Category Archives: Healthcare Reform

Discover a “Fair Price” For Your Upcoming Medical Procedure

…at Healthcare Bluebook.

I don’t know if the site above is legitimate or not. But I like the idea behind it. Check it out and see what you think.

 

 

Is There a Premium Increase in Your Future: Health Insurers Are Vacuuming Up Details About You

From ProPublica…

“Before the conference, I’d seen a press release announcing that the largest health actuarial firm in the world, Milliman, was now using the LexisNexis scores. I tracked down Marcos Dachary, who works in business development for Milliman. Actuaries calculate health care risks and help set the price of premiums for insurers. I asked Dachary if Milliman was using the LexisNexis scores to price health plans and he said: “There could be an opportunity.”

The scores could allow an insurance company to assess the risks posed by individual patients and make adjustments to protect themselves from losses, he said. For example, he said, the company could raise premiums, or revise contracts with providers. It’s too early to tell whether the LexisNexis scores will actually be useful for pricing, he said. But he was excited about the possibilities. “One thing about social determinants data — it piques your mind,” he said. Dachary acknowledged the scores could also be used to discriminate. Others, he said, have raised that concern. As much as there could be positive potential, he said, “there could also be negative potential.” It’s that negative potential that still bothers data analyst Erin Kaufman, who left the health insurance industry in January. The 35-year-old from Atlanta had earned her doctorate in public health because she wanted to help people, but one day at Aetna, her boss told her to work with a new data set.

To her surprise, the company had obtained personal information from a data broker on millions of Americans. The data contained each person’s habits and hobbies, like whether they owned a gun, and if so, what type, she said. It included whether they had magazine subscriptions, liked to ride bikes or run marathons. It had hundreds of personal details about each person. The Aetna data team merged the data with the information it had on patients it insured. The goal was to see how people’s personal interests and hobbies might relate to their health care costs. But Kaufman said it felt wrong: The information about the people who knitted or crocheted made her think of her grandmother. And the details about individuals who liked camping made her think of herself. What business did the insurance company have looking at this information? “It was a dataset that really dug into our clients’ lives,” she said. “No one gave anyone permission to do this.”

Source: Health Insurers Are Vacuuming Up Details About You —… — ProPublica

Why Your Health Insurer Doesn’t Care About Your Huge Healthcare Bills

Health insurers don’t care because they’re just going to pass the cost on to you and your employer via higher premiums. And the more your employer pays for health insurance fees, the less they can put into your paycheck.

Article like the one linked below make my blood boil.

“After Aetna approved the in-network payment of $70,882 [for a partial hip replacement] (not including the fees of the surgeon and anesthesiologist), Frank’s coinsurance required him to pay the hospital 10 percent of the total.

When Frank called NYU Langone [hospital] to question the charges, the hospital punted him to Aetna, which told him it paid the bill according to its negotiated rates. Neither Aetna nor the hospital would answer his questions about the charges.”

Source: Why Your Health Insurer Doesn’t Care About Your Big… — ProPublica

Here’s a comment left under the article:

I am a physician and have seen these games for years.
It is obvious that the insurers collude with the hospitals and pharmacies, to raise the patients copays.
It is a way of transferring costs onto the consumer.
Each insurance company has a different contract, with each hospital and pharmacy.
For example, I recently needed an MRI. I priced the charges in advance with my local hospital.
If I used my small group blue x policy, I would be charged about $2,200 dollars as my copay. I negotiated to pay the medicare rate in full, and not use my insurance. I paid $240 dollars as the full medicare rate. It was much cheaper for me not to use my insurance, than to use my insurance and pay an inflated copay.

Pharmacies are a little more forthcoming about their pricing, so their games are a little more obvious.
A pharmacy will tell you the price of a drug, but you have to tell them your insurance first.
The chain pharmacies will change the list price for a drug, depending on the insurance.
For example, I told a patient that the silver sulfadiazine cream I was prescribing should cost about $10. The next day they came back furious at me. The local chain pharmacy said it was $440, and their insurance supposedly paid $400, leaving them a copay of $40.

I called around and I found that the full cost at the chain pharmacy without insurance was much less ($35). Walmart had it as one of their $4 drugs. The $440 cream at the chain pharmacy and the $4 cream at Walmart were made by the same generic manufacturer.
I don’t believe that the insurance company was dumb enough to pay $400 dollars for a $4 tube of cream. I think that the list price of the drug was inflated, by mutual agreement between the chain pharmacy and the insurer. By inflating the list price, the patient paid $40 for a $4 tube of cream through their copay. I doubt the insurance company paid anything.

