No Politics, HC big issue for FIRE

[travelover]

............This is an amusing story, but when workarounds like this are required, there is a design problem.

Yes, poor design. The police station should have installed a small, easily replaceable window.

 

[Closet_Gamer]

I think you are wrong. Here's why.

Since ACA, health insurers must spend at least 80% of premiums on claims in any given policy year. As a result, the maximum that they have available for taxes, overhead and profit after paying for claims is 20% of premiums. If they do not spend at least 80% on claims then they need to refund any excess premiums until the claim ratio is 80%.

This is a variation of "Cost+" regulation which is, ironically, a recipe for exploding costs.

If I charge you $100 and pay $80 to the hospital, I get to keep $20.
If I charge you $200 and pay $160 to the hospital, I get to keep $40.

Hmmm....my incentive to knock down what I pay to the hospital and pharm companies is.... So long as the market moves in more or less lock step, there is every incentive to keep increasing underlying healthcare costs.

This is how phone companies were regulated for years in many states. I used to work at one where the big question was "how do we get cost xyz into the rate base?" Essentially, "how do we convince the regulators that a certain cost was critical and therefore something we should be allowed to mark-up into the price?"

Well intentioned to be sure but unlikely to be effective at containing the cost of anything.

 

[explanade]

Moral hazard? This cannot be, because the sick patient is not the one making the determination. If anything, there is conflict of interest in the insurer, who stands to profit by denying treatment.

Unfortunately, I went through this firsthand.

My father passed away and his Medicare Advantage provider said his prognosis was bad.

What was especially difficult was that he had neurological deficit (diagnosis was cancer in the brain and elsewhere), unable to speak for about the last 3 weeks of his life. My elderly mother would go to hospital every day, speak to him, hand feed him, often spend the night. She'd talk to him in a familiar and intimate way that I've never seen between them.

We researched treatments which might at least alleviate the symptoms and went to the provider to ask about them. They shut us down each and every time, said we should just focus on palliative care, let him go with dignity, etc.

He was not in any pain. He would respond to our questions with one-word answers now and then and he denied he was in pain.

The provider and the doctors didn't say what recourse we might have to seek alternate opinions. They did have a process but a person in their administrative staff said they rarely if ever approved outside services.

We did pay for a second opinion with a neurosurgeon, who recommended a way to deliver chemotherapy into the cranium but again, the Medicare Advantage provider ignored our request, wouldn't even accept it as a valid recommendation.

Maybe it would have worked or maybe it wouldn't have. But obviously would have required neurosurgery so it would have been costly.

From this experience, we changed our mother's coverage from the same Medicare Advantage plan to a Medigap plan, which costs more than double but would allow us to go to any Medicare provider.

I plan to stay away from Medicare Advantage plans as well.

 

[LARS]

Unfortunately, I went through this firsthand.



My father passed away and his Medicare Advantage provider said his prognosis was bad.



What was especially difficult was that he had neurological deficit (diagnosis was cancer in the brain and elsewhere), unable to speak for about the last 3 weeks of his life. My elderly mother would go to hospital every day, speak to him, hand feed him, often spend the night. She'd talk to him in a familiar and intimate way that I've never seen between them.



We researched treatments which might at least alleviate the symptoms and went to the provider to ask about them. They shut us down each and every time, said we should just focus on palliative care, let him go with dignity, etc.



He was not in any pain. He would respond to our questions with one-word answers now and then and he denied he was in pain.



The provider and the doctors didn't say what recourse we might have to seek alternate opinions. They did have a process but a person in their administrative staff said they rarely if ever approved outside services.



We did pay for a second opinion with a neurosurgeon, who recommended a way to deliver chemotherapy into the cranium but again, the Medicare Advantage provider ignored our request, wouldn't even accept it as a valid recommendation.



Maybe it would have worked or maybe it wouldn't have. But obviously would have required neurosurgery so it would have been costly.



From this experience, we changed our mother's coverage from the same Medicare Advantage plan to a Medigap plan, which costs more than double but would allow us to go to any Medicare provider.



I plan to stay away from Medicare Advantage plans as well.

Can I ask how old your father was at the time?

 

[Meadbh]

Unfortunately, I went through this firsthand.

My father passed away and his Medicare Advantage provider said his prognosis was bad.

What was especially difficult was that he had neurological deficit (diagnosis was cancer in the brain and elsewhere), unable to speak for about the last 3 weeks of his life. My elderly mother would go to hospital every day, speak to him, hand feed him, often spend the night. She'd talk to him in a familiar and intimate way that I've never seen between them.

