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General Health Care/Health Cost thread

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4 minutes ago, Nice Guy Eddie said:

So every company is violating anti trust law as soon as one customer negotiates a lower price than other customers? 

The more you know...

No, that's a simplistic view of it.

Don't get me wrong on any of this.  Hospitals and facilities are the worst offenders in the system and they are a wonderful example of capitalism run absolutely amok at the cost of the public.

They are an arbitrage scheme by private equity, mostly, where the arbitrage comes in at double digit percentages instead of fractions of a percent.

But I'm interested in practical solutions to the healthcare problem more generally.

Edited by TwiceHorn

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Hospitals and facilities are not really capitalism run amok they are CRONY capitalism run amok.  As stated above there is very little to no incentive, and also limited ability, for healthcare customers to do any sort of value assesment and negotiation for services.  Which compounds the problem of the system being set up to bill at an inflated rate when they know good and well they will collect $.10 on the dollar. 

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The lack of pricing transparency in healthcare is traced directly back to the billing schema instituted by CMS. 

Edited by Anastasis

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21 minutes ago, Anastasis said:

The lack of pricing transparency in healthcare is traced directly back to the billing schema instituted by CMS. 

The solution: Medicare for all!

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The AMA estimated medical costs were $3.5 trillion in 2017 and $3.2 trillion is another commonly cited figure. I decided to use those as starting points including an overly optimistic $3.2 in 2020 and consider what the costs will be in 2020 assuming annual cost increases of 8%, 5%, and 3% and got the following table.

Annual %

2017 ($trillion)

2020 ($trillion)

2023 ($trillion)

2026 ($trillion)

2030 ($trillion)

8%

3.5

4.4

5.5

7.0

9.5

8%

3.2

4.0

5.1

6.4

8.7

8%

NA

3.2

4.0

5.1

7.0

5%

3.5

4.1

4.7

5.4

6.6

5%

3.2

3.7

4.3

5.0

6.0

5%

NA

3.2

3.7

4.3

5.8

3%

3.5

3.8

4.2

4.6

5.1

3%

3.2

3.5

3.8

4.2

4.7

3%

NA

3.2

3.5

3.8

4.3

We are rapidly reaching a breaking point with corporate profit taking going up against the public's need for healthcare at a reasonable cost. The US will soon be spending more on healthcare than the rest of the world combined, and then double that in the next decade.

 

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Medicare for all will not eliminate profits from the healthcare industry.

The government isn’t going to take on providing care and medical infrastructure.

Medicare for all will only make the healthcare industry more opaque and further bastardize incentives.

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34 minutes ago, bad_teammate said:

It's true.

 

giphy.gif

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682140/

Overall Differences in Performance between MA and FFS on Clinical Quality and Patient Experience Measures

Measure N MA N FFS Unadjusted Analysisa Adjusted Analysisb
MA Mean FFS Mean Difference (MA‐FFS) MA Mean FFS Mean Difference (MA‐FFS)
Clinical quality
HEDIS administrative data‐only measures
Breast cancer screening 358,598 687,038 80.2 58.8 21.3 77.9 59.8 18.1
Glaucoma screening 1,872,719 3,997,698 75.4 66.2 9.2 74.2 65.8 8.4
Osteoporosis management for fractures 33,163 44,879 39.8 12.5 27.3 37.1 13.2 23.9
Rheumatoid arthritis management 32,887 47,115 76.9 65.3 11.6 75.7 67.0 8.7
Plan all‐cause readmissions 327,895 966,808 10.1 12.4 −2.3
HEDIS hybrid measures
Colorectal cancer screening 259,301 2,492,106 86.1 44.2 41.9 81.7 46.3 35.4
Cholesterol management LDL‐C screening 63,579 318,824 96.0 86.9 9.2 95.0 87.0 8.0
Diabetic eye exam performed 94,932 783,364 76.4 54.1 22.3 73.0 55.6 17.4
Diabetic cholesterol screening 28,658 783,364 90.6 82.4 8.2 90.1 82.7 7.4
Diabetes care: Nephropathy care 99,441 516,620 94.3 81.0 13.3 93.1 82.2 10.9
MCAHPS measure
Annual flu vaccine 32,137 28,100 71.4 67.9 3.5
Part D measures
High‐risk medication 3,053,440 3,164,305 4.2 6.4 −2.2
Diabetes treatment 645,341 740,612 86.0 82.7 3.3 85.7 82.3 3.4
Medication adherence for diabetes medications 449,830 498,695 77.2 75.1 2.1 77.3 74.6 2.6
Medication adherence for hypertension 1,360,312 1,568,631 79.0 75.9 3.0 78.8 76.0 2.8
Medication adherence for cholesterol 1,415,438 1,593,436 73.8 71.5 2.3 73.9 71.2 2.6
Patient experience
Getting needed care 24,000 15,768 83.9 85.7 −1.8
Getting appointments and care quickly 29,503 18,517 71.4 69.1 2.2
Care coordination 32,324 19,676       84.0 84.5 −0.5
Rating of health care quality 28,210 17,320 85.5 84.3 1.3
Rating of drug plan 29,991 8,606 86.7 81.8 4.9
Getting needed prescription drugs 29,212 8,640 91.4 87.3 4.2
 

