure if they'll get jobs in Britain.
re: 108
That was a very recent bolloxing up of the recruitment process, though, wasn't it? Rather than a massive oversupply of doctors. Or perhaps I'm misinformed?
The saying used to be that 90% of lifetime health care expenses are incurred within the last six months of life;
I have heard this as well (or was it 83%), but have never found a study that aggregates health-care expenditures by time-before-death. There was a big lovely NYT article decades ago exaimining fate and cost of a single medicare patient who died an expensive treated death, but no pretense of generalizability. Does anyone have a pointer to empirical data that addresses this?
100: Cala, I don't disagree, but I was just in Canada, and I spent some time talking to med students in Ottawa who said that the hospital was hiring nurses hand over fist, but that they were hiring people part-time and without benefits. I looked puzzled and everyone pointed out to me that OHIP doesn't cover prescriptions and that this is a real problem for anyone with a chronic condition.
I believe that the very poor and some old people do get drug coverage, and if you have to spend more than $10,000 on drugs it's covered but means-tested programs simply add an extra level of bureaucracy.
Grad students at a lot of Canadian universities wind up buying supplemental insurance. That doesn't really happen in the UK.
I like the Canadian system a lot, but if I were Canadian I would be lobbying for prescription drug coverage and dental.
OT: When I was in a Tom Horton's I ordered a maple-glazed doughnut, and I thought of Mary Catherine and Ari as I did it.
105: Yes, that's basically bullshit. With the exception of a few procedures with systematic scheduling problems (not enough specialists), and some underserved areas (same in the US), the whole `But Canada has waiting lists' is a bullshit. It's a convenient red herring for people trying to explain away the fact that Canada gets on average equivalent or better health care than the US, for significantly less cost. It's a problem for lobbyists and other boosters of the the current system here, because Canada is harder to dismiss as `different' than, say, France (which is nearly across the board significantly better).
When I was in a Tom Horton's I ordered a maple-glazed doughnut, and I thought of Mary Catherine and Ari as I did it.
Was it connected to a Windy's?
but if I were Canadian I would be lobbying for prescription drug coverage and dental.
Oh, absolutely. The Canadian system has problems too, they are just easier to fix than the US problems. At least in theory.
111: Oh, definitely. I didn't mean to minimize the problem, but there's a huge difference between having no prescription coverage in the U.S., and having none in Canada. I'm also more familiar with Alberta health care which seems to be better run than OHIP.
Maple-glazed donuts are great. When I was up there earlier this summer, we ordered a box of TimBits and went to the farmer's market, so we ended up gorging ourselves on donuts and fresh peas. Not a bad combination.
OFE-- I've heard of this weird medical test that doctors had to take, and they all deeply resent it. I think it's called MCAS, and doctors are going into consulting or something, because they're fed up with Blairite NHS policies.
Canada is, I think, recruiting in the UK. Canada does seem to have too many specialists and not enough GPs, but we have the same problem here.
They are also procedure-driven rather than outcome driven, so you don't get paid for thinking about a patient, but you do get paid for inserting a central line, and consequently too many central lines are inserted. It's the same problem we have here.
Cala, I bet you could get free housing if you wanted to teach kids in Alberta, which you'd need, because I've heard (as I'm sure you know) that because the oil sands are booming, rents are astronomical.
The rents are NUTS. Mortgages are worse. My brother-in-law bought a new house. It is tiny. It cost $400K. He will pay it off when he is 65. And what's weird about it, from my American perspective, is that it's in an area with comparatively low population density. Drive outside of their development and there's fields for two miles. (Also, the lot sizes are the size of postage stamps.) I know it's just demand, but no way in hell they're not going to have a crash.
My father-in-law builds houses, and it's about an 18 month wait for a new house right now.
Canada does seem to have too many specialists and not enough GPs, but we have the same problem here.
Plus, a lot of Canadian doctors are able to come here to work. It's a problem, but it's not one I'm sure generalizes to the U.S. were we to adopt UHC.
