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Old 10-25-2013, 11:57 AM   #21
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Wait .... In Florida, and I've seen this already, the plans being sold on the Exchange are identical to the ones that they're selling directly to the public. They have no "exchange" plans .... only plans that are separated by PPO, HMO, etc.

How would a physician who accepts, for example in Florida, know the difference between a "Blue Care" insurance plan acquired through the Exchange as opposed to the same "Blue Care" insurance plan acquired directly from Blue Cross?

Unless I'm missing something important here, that makes no sense.
I'm not in FL, but generally carriers can offer multiple Plans which have same name but with different features (e.g. deductibles/co-pays/etc.). Docs (or more accurately their employer, practice manager, etc.) keep track of specific Plans by policy or plan number. At my employer, even folks shifting from their group plan to "same plan" under COBRA status are issued new ID cards with different plan/policy #.

BTW- Technically, Plans sold outside the Exchange are not entirely "identical" if only because they are not eligible for gov't subsidy. Personally I would make sure to buy via the Exchange if there's even remote possibility I might qualify for subsidy (MAGI <400% FPL).

Subsidy Calculator | The Henry J. Kaiser Family Foundation
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Old 10-25-2013, 12:15 PM   #22
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I'm not in FL, but generally carriers can offer multiple Plans which have same name but with different features (e.g. deductibles/co-pays/etc.).
What I found when I looked on and off exchange in our state is that in order to provide cost sharing (lower deductibles and max out-of-pocket) on the exchange the insurance company just created what I will call sub-policies.

They would have a 2500 deductible plan with, say a 5000 max OOP both on and off the exchange. To provide cost sharing on the exchange they would use the same policy but lower the the deductible and out of pocket - the name would still include the 2500 designation but would then have a suffix to differentiate it. This would require them to create 3 additional policies for the under 150% FPL, 150 to 200% FPL and 200 to 250% FPL. So basically a 'master' policy and three sub-policies to cover all the bases.

I was looking at HSA policies with no co-pays but I expect they just change the co-pay for each sub-policy as well. It makes sense from their standpoint that they wouldn't re-invent the wheel but just work off a template.

Edit: Looking more closely at one of the policies I see that the suffix is 'CSR2' which I would imagine stands for 'Cost Sharing Reduction 2'. So there must be a master policy with CSR1, CSR2 and CSR3 variants.
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Old 10-26-2013, 09:59 AM   #23
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How would a physician who accepts, for example in Florida, know the difference between a "Blue Care" insurance plan acquired through the Exchange as opposed to the same "Blue Care" insurance plan acquired directly from Blue Cross?


Please explain.
The exchange policy would have a different group number than the one sold directly by the carrier.
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Old 10-27-2013, 10:53 AM   #24
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The exchange policy would have a different group number than the one sold directly by the carrier.
Exactly in this area BCBS offers at least 1 (maybe 2) HCA provider networks. The one 'Select' plan has 'far less providers in it than our regular network' this is staight from the marketing person at BCBS. According to her all my current providers are out of network. On the more expensive network their not listed either. The other insurer in this area still doesn't have their ACA network defined!

My DR. had told me HCA had announced they 'were not participating in these low margin ACA plans'. I think the area I live in has created an environment of limited competition.

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Old 10-27-2013, 11:41 AM   #25
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At least we know that the insurers are pushing for lower costs.
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Old 10-27-2013, 12:08 PM   #26
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insurers did not contract with a major children's hospital because the hospital refused to accept the rates.
Interesting that what I heard was only partly a rate dispute, but also an attempt to eliminate exposure to high cost care, as this is the regional hospital that treats the sickest of the sick. A friend had a $600,000 bill for a child that no other hospital would even attempt to treat.
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Old 10-27-2013, 12:45 PM   #27
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Oh insurers are making billions. But I did a quick search and 2011 spending was 2.7 trillion. Insurance company CEOs are well-compensated too

I think providers (doctors and hospitals) get more than insurers, as industries.

Pharmaceuticals probably make more than insurers too.
When looking at whether profits are excessive (or not) you really need to look at returns rather than absolute numbers. Laymen and politicians often seem outraged that a company or industry makes billions but totally fail to consider the investments that need to be made to generate those earnings.

Let's say a company makes $10 billion. That's a lot of money. If their investment is $20 billion then it is a 50% return and an outrageous profit in relation to the required investment. But if their investment is $150 billion then it is only a 6.7% return and certainly not very good even though $10 billion is a lot of money in absolute terms.