Notes: All MA/FFS differences are statistically significant (p < .001) with the exception of the Care Coordination measure (p = .11). Lower scores are better for Plan All‐Cause Readmissions and High‐risk Medication measures. The hybrid method uses both administrative data and medical record review to measure performance.

aThe Plan All‐Cause Readmissions measure and all patient experience measures require case mix adjustment.
bAll clinical quality measures are adjusted for age (18–64, 65–69, 70–75, 76–79, 80–84, ≥85), gender, dual eligibility, Part D low‐income subsidy eligibility, race/ethnicity, neighborhood socioeconomic status (SES) index, and hierarchical condition category (HCC) score. The HCC score is an index of predicted spending based on a beneficiary's sociodemographic characteristics and selected diagnoses measured from claims and represents a summary measure of comorbidity. To measure neighborhood SES, we used a six‐item scale of neighborhood characteristics measured at the zip‐code‐level from the 2008 to 2012 American Community Survey. The six items included household income, poverty, receipt of public assistance, unemployment, household structure, and educational attainment. All case mix adjustment models included propensity score weights. Propensity scores are estimates of the probability of enrollment in MA as a function of the case mix adjustment variables. Case mix adjustment for the High‐risk Medication measure is considered inappropriate because performance is dependent entirely on a physician's prescribing behavior. Plan All‐Cause Readmissions were adjusted according to HEDIS specifications. All patient experience measures are case mix adjusted using the standard CAHPS case mix adjustment methodology, which includes adjustment for age (18–64, 65–69, 70–74, 75–79, 80–84, ≥85), education (eighth grade or less, some high school, high school, less than bachelor's degree, bachelor's degree, postbachelor's degree), general health (excellent, very good, good, fair, poor), mental health (excellent, very good, good, fair, poor), dual eligibility, Part D low‐income subsidy eligibility, and use of a proxy in responding to the survey.

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A little behind the scenes...

I originally was going to post something like, "I saw this Tweet and thought of Shillastasis" (see what I did? Man, so clever. Basically Oliver Wilde with the wordplay)

But I thought, "Nah, B_T, don't start something with him for no reason."

lol

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1 minute ago, bad_teammate said:

A little behind the scenes...

I originally was going to post something like, "I saw this Tweet and thought of Shillastasis" (see what I did? Man, so clever. Basically Oliver Wilde with the wordplay)

But I thought, "Nah, B_T, don't start something with him for no reason."

lol

As if that wasn't already clear. Thus the shrug gif.

And since you are so concerned about potential conflict of interest, that study btw was funded by CMS during the Obama administration. 

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7 minutes ago, bad_teammate said:

A little behind the scenes...