Ugh, that should have been Tim Horton's. I don't know whether Wendy's still owns Tim Horton's. Percentage wise, Tim Horton's was outperforming Wendy's, and no wonder, since they make real sandwiches. I think taht Wendy's might have dumped them.
which is nearly across the board significantly better
One of the ways in which France is (superficially) worse than France is that the whole infrastructure of health care is less "gold plated". Having spent more time than I care to remember inside pediatric wards of both countries, I was struck by the fact that U.S. hospitals--as shop-worn and unattractive as they may be--are gold-plated compared to their French equivalents (especially if we are talking about the US facilities that an affluent American is likely to visit). The same tends to hold true of doctors offices. The same difference exists to an even greater degree between the US and the UK.
Because first impressions are durable, and because Americans have been trained to associate new, gleaming buildings with high quality, I would imagine that a lot of Americans get a bad impression of socialized medicine by accidental encounters with the French system. Once you get beneath the surface, the French system compares very favorably with the US on outcomes (partly because it strongly emphasizes low-cost preventive intervention; e.g. a pregnant woman is legally required to attend prenatal appointments and infant care classes). But when you see the rust-stained washbasin and the peeling paint in the clinic, the initial impression isn't good.
Isn't it a basic principle of logic, or a tautology, that France is superficially worse than France?
Or is it something special about France alone that makes it reflexively superficially worse?
Teaching the the NWT can be very lucrative. Also mining.
re: 119
Czech hospitals are like that. They look exactly like you'd imagine the Eastern Bloc looked like in 1965.
a pregnant woman is legally required to attend prenatal appointments and infant care classes
I don't think that this would go over well here.
Can't you upgrade to private clinics in France and pay the difference with supplemental insurance.
and because Americans have been trained to associate new, gleaming buildings with high quality,
There's some truth in this. Which is why it was so easy to sell Americans the highly polished turd that is US health care.
The thing with too many specialists is that here's no way for a GP / Family-health doctor to advance except by changing specialty.
It's somewhat the same in HS education, where a teacher can advance a little by moving to a better school or by getting a Masters degree, but then tops out. So a lot of the best teacher aim for administration or get out of teaching.
One thing I don't undersstand is how insured people in the US can pay a lower rate for health care than uninsured people.
I'm looking at a bill from a lab, for blood tests. It says that their normal rate is $146.21, but because I'm a Blue Cross member I'm entitled to their special rate of $39.40. I have no doubt that were I a poor, uninsured person they'd insist on the full $146.21 . I'd put it on a credit card, and with interest, end up owing about $400 instead of $40.
Doesn't this sort of screwy pricey structure make all the data on costs and unrecovered costs and mdical expenses questionable? Isn't this some sort of deceptive trade practice, considering that it's impossible to get a straight answer on the cost of a procedure before becoming liable? Doesn't this throw all the arguments about consumers making better choices into a cocked hat?
126: It's not just that. GP's may not have quite the same debt level beginning their career as the higher payed specialties, but it's still likely to be 6 figures. On top of which, they're typically going to need to buy into a practice (i.e. replace a retiring GP) for many more 100s of thousands, or try and build from scratch. It can take decades to get out of debt this way. By comparison, a specialist will typically take a hospital job at the start, get a pretty fat paycheck, and in theory anyway be able to knock of the debt fairly quickly. That has to give many med school students pause.
Realistically, though, the largest problem is probably the relative contempt that the GP path is treated with by much of the medical educational community (and general medical community for that matter). It's often looked at as the sort of thing to do if you aren't very good in med school.
From a health care outcomes point of view, this is completely insane.
Doesn't this sort of screwy pricey structure make all the data on costs and unrecovered costs and mdical expenses questionable? Isn't this some sort of deceptive trade practice, considering that it's impossible to get a straight answer on the cost of a procedure before becoming liable? Doesn't this throw all the arguments about consumers making better choices into a cocked hat?
Yes, in every case.
The place I worked at for 20+ years emphasized Family medicine. Good for them. It also got some of the hippest med students in the country, the ones who wanted to hang with alt musicians. And even some ex alt musician med students.
127.2 Yes, yes, and yes. The consumer-directed folks have a valid point when they say that paying out of pocket will put pressure on providers to price more transparently.
A lefty alternative would be a most-favored-nation clause that requires providers to offer their best price to the default government plan (to which the not otherwise insured would automatically be enrolled) if they want to accept any government-financed patients (including Medicare). This is similar to a provision that the VA has negotiated with drug companies.