We researched treatments which might at least alleviate the symptoms and went to the provider to ask about them. They shut us down each and every time, said we should just focus on palliative care, let him go with dignity, etc.

He was not in any pain. He would respond to our questions with one-word answers now and then and he denied he was in pain.

The provider and the doctors didn't say what recourse we might have to seek alternate opinions. They did have a process but a person in their administrative staff said they rarely if ever approved outside services.

We did pay for a second opinion with a neurosurgeon, who recommended a way to deliver chemotherapy into the cranium but again, the Medicare Advantage provider ignored our request, wouldn't even accept it as a valid recommendation.

Maybe it would have worked or maybe it wouldn't have. But obviously would have required neurosurgery so it would have been costly.

From this experience, we changed our mother's coverage from the same Medicare Advantage plan to a Medigap plan, which costs more than double but would allow us to go to any Medicare provider.

I plan to stay away from Medicare Advantage plans as well.

Just because you could do other things to your DF does not mean that you should.

 

[explanade]

He was two months short of turning 84.

I'm not saying their prognosis was invalid.

It's just that we felt utterly helpless. The doctors seemed insensitive, as if apathetic to us wanting to explore other options.

My sister researched and found all kinds of cases in which this same provider had concluded they would no longer offer treatment options to patients as young as those in their early 40s. One case involved a patient who was told he had months to live and sought care elsewhere and went back to sue the provider to pay for the outstanding bills on the care he got elsewhere.

Of course there are going to be complaints since this provider probably treat millions of patients in their system. I don't know how representative or unrepresentative those cases were.

I don't know if Medicare and Medigap coverage would have allowed us to pursue other options more easily. Seems like they would have, as long as we found a Medicare provider willing to see him. One highly-regarded facility said they would be willing to examine him but once they learned he had Medicare Advantage, they told us we'd have to get his provider to refer him and approve them, since the MA provider "controlled his Medicare money."

Would CMS itself have denied coverage or treatment in this situation? I don't know. But it was clear that this particular MA provider did.

 

[pb4uski]

This is a variation of "Cost+" regulation which is, ironically, a recipe for exploding costs.

If I charge you $100 and pay $80 to the hospital, I get to keep $20.
If I charge you $200 and pay $160 to the hospital, I get to keep $40.

Hmmm....my incentive to knock down what I pay to the hospital and pharm companies is.... So long as the market moves in more or less lock step, there is every incentive to keep increasing underlying healthcare costs.

This is how phone companies were regulated for years in many states. I used to work at one where the big question was "how do we get cost xyz into the rate base?" Essentially, "how do we convince the regulators that a certain cost was critical and therefore something we should be allowed to mark-up into the price?"

Well intentioned to be sure but unlikely to be effective at containing the cost of anything.

Only one little hitch in your logic... well.... actually a big one... it isn't totally cost plus because the health insurers have to compete with other health insurers and their customers chose who to buy from principally based on cost (unlike your former employer whwre there was no or limited competition for many years).

Also, there are those pesky insurance regulators and public filings and actuarial reviews and public hearings for rate approvals and things like that.

There is not a lot of getting additional things into the cost base... a claim is a claim... there might be a little grey around claim administration costs but that's about it.

 

[pb4uski]

Just because you could do other things to your DF does not mean that you should.

+1

 

[ncbill]

I love the idea of single payer, but everyone does understand how they have to operate to at least try to remain solvent?

There is always some form of gatekeeper deciding whether or not the plan even covers a specific treatment or medication.

Such a plan would never cover those "live a few months longer with your advanced cancer by paying 6-figures for our medication" treatments seen advertised on TV here in the U.S.

I believe covering the most people at the lowest cost makes that an acceptable trade-off, but it's clear reading the posts here many would not agree.

 

[pb4uski]

+1 essentially "society" would make those difficult decisions since "society" is paying for it... hopefully balancing humanity and economics..... that would be fine with me as I believe that we spend too much trying to prolong life where there is poor quality of life.... and those who have the means and want to spend their money on expensive treatments to prolong their life a little would be free to do so if they wish.

 

[Scuba]

+1



The word for this is "moral hazard". If I were really sick, and there's a $1-million dollar treatment that would give me a mere 1% chance of living another 5 years, I would say "go for it", but only if I do not have to pay.

When someone else is paying, the sky is the limit.