I originally was going to post something like, "I saw this Tweet and thought of Shillastasis" (see what I did? Man, so clever. Basically Oliver Wilde with the wordplay)

But I thought, "Nah, B_T, don't start something with him for no reason."

lol

Who the hell is Oliver Wilde?  

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Yes, Medicare isn't being run nearly as well as it should, we agree. Excellent.

Private insurance is a scam.

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2 minutes ago, DixonHur said:

Who the hell is Oliver Wilde?  

A guy I invent when my fingers outrun my brain. One of the hazards of Always Posting

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2 minutes ago, bad_teammate said:

A guy I invent when my fingers outrun my brain. One of the hazards of Always Posting

I thought perhaps Oscar's ghost had impregnated Olivia and Oliver was the result.

Edited by DixonHur

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Hospitals and facilities are not really capitalism run amok they are CRONY capitalism run amok.  As stated above there is very little to no incentive, and also limited ability, for healthcare customers to do any sort of value assesment and negotiation for services.  Which compounds the problem of the system being set up to bill at an inflated rate when they know good and well they will collect $.10 on the dollar. 

At least there isn’t a horse loose

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4 minutes ago, DixonHur said:

I thought perhaps Oscar's ghost had impregnated Olivia and Oliver was the result.

I will take on this difficult task since Oscar both finds himself unable and unwilling to perform the necessaries.

I am a noble man, willing to sacrifice.

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8 minutes ago, bad_teammate said:

Yes, Medicare isn't being run nearly as well as it should, we agree. Excellent.

I wonder what the magical force is that drives private implementations of Medicare to deliver better clinical and satisfaction outcomes compared to government-run Medicare.

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5 minutes ago, Anastasis said:

I wonder what the magical force is that drives private implementations of Medicare to deliver better clinical and satisfaction outcomes compared to government-run Medicare.

It's more expensive. When you spend resources on things, those things improve.

It's not magic.

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9 minutes ago, bad_teammate said:

I will take on this difficult task since Oscar both finds himself unable and unwilling to perform the necessaries.

I am a noble man, willing to sacrifice.

Everyone has a cross to bear...

On a related note, I got to spend a few months working on a movie with her about 8 years ago and she's as nice, funny, and smart as she is good looking.

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3 minutes ago, bad_teammate said:

It's more expensive. When you spend resources on things, those things improve.

It's not magic.

Not really.

From CMS' perspective the per capita capitated payment made to plans is basically equivalent to the per capita costs under FFS.

In terms of healthcare expenditures, FFS and MA are overall very similar. The spending mix is different though.  FFS spends more on inpatient services, while MA spends more on physician office visits and preventative medicine. When you look at the high risk populations (multimorbidity, dual eligibles, disabled) MA outperforms FFS both in terms of clinical outcome and expenditures, with the same underlying pattern. More spending on preventative and physician services, resulting in reduction in inpatient expenditures.  So the general trends are, generally, better outcomes, better satisfaction, equivalent costs overall, maybe lower costs in some of the more medically complex segments. 

Now I know that you don't really agree, but I think that market competition in the delivery and financing of health care can be a good thing. I think that it is that competition that drives improved quality and better outcomes. Yes, there are many many many problems in the system that need to be addressed.  We've discussed them here many times. I think that the real fundamental issue is that you have to align incentives, from patient to provider to payer, to focus on outcomes and cost-effective care.

But none of that really matters, politically. Here is the real reason why most of the D candidates are going to tip toe around Medicare Advantage and find a home for it in whatever they pitch as Medicare 4 All.  Medicare beneficiaries in MA plans like their MA plans.  And more choose MA over FFS every year. Politicians don't want to to tell a significant number of seniors in FL, PA, WI, OH, MI, and MN that they are going to take away their "Medicare". I think the most politically viable approach for M4A is going to be simply altering the eligibility criteria or creating a buy-in. We should be able to check back sometime late 2021 early 2022 to see what the emerging plan actually looks like.