130: Good for them. Unfortunately rare.
127: It also ensures that almost no one knows what the hell their care actually costs. Which leads to lots of asinine policy pronouncements/asshat moralizing. It's not quite at the level of 'drugs cost $20 because that's what my co-pay is!', but it's pretty damn close.
The consumer-directed folks have a valid point when they say that paying out of pocket will put pressure on providers to price more transparently.
Of course it will. It will also mean that people who have to pay out-of-pocket will go to the doctor less often. This doesn't mean they'll spend less overall (the big expenses are not avoidable), or have better health outcomes (skipping checkups means you don't catch problems early), but if you have to pay out of pocket to see the doctor for the flu, chances are, you try to wait it out. Doctor's not going to be able to do much anyway.
74
"For Big Telecom Corp., the current stats are that 20% of participants are 80% of the cost."
This means the high cost 20% have average costs 16 times the average costs for the other 80%. However this is looking backwards, how much of the expected cost looking forward is accounted for by the worst 20% of the risks.
And I assume this is per year, what happens if you average over longer periods of time?
CZ health care suffers from the same screwy incentives that corrupt health care in the US. Doctors in small clinics, which is where people go for care rather than for serious procedures, have a financial interest in the clinic, and the clinic's profit center is selling Rx and OTC. It doesn't generally lead to abuse, but it's a screwy incentive.
The US already has several tiers of medical care with caregivers of varying quality. A DO or nurse practitioner will listen to a patient's symptom description for ongoing problems, while an MD's schedule is divided into tiny chunks that make it hard for the MD to listen.
Cala, sympathies for the insurance headache. We got married in order to share the benefit of my grad student insurance. We liked each other and everything, but the decision to formalize was driven by insurance.
Dsquared's fatty post was nice. "Fatty fatty" is IMO the greatest Heptones song.
107
"Further to 106: Before anyone says "but if you limit doctors' incomes, they will flee the profession and we'll be short of doctors, or we will get less capable doctors," save it."
How about if you propose a plan that limits doctors incomes, doctors will be upset and tell everyone starting with their patients and their Congressional representatives that the plan is a disaster which will ruin health care in America?
...requires providers to offer their best price to the default government plan...
That might work.
From where I'm sitting it looks like a protection racket crossed with a combination in restraint of trade. The insurance company is saying "unless you pay me big bucks, that big mean guy over there is going to bust your kneecaps charge you four times as much for all your health care".
...(the big expenses are not avoidable)
Thats where I get confused again.
If I'm reading this bill corrctly, the screening test for prostate cancer (standard for my age and sex) was billed at $86.52, but my special member's only rate is $17.27. Catching prostate cancer early in people my age (55) can avoid all kids of expensive stuff. So once again, the uninsured are being diverted into worse and more expensive outcomes.
77. Like we don't underrate Doris Day. Her funniest part was as the girlfriend of Sly Stone in real life.
HMOs are already limiting doctors' incomes, along with putting them on the clock. Purely greedy people now go into medical administration, obvs.
We got married in order to share the benefit of my grad student insurance.
I'm not certain if I have health insurance at the moment (I should have received the bill in this month's university statement, and it wasn't there), but while my policy would allow me to add him, and it's good health insurance, they want the entire year's premiums up front.
116. Microsoft Certified Application Specialists? Not heard of that. Certainly British GPs are seriously pissed off by Blairite politics, and not without reason, because it's characterised by a series of people who wouldn't know a health professional from a hole in the ground coming in with a series of bright ideas that they commit billions of pounds to before they fail, so that actual day to day health care is underfunded. The senior partner at our practice resigned the other day at 60, basically exhausted by fighting the bureaucracy.
(In other news, he's also a field surgeon in the Territorial Army, and he's been asked to be ready to go to Afghanistan for 5 years, in case you're interested in the time scales they're really working to.)
137: Let me put it this way. Suppose you're feeling fine. Healthy as the proverbial horse. And money's a little tight, and that screening test is going to cost you $90 that you don't really have. Are you going to make that a priority, or are you going to put the $90 towards the kids, or save it for a rainy day?
