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Old 08-28-2014, 09:21 PM   #21
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Another interesting measure that might be empowering is a "two price only" mandate. Providers can bill to all comers - insurers, Medicare, cash customers - one price for insurance reimbursement and a second price for immediate cash payment.
I've thought along similar lines, but why not a "one price only" mandate? For various reasons, there will always be cash buyers of medical services (foreign travelers, people who choose not to buy policies, etc).

But, there would need to be some flexibility for medical coverage models that don't use the fee-for-service approach at all.

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I guess I'm saying that pricing offered to current customers is a step in the right direction, but not sufficient for true decision making when trying to optimize a healthcare insurance purchase decision. If all insurance companies that sold on healthcare.gov were required to have a pricing tool available to prospective customers, that might provide the consumer enough to make a well informed decision.
Pricing is one bit of information, but somehow we also need to provide information on the availability of the services. Medicaid prices look great to the clients, until it is discovered that it's hard to find a doctor willing to actually provide them (in many cases). Health care coverage isn't the same as health care.

Mrs Smith went to Max, her butcher, and noticed that ground beef was $4 per pound. "Four dollars a pound! Why, Kroger is selling it for three dollars a pound!"
Max: "Then why don't you buy it at Kroger?"
Mrs Smith: "Because they are out of it."
Max: "If I were out of it, I could sell it for three dollars, too!"
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Old 08-28-2014, 11:41 PM   #22
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I've thought along similar lines, but why not a "one price only" mandate? For various reasons, there will always be cash buyers of medical services (foreign travelers, people who choose not to buy policies, etc).
Alas, this would fail to address what health care executives call the "Saudi sheikh problem" at some hospitals.
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"You don't really want to change your charges if you have a Saudi sheikh come in with a suitcase full of cash who's going to pay full charges."

-- Dr. Warren Browner, the chief executive officer of California Pacific Medical Center
The chargemaster rates have to be nice and high just in case a customer with a suitcase full of cash walks in, or is otherwise delivered.
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Old 08-29-2014, 06:17 AM   #23
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I've thought along similar lines, but why not a "one price only" mandate? For various reasons, there will always be cash buyers of medical services (foreign travelers, people who choose not to buy policies, etc).

But, there would need to be some flexibility for medical coverage models that don't use the fee-for-service approach at all.
Agree on both points.
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Old 08-29-2014, 07:29 AM   #24
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"You don't really want to change your charges if you have a Saudi sheikh come in with a suitcase full of cash who's going to pay full charges."

-- Dr. Warren Browner, the chief executive officer of California Pacific Medical Center
Pragmatic perhaps, but warped as well. I'm trying to think of any other business that "ability to pay" affects prices as much as medical services and I'm coming up blank.
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Old 08-29-2014, 07:49 AM   #25
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Alas, this would fail to address what health care executives call the "Saudi sheikh problem" at some hospitals.

The chargemaster rates have to be nice and high just in case a customer with a suitcase full of cash walks in, or is otherwise delivered.
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Pragmatic perhaps, but warped as well. I'm trying to think of any other business that "ability to pay" affects prices as much as medical services and I'm coming up blank.
The Saudi sheikh with a suitcase full of cash is a fantasy. The practice is morally repugnant distasteful and creates a significant obstacle to health care reform in the US.
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Old 08-29-2014, 07:55 AM   #26
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Old 08-29-2014, 07:57 AM   #27
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Pragmatic perhaps, but warped as well. I'm trying to think of any other business that "ability to pay" affects prices as much as medical services and I'm coming up blank.
Sex trade? Nah, they have better ethics.
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Old 08-29-2014, 08:05 AM   #28
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Unfortunately, I don't think we'll have a clue what policies will be priced at until open enrollment begins. Right now states have a vested interest in predicting low price increases especially if they invested heavily in the process. Even after open enrollment begins we could have adjustments if the computer glitches haven't been fully resolved (still an open question). Then to make things more interesting, there are the law suits that will eventully find their way to SCOTUS on whether the law is what it says (subsidies require state exchanges) or what some people want it to mean (subsidies through HealthCare.gov also apply). Throw that in with all our usual political pot stirring and who knows what will happen. It certainly appears that so far the ACA hasn't contained health care costs. Transparency in plans, networks, coverage and costs certainly doesn't exist now but one can only hope.
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Old 08-29-2014, 11:59 AM   #29
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In most states the process of setting premium rates is subject to regulatory approval and the 2015 rates have been submitted by the insurers, so in many states one can get a good idea of 2015 rates with a little googling. Also, I suspect that in some states that premiums have already been approved.

