Individuals’ Catastrophic Medical costs.

imagep said:

Thing is, because people don't price shop, due to the fact that they have insurance, that spine surgery is vastly higher than it should be. If the free market was allowed to work properly, it likely would cost less than what a years worth of insurance would cost.

Again, not every patient has to price shop for the free market to work correctly. It just takes a critical mass of price shoppers.

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Poop. Look.. you need to read what Greenbeard has written. I am now convinced you just don't want to listen to the truth.

You keep saying "people don't price shop". They sure as heck do price shop!.. especially in todays world of deductibles, and out of pocket payments and so forth.

but there are limits..... so you are going to look for discount spine surgery? Is that the key?

You realize that the reason that one place may be more expensive.. is not because there is not competition.. but because that facility also has the gamut of services to save your life if your spine surgery goes south. While that cheaper outpatient surgery center would have to ship you.. and that may take precious life saving time.

Sorry.. but the facts just do not support your contention that "we need to make the free market work". The free market already works.. but at the end of the day.. its the third party payers that are price shopping. And they do. Despite what you have created in your mind.

Look.... even pricing.. doesn;t work the way you think it does. I challenged Ludin to look up what prospective payment is and DRG. Its how most hospitals get paid for the most part. I challenge you to do the same.. and you figure out how you would "price shop" in such a situation.

I'm Supposn said:

Jaaeger19, a single payer system of government medical insurance can cover as much or as little as specified within the laws as they're drafted. Why would you believe that single payer rather than other medical funding alternatives would in aggregate cover more or less?

JONRID and I are among those believing single payer government basic medical insurance which allows for individuals purchasing any additional auxiliary options, is the way to go.

Annual deductible amounts not covered by insurance makes no sense. No out of pocket costs for recommended medical screening makes a great deal of sense; a stitch in time saves more than nine, it also saves lives. Prudent medical insurance practices require that we encourage medical screening, healthy behavior. Its not that difficult to promote medical prudence while avoiding financial waste due to hypochondriacs, wasteful squandering of of the insurance budgets for luxury or purely cosmetic purposes.

To all sides of of opinions regarding socialized medical insurance or socialized medical insurance and service providers, individual's entitlement of government funding and encouraging individuals to be medically screened on a regular basis, and government funding of catastrophic medical expenses should be acceptable; it makes sense.

Respectfully, Supposn

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Okay.. why would I believe that single payer would cover less? BECAUSE THERE IS NO FREE LUNCH HERE. Sorry for yelling.. but I have this conversation a lot. Look at your Jonrids post: We pay the most in GDP. Yep we do... and IF YOU EXPECT TO GET THE SAVINGS THAT OTHER COUNTRIES GET... THEN YOU MUST EXPECT TO HAVE AN INSURANCE THAT COVERS WHAT THEY DO.

People that push single payer think that there is some free lunch here. On one hand "look at how Canada (or insert other country) does it cheaper"...

Yep.. and I point out that Canadian government single payer does not pay for outpatient services, outpatient medicines, outpatient therapies, home health and durable medical goods. While our Medicaid.. does.

So.. there is no free lunch here. If you want to get the savings that other countries get., and that's the reason for single payer.. then be honest about what that single payer is going to be.

Claiming that the savings is just going to happen because of single payer.. is just not valid.

ludin said:

It is also very difficult to price shop with insurance as you are bound to use the providers in your network.

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hmmm.. why do you think that insurance binds you to use a network? You think its for fun?

Or is it because the insurance company has negotiated for lower prices from those "network" providers?


Wait.. its a great conspiracy right?

jaeger19 said:

hmmm.. why do you think that insurance binds you to use a network? You think its for fun?

Or is it because the insurance company has negotiated for lower prices from those "network" providers?


Wait.. its a great conspiracy right?

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sure they have contracts with those people, but they haven't negotiated the best rate.
cash gets you the best cheapest price on a great many things.

ludin said:

sure they have contracts with those people, but they haven't negotiated the best rate.
cash gets you the best cheapest price on a great many things.