According to Yahoo Finance, Health Care Plans average ROE is ~13% - good but not outrageous and certainly not excessive enough to cause indignation. Major drug manufacturers average ROE is 20% - again, solid but not outrageous. Also see Sector List - Yahoo! Finance Industry Browser
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Old 10-27-2013, 03:07 PM   #28
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I'm saying the health insurance industry as a whole doesn't take up a big percentage of the money the US spends on health care every year.

Not saying this or that industry has outrageous margins.
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Old 10-28-2013, 06:47 AM   #29
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I'm saying the health insurance industry as a whole doesn't take up a big percentage of the money the US spends on health care every year.

Not saying this or that industry has outrageous margins.
One of the questions that this whole healthcare debate has raised in my mind is how do we really know how much we spend on health care.

An uninsured guy has an accident. They hospital treats and save his life.
They then present him with a bill for $250,000 Now if he had been insured, the insurance company might only owe $50K to the hospital. But since the guy is uninsured and probably poor, the hospital might ultimately decide to settle for say 25K spread out over 5 years.

So how much did we spend on healthcare for this guy $25,000 that he really paid or the $250,000 that hospital billed? What organization keeps track of these expenditures?.
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Old 10-28-2013, 10:18 AM   #30
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You have to pass it to see what's in it...

Some health insurance gets pricier as Obamacare rolls out - latimes.com
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Old 10-28-2013, 10:21 AM   #31
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Please, an explanation or snippet so members know what the link leads to.
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Old 10-28-2013, 10:33 AM   #32
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One of the things that is missed when people talk about the margins earned by the various firms is the amount of healthcare that is not needed but done...

I have had a sister and my mom go into the hospital the last couple of years... my sister had a good number of doctors come by and do tests on her... some were never needed and never requested... but the spending was done anyhow.... so they made a profit of 13% or so.... but 100% of the costs were not needed...


My mom was recently in for fainting and falling... they have done a good number of tests on her as they do not know why... the costs have piled up and I am still dealing with them.... they think there is some 'growth' on her heart.... when I asked my sister (a nurse) what could be done she said nothing.... nobody is going to do open heart surgery on a 94 YO.... so they continued to do tests anyhow... they did a blood flow test on her legs.... why It costs hundreds of dollars to do with no change in her diagnosis....


Sometimes the doctors that we trust are doing things to us that should not be done.... for a profit... even a 13% profit....
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Old 10-28-2013, 10:43 AM   #33
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[...]when I asked my sister (a nurse) what could be done she said nothing.... nobody is going to do open heart surgery on a 94 YO.... so they continued to do tests anyhow... they did a blood flow test on her legs.... why It costs hundreds of dollars to do with no change in her diagnosis....
It does sound like you and she deserve a good explanation of why these tests were being done.

I can think of one possible reason in particular. When my mother was about that age, she had to have her legs amputated at the knee because of impending gangrene, due to low blood flow, threatening her life. We were told that these circulatory issues were due to her extreme old age causing her blood vessels to break down at that time. It took four more years before most of the rest of her organs failed due to her advanced age, almost simultaneously, and at that time she passed away at age 98 (well, two weeks short of 98).

She truly enjoyed her last four years of life, though, even without her legs.
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Old 10-28-2013, 11:22 AM   #34
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.... they think there is some 'growth' on her heart.... when I asked my sister (a nurse) what could be done she said nothing.... nobody is going to do open heart surgery on a 94 YO.... so they continued to do tests anyhow... they did a blood flow test on her legs.... why It costs hundreds of dollars to do with no change in her diagnosis....


Sometimes the doctors that we trust are doing things to us that should not be done.... for a profit... even a 13% profit....
The blood flow test may have been done in preparation for open heart surgery . The take vessels from the legs to use as grafts .My Mom is 97 and when they recommend tests to her she just nicely refuses .
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Old 10-28-2013, 12:47 PM   #35
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One of the questions that this whole healthcare debate has raised in my mind is how do we really know how much we spend on health care.

An uninsured guy has an accident. They hospital treats and save his life.
They then present him with a bill for $250,000 Now if he had been insured, the insurance company might only owe $50K to the hospital. But since the guy is uninsured and probably poor, the hospital might ultimately decide to settle for say 25K spread out over 5 years.

So how much did we spend on healthcare for this guy $25,000 that he really paid or the $250,000 that hospital billed? What organization keeps track of these expenditures?.
I found this document:

http://www.cms.gov/Research-Statisti...highlights.pdf

Then of course, during this whole health care debate, there was a lot written about comparative costs and results across different countries.

A key metric is expressed in terms of GDP. I think the US is around 17% of GDP while the next closest nation was around 12% of GDP.

US GDP is $14 to $16 trillion I believe.
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Old 10-28-2013, 12:50 PM   #36
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One of the things that is missed when people talk about the margins earned by the various firms is the amount of healthcare that is not needed but done...