 

2052-22-Figure-2.png?resize=735,551  

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Just had a close friend that started garbling words from time to time. Went to her doc at the behest if her husband and was told it could be schizophrenia or a tumor but to get a MRI scan . Insurance wouldn't pay for it. Fast forward a few months and insurance finally agreed. Brain tumor. Just had N emergency surgery today. Her parents were staunch republicans, father a doctor. He told them to sue. 

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When you spend more money on healthier people (i.e., the ones not rejected for pre-existing conditions, etc...), you get better outcomes. When you only have a population with the means to afford supplementary care, you get better outcomes and reviews. If you have to deal with the sickest and poorest, you get worse outcomes and reviews.

It's like picking an A-team from the 10th grade class and giving a co-worker a B-team and saying your amazing coaching skills are why the A-team keeps winning.

Look at this again, "FFS spends more on inpatient services, while MA spends more on physician office visits and preventative medicine."

Why does this happen? Is it because original Medicare doesn't deny anyone for pre-existing conditions, so they get more expensive, sickest, poorest, and most acute cases to handle? Or is it simply because the government is too dumb to push preventative medicine?

Stupid, overcomplicated, wasteful bullshit. A scam.

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4 hours ago, bad_teammate said:

It's more expensive. When you spend resources on things, those things improve.

It's not magic.

Yeah, but how else is anastasia gonna get his, man? No shit he's going to be against a public option, it'll hurt his pocketbook. 

For profit healthcare is nothing more than holding sick people (and their families) hostage when you're in a life-or-death situation and you just care about making your loved ones better. It's fucking evil to stand in front of those people and upcharge them with bullshit fees and pricing at the hospital. 

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23 hours ago, bad_teammate said:

When you spend more money on healthier people (i.e., the ones not rejected for pre-existing conditions, etc...), you get better outcomes.

MA cannot reject eligible medicare beneficiaries based on pre-existing conditions. 

In addition, the data I quoted earlier are risk adjusted. 

You are not really engaging in a meaningful exchange. You are just throwing dung against the wall.

23 hours ago, bad_teammate said:

When you only have a population with the means to afford supplementary care, you get better outcomes and reviews.

The majority of MA plans, which include Rx coverage btw, have zero premium cost. It's really not a matter of affordability.

23 hours ago, bad_teammate said:

Is it because original Medicare doesn't deny anyone for pre-existing conditions, so they get more expensive, sickest, poorest, and most acute cases to handle?

Again, MA cannot deny any eligible individual.  You really don't know what you are talking about. 

22 hours ago, Captainant said:

Yeah, but how else is anastasia gonna get his, man? No shit he's going to be against a public option, it'll hurt his pocketbook. 

My livelihood does not depend on private insurance.  My livelihood depends on a relatively niche skillset developed at one of the best programs in the country. That, and access to health care data. Don't worry about me my man. I'm be OK no matter how the debate on American healthcare policy shakes out.  In fact, I'd be happy to share my thoughts in terms of my particular area of expertise, and how I think there are certain advantages that could be realized under a M4A system, but you guys are too cross eyed on nonsense to engage that discussion.  

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1 minute ago, Anastasis said:

Again, MA cannot deny any eligible individual.

That's weird because I have a relative on dialysis who was denied MA with no SNP in her area.

That's what she says, at least. She's probably lying to besmirch the good name of private insurers.

Quote

The majority of MA plans, which include Rx coverage btw, have zero premium cost. It's really not a matter of affordability.

TIL that premiums are the only out-of-pocket costs for MA plans.

It would be super cool if you could answer this, though:

Quote

Why does this happen? Is it because original Medicare doesn't deny anyone for pre-existing conditions, so they get more expensive, sickest, poorest, and most acute cases to handle? Or is it simply because the government is too dumb to push preventative medicine?

 

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26 minutes ago, bad_teammate said:

That's weird because I have a relative on dialysis who was denied MA with no SNP in her area.

That's what she says, at least. She's probably lying to besmirch the good name of private insurers.

