No Politics, HC big issue for FIRE

[pb4uski]

So if I ran a health insurance company, I'd buy some hospitals (different company registration) and have my hospitals charge the health ins company a high rate to ensure the 80% is met, then pay out dividends to the company owner (which is the health ins company).
I'd probably add some pharmacies/drug companies in the mix to make sure all my customers spent the full amount as many each year would not go to hospitals.

A nice vertically integrated system of companies would assure removal of pesky refunds.

Great idea! Problem is that the regulatory and commercial capital requirements for an insurer owning a hospital would high so that is unlikely to happen.

The inverse may work though..... you may have seen in the news last week that CVS is buying Aetna.... but between competiton and regulatory constraints gouging is unlikely to happen but CVS may well be able to capture a bigger slice of the pie.

 

[Rianne]

Does anyone know how small, medium, large companies fare in the HI pool. Obviously, large companies, 6000 employees or more get the best rate for their employees. Or is it based on how healthy those employees are? I recall our mega corp HI had a $1 M cap on what they'd pay out. Our yearly choice of plans offered low deductible to high deductible plans based on monthly premiums and HSA's etc, but we never paid attention to that $1 M cap because it seemed out of the question that would ever happen. The ACA did away with that cap, right?

And one more thing, other countries who offer single payor negotiate the cost of services, tests, ex rays, prescription drugs. Our insurance companies also negotiate the cost of services with the hospital. My hospital charged around $1141 for a CT scan. The insurance adjusted that cost down to $138.06 based on explanation of benefits. So, a person without insurance gets a CT scan and the full amount, $1141 is either written off or charged to tax payers. The amount charged to my deductible is $138.06. Where does the hospital get the figure $1141? Someone told me if I went to a hospital 50 miles away, they might charge $500 for a CT scan. But if that hospital is out of network, I pay the whole $500. This does not make sense. And if you go to the ER, your insurance covers everything, except co insurance. So you go to the expensive ER and get covered. Craziness!

 

[Chuckanut]

Can't afford necessary health care?

Go out and commit a serious felony. Don't try to cover your tracks, leave plenty of incriminating evidence. Get tossed into prison. You know get free health care.

 

[pb4uski]

Does anyone know how small, medium, large companies fare in the HI pool. ...

There is really no HI pool. Most medium and large companies self-insure... they hire an insurer to help them design a program and to administer their claims for a fee and they sometimes buy stop-loss coverage in case they have a particularly bad year.

 

[Curmudgeon]

-4th child born with rare disease and family racing all over the country for specialists to cure child. The child passes away at 5 yrs. old.

Sad to say it, but there will always be situations that are beyond fixing. Some diseases can't be cured, and some diseases may be curable but at a cost that makes it unreasonable to do so. People will always die.

I think the best we can hope for is healthcare system that provides relief for the most common, addressable health issues at a cost that doesn't bankrupt us.

 

[Senator]

Can't afford necessary health care?

Go out and commit a serious felony. Don't try to cover your tracks, leave plenty of incriminating evidence. Get tossed into prison. You know get free health care.

Better yet, give all your income producing assets to me, and you will be low-income. Same result and no prison.

You can have all the assets you want, you just need to be low-income and it's free.

 

[explanade]

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%.

So if they collect $100 in premiums and only spend $75 on claims then they would need to refund $6.25 in premiums to policyholders.

The recent escalation of health insurance premiums is not greed on the part of the health insurers since their margins are limited by law.... but rather is the escalating cost of health care (docs, hosptals, meds, etc).

The 80% was typical even before the law required it... we know this because in the year that the MLR requirements went into effect there were some minor refunds but not a lot in the whole scheme of things.

That's the Medical Loss Ratio for insurers.

But there is no MLR for pharmaceuticals, hospitals, doctors, medical device makers, etc.

Cost is the biggest problem in the US health care system and that comes down to prices charged. We've seen the articles about how the same procedure, such as MRI scans or hip replacement, is charged by different providers across the country.

And also the difference in prices for those procedures between those who are insured and uninsured.