How To Negotiate 80% Discounts Off Your Medical Bills

Click the link below for details. It’s a long article but could save you thousands of dollars unless you’re covered by one of the semi-socialized health insurance schemes like Medicare, Tricare, or Medicaid.

The author knows what he’s talking about. The only potential error I found is where he says federal law requires every U.S. healthcare provider must always charge the same fee for each specific service (CPT code). In other words, they can’t charge one person less or more than someone else. As far as I know, that only applies to Medicare (and Medicaid?) patients.

If you buy a lot of healthcare services, you must read this article.

In a nutshell, the author does this when he needs non-emergency services:

Here we go, step by step:

1) I usually prefer to skip the added expense of going to a GP or family practice intermediary just to get a referral to a specialist that can actually help, especially when I can determine what medical specialty is likely to be most helpful for by medical condition by visiting the website of the American Board of Medical Specialties.  (Is your ignition system acting up, your suspension riding a little rough, need new tires, brakes squeaking, transmission grinding?)                http://www.abms.org/member-boards/specialty-subspecialty-certificates/

2) Use the links on abms.org to visit the appropriate specialty board’s website, and then use their “find a physician” with the sub-specialty likely to be most helpful for the condition.

3) Start calling the sub-specialty physician offices listed, tell them you are a prospective new patient, and ask to speak to the Business Office Manager.  Ask him or her the following questions:   a) “Do you accept Medicare and/or Medicaid insurance?”  If yes, then…   b) “Super!  Do you accept cash payment at the time of service?”  If yes, then…   c)  “Great!  Then, of course, you will accept as payment in full, the Medicaid allowable, but paid in cash by me to you, directly, at the time of service?  Correct?”  If yes, then (e).  If no then (d).   d) “I guess I understand.  Well, then surely you will at least accept as payment the Medi­care allowable, paid in cash by me to you, directly, at the time of service?  If yes, then (e).  If no then conclude the call, because you cannot fix stupid.   e) “Thank you!  Can you please tell me what the estimated amount is for an office visit, using this fee schedule, so I can know how much money to bring, and please make a note on my account that we have negotiated a Single Case Agreement for me to pay these rates to you, in cash, at the time of service?   f) Tell him or her your specific reason for the visit (I am leaking red fluid on the floor of my garage) and that you want to be fully prepared for the visit.  Ask what diagnostic tests, if any, are usually required for this type of problem, lab, X-ray, CT, MRI, ultrasound, etc., and which ones would probably need to be done outside the physician’s clinic?    g) Make sure to get the business office manager’s name and contact information, and the appointment time and date.

Source: How to negotiate directly with physicians and hospitals. | Zero Hedge | Zero Hedge

Another Example of Corruption and Collusion in the Medical-Industrial Complex

“Patients frequently paid more for drugs through copays than the cost of those medications to insurers or pharmacy benefit managers, a research letter in JAMA indicated.”

Source: Over 20% of Copays Exceed Actual Drug Cost (JAMA) | Medpage Today

Thoughts on the Denninger Healthcare Reform Plan

The only way to improve U.S. healthcare while bringing costs down is to introduce serious competition for healthcare dollars.

This post is for U.S. citizens since the federales are going to tinker with our health insurance reform very soon. This would be a great opportunity to make helpful changes  to the system. I have no faith they will do it.

Healthcare in the U.S. consumes one of every five dollars spent in the economy. We are not getting our money’s worth, at least judging from average lifespan.

Karl Dennnger has put a lot of thought into the problem over the last decade, and has a concrete legislative proposal that makes a lot of sense. I endorse it. As you consider the possibilities, you need to keep in mind that the cost of healthcare will drop drastically. Not just by 50%. More like 80% or more. Healthcare will be so cheap you won’t even need insurance to pay for most of it.

How are these price reductions possible? Because the Dennniger plan introduces competition and moves us closer to a free market situation without third-party interference from insurers and government.