She is not lying. She probably just doesn't fully appreciate that it is not a MA plan that is restricting her ability to enroll in MA, that is a result of CMS restrictions related narrowly to end stage renal disease. SI suspect however that you probably are aware of this CMS imposed limitation, and disingenuously deploy a narrow restriction promulgated by the government to posture against private implementations of Medicare. 

 

35 minutes ago, bad_teammate said:

It would be super cool if you could answer this, though:

Complex answer. No, as previously pointed out. It's not simply that.

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Love to not properly appreciate brilliant economic and corporate complexities that exist as potassium endlessly threatens to kill me.

Quote

SI suspect however that you probably are aware of this CMS imposed limitation, and disingenuously deploy a narrow restriction promulgated by the government to posture against private implementations of Medicare. 

Or I'm just providing a concrete and real example of how MA denies coverage to people with pre-existing conditions despite your (false) assertion that it doesn't happen.

How many Americans have kidney failure/disease? Half a million? Probably more?

Quote

Complex answer. No, as previously pointed out. It's not simply that.

It's not simply that. It's partially that, but not entirely.

I'm assuming the complex answer is forthcoming.

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12 minutes ago, bad_teammate said:

Or I'm just providing a concrete and real example of how MA denies coverage to people with pre-existing conditions despite your (false) assertion that it doesn't happen.

It's telling that you are focusing very narrowly on ESRD, which has totally carved out Medicare eligibility requirements dictated by CMS, while you generalize to the broader Medicare and MA. The ESRD Medicare population and their eligibility for Medicare programs (including C) are governed wholly by CMS.   

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Anastasis: "Again, MA cannot deny any eligible individual."

Me: "Yes, they can. Here is a real-life example."

Anastasis:

giphy.gif

You keep using the "narrow" talking point. Perhaps that's something they teach you guys in shill school. But here are some actual facts about ESRD and prevalence/costs...

- Nearly 750,000 patients per year in the United States ... are affected by end stage renal disease (ESRD).

- Those who live with ESRD are 1% of the U.S. Medicare population but account for 7% of the Medicare budget.

Private insurance reaps profits and shows success by denying coverage to the sickest and most expensive and foisting them on the public dollar. It's a scam for vultures and I hope very soon that it dies completely.

 

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Lol. ESRD is not a narrow example because of its prevalence or expenditures. It is a narrow example because it is the SINGULAR exception for MA eligibility among Medicare beneficiaries. That exception itself only applies in certain situations, is based on a series of CMS rules that relate specifically to ESRD as a special population, and is not a coverage decision made by private insurers to create a favorable case mix. 

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3 hours ago, bad_teammate said:

Anastasis: "Again, MA cannot deny any eligible individual."

Me: "Yes, they can. Here is a real-life example."

Anastasis:

giphy.gif

You keep using the "narrow" talking point. Perhaps that's something they teach you guys in shill school. But here are some actual facts about ESRD and prevalence/costs...

- Nearly 750,000 patients per year in the United States ... are affected by end stage renal disease (ESRD).

- Those who live with ESRD are 1% of the U.S. Medicare population but account for 7% of the Medicare budget.

Private insurance reaps profits and shows success by denying coverage to the sickest and most expensive and foisting them on the public dollar. It's a scam for vultures and I hope very soon that it dies completely.

 

OK. So she can't enroll in Medicare Advantage. 

Is her dialysis covered by Medicare?

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49 minutes ago, Anastasis said:

That exception itself only applies in certain situations, is based on a series of CMS rules that relate specifically to ESRD as a special population, and is not a coverage decision made by private insurers to create a favorable case mix. 

Why do you keep mentioning CMS rules-making as distinct from corporate desires? The head of CMS is literally a healthcare industry executive.

As for the bolded statement, you should calm down with the absolutist statements because your track record is poor. Medicare Advantage DOES deny Medicare-eligible people coverage and the CMS absolutely IS influenced by corporate agendas.

Shills gonna shill.

37 minutes ago, David Dennison said:

OK. So she can't enroll in Medicare Advantage. 

Is her dialysis covered by Medicare?

Not as well as it should be, but yes.

