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Old 02-27-2016, 03:08 PM   #41
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... If we, as consumers, had the option of health care at the same price as the insurer, the market might structure itself more like auto insurance...
I have told this story before, but it is worth repeating.

About 30 years ago, the megacorp I was with was seeing the handwriting on the wall about escalating health care costs. It pushed for more transparency in hospital billing, requirement that the patient be informed of options, having 2nd opinion, etc.... It tried to form a coalition with other major employers in town to push state laws mandating some of these ideas. They were trying to get patients to understand and appreciate the cost of healthcare.

Nope, the measure failed in the poll. People just did not care. Back then, I got free healthcare and dental coverage as an employee. My family was covered by me paying peanuts ($50 a month perhaps, too low to even remember). And I could go to any specialist for anything.

And I think the deal like the above was pretty much standard then. People were spoiled, and they thought that any change would mean they would not get the status quo, so why changed anything at all. Of course the cost increase was not sustainable, and look at how expensive health insurance is now from employers, and the high deductible of several $K is now standard.

I say people get what they deserve.

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The "insurer" is not simply insuring risk, as is the case with life and homeowners. They are imposing themselves between providers and consumers and extracting money from each.
Another entity that would provide the same function would also have a "friction cost".
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Old 02-27-2016, 03:15 PM   #42
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Many people are finding that health care providers offer cash discounts on their services over the prices negotiated with insurers:

How to Cut Your Health-Care Bill: Pay Cash - WSJ
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Old 02-27-2016, 04:04 PM   #43
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Except it really isn't. A better name would be called health care intermediation, with a rider for insurance. The "insurer" is not simply insuring risk, as is the case with life and homeowners. They are imposing themselves between providers and consumers and extracting money from each.

What money are they extracting from providers?
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Old 02-27-2016, 04:34 PM   #44
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What money are they extracting from providers?
Are you kidding? Have you ever looked at a medical bill?

Amount for procedure: $989
Insurer negotiated amount: $102
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Old 02-27-2016, 05:06 PM   #45
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Bear in mind that the 'amount for procedure' number, the chargemaster price, is set to address the "Saudi sheikh problem" , and isn't related to the actual cost and normal profit margin for a procedure.

"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."
-- Warren Browner, California Pacific Medical Center CEO
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Old 02-27-2016, 05:18 PM   #46
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Right, but if I go in with no insurance and hand them a credit card, do you think I only pay the $102 amount?
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Old 02-27-2016, 05:28 PM   #47
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Right, but if I go in with no insurance and hand them a credit card, do you think I only pay the $102 amount?
They'll generate a statement with the chargemaster amount, but if you are wise you'll dicker to pay up front if possible at a reduced rate. If after the fact, you'll want to offer immediate payment of a smaller amount as payment in full. Get a starting price with one of these:
https://www.healthcarebluebook.com/
FH Consumer Cost Lookup

You won't get the insurance company price, but you'll do better than the chargemaster rate. Ask for a "prompt pay" discount.
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Old 02-27-2016, 08:19 PM   #48
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Why do you think they call it insurance?



For car insurance you pay premiums and most years don't have any claims but every once in a while you do. Ditto with home insurance. In fact, home insurance is probably a better analogy in that some years you have no claims, some years perhaps a small claim and every so often someone has a big claim.
I'm not sure your analogy to car and house insurance is appropriate. People use health insurance for well check too. Not just for catastrophic.
It doesn't work the way people expect it to work. If you have a deductible of $12,000 per year then it's almost as if you have no insurance. This is very common complain for ACA.


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Old 02-27-2016, 08:28 PM   #49
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It doesn't work the way people expect it to work. If you have a deductible of $12,000 per year then it's almost as if you have no insurance. This is very common complain for ACA.
It's a common complaint. And a fairly misleading one too. One huge benefit of health insurance is that you get charged your insurer's "negotiated rate" for services. For me, that price is about 1/8th the sticker price.

So even if I don't exceed my deductible and never get reimbursed a single cent from my insurance company I may still get tremendous value from the policy. In fact that was my situation in 2015 where we more than earned back our insurance premium just through negotiated discounts.

Now some argue that you can get those same prices and better by negotiating to pay cash. I personally have never been able to make that work. And it certainly wouldn't work in any emergency scenario.
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Old 02-27-2016, 09:27 PM   #50
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DH tried this with an office visit.

His PCP of many years retired in 2015 and passed him to his replacement MD. Nice enough new doctor but he changed DHs high blood pressure medication and started him on a statin. He said they do things differently than the retired PCP.