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Of course not.. because you think your "cash rate" is the cheapest despite the fact that on a great many things.. as already was pointed out.. those that DON:T HAVE INSURANCE.. end up paying a lot more.

But hey.. you got it.. when maybe 3 people a year come with cash.. they can negotiate rates so much better than an insurance company that can direct maybe 1000 patients my way.

Like I said.. you go do some research on what Prospective Payment is.. and what a DRG is.

Then get back to the group about negotiating.. and cash price.

jaeger19 said:

hmmm.. why do you think that insurance binds you to use a network? You think its for fun?

Or is it because the insurance company has negotiated for lower prices from those "network" providers?


Wait.. its a great conspiracy right?

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The thing is, almost every medical provider is a member of some network. And the insurance company needs providers in their networks so that people will purchase their insurance. We only have one individual insurance provider in my market, that insurance company offers two different network options (pick one, not both). All the members of both networks will get lot's of business, and almost every medical provider is a member of one or the other or possibly both providers. I don't see how any of this means that any prices have been "well negotiated".

imagep said:

The thing is, almost every medical provider is a member of some network. And the insurance company needs providers in their networks so that people will purchase their insurance. We only have one individual insurance provider in my market, that insurance company offers two different network options (pick one, not both). All the members of both networks will get lot's of business, and almost every medical provider is a member of one or the other or possibly both providers. I don't see how any of this means that any prices have been "well negotiated".

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well first lets start with "almost every medical provider is a member of some network". WEll.. that's seems to directly contradict that claim by ludin and perhaps you that people cannot shop for providers because they have to go where insurance tells them.

However.. the insurance company only needs certain providers in its network so that people will purchase their insurance.

so you have only one individual insurance provider in your market.. which means that the insurance company can drive the price to those providers because what is a provider to do? You think a provider can tell the major blue cross that has 100% of the market.. to go pound sand?

Probably not. So.. the insurance because of their giant marketshare.. has negotiated a tremendously good price for itself. The only caveat to that is that sometimes the insurance companies especially if they have a virtual monopoly.. drive the reimbursement prices so low.. that smaller facilities can't make it... so those smaller facilities .. sell out to the bigger network hospital system. then the insurance because they have lowered reimbursement so low.. that now they end up creating a situation in which all the smaller providers are out.. and now there is only one or two big hospital systems. And THEN.. the hospital systems can now force the reimbursement price BACK UP.. because they now have the majority of marketshare.

jaeger19 said:

well first lets start with "almost every medical provider is a member of some network". WEll.. that's seems to directly contradict that claim by ludin and perhaps you that people cannot shop for providers because they have to go where insurance tells them.

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No it doesn't. Each patient still can only go to providers within their particular network. Not every provider is in the same network.

However.. the insurance company only needs certain providers in its network so that people will purchase their insurance.

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Not "certain providers", they just need enough medical care providers.

so you have only one individual insurance provider in your market.. which means that the insurance company can drive the price to those providers because what is a provider to do? You think a provider can tell the major blue cross that has 100% of the market.. to go pound sand?

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Some do, most don't. My particular family doctor does not take any insurance at all. In my market, BC/BS is the only insurance company which offers policies to individuals. BC/BS has two sets of insurance options, one set with one network, and the other set with the other network. The cost for either network policy is about the same.

Probably not. So.. the insurance because of their giant marketshare.. has negotiated a tremendously good price for itself. The only caveat to that is that sometimes the insurance companies especially if they have a virtual monopoly.. drive the reimbursement prices so low.. that smaller facilities can't make it... so those smaller facilities .. sell out to the bigger network hospital system. then the insurance because they have lowered reimbursement so low.. that now they end up creating a situation in which all the smaller providers are out.. and now there is only one or two big hospital systems. And THEN.. the hospital systems can now force the reimbursement price BACK UP.. because they now have the majority of marketshare.

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Yup. That's exactly what happened in my market. About 15 years ago, our local newspaper published the financials for our state non-profit hospital. Turned out that the hospital had enough cash to operate for years, without charging a dime. That year, the hospital started purchasing every independent medical care provider that it could, eventually it owned almost all of them, so it started opening more locations. they said that it was to insure that our county has adequate medical care facilities. The truth is, they knew that they had to get rid of much of that cash, or else the media would keep beating them up over it until they forced them to lower prices.