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28 minutes ago, bad_teammate said:

As for the bolded statement, you should calm down with the absolutist statements because your track record is poor. Medicare Advantage DOES deny Medicare-eligible people coverage and the CMS absolutely IS influenced by corporate agendas.

Provide a single example of an individual being denied enrollment in an MA plan, other than the case of individuals who qualify for Medicare based on ESRD and are in general restricted by law and regulation from being enrolling in a MA plan.

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That NEVER happens, except when <massive list of examples that I want to dismiss because I'm a shill>.

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*corporate whores placed in government power by bought politicians enact corporation-enriching policies designed by those corporations*

Shills, "Look, it's the law! Whaddya gonna do!?"

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Just now, bad_teammate said:

That NEVER happens, except when <massive list of examples that I want to dismiss because I'm a shill>.

Then it should be very easy for you to provide a single example of an individual other than one qualifying based on ESRD status being denied enrollment based on a pre-existing condition. 


BT, it's easy to have a good debate about health care policy and the role of the private and public sectors without being intellectually dishonest and using ad hominem as your primary rhetoric device.  You should try it. 

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 BTW, I've actually tried to find some legislative history as to the rationale for the exclusion of ESRD under the 1997 BBA that created Medicare+Choice but have not had any luck.  If anyone knows a good source for committee testimony or other documentation that might actually shed light on the rationale, I'd appreciate it. I suspect that the primary rationale relates to CMS wanting to keep the ESRD population in FFS such as to minimize the impact on the risk adjusted payment model. 

Edited by Anastasis

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2 minutes ago, Anastasis said:

Then it should be very easy for you to provide a single example of an individual other than one qualifying based on ESRD status being denied enrollment based on a pre-existing condition. 

You claimed Medicare Advantage does not deny Medicare-eligible applicants. That's not true. You said a false thing, knowing it was false, and now that you've been called on it you're flailing.

It doesn't matter if it's one set of pre-existing conditions that Medicare Advantage denies coverage based on or a dozen. Even ONE demonstrates that Medicare Advantage denies coverage to the extremely expensive and extremely numerous patients that require dialysis, because like all other instances of private insurance in the US, their model is to eliminate responsibility for the most expensive people to care for and push that responsibility onto the public dollar.

Quote

I suspect that the primary rationale relates to CMS wanting to keep the ESRD population in FFS such as to minimize the impact on the risk adjusted payment model. 

giphy.gif

I would love to hear that complex answer about why Medicare traditional doesn't focus as much on preventative medicine as Medicare Advantage.

Is it because their user base requires different care (i.e., Medicare traditional has to handle more acute/expensive care?) or is it because Medicare traditional is not innovative and smart like the private insurers?

hmmmmmmmmmmmmmm

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Except that you're totally wrong about a MA provider declining coverage because of a pre-existing condition in the form of ESRD.

MEDICARE FORBIDS PEOPLE WITH ESRD from enrolling in MA.  Not the MA provider. MEDICARE.  The US government.

Quote

 In most cases you can’t enroll in a Medicare Advantage plan when you have ESRD.

https://medicare.com/medicare-advantage/medicare-advantage-and-end-stage-renal-disease/

Part of the reason for this disparate treatment seems to stem from the fact that people who have not attained 65 can enroll in medicare early if they have ESRD.  It's almost a separate form of medicare.

https://blog.medicarerights.org/kidney-failure-medicare-know/

There seems to be a similar program for ALS.

Edited by TwiceHorn

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6 minutes ago, bad_teammate said:

You claimed Medicare Advantage does not deny Medicare-eligible applicants. That's not true. You said a false thing, knowing it was false, and now that you've been called on it you're flailing.

You are really disappointing me is this exchange. You are smart enough to have an engaging debate on this topic without being intellectually dishonest and deflecting into a red herring about ESRD eligibility for MA enrollment.

What I said was:

"MA cannot reject eligible medicare beneficiaries based on pre-existing conditions."

 That statement is 100% accurate and true, and you know that your restatement of my claim so that you can say it is false is intellectually dishonest.  Rhetorically advantageous, as I would expect from you, but dishonest. 