DH tried the new dosages and the statin and needed a minor adjustment. He needed to come back for an office visit in Jan 2016. By then we had changed insurances and his new PCP is currently out of network. The new insurance is a HMO and there is no coverage for out of network.

Fine. DH knew he would be seeing the PCP for one last visit and our insurance would not cover it. I explained the cost of this and DH wanted to see the now out of network PCP.

So he went to his office visit in Jan 2016 and explained to the staff that he wanted to pay for this outside of the insurance. He took a credit card and cash and asked to pay, hopefully with a discount of some sort.

They told him that they could not process an office visit like that. All visits had to be sent to their billing department. He tried to explain that he changed insurance, etc and to not submit it, no one would be paying this but him.

The answer was that they had to submit it, there was no other way. So they submitted it to our 2015 insurance which took a few weeks and rejected it. They billed us and he called to explain and they said they had to submit it to his current insurance. So he gave them the info and it was rejected as out of network and not preapproved.

When the next bill comes he will call them again and at most they will offer a 10% discount. The bill is $178 and our old insurance used to adjust it to $112 as the negotiated rate, but we will probably have to pay $160.

This really bugs me because DH could have just found a new PCP with our new HMO and only paid $40 co-pay (ACA Bronze plan with $6650 deductible but not HSA eligible) but he insisted that he wanted to follow through with the one who changed his dosages.

So yeah, the idea that you can just go in and pay cash and not bother with insurance hassles......I wish it was that simple!
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Old 02-27-2016, 09:35 PM   #51
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It's a common complaint. And a fairly misleading one too. One huge benefit of health insurance is that you get charged your insurer's "negotiated rate" for services. For me, that price is about 1/8th the sticker price.



So even if I don't exceed my deductible and never get reimbursed a single cent from my insurance company I may still get tremendous value from the policy. In fact that was my situation in 2015 where we more than earned back our insurance premium just through negotiated discounts.



Now some argue that you can get those same prices and better by negotiating to pay cash. I personally have never been able to make that work. And it certainly wouldn't work in any emergency scenario.

Maybe to you but I don't think that's how people expect insurance to work. I don't think it's misleading. Maybe we should pay negotiated rate without the insurance.

BTW, I did manage to get discount on emergency. I told them I didn't have any money. I recalled they did reduce some. I think the insurance paid the full bill but I lost my job and already spent the money. I think it was outrageous ambulance fee.


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Old 02-27-2016, 09:37 PM   #52
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....It doesn't work the way people expect it to work. If you have a deductible of $12,000 per year then it's almost as if you have no insurance. This is very common complain for ACA. ..
I don't get what the complaint is about. When you apply for the policy you know what you have to pay for premiums and that (other than certain well care defined in the policy) your costs have to exceed $12,000 before the insurer pays any claims. Why would people expect it to work any other way unless they are ignorant as to what they are buying? They may think it is too expensive but is it what it is and premiums are a function of medical costs.

They have insurance... if you have a serious illness and rack up a $100,000 hospital bill then you pay $12,000 and the insurer pays $88,000.

People complained about the cost of medical services and medical insurance for the last 10 years, both before and after ACA.
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Old 02-27-2016, 09:48 PM   #53
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DH tried this with an office visit.

His PCP of many years retired in 2015 and passed him to his replacement MD. Nice enough new doctor but he changed DHs high blood pressure medication and started him on a statin. He said they do things differently than the retired PCP.

During my recent yearly physical, my PCP mentioned that he is "graded" by the insurance companies. If you have certain markers, stuff like high "cholesterol", high blood sugar, etc., the insurance company actually expects (demands?) the doctor put you on the appropriate "drugs".
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Old 02-27-2016, 09:55 PM   #54
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I don't get what the complaint is about. When you apply for the policy you know what you have to pay for premiums and that (other than certain well care defined in the policy) your costs have to exceed $12,000 before the insurer pays any claims. Why would people expect it to work any other way unless they are ignorant as to what they are buying? They may think it is too expensive but is it what it is and premiums are a function of medical costs.



They have insurance... if you have a serious illness and rack up a $100,000 hospital bill then you pay $12,000 and the insurer pays $88,000.



People complained about the cost of medical services and medical insurance for the last 10 years, both before and after ACA.