At the time, this hospital system was one of my largest customers, which was pretty awesome for me because we started getting no-bid "preferred vendor" status at all the doctors offices which the hospital system purchased. Eventually, the management changed, the CEO was paid millions to resign (the reason was undisclosed), and my contacts all left. The hospital then started a "pay to play" policy with their vendors, and charged each vendor $4k/yr to be on their vendor list. I wasn't having any part of that, it just didn't feel right, so I moved on to other customers.

imagep said:

No it doesn't. Each patient still can only go to providers within their particular network. Not every provider is in the same network.
.

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So they can still go to other providers then outside their network and "negotiate for that low cash price".

Not "certain providers", they just need enough medical care providers.

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No.. certain providers. If you don't have a neurologist and a neurosurgeon, and a cardiologist and a ......

In your network.. then its harder to sell insurance.

A ton of GPs and no specialists? Not likely to work.

Some do, most don't

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I think you would find most go with the network. Particularly any specialist except for psychiatry and perhaps dermatology.

Yup. That's exactly what happened in my market. About 15 years ago, our local newspaper published the financials for our state non-profit hospital. Turned out that the hospital had enough cash to operate for years, without charging a dime. That year, the hospital started purchasing every independent medical care provider that it could, eventually it owned almost all of them, so it started opening more locations. they said that it was to insure that our county has adequate medical care facilities. The truth is, they knew that they had to get rid of much of that cash, or else the media would keep beating them up over it until they forced them to lower prices.

At the time, this hospital system was one of my largest customers, which was pretty awesome for me because we started getting no-bid "preferred vendor" status at all the doctors offices which the hospital system purchased. Eventually, the management changed, the CEO was paid millions to resign (the reason was undisclosed), and my contacts all left. The hospital then started a "pay to play" policy with their vendors, and charged each vendor $4k/yr to be on their vendor list. I wasn't having any part of that, it just didn't feel right, so I moved on to other customers.

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Yeah no... See.. lets think about this... the large hospital was buying up all the smaller providers... WHY? IF the hospital was charging these very high prices.. and was not competitive.. then people would go to the smaller providers and the small providers would make a ton of money... why would they want to sell out to the big hospital? And all the hassles that ensue then?

What most likely happened.. in fact I would guarantee it.. is that reimbursement was dropping across the board.. from medicare to Medicaid and the private insurer in your area did the same thing. And what happened is that the hospital networks could take the lower reimbursement.. because 1. Economy of scale.. it was more efficient from size. 2. Because of size it can somewhat drive its own reimbursement by controlling the referral systems.

The insurance provider in your area was more than happy to benefit from the low reimbursement rates it gave everyone in the area.. slowly squeezing the smaller provider to the point where they had no choice but to sell out to the big network or go concierge and away from insurance all together. .. and this continued over and over.. until some time.. when your blue cross insurance will look up and see.. that the only providers available, are the two big hospital networks. Because the insurance companies squeezed everyone else out. and now.. the hospital networks have a better position to drive prices back up.

The reason that smaller providers sell out.. is because they have to.

jaeger19 said:

...
Yeah no... See.. lets think about this... the large hospital was buying up all the smaller providers... WHY?

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I explained that. they had money they needed to get rid of, and "to ensure adequate health care in the fututure", although it was meaningless, it sounded good to most people.

IF the hospital was charging these very high prices.. and was not competitive.. then people would go to the smaller providers and the small providers would make a ton of money...

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At the time, the only medical facilitites in our county which were able to provide an operating room and overnight accomidations were our two hospitals (the other hospital had a reputation for being expensive as it is privately owned for profit).

why would they want to sell out to the big hospital? And all the hassles that ensue then?

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It put millions of cash in the owners pockets, and the contract agreed to keep the staff and doctors on the payroll.