I think the medal designations (platinum/gold/silver/bronze) was a good first step in providing more transparency in that they provide insight as to how much of your health care costs will be covered by health insurance.

I concede that there is a lot of room for improvement, but IMO ACA hasn't been the disaster that some pundits predicted and health insurance increases for 2015 seem to be about the same as they were in the last few years.
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Old 08-29-2014, 12:18 PM   #30
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Have most ER members who got ACA gone for Bronze?
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Old 08-29-2014, 12:57 PM   #31
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.....Even if you are already a customer and you price out a prescription, for instance, you are getting the information from the formulary associated with your current policy. Next year you may or may not have that same formulary list, or the list could change......
One might also call local big box pharmacies and ask for their best prices. Some participate in various non-HI drug discount programs. Most such programs do not seem to care whether you have other HI or not. For some lower cost meds it can be cheaper to pay the best 'no-insurance' discount price rather than the ever-increasing HI policy co-pay. Only down side is that these 'off-insurance' buys (i.e. not using your HI's pharm program) do not appear to count towards deductibles/OOPmax. I think this is rather unfair, particularly when your policy's pharm network happens to be out-of-stock for a med you need quickly (unusual, but has happened to relatives).

And just to add to the bureaucratic fun, formulary lists & even the pharmaceutical vendors your HI plan contracts with can change DURING your plan-year. Hard to keep up sometimes, but it can save some $$.
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Old 08-29-2014, 02:32 PM   #32
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.....IMO ACA hasn't been the disaster that some pundits predicted........
Guess that depends upon one's perspective. All data (inc. Fed's) show that since ACA's passage HC costs have continued to rise well above inflation. Against Obama's own oft-repeated benchmark of saving families, employers, and the country $2500/family/yr in HI premiums and costs, ACA has been a disastrous failure.



Many felt that the HI rates for 2014 were artificially set a bit high by the HI companies for CYA reasons ('fudge factor' while adjusting to new system). According to this view, cost containment efforts implemented in 2014 (narrower networks, improved efficiencies of care delivery, negotiation of better prices from providers/hospitals/suppliers, etc.) would begin to pay off and 2015 would see a broad premium DEcrease to what would be more "normal" levels. Unfortunately, the premium increases many are predicted to see for 2015 show the fiscal monster of HC inflation marches on. This does not bode well for the years to come.
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Old 08-29-2014, 02:51 PM   #33
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Another interesting measure that might be empowering is a "two price only" mandate. Providers can bill to all comers - insurers, Medicare, cash customers - one price for insurance reimbursement and a second price for immediate cash payment. When everyone has access to the same price and that price is publicly available, insurers and patients alike can begin to make more positive choices.
That would go a long way to making shopping easier. We might need to make a three price mandate...need to add the rich saudi price, hehe.

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Have most ER members who got ACA gone for Bronze?
Bronze is common, I think (that's what I did). But depending on your normal usage of medical services, the cost sharing available on Silver if your income is in a specific range, can be a better deal. Low utilizers that can't get a subsidy have jumped through hoops get catestrophic ("over age 30" "cheapest bronze is >8% of O-MAGI"). So it just depends on your income and how much medical you think you'll need.

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One might also call local big box pharmacies and ask for their best prices. Some participate in various non-HI drug discount programs.
...
I do ask about the best non-HI price, then check goodrx.com.
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Old 08-29-2014, 06:02 PM   #34
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Guess that depends upon one's perspective. All data (inc. Fed's) show that since ACA's passage HC costs have continued to rise well above inflation. Against Obama's own oft-repeated benchmark of saving families, employers, and the country $2500/family/yr in HI premiums and costs, ACA has been a disastrous failure. ......

Many felt that the HI rates for 2014 were artificially set a bit high by the HI companies for CYA reasons ('fudge factor' while adjusting to new system). According to this view, cost containment efforts implemented in 2014 (narrower networks, improved efficiencies of care delivery, negotiation of better prices from providers/hospitals/suppliers, etc.) would begin to pay off and 2015 would see a broad premium DEcrease to what would be more "normal" levels. Unfortunately, the premium increases many are predicted to see for 2015 show the fiscal monster of HC inflation marches on. This does not bode well for the years to come.
Health care and health insurance costs were increasing at much more than the general rate of inflation before ACA as well, so I guess then we'll agree to disagree. Note that I said that it wasn't the disaster that some predicted - costs and insurance costs have been relatively stable all things considered.