I have had a sister and my mom go into the hospital the last couple of years... my sister had a good number of doctors come by and do tests on her... some were never needed and never requested... but the spending was done anyhow.... so they made a profit of 13% or so.... but 100% of the costs were not needed...


My mom was recently in for fainting and falling... they have done a good number of tests on her as they do not know why... the costs have piled up and I am still dealing with them.... they think there is some 'growth' on her heart.... when I asked my sister (a nurse) what could be done she said nothing.... nobody is going to do open heart surgery on a 94 YO.... so they continued to do tests anyhow... they did a blood flow test on her legs.... why It costs hundreds of dollars to do with no change in her diagnosis....


Sometimes the doctors that we trust are doing things to us that should not be done.... for a profit... even a 13% profit....
Some of the additional procedures are attributed to defensive medicine. Doctors doing tests to document that they tried different diagnostic methods to determine the problem.

Then there have been articles about doctors owning a lot of these testing labs and facilities, which bill for the various tests.
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Old 10-28-2013, 03:20 PM   #37
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I found this document:

http://www.cms.gov/Research-Statisti...highlights.pdf

Then of course, during this whole health care debate, there was a lot written about comparative costs and results across different countries.

A key metric is expressed in terms of GDP. I think the US is around 17% of GDP while the next closest nation was around 12% of GDP.

US GDP is $14 to $16 trillion I believe.
Interesting document, but I still was unable to find their methodology for how they collected the data. It is relatively easy to figure out in single payer system like Medicare.
Health Care expendentures = Money Uncle Sam paid + Medicare Premiums+ supplemental insurance premiums.

However, I think it is really hard to get accurate data in the confusing system we have.

In the example I gave where the bill was $250,000 but the amount paid was only $25K. Did we spend $250K for health care or $25K?

Say I hired a contractor to build me a McMansion on some leased property and the bill for the initial phase (say architect drawings, permits, pour the foundation, demoing the old hose) was $250K, but I only paid him $25K before going broke. The contractor would have had $250k revenue and bad debt of $225K on his books. In compiling statistics on home builders in city or state, it is perfectly reasonable to count the full $250K ,because massive price discounts/bad debt are uncommon.

The hospital accountants would probably (I am guessing) treat the bill the same way $250K worth of revenue and 225K worth of bad debt. The big difference is that massive price discounts are common in the health care. So when they (whoever they is) compile data on the hundreds of billions the uninsured are costing us, I bet they are treating the full $250K bill as the cost. However I'd argue the real cost of this operation was the $50K that an insurance company would pay, not the $250K the hospital would like to bill some sucker. Since this is a pretty common occurrence, my guess is there is a good chance that amount we spend on Health Care probably has a lot to do with fictitious accounting, and is probably exaggerated.
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Old 10-28-2013, 03:28 PM   #38
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Health Care expendentures = Money Uncle Sam paid + Medicare Premiums+ supplemental insurance premiums.
Lots more than just that. Long term care, spending not covered by insurance, over the counter medication, alternative medicine, research and development to name a few.
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Old 10-28-2013, 04:41 PM   #39
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However, I think it is really hard to get accurate data in the confusing system we have.

In the example I gave where the bill was $250,000 but the amount paid was only $25K. Did we spend $250K for health care or $25K?
As you mentioned padded up bills are the norm in healthcare. So, I really doubt they would be allowed to write off the difference betn. initial bill and actual as bad debt. If that's the case all bills paid by insurance companies would still result in millions of $ is deductions for the hospital.

More likely, they use what Medicare pays as the "imputed value" of the service, and they can only write off up to that amount. Although it all looks like black magic to us, there is an elaborate system of procedure codes, allowed rates, and equipment depreciation tables that go into the belly of the beast. There may be some shenanigans in that too, but that would be just pure garden variety fraud.

There is a possibility that IRS allows them to use a slightly higher number if they can reliably show some average number -- but somewhat less likely.
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Old 10-28-2013, 05:04 PM   #40
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Lots more than just that. Long term care, spending not covered by insurance, over the counter medication, alternative medicine, research and development to name a few.
Fair enough, I was just pointing out that is a lot easier to get handle on cost in a single payer system then in our morass.

BTW I am not sure I'd agree that R&D expense is part of health care cost. In theory the cost of the drug should reflect the past and expected R&D cost o0f the pharmaceutical industry. Which sort of makes my point it isn't easy to get a handle on the numbers.

Of course the reality is that American's subsidies most of the $100 billion R&D expenditures of big pharma, in the form of higher cost for prescription degrees. Countries like Canada with a single payer system negotiated a lower cost.
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