Chances are, you figure that a screening test isn't really worth it. Meaning that by the time it's worth it for you to pay out of pocket for the test (because you're noticing something), you're at the point where you're spending a lot of money, not a little. If you have cancer, you're going to be spending a lot of money.
Plus, "big expenses not avoidable" includes accidents.
127
"One thing I don't undersstand is how insured people in the US can pay a lower rate for health care than uninsured people."
Because the insurance companies can negotiate better rates. This is a major benefit of being insured but is not really traditional insurance which protects against rare events. It is more like getting a discount for being a member of AAA. Hence the view that the plans should be called health coverage rather than health insurance. Although of course there is also an insurance component to the plans.
How about if you propose a plan that limits doctors incomes, doctors will be upset and tell everyone starting with their patients and their Congressional representatives that the plan is a disaster which will ruin health care in America?
Yes, alas, that is true. And faced with the choice of joining forces with the doctors to fuck over the insurance companies or joining forces with the insurance companies to fuck over the doctors, I'll go with the former. We'll get to the doctors in due time, once the insurance companies are neutered.
The AMA sees this logic pretty clearly, which is why they have historically opposed every attempt to guarantee UHC.
However this is looking backwards, how much of the expected cost looking forward is accounted for by the worst 20% of the risks.
Actually, this is the actuarial perspective. There is some debate about whether the real number is closer to 80% or closer to 60%, but no one disputes that riskiest quintile of insured patients accounts for at least three quintiles of lifetime spending.
137
"... Catching prostate cancer early in people my age (55) can avoid all kids of expensive stuff. So once again, the uninsured are being diverted into worse and more expensive outcomes."
Prostate cancer may not be the best example as there is some evidence it is overtreated. Is there really much gain in catching it early? For many cancers there isn't much.
There's also stuff about hospital at night that pisses off teh bloggers and reams of things about helping people on their healthcare journeys which gets the codgers.
Dr. Crippen of nhsblogdoc is centre-right, but I believe that he's voted Labour in the past and is pissed off enough at the way teh Labour Government has handled the Health Service that he's willing to consider voting for a Conservative.
Certainly British GPs are seriously pissed off by Blairite politics, and not without reason, because it's characterised by a series of people who wouldn't know a health professional from a hole in the ground coming in with a series of bright ideas that they commit billions of pounds to before they fail, so that actual day to day health care is underfunded.
Yeah, although it's also true that average GPs incomes have risen stratospherically. So they do have that compensation.
144
"Actually, this is the actuarial perspective. There is some debate about whether the real number is closer to 80% or closer to 60%, but no one disputes that riskiest quintile of insured patients accounts for at least three quintiles of lifetime spending."
60% would mean average cost 6 times the average for the other 80%. At what point are you identifying the bad risks? At birth? At age 18?
142: Right. I think I understand that.
What I'm saying, I think, is that if everyone got the $17 rate for the screening instead of some people getting the $90 rate, more people would screen. This would lead to some people getting the cheaper, earlier treatment rather than the surgery plus the chemo plus the radiation plus whatever.
That is, as with colonoscopies, a comparatively cheap screen can save tens of thousands of dollars (and years of life).
However, the way the system is set up, for those at the margins the incentives all favor skipping the screenings and hoping for the best - figuring that if their luck turns sour medicaid will pay and they'll die young.
Which sucks.
145: Yes, some postate cancer is overtreated. However, my (limited) understanding is that for the younger set (my age, rather than 85) and with some types of prostate cancer, you can treat early and cheaply and live a lot longer. The problem is the slow growing types, which may take 15 years to become serious, which may not be worth treating in an 85 year old.
For other types of cancer (breast and colon are the two I'm certain of) early detection does make all the difference. Both in longevity an in cost.
Because the insurance companies can negotiate better rates.
It's not a simple as that, James, because the billing rates have often only a passing acquaintance with actual costs. Much of it is based on insurance codes, which is complicated, political, and gives a feedback to the system.
Yeah, although it's also true that average GPs incomes have risen stratospherically. So they do have that compensation.
That was the government's own idea. If you go into work tomorrow and your boss comes up to you and offers you a deal where you do shorter hours for 50% more moolah, I bet you're not going to turn it down.