Here are the major points:

  • All healthcare providers must publicly post (e.g., on the web) prices which apply to everyone. E.g., not  a price depending on which insurance you have, whether you are paying cash up front, etc.
  • All customers must be billed for actual charges at the same posted prices at the time services or product is rendered. This removes the third party (insurer or government). You file the claim and every one pays the same price. In a way, medical care isn’t too expensive; too often it’s “free,” because someone else is paying. So there’s no comparison shopping. You see posted prices and you pay them yourself when you buy gasoline, groceries, cell phones, computers, TVs, cars, and houses. A valid and collectible bill must be consented to in writing before the service or product is provided. Actual price, no open-ended add-ons.
  • No event caused by or a consequence of treatment can be billed to the customer. (I’m not sure I like this. What about unforeseeable complications like C diff infection after antibiotics, or anaphylactic reactions to drugs? Providers could eventually get insurance to cover those costs, but it would be a brand new insurance market.)
  • True emergency patients who are unable to consent must receive the same price for same service as a person who consents to said service.
  • All medical records belong to the patient and shall be delivered to the patient (customer) at the time of service.
  • Auxiliary services (e.g., x-rays, lab work) may not be required to be purchased at the point of use. Example: an orthopedist wants you to get a knee MRI scan on his machine. You can shop around other places for a cheaper or better-quality MRI scan.
  • All anti-trust and consumer protection laws shall be enforced against all medically-related firms, and any claimed exemptions are hereby deemed void. Stiff penalties and fines for violations. Private lawyers must have access to sue.
  • You are free to purchase any medical test you want if no radiation or drug is required to perform the test. (You can already do this in Arizona, but in many states you need a “doctors order” for the test.)
  • There will be no government payments for care or products when a lifestyle change will provide a substantially equivalent or better benefit, when the customer refuses to implement the lifestyle change. (This point needs some fine-tuning. Who decides when and which lifestyle change would provide an equivalent benefit?])
  • Health insurance companies must sell true insurance, to sell any health-related policy at all. No insurance coverage for an event or condition of which you received treatment over the last 24 months.  If an adverse event occurs, insurance pays for all of it. E.g,, if you get an expensive cancer, the insurance company cannot drop you. The insurance must cover, with a selection of available deductibles, all accidental injuries and true life-threatening emergencies. Medical underwriting is permitted (e.g., insurers can charge higher premiums for smokers, couch potatoes, obese folks, etc. I have long thought that people in the top 25% of fitness, determined by a treadmill exercise test, should get a discount on insurance premiums).
  • All health insurers providers selling true insurance, in whole or in part, must provide within their “true insurance” the ability to replace like with like.” (I don’t know what Karl means by this.)
  • Medicare becomes just another insurance provider. No more Part B (outpatient services).
  • Medicaid is repealed entirely.
  • What about U.S. citizens and “lawful permanent residents” who can’t pay for care but still need attention? For true emergencies, the hospital or Emergency Department bills the U.S. Treasury, who pays within 30 days. For non-emergencies, the provider bills the U.S. Treasury and will be paid within 30 days except no billing for government payment if the condition resulted from a lifestyle decision the patient made. After the Treasury Department pays the provider, Treasury will send an invoice to the customer (patient or taxpayer), which may be settled within 90 days at no penalty. If charges are not paid, they become a tax lien subject to collection from refundable tax credits, tax refunds, other entitlement checks (except Social Security retirement), and windfall amounts (either money or property).
  • Repeal all aspects of Obamacare/PPACA.

You need a break after all that. Almost done. Hang in there!

I don’t recall Karl recommending a specific deductible amount, but often saw mention of $2,000 as a deductible. “Deductible” is what you pay out of pocket before insurance pays anything. I like a high deductible over “first-dollar” coverage, because the high deductible automatically creates 200 million shoppers who are going to check prices for sure before buying healthcare. (Of 320 million people in the U.S., I’m guessing 200 million are adults.)

Karl favors “catastrophic” policies, as do I. Your car needs new tires every few years, oil changes much more often, and periodic repairs, but you don’t expect car insurance to pay for those non-catastrophic costs.

Who would get hurt by this plan? Lobbyists, insurance and healthcare administrators, drug reps, pharmacy benefits managers, and those who refuse to make healthy lifestyle changes.

I don’t recall Karl addressing unreasonable insurance mandates, managed care plans (like Kaiser Permanente in CA), accountable care organizations, liability reform (we need the English Rule), tax parity (businesses buying insurance for employees get a tax break, but private individuals buying their own policies don’t), or much about enforcement. But he may have; Karl’s a very smart guy.

Steve Parker, M.D.

 

Let’s Call it KarlCare

Karl Denninger has fleshed out his U.S. healthcare system reform recommendations in a form ready for legislation.

I’ve only read it once and admit I don’t fully understand it. But I can tell already that it would be a major improvement over our current system.

Steve Parker, M.D.