I'm actually paying 35% less than I was last year because I now qualify for catastrophic coverage that was not previously available. My current HDHI premiums are less than half of my COBRA when I retired in 2011. Same network by the way.
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Old 08-29-2014, 06:04 PM   #35
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Have most ER members who got ACA gone for Bronze?
Was bronze for the first half of the year but now have a catastrophic policy that is a bit less coverage then bronze for 40% less. If one is healthy and not on any expensive prescriptions, I think bronze or cat is the way to go.
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Old 08-29-2014, 06:15 PM   #36
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Was bronze for the first half of the year but now have a catastrophic policy that is a bit less coverage then bronze for 40% less. If one is healthy and not on any expensive prescriptions, I think bronze or cat is the way to go.
Does your catastrophic policy include any preventive, like once a year physicals?

Do you pay the full doctor's bill until you meet the physical or is there also a high copay.

The Bronze copays I've seen are like $75 for a doctor's visit IIRC.
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Old 08-29-2014, 06:29 PM   #37
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My costs are down. Weird, huh?

For next year, after factoring out the age change in the rates, I'm looking at a rise of less than 3% in the insurance premiums. How very un-disasterish...

If I manage to qualify for the premium subsidy tax credit, I'll see a tremendous drop in my out of pocket cost. Curious how that works...

It is a puzzlement...
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Old 08-29-2014, 06:43 PM   #38
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Guess that depends upon one's perspective. All data (inc. Fed's) show that since ACA's passage HC costs have continued to rise well above inflation. Against Obama's own oft-repeated benchmark of saving families, employers, and the country $2500/family/yr in HI premiums and costs, ACA has been a disastrous failure.



Many felt that the HI rates for 2014 were artificially set a bit high by the HI companies for CYA reasons ('fudge factor' while adjusting to new system). According to this view, cost containment efforts implemented in 2014 (narrower networks, improved efficiencies of care delivery, negotiation of better prices from providers/hospitals/suppliers, etc.) would begin to pay off and 2015 would see a broad premium DEcrease to what would be more "normal" levels. Unfortunately, the premium increases many are predicted to see for 2015 show the fiscal monster of HC inflation marches on. This does not bode well for the years to come.
I'm not really much into the politics of this thing and my measurement stick is really short - how does this thing impact me? It looks like for the first time in history health insurance rates in Oregon will actually decrease from the prior year. Amazing! State releases Oregon's 2015 health insurance rates for individuals, small businesses | OregonLive.com
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Old 08-29-2014, 06:58 PM   #39
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The Saudi sheikh with a suitcase full of cash is a fantasy. The practice is morally repugnant distasteful and creates a significant obstacle to health care reform in the US.
Agree 100% that the Saudi sheikh issue is pure, unadulterated fantasy for the vast majority of US hospitals. Very few hospitals ever see ANY patients with a huge net worth. And for those hospitals that do, the REAL $$$ sure as heck is NOT coming from the $5k vs $2k ER visit. It comes from the multi-million$$ donations/endowments given in appreciation of the (presumably) outstanding care received.
IMHO- The real reason behind this hyper-billing is historical. For many years both providers and insurers wanted/needed to show they got 'results' in annual contract negotiations. The insurer had to show they got increasing discounts from billed prices, and the providers continually & artificially raised prices to maintain or increase net income after granting these big artificial discounts. Over time the billed amounts grew progressively more ridiculous. In some ways it's become a profitable game of liar's poker. For most providers/hospitals, relatively few uninsured actually pay anywhere near these fantasy prices after renegotiations, bankruptcies, or simple refusals to pay. FWIW- I do not see this charade as any legitimate obstacle to serious HC reform. The charade becomes irrelevant if we do what is done in many other developed countries and simply set (negotiate) defined market prices for specific services and publish them. Full market transparency. Like everyone paying the same menu price for their BigMac Value Meal. Medicare basically does this (with some regional differences) by setting max allowable charges for specific HC services. These fantasy billings are now essentially irrelevant to the Medicare marketplace.
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Old 08-30-2014, 07:24 AM   #40
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Does your catastrophic policy include any preventive, like once a year physicals?

Do you pay the full doctor's bill until you meet the physical or is there also a high copay.

The Bronze copays I've seen are like $75 for a doctor's visit IIRC.
Yes, annual physicals are covered/free and paid directly by the insurer. For other services it works the same as the bronze policy (same carrier). Generally speaking just a high deductible policy with slightly higher deductibles than the bronze ($6,350 vs $5,000) but actually a lower maximum cost since the premiums are $1,500 a year lower. Since we are relatively healthy it works out cheaper for us and gives us access to negotiated rates for medical services and protects us from the financial coat of a catastrophic illness.
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