Blue Cross absolutely refused to tell me in advance how much of a psychiatrist's bill they would pay, or what they were using as the UCR (usual & customary rates). They claimed that if they told me the UCR for a certain area then providers would use the info to game the system. But once a single EOB is issued, the information is out there anyway. It was un-fucking-believable.
I'm about to disagree quite strongly with OFE, because I've recently seen a number of people close to me suffer from quite appalling GP diagnosis failures, one of whom is quite probably going to die as a result. My impression is that you're OK once you get past the buggers into the actual national healthcare bit, which tends to do a cracking job.
Meanwhile, One of the ways in which France is (superficially) worse than France is that the whole infrastructure of health care is less "gold plated". This is true of French infrastructure in general. The public transport system works beautifully, but you wouldn't call a lot of it pretty or clean. If you're not capable of climbing lots of stairs continually, using the Paris Metro is absolutely impossible; I think the engineers had to use up the stairs budget or hand it back.
Similarly, the older TGVs are now getting a bit defunded school stairwell inside, at least where I sit in second class. (The Eurostar is an interesting comparison; the trains are the same vintage as the ones on the Atlantic Coast routes, but they are a lot smarter inside.) However, the last TGV I took was an old Atlantic one, that had just been done up to a very spiffy standard indeed, so I take it SNCF is refurbishing them as they go in for overhaul.
It's a different mindset; get it right and ignore it for 30 years.
60% would mean average cost 6 times the average for the other 80%.
Yes, that's correct. And not so surprising once you become acquainted with the costs of treating certain illnesses.
The implications of that fact are quite startling once you absorb them: Even if you, as a responsible health insurer, were able to reduce the expense of caring for the less risky 80% to zero (i.e. absolutely no unnecessary care, and all the necessary care provided at zero cost), it would still be *six times as lucrative* (or 8 times, depending on whose data you believe) to avoid insuring any of the high cost 20% than to reduce the cost of carrying for the 80%. Is it any wonder, then, that insurance companies focus on risk selection rather than on promoting efficient delivery of health care?
At what point are you identifying the bad risks? At birth? At age 18?
Retrospectively. They can't be identified with certainty in advance (though the underwriters in the individual insurance market sure as hell try).
When the insurance companies have perfected their analysis and get a good dataset, we'll be at an equilibrium where, if it's possible for you to buy insurance, you'll know you don't need it. You'll be able to plan for old age cheerfully and without worries or insurance.
re: 153
I'm about to disagree quite strongly with OFE, because I've recently seen a number of people close to me suffer from quite appalling GP diagnosis failures, one of whom is quite probably going to die as a result. My impression is that you're OK once you get past the buggers into the actual national healthcare bit, which tends to do a cracking job.
There can be a bit of that, yeah.
I have a very rare illness. It took me ages to convince anyone that there was anything there at all. After two years or so of badgering my GP [and various other GPs] someone suddenly told me (paraphrasing) "shit, this could be [fatal condition]".
As it happens, in my case the illness is almost totally benign but the symptoms are sometimes the result of some really serious life-threatening things and the illness is also (rarely) a secondary complication of some other really nasty diseases. So, I'm perfectly healthy but the doctors really could not have known that without doing a load of tests, which I wasn't referred for until well past the point where I'd have been in deep shit.
Blue Cross absolutely refused to tell me in advance how much of a psychiatrist's bill they would pay, or what they were using as the UCR (usual & customary rates). ... It was un-fucking-believable.
In the sense that "unbelievable" means "typical", it certainly was. I've tried repeatedly to be a rational, informed consumer, and been thwarted repeatedly.
152: In California I had Blue Cross (note to all, in CA Blue Shield was separate from Blue Cross and Blue Cross was for profit) covered 80% of in-network doctors bills and 70% of out-of-network. My doctor didn't take insurance, so I had to submit the billa. I still think I made out ahead, since he wouldn't see me for less than 30 minutes--and generally got to the answer the first time--and they paid for a 3 hour initial consultation. Of course I had to get primary care at the student health service, and since we had to pay cash for that--and I had a humiliating experience when I went there--I never did get a physical that whole time.
They did mail payments to a doctor that should have been mailed to me, then pester him to get the money back. I could have just paid him less at the next visit.