+1
We have a plan with high deductibles and OOP max. I have to admit we ask a lot more questions up front about costs and alternatives than we did when an employer policy covered everything except small co-pays.

 

[Scuba]

Unfortunately, I went through this firsthand.



My father passed away and his Medicare Advantage provider said his prognosis was bad.



What was especially difficult was that he had neurological deficit (diagnosis was cancer in the brain and elsewhere), unable to speak for about the last 3 weeks of his life. My elderly mother would go to hospital every day, speak to him, hand feed him, often spend the night. She'd talk to him in a familiar and intimate way that I've never seen between them.



We researched treatments which might at least alleviate the symptoms and went to the provider to ask about them. They shut us down each and every time, said we should just focus on palliative care, let him go with dignity, etc.



He was not in any pain. He would respond to our questions with one-word answers now and then and he denied he was in pain.



The provider and the doctors didn't say what recourse we might have to seek alternate opinions. They did have a process but a person in their administrative staff said they rarely if ever approved outside services.



We did pay for a second opinion with a neurosurgeon, who recommended a way to deliver chemotherapy into the cranium but again, the Medicare Advantage provider ignored our request, wouldn't even accept it as a valid recommendation.



Maybe it would have worked or maybe it wouldn't have. But obviously would have required neurosurgery so it would have been costly.



From this experience, we changed our mother's coverage from the same Medicare Advantage plan to a Medigap plan, which costs more than double but would allow us to go to any Medicare provider.



I plan to stay away from Medicare Advantage plans as well.

I'm not too close to Medicare age yet, but my understanding is that Medicare Advantage is like an HMO while Medigap is like a PPO. We have PPO coverage now. We try to stay on-network to help manage costs but are willing to pay more for a PPO so that we have some coverage for any provider we choose.

 

[Winemaker]

I hope you are right - for the sake of our grand children. I don't see it happens in my life time :-(

I hope you live for another 250 years.

 

[Maenad]

I love the idea of single payer, but everyone does understand how they have to operate to at least try to remain solvent?

There is always some form of gatekeeper deciding whether or not the plan even covers a specific treatment or medication.

And? Those gatekeepers exist now. They will always exist for everyone but the very richest, who can pay however much they want for the most cutting-edge treatments. Single payer or some other gov't-provided/managed health insurance won't create a new problem in this.

 

[flintnational]

My 2 cents.

Healthcare is broken and will need significant reforms. (No news there.) IMHO, the reforms will come sooner rather than later. We are at the breaking point.

Cost Control - Either a true free market system (free market is not what we currently have) or single payer. Either will cap costs.

Gate keeper - In a free market system or a single payer system there is a gate keeper rationing care. (In the free market it is price.)

Litigation reform - A fair percent of health care dollars are apparently spent avoiding legal claims.

Prevention vs. maintenance - Probably the biggest needed change. I cannot think of any other area of our lives where we do not work on the root cause of a problem. But, in health care it is acceptable to treat the symptoms and ignore the root causes. We need to change the system to focus on disease prevention. This might entail more education for the public, changes to the way doctors are trained and reforms in the drug industry.

IMHO, the good news is that the current system is probably not sustainable long term. Change will come. Lets just hope the new will be better than the old.

 

[LARS]

And? Those gatekeepers exist now. They will always exist for everyone but the very richest, who can pay however much they want for the most cutting-edge treatments. Single payer or some other gov't-provided/managed health insurance won't create a new problem in this.

What a very true statement that is not obvious when most have this discussion. I guess the old Ronald Reagan quote clouds the issue: "The most terrifying words in the English language are: I'm from the government and I'm here to help."

 

[Luvdogs]

This may be really far-fetched but maybe the brains at Amazon should get involved . They may be able to find a much better way to manage healthcare.

 

[REWahoo]

This may be really far-fetched but maybe the brains at Amazon should get involved . They may be able to find a much better way to manage healthcare.

I like it.

You could order an appendectomy online and a Dr. could show up at your house within two hours, let himself in using a special door code, and do the surgery on your kitchen counter. The reduced overhead cost would allow for a huge savings!

 

[pb4uski]

I guess that I would like to a single payer of a different sort... a literal single payer... where there would be a single, Medicare-style administrator to negotiate prices for services and handle claims administration so medical providers only have to deal with one system rather than many. Unit costs would be known and insurers could design premiums based on those costs and their views on utilization so price and perhaps ancillary programs would be main determinants for consumers shopping for health insurance. Insurers would then pay the single payer for the claim costs of their insureds and an administrative fee for each insured.

