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Old 05-28-2011, 02:06 PM   #41
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Suppose Mr Ryan's $14k voucher plan became law, what would happen when folks reached 65 or whatever age deemed eligible? SS spent $14000 per recipient in 2004, and costs have risen dramatically since then, so seniors would have to make up the difference.
You're doing static analysis. A prime reason medical costs are rising is because Medicare keeps dumping money into that system (more dollars chasing the same basket of goods= higher prices). Medicare pays per procedure, so more procedures = more money for health care providers (which is sometimes the only way they can make up for low per-procedure reimbursement rates for some items--perform other procedures with higher reimbursement rates). There are better models for providing health care services, and private insurers will use them when they've gort an incentive to do so.

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However, that isn't the main problem. I predict that no for-profit insurance company would willingly write health insurance for those over the age of eligibility. That is one of the main reasons Medicare was created in 1967. Old people couldn't buy coverage at any price.
Private insurers now cover government employees of all ages, this is no different.
If the premium support payments prove to be insufficient to provide the quality of care we (collectively) decide is right, then Congress can amend the law to provide higher payments (just as they do now every year for Medicare). This is not some type of unalterabe autopilot. The difference is that we'll have competition in the provision of health care, and I trust that mechanism to do a much better job of controlling costs than any top-down centralized price-control system.

Remember that the present health care reform law already calls for big cuts to Medicare. Let's try something (competition) that works throughout the rest of the economy rather than keep doing the same dumb thing.
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Old 05-28-2011, 03:17 PM   #42
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A prime reason medical costs are rising is because Medicare keeps dumping money into that system (more dollars chasing the same basket of goods= higher prices).
That makes sense to me, but of course just because something makes sense, that doesn't make it true. The "dumping money" description suggests that a Medicare paid for procedure is less carefully monitored and more freely approved than it would be if the insurer were private. I don't know this to be true. I kept an eye on my mother's expenses when she was on Medicare, and last summer when I went from private health insurance to Medicare, I haven't noticed any special laxity developing. For instance, last Fall I had a colonoscopy which was given after an interval of less than 5 years from my preceding colonoscopy, so Medicare refused to pay. Well, I was able to straighten that out, because the procedure was not just for screening, but was given for medical diagnostic reasons. But the point is, someone was watching, trying to make sure the rules were observed.
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Old 05-28-2011, 04:28 PM   #43
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The "dumping money" description suggests that a Medicare paid for procedure is less carefully monitored and more freely approved than it would be if the insurer were private.
Since we both lack data (for now), let's back up a step and look at incentives as a means to discern likely impacts on costs.

Present Medicare: The providers make more money if they supply more services. Some have a higher "markup" than others. They have incentives to render more services overall, and especially ones that yield more profit. To try to reign this in, Medicare imposes various rules/limits/etc (as you found out--limits on colonoscopy screenings. As your provider found out: call it a "diagnostic procedure" and not a "screening" and Medicare will still pay). To cut costs (as required under present law) there will be more rules/hurdles/required parameters to be met (and documented--OMG),

What if: 5 years from now, GregLee can use his "voucher" to buy medical care from MayoClinicMedical, Inc. They don't get paid by the procedure--they get paid to keep you healthy. The "must cover" items are spelled out in the policy you buy. They can offer you all kinds of incentives if you'll come in for vaccinations, screenings, etc because it will save them money. Quit smoking, lose weight, etc and maybe there's something in it for you (reduced copays?). The healthier you stay, the more profit they make. That sounds like the incentives are right.

Now, we can argue that under this plan MayoClinicMedical has incentives to deny you expensive care, and there are fixes for that. But at least the incentives to control costs would be in place: providers aren't under pressure to order more procedures to make more money.

Not all private insurance would need to work like this--some might still be fee for service. The marketplace will decide the winner.
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Old 05-28-2011, 04:45 PM   #44
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As your provider found out: call it a "diagnostic procedure" and not a "screening" and Medicare will still pay).
Just to keep straight about the anecdote, it was actually a diagnostic procedure. Characterizing it as a screening was just a staff error. Previously, a radiologist interpreting my CT scan had reported an apparent thickening of the bowel wall and had explicitly recommended an endoscopic examination. There was a specific medical rationale for the colonoscopy, so it should not have been characterized as "screening".