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There is also the fucking mystery why it is 4 weeks lead time to get an MRI or other advanced testing and than most of the times I have shown up to a completely empty waiting area.  Yet the appointment is 20 min behind schedule.

I was told we have a great system by the right and that only socialist countries have wait times. I tried telling Texas Children’s Hospital that my son needed some testing and that it was fake news that we would have to wait nearly a year after we got on the list. I was also told that tort reform was going to cause wait times to drop and costs to go down. Hmmm. I am starting to think these people are not telling me the truth?




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38 minutes ago, TwiceHorn said:

MEDICARE FORBIDS PEOPLE WITH ESRD from enrolling in MA.  Not the MA provider. MEDICARE.  The US government.

I don't know why you and Anastasis keep saying this like it means something. Yes, the policy exists that Medicare Advantage can deny coverage based on that set of circumstances. Do you think "THE US GOVERNMENT" came up with that exception for an extremely expensive set of patients in a vacuum?

The head of the CMS is a healthcare industry executive. Medicare Advantage came into existence under the direction of corporate-owned reps who wanted to privatize SS as much as possible to hide the costs from the federal budget. The entire scheme is a corporate giveaway. So yes, it is designed to be that. Congratulations on realizing this.

37 minutes ago, Anastasis said:

What I said was:

"MA cannot reject eligible medicare beneficiaries based on pre-existing conditions."

 That statement is 100% accurate and true, and you know that your restatement of my claim so that you can say it is false is intellectually dishonest.  Rhetorically advantageous, as I would expect from you, but dishonest. 

The statement in bold is false. Medicare Advantage providers can, and do, reject applicants with ESRD.

I guess if we want to expand "eligible" to mean "those without the pre-existing condition that precludes inclusion" then literally zero insurance providers anywhere reject "eligible" beneficiaries. lol

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https://www.urban.org/sites/default/files/2019/10/15/from_incremental_to_comprehensive_health_insurance_reform-how_various_reform_options_compare_on_coverage_and_costs.pdf

Abstract

Report:
From Incremental to Comprehensive Health Insurance Reform: How Various Reform Options Compare on Coverage and Costs

Brief:
Comparing Health Insurance Reform Options: From “Building on the ACA” to Single Payer

Policymakers, including candidates in the 2020 presidential campaign and members of Congress, have proposed a variety of options to address the shortcomings of the current health care system. These range from improvements to the Affordable Care Act to robust single-payer reform.

There are numerous challenging trade-offs when choosing an approach to health care reform, including covering the uninsured, improving the affordability of health care, and raising the government funding required to implement them. The public and policymakers alike need more information about the potential effects of various health reform proposals.

This study analyzes eight health care reforms and their potential effects on health insurance coverage and spending. Each of the analyzed reform proposals makes health insurance considerably more affordable by reducing people’s premiums and cost sharing. Some reforms also reduce US health care costs, and all require additional federal dollars.

Key findings:

  • Within the existing public-private health care system, near universal coverage and improved affordability could be achieved with moderate increases in national health spending. Under one of the plans modeled in the report, which proposes a mix of private and public health insurance, everyone in the US could be covered except for undocumented immigrants. The plan would enable workers to opt for subsidized nongroup coverage instead of their employer’s insurance plan. It would also improve the ACA’s subsidies to help people afford coverage, cover people in states that have not expanded Medicaid, require everyone to have insurance with an auto-enrollment backup, offer a public insurance option, and cap provider payment rates.