In essence, it would be similar in ways to what large employers do... where they hire an insurer to design the programs, negotiate prices and process claims and the employer takes the incidence risk (sometimes subject to a stop-loss) but replacing the single payer for the insurer and the insurer for the employer and the insured for the employee.

 

[tulak]

And? Those gatekeepers exist now. They will always exist for everyone but the very richest, who can pay however much they want for the most cutting-edge treatments. Single payer or some other gov't-provided/managed health insurance won't create a new problem in this.

Yes, the gatekeepers exist today. I read the following article this morning:

http://www.cnn.com/2017/12/11/health/aetna-surgery-denied-for-girl/index.html

The 15-year-old tried to absorb the devastating news relayed by her parents: that their insurance company, Aetna, denied her for a minimally invasive brain surgery that could end the seizures that have haunted her since she was 9 years old.

It’s a sad case. Hopefully it works out for them.

 

[LARS]

This may be really far-fetched but maybe the brains at Amazon should get involved . They may be able to find a much better way to manage healthcare.

Generally speaking with Healthcare in America IMHO the issue isn’t the what of the problem, but instead the how of the problem, which is to say forcing consensus, and then change, among the varied interested/competing parties.

 

[jollystomper]

Prevention vs. maintenance - Probably the biggest needed change. I cannot think of any other area of our lives where we do not work on the root cause of a problem. But, in health care it is acceptable to treat the symptoms and ignore the root causes. We need to change the system to focus on disease prevention. This might entail more education for the public, changes to the way doctors are trained and reforms in the drug industry.

One of the challenges with prevention vs. maintenance is that there are heavily investments in the items people could cut back on for prevention.

For example, there is the message about the explosion of obesity in the U.S. and the impact of that on the health care system. But one of the reasons some give is the abundance of cheap fast/prepared food containing unhealthy levels of ingredients that is readily available everywhere. In fact, one could argue that the cheaper the food is, the more likely it contains stuff that in the long run is not healthy for you.

Another aspect is the reduced amount of physical activity. I recall schools would have recess where everyone would be out running around, and a gym class a couple of times a week. I now see modern schools being built without playground yards, or with fancy sports fields that only the school teams are allowed to use. One reason I have been told is the liability schools fear if a kid gets injured during "free play time".

Somehow it is also related to the general increased impatience... everyone wants to see results in weeks or a month, and the message of "do this with discipline over the years, and it will make a difference in your health" does not resonate as well.

While I agree the health care is out of control, I also think that one cannot ignore the aspect that people have some stake in trying to do preventive things themselves. Some - but not all - of that can be helped with health care incentives.

 

[Senator]

Much of the healthcare cost are attributed to salaries in the healthcare field. If we could train more doctors and nurses, at the Governments expense, there could be 100X more doctors and nurses than today. Of course, a certain number of years of working at the proper rates would be required after the free training or loan forgiveness.

Education would be cheaper than allowing the price of healthcare to continue to go up.

Why is it so hard to get into medical school? It should not be that way. Train more specialists like Nurse Practitioners that can do many simple surgeries. It doesn't take a Doctor. I am convinced that a Dr. probably knows too much for most of the tasks they perform.

A pharmacist should be able to prescribe many medications. It doesn't take a Dr. to prescribe a acid reducer. Prescribing exercise and diet should also be first on the list rather than drugs. If you do not follow the plan, the results may not be any different than not taking a heart medication.

Let people order more drugs on-line, and self-prescribe. Why waste a Drs. time for someone that needs a blue pill or a commonly accepted safe drug. If a person is ordering online, they can read warnings.

There are lots of way to make healthcare cheaper and more efficient, here in the USA we are not ready for the realities of it. It is time to get away from doing the same thing, rather than just pushing the same higher costs onto someone else.

 

[explanade]

With all the money in health care, of course there are people who benefit from the current state and they're going to make sure their interests are protected.

So they will spend heavily on lobbying to protect or enhance their business, such as what happened with Medicare Part D.

 

[Moemg]

I'm not too close to Medicare age yet, but my understanding is that Medicare Advantage is like an HMO while Medigap is like a PPO. We have PPO coverage now. We try to stay on-network to help manage costs but are willing to pay more for a PPO so that we have some coverage for any provider we choose.

You can get Medicare advantage PPO's . That is what my SO has . He orginally had a HMO and it was too restrictive but with the PPO He has had excellent care .