While I understand the suspicion that providers of health care might be tempted to work the system to maximize their incomes, I don't think a sort of free-floating paranoia should lead us to the conclusion that it's actually happening, absent actual evidence.
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Old 05-28-2011, 06:34 PM   #45
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. . . I don't think a sort of free-floating paranoia should lead us to the conclusion that it's actually happening, absent actual evidence.
Paranoia? That may be a bit over the top. It's easy enough to compare costs of fee-for-service approaches to capitation approaches. Or HMO vs PPO. These give indications of the results produced by different incentives. This is an exercise left to the reader.
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Old 05-28-2011, 06:49 PM   #46
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You're doing static analysis. A prime reason medical costs are rising is because Medicare keeps dumping money into that system (more dollars chasing the same basket of goods= higher prices).
It's an interesting idea, and I know you're just positing it, but I'm not sure I agree with it completely (as in, it's all Medicare's fault).

However, expanding that train of thought a bit... I wonder if health care would be cheaper if insurance were divorced from employment. Many people purchase group health care through their employer and, as a result, are often ignorant to the true cost of the plan. At megacorp, I just went with a PPO for $130 a month for two and I knew my employer was on the hook for another $9k a year. We could see any specialist we wanted for anything we wanted. Cost was irrelevant.

So, more dollars chasing the same basket of goods, but on the private side as well.

Now we get to the anecdotal part of the post just based on my personal experiences

I've also noticed that, if the answer to a problem for a doctor is "I don't know", the default is to send you on to a specialist for more tests. If that specialist doesn't know, then the default is to send you on for more tests. I'm not blaming this on threat of lawsuits. After all, I'd rather find out and prevent something bad than not.

However, if I were on the hook for more of my medical cost, then I imagine I'd have more talks with my doctor where I decide not to go in for more tests if we both assume the risk is low enough to wait and see.

Now that we have a high deductible plan (individual insurance), we're less likely to go to a doctor and we're more likely to take a wait and see approach on many minor things to see if a trip to the doctor is warranted. For example, my wife likely broke her toe or at least jammed it on Tuesday. Rather than running off to urgent care as we would have on the PPO plan, she assessed the pain and swelling herself and decided, based on it subsiding by Thursday, that she wasn't going to bother.

I'm not saying this is a smart move over the long run, but, for the issue at hand (health care cost) it is having a pronounced effect.
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Old 05-28-2011, 06:59 PM   #47
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While I understand the suspicion that providers of health care might be tempted to work the system to maximize their incomes, I don't think a sort of free-floating paranoia should lead us to the conclusion that it's actually happening, absent actual evidence.
I doubt most doctors are working the system (always a few bad apples in any bunch). I doubt most providers are working the system (again, bad apples).

One thing that is interesting, to me, is the amount of waste in the system. I'm not sure if one can trace this waste to any single cause... but it's there.

Our doctor bills through a provider. The provider then bills our insurance company even though we both know the claim will be rejected. When the claim comes back rejected, we then pay the provider's negotiated rate for service. This negotiated rate is significantly lower across the board than if I had just paid directly at the doctor's office.

Additionally, that provider (at least the one I helped out in writing a billing system for) assumes, by insurance carrier, a certain amount of write-off that they'll never be paid for. That is, your regional hospital assumes it might not see, say, 20% of the money it bills to UHG or Aetna. These rules were actually built into the system we wrote, which means it's just part of the standard way of doing business.

My wife went to see her doctor this winter to see if she had pneumonia or bronchitis or something else. Four months later, we're still getting bills related to the visit. There were two different lab bills (apparently the techs that took the xray were billed through a different company than the radiologist who interpreted the xray), a bill from the doctor, and some other bill. Think of the overhead for that. Four different companies employing staff just to ensure payment for a single visit. High touch in paperwork is never good.

In this regard, a single payor system may (may) reduce cost and overhead. I'm not sure. On the other hand, I'm not seeing a lot of efficiency now and I doubt that introducing a government program would enable that.
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Old 05-28-2011, 08:31 PM   #48
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The GOP just wants to get rid of the problem. They are not interested in fixing it. How on earth can anyone actually believe the insurance would be cheaper with private insurers for seniors?

Yes, I agree there is waste and inefficiency in health care in both private and government insurers. There are so many things that could be fixed to lessen costs. I'm on medicare and recently at a visit to my GP office, the nurse I know was saying that the doctor regretted his decision to move his location. I asked her why and she said the seniors were getting to him. So I asked him about it and he said he just gets too many seniors coming in multiple times when there is nothing wrong with them. I said "there should be some kind of office visit co-pay for office visits maybe on a sliding scale, and he agreed whole heatedly and said if there was even a $25 co-pay this would stop 80% of the unnecessary visits." So I agree there needs to incentives as well as decentives for all parties involved.