What most likely happened.. in fact I would guarantee it.. is that reimbursement was dropping across the board.. from medicare to Medicaid and the private insurer in your area did the same thing. And what happened is that the hospital networks could take the lower reimbursement.. because 1. Economy of scale.. it was more efficient from size. 2. Because of size it can somewhat drive its own reimbursement by controlling the referral systems.

The insurance provider in your area was more than happy to benefit from the low reimbursement rates it gave everyone in the area.. slowly squeezing the smaller provider to the point where they had no choice but to sell out to the big network or go concierge and away from insurance all together. .. and this continued over and over.. until some time.. when your blue cross insurance will look up and see.. that the only providers available, are the two big hospital networks. Because the insurance companies squeezed everyone else out. and now.. the hospital networks have a better position to drive prices back up.

The reason that smaller providers sell out.. is because they have to.

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Can you link to any articles about reimbursements becoming lower? I really wasn't under the impression that was happening.

imagep said:

I explained that. they had money they needed to get rid of, and "to ensure adequate health care in the fututure", although it was meaningless, it sounded good to most people.

.

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just because "they had money they needed to get rid of".. is pretty meaningless for why they were able to buy out private providers.

At the time, the only medical facilitites in our county which were able to provide an operating room and overnight accomidations were our two hospitals (the other hospital had a reputation for being expensive as it is privately owned for profit).

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So.. whats the issue? If they were the only ones.. who did they buy up then? You said they were purchasing private medical providers.

the truth is. they were competing with these medical providers.. and these medical providers must have had a reason to sell.

It put millions of cash in the owners pockets, and the contract agreed to keep the staff and doctors on the payroll.

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Lets see.. if it put millions of cash in the owners pockets.. it was because it was worth that. So.. the owners had to have a reason to sell. And that's because at the end of the day.. they realized it was better to sell out.. than to try and keep the doors open. And sure the contract agreed to keep the staff and doctors on payroll. With now more big hospital supervision and bureaucracy. The perk of working for a hospital is that you get paid regularly. you aren;t going to make the money you would in private practice (or did).. but with reimbursements getting squeezed.. that means.. insurance paying you less.... the hospital is a viable option.

Can you link to any articles about reimbursements becoming lower? I really wasn't under the impression that was happening

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.

Sure: On big insurances and their bargaining power for rates:

The bigger the health insurer, the lower the prices it can negotiate from physician groups, a Harvard Medical School study published Monday concluded. The findings add to a growing catalog of evidence that consolidation among health insurers, such as the pending tie-ups between four of the largest national health insurers, affects the cost of healthcare for both providers and patients.

Large insurers with market shares of 15% paid prices for independent physician office visits that were 21% lower on average than prices negotiated by small insurers with shares of less than 5% of a given market, according to the study published in Health Affairs.

The bottom line: “Bigger insurers have this bargaining power they are using to negotiate lower prices,” said Eric T. Roberts,a postdoctoral fellow in the Department of Health Care Policy at Harvard Medical School who authored the study.

The researchers used a multipayer claims database, FAIR Health, to analyze how much commercial health plans paid for about 15 million doctors' visits in 2014.

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Larger insurers negotiate lower prices from physicians - Modern Healthcare

What's Killing Private Practice? | Healthcare Careers

Reimbursement rate increases below inflation coupled with the continued swelling of staffing and technology expenses will put a damper on not-for-profit and public healthcare next year, Moody's Investors Service announced in its year-ahead outlook released Monday.

The firm downgraded the sector from its current stable status to negative for 2018. It predicts operating cash flow will continue to decline at the current rate of 2% to 4% over the next 12 to 18 months thanks to very low reimbursement rate increases, government payers comprising a larger proportion of overall business and expense pressure.

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Low reimbursement, high expenses contribute to poor 2018 not-for-profit healthcare outlook - Modern Healthcare

https://www.forbes.com/sites/merrillmatthews/2015/01/05/doctors-face-a-huge-medicare-and-medicaid-pay-cut-in-2015/#40dbba1a3173

Since 1997 with the Balanced budget act.. all the way to the ACA.. the federal government has sought to reduce medical reimbursement.