In general Blue Cross of California sucks, because they were cancelling so many people's individual plans after they got sick. They'd never underwrite me anyway.
My health plan covers emergencies that occur abroad. Emergencies in the sense of emergent, requiring immediate treatment. One of my friends was travelling, and felt ill, and suspected she had a UTI. But she couldn't rule out whether it was a yeast infection*, and so she called the health plan people to ask whether she'd be covered. The UTI would be covered, the yeast infection would not. It's hard to decide whether you're covered without a diagnosis but without a diagnosis it's hard to decide whether it's worth it to go in.
*Having experienced both, I'm not sure why she was confused, but whatever.
I bought travel insurance for my trip to Canada, but I'm not sure that they wouldn't have rquired me to pay for the X-rays and cast upfront had I needed one, and of course, they would try awfully hard to find out whether by MA-based insurer would pay for it, which I'm pretty sure they wouldn't, since they don't really cover care out of state.
A vivid real-life example of the phenomenon described in 154 comes from a relative of mine, call him "Brad", who has a medical background and worked for a company that did claims audits on contract for one of the most respected, reputable automobile insurance companies (medical liability is by far the biggest part of the claims loss of auto insurers).
Brad was, in effect, part of the multi-billion dollar industry devoted to allowing insurance companies not to pay for medical claims.
There was a part of the job that Brad really loved: cracking down on chiropracters who would bring the accident victims in for endless follow-up visits, citing unverifiable soft-tissue injuries, and perform tons of procedures of questionable value. He knew all their tricks, and had his own tricks to persuade the insureds to stop making these office visits.
So what's not to like? He was putting up resistance to inflated costs, helping to improve the efficiency of care, etc. The problem was, that wasn't where the money was for the client (the auto insurer). So his employer redeployed him from the soft-tissue beat to the cranio-spinal beat, where a single successful claim denial could save the insurer three or four million dollars (because these patients often required round-the-clock care for decades).
Brad found that he was being pushed to find colorable grounds for denial on cases that were clearly meritorious. He would often tell his supervisor, "I'm sorry, this injury is exactly what it appears to be, and we're going to have to suck it up and pay it." And he would get responses like "We'll let the court decide if we have to pay it, in the meantime we need something our lawyers can show to the judge."
He didn't stay long in the job after that. But who can blame the insurance company, really? That's the behavior our incentive system promotes. They're just following the invisible hand where it leads them, and if they didn't, they might soon be out of business.
That's the behavior our incentive system promotes
Yeah, the old limited liability/fiduciary responsibity one-two.
I've tried repeatedly to be a rational, informed consumer, and been thwarted repeatedly.
I think this is the tipping point we're reaching on this issue. I can't recall the numbers, but the percentage of people getting simple, good coverage from their employers has plummeted since '92. There's still the artifactual "Health insurers suck, but mine's OK" thing, but far more people have experienced the relentless (market-enforced!) assholery of the HI industry than had back then. Even people who haven't been screwed have learned that the only thing scarier than "We're from the gov't and we're here to help" is "We're from Blue Cross, and we're here to help [fuck you over]." (they always mumble the last part - tricksy!)
Cala,
Why can't you put shivbunny on your healthplan? When my Dad was at E/D/S which gets its healthcare through Harvard University Health Services, my sister and Mom were both covered.
I also know that male HBS students spouses often had kids using UHS and the student Blue Cross coverage.
But who can blame the insurance company, really?
Which is why there is no real possibility of fixing health care without removing the HI industry from the central position it now holds.
Don't blame them, liquidate them!
No-fault liquidation: an idea whose time has come.
150
"It's not a simple as that, James, because the billing rates have often only a passing acquaintance with actual costs. Much of it is based on insurance codes, which is complicated, political, and gives a feedback to the system."
What exactly is your objection? You don't believe uninsured people pay more? You think there is another explanantion?
Shearer's commenting philosopher is never to defend a position, always sniping and changing the subject whenever necessary. If he succeeds in getting you to lose your temper, he wins and you lose.
154
"Retrospectively. They can't be identified with certainty in advance (though the underwriters in the individual insurance market sure as hell try)."