Health care for profit is absurd, but private insurance for seniors (under whatever new name the GOP packages it) is insane. However, rational people (even liberals like me) have to be realistic and understand that we need to really overhaull the system and do everything we can to control costs. (In addition to cutting other areas and raising revenues at the same time)

People who shout "hands off my medicare" and in the same breath, say but do not raise my taxes, or weaken our military presence, or change social security in any way", are living in a dream world. But changes can be made and belts tightened without throwing grandma off the cliff and dumping the seriously disabled out on the street.

It is a time for re-evaluating priorities, and lots of fixing. If we could just stop fighting each other, we could actually effect change.
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Old 05-28-2011, 08:53 PM   #49
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Think of the overhead for that. Four different companies employing staff just to ensure payment for a single visit. High touch in paperwork is never good.
I'm thinking, thinking. Where exactly is the overhead? Everyone has to have staff to handle billing, anyway. Everyone has to pay Webzter for the computer software, anyway. If staff actually had to understand and work through the details of this arcane system that has evolved, I can see that we'd be in big trouble. But since Webzter's software handles the details, why should we care about the complications? We'll just let your programs figure it all out for us.
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Old 05-28-2011, 09:28 PM   #50
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The GOP just wants to get rid of the problem. They are not interested in fixing it. How on earth can anyone actually believe the insurance would be cheaper with private insurers for seniors?

Yes, I agree there is waste and inefficiency in health care in both private and government insurers. There are so many things that could be fixed to lessen costs. I'm on medicare and recently at a visit to my GP office, the nurse I know was saying that the doctor regretted his decision to move his location. I asked her why and she said the seniors were getting to him. So I asked him about it and he said he just gets too many seniors coming in multiple times when there is nothing wrong with them. I said "there should be some kind of office visit co-pay for office visits maybe on a sliding scale, and he agreed whole heatedly and said if there was even a $25 co-pay this would stop 80% of the unnecessary visits." So I agree there needs to incentives as well as decentives for all parties involved.

Health care for profit is absurd, but private insurance for seniors (under whatever new name the GOP packages it) is insane. However, rational people (even liberals like me) have to be realistic and understand that we need to really overhaull the system and do everything we can to control costs. (In addition to cutting other areas and raising revenues at the same time)

People who shout "hands off my medicare" and in the same breath, say but do not raise my taxes, or weaken our military presence, or change social security in any way", are living in a dream world. But changes can be made and belts tightened without throwing grandma off the cliff and dumping the seriously disabled out on the street.

It is a time for re-evaluating priorities, and lots of fixing. If we could just stop fighting each other, we could actually effect change.
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Old 05-28-2011, 09:42 PM   #51
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It's artful the way you can work this:
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Originally Posted by modhatter View Post
The GOP just wants to get rid of the problem. They are not interested in fixing it.
and this . . .
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Originally Posted by modhatter View Post
If we could just stop fighting each other, we could actually effect change.
into the same post. The words, the imagery you've chosen aren't calculated to stop the fighting, are they? (there goes granny off the cliff, or she's being dumped into the street)

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It is a time for re-evaluating priorities, and lots of fixing.
We agree.
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Old 05-28-2011, 10:24 PM   #52
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I'm thinking, thinking. Where exactly is the overhead? Everyone has to have staff to handle billing, anyway.
Why is that?
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Old 05-28-2011, 10:33 PM   #53
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i have 2 suggestions to help fix our health care's growing expense.
1) make medicare a HDHP at say 2k (or even 1k) annual deductable (also a low max out of pocket amount). this should help provide a disincentive for getting unneeded health care (reducing demand) and make medicare over all less expensive (btw, once this is done the gov could contract out the coverage to private insurers like they do the fed policies)
2) expand the supply of doctors via government education grants and put the drs that go through this program on salary for a specific period of time to "pay the grant back". that increase in supply, at a fixed cost, should also lower costs.
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Old 05-28-2011, 11:02 PM   #54
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Why is that?
Given that there are a bunch of different people who don't all work for the same office/hospital/lab, and they all need to be paid, they all need to generate bills. I noticed that for my CT scans, the scans themselves and the radiologist's services were all billed through the hospital where I went to get the scans, because, I guess, the hospital owns the facility and employs the CT technicians and the radiologist. However, my mother had several CT scans at the same hospital, and the scans themselves were billed through the hospital, but her radiologist billed from some organization in Florida, thousands of miles away. And why shouldn't my local hospital offload radiologist interpretation, if that's cheaper or more convenient for them?