And how those prices, regardless of where in the country or whether insurance rates are in effect or not are higher than those in other countries.

There is no attempt to address prices or "bend the cost curve" because it just may not be possible to tell doctors, pharmaceuticals, hospitals, etc. that they must take less money than they've been getting all these years.

 

[NW-Bound]

...The recent escalation of health insurance premiums is not greed on the part of the health insurers since their margins are limited by law.... but rather is the escalating cost of health care (docs, hosptals, meds, etc)...

+1

Yep. The profits insurers are making are transparent and easily monitored. We know what they are.

The costs insurers are paying on our behalf are not so transparent. And insurance customers are part of the problem screaming bloody murder when their choice of providers (based on cost to the insurance companies) is limited by networks, etc. We all want to go where we want to go with cost as a secondary consideration and have insurance pick up the bill. Then we gasp when we find out what was paid and when premiums go up...

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.

 

[purplesky]

The Healthcare crisis in the United States will only be solved with some type of socialized healthcare system.

The millennial generation demographic does have the ability to make it happen.
We almost just witnessed it.

As the WW2 generation and the older baby boomers die off the The United States will see real change from younger generations to create socialized healthcare.

It will happen.

 

[pb4uski]

That's the Medical Loss Ratio for insurers.

But there is no MLR for pharmaceuticals, hospitals, doctors, medical device makers, etc.

Cost is the biggest problem in the US health care system and that comes down to prices charged. We've seen the articles about how the same procedure, such as MRI scans or hip replacement, is charged by different providers across the country.

And also the difference in prices for those procedures between those who are insured and uninsured.

And how those prices, regardless of where in the country or whether insurance rates are in effect or not are higher than those in other countries.

There is no attempt to address prices or "bend the cost curve" because it just may not be possible to tell doctors, pharmaceuticals, hospitals, etc. that they must take less money than they've been getting all these years.

I totally agree with all of what you wrote. I was responding to a previous post that opined that the problem with health insurance costs started when health insurers became for-profit companies.

If I were king, any health services provider would be prohibited from charging for any service more than twice the lowest cost negotiated rate charged to heath insurers (excluding Medicare/Medicaid prices since they are imposed by the provider)... that would tighten up pricing but still provide some leeway to differentiate.

 

[neihn]

The Healthcare crisis in the United States will only be solved with some type of socialized healthcare system.

The millennial generation demographic does have the ability to make it happen.
We almost just witnessed it.

As the WW2 generation and the older baby boomers die off the The United States will see real change from younger generations to create socialized healthcare.

It will happen.

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

 

[Walt34]

Is there really a case where someone is absolutely refused lifesaving care due to no insurance? I have always been under the impression that part of the reason our HC insurance and medical costs are so high is that they have to cover the uninsured through the insured and paying?

I think it depends on the nature of the illness. In the case you posted about the need was clear and immediate so of course the surgeries were done. But what if the need for care is spread over a longer time and is less immediate?

I have undergone surgery twice this year for melanoma. Fortunately I have excellent health insurance that picks up where Medicare leaves off and I usually don't even get a medical bill at all. BTW, in both cases the melanoma was caught very early so no issues with that.

But the second instance was found during a follow-up visit after the surgery for the first and the surgeon acknowledged that he wouldn't have biopsied it if he hadn't known about the history because it looked so benign. That one also turned out to be malignant and I got the needed care before it got any worse.

It occurs to me though, that had I not have the HI that I do, would I have had the same results? I kind of doubt it. The first instance was just a funny-looking dark spot on my arm but it certainly didn't scream "melanoma". Even the dermatologist that I went to didn't seem concerned and said it was probably a keratosis, which is not harmful.

So had I waited because I had no HI, by the time the melanoma had progressed to the point that I clearly would be needing medical care it may well have been that the care most appropriate would be hospice. I think it fair to say that I will (probably) live much longer simply because I have good HI.

Can't afford necessary health care?

Go out and commit a serious felony. Don't try to cover your tracks, leave plenty of incriminating evidence. Get tossed into prison. You know get free health care.