I see the point, though it's not about confusion over expectations. Thank your lucky stars you only have to pay $12k that year you need a bypass or chemo, but for other less critical medical issues, for many, a $12k deductible is equivalent to having no "insurance", in the sense that that sprained ankle or upper respiratory infection is all out-of-pocket.
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Old 02-27-2016, 10:25 PM   #55
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I don't get what the complaint is about. When you apply for the policy you know what you have to pay for premiums and that (other than certain well care defined in the policy) your costs have to exceed $12,000 before the insurer pays any claims. Why would people expect it to work any other way unless they are ignorant as to what they are buying? They may think it is too expensive but is it what it is and premiums are a function of medical costs.



They have insurance... if you have a serious illness and rack up a $100,000 hospital bill then you pay $12,000 and the insurer pays $88,000.



People complained about the cost of medical services and medical insurance for the last 10 years, both before and after ACA.

Because in the past, they paid for the same premium with much lower deductible. Now they pay the same cost for $12,000 deductible. I'm sure people thought their health plans would get better post-ACA but they didn't. False promise often results in complaints.
Very few people would have $100,000 hospital bill. I'm 56, I haven't been seriously ill to ever paid that much in any year. If I have to pay $12,000 a year and don't ever get to use it, I'm sure I wouldn't be happy.
For the record, I have very good insurance through my husband. But everywhere I go, particularly for small business owner, this is the complaint I've often heard.
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Old 02-27-2016, 10:28 PM   #56
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During my recent yearly physical, my PCP mentioned that he is "graded" by the insurance companies. If you have certain markers, stuff like high "cholesterol", high blood sugar, etc., the insurance company actually expects (demands?) the doctor put you on the appropriate "drugs".

This is crazy. My doctor likes to push me to do extra tests. I often ignore him.


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Old 02-27-2016, 11:01 PM   #57
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Are you kidding? Have you ever looked at a medical bill?

Amount for procedure: $989
Insurer negotiated amount: $102
I had a special blood test. The bill was something like $150, readjusted down to $35. What was really interesting was a certain item that was billed at a few dollars, and readjusted down to something like a few pennies! What could that be? A BandAid?

This is crazy. There's no other business that gouges like that. Even new car dealers are not so bad.

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... DH knew he would be seeing the PCP for one last visit and our insurance would not cover it. I explained the cost of this and DH wanted to see the now out of network PCP.

So he went to his office visit in Jan 2016 and explained to the staff that he wanted to pay for this outside of the insurance. He took a credit card and cash and asked to pay, hopefully with a discount of some sort.

They told him that they could not process an office visit like that. All visits had to be sent to their billing department. He tried to explain that he changed insurance, etc and to not submit it, no one would be paying this but him.

The answer was that they had to submit it, there was no other way. So they submitted it to our 2015 insurance which took a few weeks and rejected it. They billed us and he called to explain and they said they had to submit it to his current insurance. So he gave them the info and it was rejected as out of network and not preapproved.

When the next bill comes he will call them again and at most they will offer a 10% discount. The bill is $178 and our old insurance used to adjust it to $112 as the negotiated rate, but we will probably have to pay $160.

This really bugs me because DH could have just found a new PCP with our new HMO and only paid $40 co-pay (ACA Bronze plan with $6650 deductible but not HSA eligible) but he insisted that he wanted to follow through with the one who changed his dosages.

So yeah, the idea that you can just go in and pay cash and not bother with insurance hassles......I wish it was that simple!
Isn't that crazy? The healthcare providers' bill processors are like automatons that cannot deviate from standard procedures, and the standard procedures do not cover people paying with cash out of their pocket.

Compare that to dental care. My dentist advertised a $49 checkup. So, I showed up, and after an X-ray and quick exam he told me everything looked good but I needed some cleaning. I expected that, as my last dental visit was 3 years ago. The dental assistant told me the cost, and it was reasonable so I accepted, and paid on the way out when it was all done.

An older friend told me that was how it was with doctors when he was growing up. His father was a milkman and did not have health insurance (perhaps back then nobody had health insurance). When the kids were sick, his father just took them to go see the family doctor and paid cash. I don't know how people settled bigger hospital bills back then.

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Because in the past, they paid for the same premium with much lower deductible. Now they pay the same cost for $12,000 deductible. I'm sure people thought their health plans would get better post-ACA but they didn't. False promise often results in complaints.

Very few people would have $100,000 hospital bill. I'm 56, I haven't been seriously ill to ever paid that much in any year. If I have to pay $12,000 a year and don't ever get to use it, I'm sure I wouldn't be happy...
When people get older, they will have plenty of chances to use healthcare, and lots of it. That's why Medicare is going bankrupt.