But that is meaningless. 1% of insured probably account for 99% of claims paid when it comes to fire insurance. That's the nature of insurance.
Anyway you all don't seem that real. And of course I was brought up to see losing your temper as a sign of weakness.
A common error.
What exactly is your objection?
Sorry if that was unclear. My objection was that `negotiating better rates' is all that's going on. It's not nearly as simple as that.
172
So what else is going on?
173: which part of
because the billing rates have often only a passing acquaintance with actual costs. Much of it is based on insurance codes, which is complicated, political, and gives a feedback to the system.
was problematic?
If the billing is not directly tied very directly to actual costs, the MDs -> HI -> MDs loop is free to bump up the nominal billing arbitrarily high (until acted on by govt., say, which as KR brought up has happened) and then negotiate individual claims down. This leaves people outside the system in much worse shape than the procedure actually costs X, but HI negotiates a better rate Y. Because in this case there is little rational basis for X.
174
"was problematic?"
What's problematic to me is what distinction you are making between what actually happens and my claim that the insurance company can negotiate a better rate than the average individual can? This doesn't mean that even individuals typically pay the stated list price just that they won't typically obtain the insurance company rate.
And "actual costs" is a very fuzzy concept, the marginal cost may be much lower than the total cost and the proper way to allocate overhead among various procedures unclear.
soup--do you know about specific procedures/practices where this occurs/has occurred. I'm not doubting what you say at all, but a concrete example would help me get my head around it.
I know that there are people who spend their entire days coding bills. It sounds like one of the most awful indoor jobs that I can imagine.
When I worked at a medical bookstore we sold coding books in bulk: HCHPC, DSL, CPT. ICD-9. I've been told that some of these books are useful for diagnostic and charting purposes, but diagnosis and charting seem to be excessively influenced by insurance payment schemes.
Ok, I only have a minute but I'll try and walk through one example how this might be a problem in practice.
As a clinical practitioner, you cannot bill anything to insurance without a billing code. These define the procedures fairly precisely, and who pays what, and are fairly long-lived. For these reasons, they take a while to negotiate. To make this clear, you need FDA approval to legally apply a procedure or prescription in a clinical setting in this country, but that's next to useless in practice without the insurance industry agreeing in terms of a billing code. For new versions of older things, this is easier than for brand new things. Note that HIPAA is changing things and I'm a bit out of touch, so take with a grain of salt.
A couple of ways this can hurt you in practice as I understand them:
a scenario: First, a hot new technology gets FDA approval and pushes through with the original tech for a code that bills out at, say $75,000 because the new tech is expensive and people are worried about workflow. Let's say now the tech is now older, and people have figured out how to do it very cheaply in some case, and it's fit into the normal workflow with the push of a button. Say the nominal cost is now $2,500 by amortizing over life of machines, etc. for this particular case
However, your clinical practitioner cannot bill this at $2,500, they can only bill it at $75,000 (because they can't bill the same procedure variably). Furthermore, by law (at least some places) they cannot perform it and not bill it. Insurance will only agree to it when it makes sense at $75000, so if it is a helpful but not critical improvement, it just isn't done. Even if actuarially it makes every kind of sense.
So your standard of care drops because of the billing system. The simple answer would be to have an expedited system to review and change or add codes, but this isn't likely it seems (meaning, that's what I've been told by people who seem to have a good feel for it). I know of cases pretty much identical to this, same orders of magnitude in billing). So to be fair this isn't a condemnation of the billing system per se, but of it in practice being too rigid in some ways.
The second issue:
Your practitioner bills out at higher than the expected allowable from the insurance plan, always. They argue back and forth about it, but the insurer will pay a (sometimes quite small) percentage of the original bill, and you're on the hook for co-pay and sometimes disallowed, etc.
If you don't have any insurance, you'll get billed at the top rate with no negotiation. This rate is largely determined by the expected insurance billing process + some upward adjustment, not by the actual costs of the procedure to the practitioner or whatever. In other words, that $75,000 fee above will be billed out to you at $75,000 regardless of the nominal cost. The practitioner may not be able (by law) to `give you a deal' on this even if it doesn't cost her anything like $75k, because that would be unfair to insured people who are billed at $75k but actually pay (via insurance), say $25k.