I know this is supposed to be facetious but I knew a guy who did exactly that. Destruction of County property is a felony in MD. He needed kidney dialysis on a regular basis and would periodically throw a large rock through the glass door on the police station, be arrested, go to jail, and then get his dialysis on the County's dime.

In the winter this caused the desk clerks to freeze because it took several days to get a new door, and the door was very expensive, so we asked him to throw his rock through one of the smaller windows that would cause less heat loss and were a lot cheaper to replace. Unfortunately we didn't specify which window, so the next time he obliged and threw the rock through the station commander's office window. To say he was unhappy about it is a gross understatement.

 

[Sunset]

Well we have, and don't see any reason in the future we won't continue to have, health insurance. So I cannot imagine an issue that would sink us.

That said I have to wonder if I'd being willing to spend personally (on myself) beyond a $1 million in the event of a specific medical crisis. Sitting here today, I cannot imagine that that $ amount and my desired future ongoing physical quality of life are compatible.

But this is one of those situations you hope to the Gods you never get tested on...

They are rare, but I recall reading of one family where the ins. dropped them after spending millions, as the insurance company claimed they exceeded there $5 MM limit !!

Even ins. companies know you can spend more than $5 MM on a health issue, which is why this seems to be a common limitation.

County employee files $5 million health insurance claim

 

[pb4uski]

....Is there really a case where someone is absolutely refused lifesaving care due to no insurance? I have always been under the impression that part of the reason our HC insurance and medical costs are so high is that they have to cover the uninsured through the insured and paying? ....

I'm no expert but the impression that I have is that if you have an injury that is life threatening that you will be treated whether or not you have insurance... however, if you have an illness like cancer that is life threatening and don't have insurance that you are up a crick without a paddle and would have to rely on charity care.

 

[LARS]

They are rare, but I recall reading of one family where the ins. dropped them after spending millions, as the insurance company claimed they exceeded there $5 MM limit !!

Even ins. companies know you can spend more than $5 MM on a health issue, which is why this seems to be a common limitation.

County employee files $5 million health insurance claim

Not saying it can’t happen: just for me out of pocket north of $1 million... I don’t know.

In any case, at least for now with ACA being law of the land HI can no longer have a lifetime cap (at least that is my memory of law).

 

[MichaelB]

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.

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. Perhaps moral hazard for the health care provider, who sees a desperate patient and charges much more because of that.

$1M is really not a great deal of money for health care. The cost of treatment for a chronic disease can be much higher, and the service providers push on pricing as hard as they can.

The state of Iowa has one patient in the individual market that suffers from a genetic disorder and the treatment costs $1M per month. This single situation has led multiple insurers to curtail their offerings in that health market, as they have no effective reinsurance and even though there are millions of people getting health insurance in that state, the individual policies are priced using very small risk pools. https://www.desmoinesregister.com/s...g-iowa-insurer-1-million-per-month/356179001/

 

[Walt34]

In any case, at least for now with ACA being law of the land HI can no longer have a lifetime cap (at least that is my memory of law).

Yes, that's what I understand too. While I do have excellent coverage from my former employer I had some concerns about that because the coverage did have a $2 million lifetime cap. Now that cap is gone. So while hopefully I won't need any treatment that costly the ACA as it stands certainly did affect me.

 

[purplesky]

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

Socialized healthcare in the United States will happen overnight when the next generation has the power to make it happen. That will be sooner than later.

The big ripoff hospital system profit centers and their lobbyists need to go. Capitalism is great but this game we play as a society with healthcare costs just isn't sustainable.

The huge increase in wealth and wage inequality will just make it happen that much quicker.

 

[ShokWaveRider]

Very few products are given to everyone, yet paid for by few.

That is why single payer makes sense. Most people pay via taxes.

 

[CaptTom]

This is an interesting discussion. I agree it's much more nuanced than my simplistic theory that cherry-picking healthy workers away from Blue Cross started the whole thing. I'm not totally convinced that wasn't a factor, but I'll stipulate it wasn't the only cause.