My pre-ACA policy was very simple; below $10K I paid everything, while above $10K they paid everything. There was no copay or coinsurance. The $10K was also max out-of-pocket. Now, with ACA the premium is more, and the max out-of-pocket is also higher.

But, but, but there are some big differences. Pre-existing conditions are no longer excluded. And then, there is now no lifetime limit on coverage. My pre-ACA policy had a lifetime limit, which I never paid attention to because I told myself if I were that sick I would not want to live. It was probably $1M, or perhaps only $500K.

It only takes a few patients whose treatments cost a few $M to drive up the premium for everybody. And perversely, the really sick ones are cheap to cover. They die relatively quickly. Examples include lung cancer patients. After $100K or $200K, they are gone. Brain cancer kills even quicker, and many patients do not respond to treatments at all. Poof, they are gone in a couple of months after diagnosis. On the other hand, some chronic illnesses cost a lot more as they can go on for years before the patient dies, and cause all kinds of complications.
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Old 02-27-2016, 11:02 PM   #58
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DH tried this with an office visit.

His PCP of many years retired in 2015 and passed him to his replacement MD. Nice enough new doctor but he changed DHs high blood pressure medication and started him on a statin. He said they do things differently than the retired PCP.

DH tried the new dosages and the statin and needed a minor adjustment. He needed to come back for an office visit in Jan 2016. By then we had changed insurances and his new PCP is currently out of network. The new insurance is a HMO and there is no coverage for out of network.

Fine. DH knew he would be seeing the PCP for one last visit and our insurance would not cover it. I explained the cost of this and DH wanted to see the now out of network PCP.

So he went to his office visit in Jan 2016 and explained to the staff that he wanted to pay for this outside of the insurance. He took a credit card and cash and asked to pay, hopefully with a discount of some sort.

They told him that they could not process an office visit like that. All visits had to be sent to their billing department. He tried to explain that he changed insurance, etc and to not submit it, no one would be paying this but him.

The answer was that they had to submit it, there was no other way. So they submitted it to our 2015 insurance which took a few weeks and rejected it. They billed us and he called to explain and they said they had to submit it to his current insurance. So he gave them the info and it was rejected as out of network and not preapproved.

When the next bill comes he will call them again and at most they will offer a 10% discount. The bill is $178 and our old insurance used to adjust it to $112 as the negotiated rate, but we will probably have to pay $160.

This really bugs me because DH could have just found a new PCP with our new HMO and only paid $40 co-pay (ACA Bronze plan with $6650 deductible but not HSA eligible) but he insisted that he wanted to follow through with the one who changed his dosages.

So yeah, the idea that you can just go in and pay cash and not bother with insurance hassles......I wish it was that simple!

That is just a bad Dr office.... my old PCP is not in my network and he said he would charge me $70 for a visit and his cost for any tests.... no markup... I have been to him once since then and will go to him in a month or two... paid right on the spot and never was submitted to insurance....

I do this because I only get 2 $40 copay with my in network PCP, so I save them for if something else happens...
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Old 02-28-2016, 05:02 AM   #59
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Bear in mind that the 'amount for procedure' number, the chargemaster price, is set to address the "Saudi sheikh problem" , and isn't related to the actual cost and normal profit margin for a procedure.

"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."
-- Warren Browner, California Pacific Medical Center CEO
I've read this and seen it referenced a number of times, but think it's just a clever way to describe a practice that is actually much more distasteful. Reference prices that are 10x the negotiated insurance price are not real list prices, they are wildly exploitative and greedy. Like the secret negotiated prices for insurance intermediaries, they should be prohibited, as they disrupt the normal functioning of the pricing mechanism and exploit people when they are most vulnerable.
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Old 02-28-2016, 06:21 AM   #60
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I've read this and seen it referenced a number of times, but think it's just a clever way to describe a practice that is actually much more distasteful. Reference prices that are 10x the negotiated insurance price are not real list prices, they are wildly exploitative and greedy. Like the secret negotiated prices for insurance intermediaries, they should be prohibited, as they disrupt the normal functioning of the pricing mechanism and exploit people when they are most vulnerable.
Agreed!

My doctor's office sends blood work labs to their "in house" place for cash paying customers for about $150 that they pay up front. But for patients with insurance, it gets sent to a major lab chain which bills the insurance company directly, about 10x the amount - like $1500-$1700 for the same fairly standard labwork! This in turn gets heavily "discounted" by the insurance company, so that the patient iultimately owes like $145.

It's insane!
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