Medicine is getting more specialized and more complicated. When specialists are working for different organizations, there are going to be different bills for their services.
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Old 05-28-2011, 11:40 PM   #55
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Now, we can argue that under this plan MayoClinicMedical has incentives to deny you expensive care, and there are fixes for that. But at least the incentives to control costs would be in place: providers aren't under pressure to order more procedures to make more money.

Not all private insurance would need to work like this--some might still be fee for service. The marketplace will decide the winner.
That's a nice thought. But it hasn't worked out like that in actual practice. I remember when people thought that HMOs were the saviors who would do just that. Then people were shocked, absolutely shocked, to find out that HMOs that got paid the same to treat the healthy and the really sick didn't really want to treat the sick and did everything they could to deny expensive care -- no matter how needed -- because it was expensive.

The goal of a private insurance company is to make money. It's reason for existence is to turn a profit. They private insurance company doesn't care if you stay healthy or if you die. And, it isn't supposed to care. It is supposed to make a profit. That is perfectly fine for many types of industries. But it isn't fine for healthcare.

So many pie in the sky ways to cut costs create incentives for care to be denied.

I do agree that there are problems with the current system. I just don't agree that getting more private insurers involved and simply throwing people out there with no guarantee of getting coverage at a reasonable cost is going to do anything. When 70 year olds can't afford medical insurance because the voucher is pitifully inadeqaute it will be cold comfort to tell them that that, sorry, the free market just has to charge way more since (what a shock!) old people need a lot of medical care.
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Old 05-29-2011, 06:16 AM   #56
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I think anyone who has read almost anything I have written would know I oppose the Ryan plan That said, however, a voucher approach to Medicare would not seem like such a disaster if it was proposed as part of a "fix" to Obamacare. If all Americans were insured from cradle to grave with guaranteed Government premium payments for seniors tilted toward the poor (which Ryan says his do) I would be more open to it. But this was advertised as round one with repeal of Obamacare to come. The GOP has become just as adamant on "no mandatory insurance" as they are on "no taxes." The only constitution approach the GOP would recognize would seem to be Medicare for all. I think that would be a better, easier fix
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Old 05-29-2011, 07:14 AM   #57
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Given that there are a bunch of different people who don't all work for the same office/hospital/lab, and they all need to be paid, they all need to generate bills.
But why do they need to bill my insurance company, have it rejected, and then bill me? They're guaranteed to handle my bill, and plenty of others, twice. Why is that kind of waste necessary or good? And, no, computer systems don't just magically fix that.
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Old 05-29-2011, 07:15 AM   #58
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You're doing static analysis.
Which usually means "I don't like the conclusions derived from simple arithmetic, so let's make a bunch of wild assumptions favorable to my argument." So let's, for example, assume that competition for insurance will drive down the cost of medical care . . . wallah, see how well my plan works at controlling the cost of medical care?

Any-who . . . competition for private insurance already exists. Large corporations have tremendous incentive to keep insurance costs down. It is a cost of labor for them. If there were any savings to be had there, we'd be seeing it. If insurance companies could figure out how to reduce their costs relative to their competitors, they'd be doing it already.
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Old 05-29-2011, 07:46 AM   #59
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Any-who . . . competition for private insurance already exists. Large corporations have tremendous incentive to keep insurance costs down for their employees. If there were any savings to be had there, we'd be seeing it. And gee, shouldn't the individual market reflect all of the great benefits of competition already?
Large corporations (who have increasingly bought our government and institutions, IMO) may complain about health care and the dysfunctional nature of our system, but in reality it favors them. They can negotiate with insurers in ways small businesses can only dream of, making it easier to offer health insurance to employees and giving them a big advantage in recruiting and retention.

Yet another reason, IMO, to separate health insurance from employers.
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Old 05-29-2011, 07:52 AM   #60
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Fixed it.
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Which usually means "I don't like the conclusions derived from simple arithmetic, so let's make a bunch of wild assumptions favorable to my argument." "People respond to incentives"

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Any-who . . . competition among for private insurance already exists. Large corporations have tremendous incentive to keep insurance costs down for their employees. If there were any savings to be had there, we'd be seeing it.
And we are. When we look at the total cost of care (paid by the insurer plus Medigap policies, plus out-of-pocket costs the patient pays), Medicare is doing a poorer job of controlling costs than private insurers are doing. (Ref). And, as a bonus, with Medicare you get poorer access to physicians, since fewer and fewer are seeing new Medicare patients. The proposed fix to this is lowering reimbursement rates. Yep, that should work well.

And the study above doesn't even address the cost-shifting by which private insurers help pay for care provided under Medicare. Throw that in and see how the numbers come out. Maybe that analysis is too "dynamic" for some.
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