Meanwhile, the question I haven't seen an answer to was asking for a better alternative to a single-payer government system.

 

[Mr._Graybeard]

Meanwhile, the question I haven't seen an answer to was asking for a better alternative to a single-payer government system.

The private sector's answer seems to be ever-larger medical groups, such as Aurora Health Care in my area. Right now the company is pursuing a merger with an Illinois provider that together will result in the 10th-largest nonprofit healthcare provider in the United States.

It seems as though healthcare costs started to really soar as the trend toward consolidated healthcare networks accelerated. Chicken or egg?

 

[MichaelB]

Meanwhile, the question I haven't seen an answer to was asking for a better alternative to a single-payer government system.

There are examples of health care systems around the world that appear to work well that use private insurance or so combination of gov't and private - like Medicare. Switzerland, Netherlands and Germany. https://www.economist.com/news/unit...se-look-fix-american-health-care-can-be-found

 

[razztazz]

There are examples of health care systems around the world that appear to work well that use private insurance or so combination of gov't and private - like Medicare. Switzerland, Netherlands and Germany. https://www.economist.com/news/unit...se-look-fix-american-health-care-can-be-found

We already have that and people still can't afford it. And the cure according to some is: For the system to work for those for whom it works, others will have to die. Rationing. Bankruptcy. Hope they have a "clear head" and play their part by not want medical attention at the appropriate time, as some here have "declared." We already have private and government and it is simply not doable for all but the unlimitedly wealthy to secure sufficient insurance to actually be insurance. How are people's pockets being filled with money to buy this stuff? That's a rhetorical question. Today's my carbing day.

-------------------------------------------
PS: Was able to get past the pay wall. It still comes down to subsidies and government "handing". Fine. They can arrange the furniture any way they want. They still have to get money from where it is (taxes) to where it is needed: Everybody who is not super rich. That is what is called The Wealth of Nations.

I knew the ACA was essentially the German and Swiss system because I used to live there. It's all in how it is managed and that all has to do with the people who are trying to manage it.

 

[NW-Bound]

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. Perhaps moral hazard for the health care provider, who sees a desperate patient and charges much more because of that.

$1M is really not a great deal of money for health care. The cost of treatment for a chronic disease can be much higher, and the service providers push on pricing as hard as they can.

The state of Iowa has one patient in the individual market that suffers from a genetic disorder and the treatment costs $1M per month. This single situation has led multiple insurers to curtail their offerings in that health market, as they have no effective reinsurance and even though there are millions of people getting health insurance in that state, the individual policies are priced using very small risk pools. https://www.desmoinesregister.com/s...g-iowa-insurer-1-million-per-month/356179001/

I was thinking of some treatments for cancer patients that have a very low chance of success.

The case of severe hemophilia is different, in that the treatment is effective, but extremely expensive. The cost for something like this, if society determines that it is worthwhile, must be spread over a much larger pool. Right now, the smaller markets defined by ACA cannot work for situations like this.

Most of the cost is for the clotting factor replacement therapy (CFRT), which involves infusion of proteins that are very expensive to produce. CFRT started in 1960, and if still expensive at this point, it does not look like it will get cheaper any time soon. The drug accounts for 97% of the total medical cost.

Out of curiosity, I look to see the cost of severe hemophilia treatment in developed countries. It is less expensive than in the US, but still averages 312,157 euros in Germany.

 

[Meadbh]

Re: going to prison to get access to health care:

I know this is supposed to be facetious but I knew a guy who did exactly that. Destruction of County property is a felony in MD. He needed kidney dialysis on a regular basis and would periodically throw a large rock through the glass door on the police station, be arrested, go to jail, and then get his dialysis on the County's dime.

In the winter this caused the desk clerks to freeze because it took several days to get a new door, and the door was very expensive, so we asked him to throw his rock through one of the smaller windows that would cause less heat loss and were a lot cheaper to replace. Unfortunately we didn't specify which window, so the next time he obliged and threw the rock through the station commander's office window. To say he was unhappy about it is a gross understatement.

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