In this way as an uninsured patient you can be far worse off than if the physician was independently determining their own costs to present you with a bill (not that I'm suggesting this is workable).
The scenario above is a little extreme (but based on a real one, without exaggerating the difference in cost/billing cost) but gives you the gist of only two of the practical problems.
All of the above is a vast simplification of the general medical billing process, which is pretty horrendous. Things get more complicated when local law affects allowable fee schedules, etc.
Of course in the previous scenario in practice, the uninsured person probably just doesn't get the procedure. And in some instances, they're renegotiate.
I used to know someone who made her living in an office which recalculated trucking bills. If the bill was erroneous to the client's disadvantage, they'd inform the client so he could get an adjustment.
The complexity of regulated freight weights was one of the big arguments for deregulation. That makes sense on the face of it.
But private insurance has created the same problem in the much weightier world of health care -- though as far as I know, recalculation and getting an adjustment is rarely possible.
But since it's mostly private, the deregulation mouthpieces have nothing to say.
And yes, under socialized medicine these same problems would still be there. But the opponents of socialized medicine pretend that they're not here already.
further to 178 for balance: on the whole it is a highly distorted affair, but it happens in the other direction as well. For example, there are diagnostic proceedures that are typically done at a loss by practitioners, because HI won't bill them higher and won't let the practitioners cherry-pick proceedures (e.g. screening mammo, for many radiologists was a case of this in the past, not sure about today)
178
"If you don't have any insurance, you'll get billed at the top rate with no negotiation. This rate is largely determined by the expected insurance billing process + some upward adjustment, not by the actual costs of the procedure to the practitioner or whatever. In other words, that $75,000 fee above will be billed out to you at $75,000 regardless of the nominal cost. The practitioner may not be able (by law) to `give you a deal' on this even if it doesn't cost her anything like $75k, because that would be unfair to insured people who are billed at $75k but actually pay (via insurance), say $25k."
This doesn't make a lot of sense to me. You say doctors are allowed by law to give insurance companies discounts but are not allowed by law to give individuals discounts?
Thanks for the reading suggestions (and caveats), everyone.
178
"However, your clinical practitioner cannot bill this at $2,500, they can only bill it at $75,000 (because they can't bill the same procedure variably). Furthermore, by law (at least some places) they cannot perform it and not bill it. Insurance will only agree to it when it makes sense at $75000, so if it is a helpful but not critical improvement, it just isn't done. Even if actuarially it makes every kind of sense."
This sort of makes sense. You are saying they find a cheaper way to do it half the time but have to bill it the same until someone gets around to splitting the code.
182: Depending where you are (laws vary by state iirc), you're not allowed to bill at different rates, which makes sense. But what you bill isn't typically anything like what you actually receive. Certainly individuals can attempt to adjust the bill, but they really don't have a lot of leverage on the practitioner (unlike insurance companies).
As I understand it, at an individual level this is much more likely to happen in a default situation rather than up front.
"everyone" in 183 meaning pretty much KR and baa.
185
"Depending where you are (laws vary by state iirc), you're not allowed to bill at different rates, which makes sense. But what you bill isn't typically anything like what you actually receive. Certainly individuals can attempt to adjust the bill, but they really don't have a lot of leverage on the practitioner (unlike insurance companies)."
This seems like a distinction without a difference to me. Instead of negotiating a better list price insurance companies are able to negotiate a bigger discount from list than individuals can.
This doesn't make a lot of sense to me. You say doctors are allowed by law to give insurance companies discounts but are not allowed by law to give individuals discounts?
The doctors and insurance companies have escalated the billing battles to a high level due to the amount of money at stake per entity (doctor's office or insurance company). John Q. Public can bring much less negotiating effort to bear, is grossly overmatched, and so gets screwed.
This seems like a distinction without a difference to me.
There is a huge difference, James, because one of the primary determining factors of what the `list' price is, is the billing code and fee schedule. In other words, medicine is often practiced according to how it's billed, and it's billed largely according to the HI industry. Feedback which can elevate the `list' price, as you call it (but don't call it a list price, because just try and get a number out of anyone before you already owe it) without changing the effective price for the insured -- just anyone else.