    Coverage and costs:
    This reform plan achieves universal coverage for people legally present in the US, covering 25.6 million people who would otherwise be uninsured. However, the plan leaves 6.6. million undocumented immigrants without coverage. National spending on health care would decrease modestly, by $22.6 billion or 0.6 percent, compared with current law in 2020. Federal government spending would increase by $122.1 billion in 2020, or $1.5 trillion over 10 years.
  • One single-payer approach would leave no one uninsured and largely eliminate consumers’ out-of-pocket medical costs but would require much greater federal spending to finance. The modeled “enhanced” single-payer system would cover everyone, including undocumented immigrants. The reform would include benefits more comprehensive than Medicare’s—including adult dental, vision, hearing, and long-term services and supports—with no premiums or cost sharing. All current forms of insurance for acute care would be eliminated, including private insurance, Medicaid, and Medicare, and everyone residing in the US would be covered by a new public insurance program. Providers would be paid rates closer to Medicare’s. Health spending by employers would be eliminated, and household and state health spending would decline considerably while federal spending would increase significantly.

    Coverage and costs:
    This reform option covers the entire US population. National spending on health care would grow by about $720 billion in 2020. Federal government spending would increase by $2.8 trillion in 2020, or $34.0 trillion over 10 years.
  • A second single-payer approach can be constructed with lower federal and system-wide costs. In addition to the enhanced single-payer plan above, researchers examined a single-payer “lite” plan that is similar to the enhanced version but includes cost sharing for out-of-pocket expenses based on income, adds fewer new covered benefits, and only covers legally residing US residents. Single-payer “lite” lowers total national health spending, decreasing health spending by households, employers, and state governments and increasing federal government spending by less than the enhanced single-payer reform.

    Coverage and costs:
    This reform plan achieves universal coverage for people legally present in the US, covering 25.6 million people who were uninsured. However, the plan leaves all 10.8 million undocumented immigrants without coverage (due to the elimination of private insurance). National spending on health care would decrease by $209.5 billion, or 6 percent, in 2020. Federal government spending would increase by $1.5 trillion in 2020, or by $17.6 trillion over 10 years. The analysis demonstrates that there is more than one effective approach to achieving universal health care coverage in the United States and highlights the trade-offs of different reform strategies.

The analysis demonstrates that there is more than one effective approach to achieving universal health care coverage in the United States and highlights the trade-offs of different reform strategies.

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For context, total tax revenue for 2020 projected to be $3.6T, including Medicare and SS. 

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The reason I knew something about ESRD and Medicare is that I owned a stock of a company that made a treatment for ESRD patients.

I came to realize that Medicare and its pretty stingy reimbursements covered almost all ESRD patients, of any age, and that there was no private insurance reimbursement.  Thus, there was no market for the product until basically getting approved by CMS or proving to the 2-3 providers of dialysis services that the product was a better use of limited reimbursement dollars than the current standard of care.

There are several drugs out there like that.  Oddly enough, one drug that somehow weaseled its way into the standard of care is the enormously expensive, patented (until recently I believe) erythropoietin.

Anyway I did not know the precise reason for the lack of private insurance coverage of ESRD in the US until this thread.  But I thought mentioning some of the "consequences" of it were worth bringing up.

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Hospital and facility rates and billing practices are a huge part of why we get $1000 monthly premiums for a high deductible plan.  This is a good development in my opinion.

https://www.nytimes.com/2019/11/15/health/list-hospital-prices-trump.html

 

To Lower Costs, Trump to Force Hospitals to Reveal Price of Care

A proposed federal rule would make hospitals list the prices they negotiate with insurers, allowing consumers to seek better deals for care.

 

The Trump administration on Friday announced it would begin forcing hospitals to publicly disclose the discounted prices they negotiate with insurance companies, a potentially bold move to help people shop for better deals on a range of medical services, from hip replacements to brain scans.

For decades, hospitals, insurance companies, lobbyists and special interests have hidden prices from consumers, so they could drive up costs for you, and you had no idea what was happening,” President Trump said Friday afternoon in the White House’s Roosevelt Room. “You’d get bills that were unbelievable and you’d have no idea why.”

Patients, he said, have “been ripped off for years.”

The federal rule, which would not take effect until 2021, is part of a broader push by Trump officials to make health care markets more transparent to patients. The administration also unveiled a proposed rule to require insurers to allow patients to get advanced estimates of their out-of-pocket costs before they see a doctor or go to the hospital.

Mr. Trump rolled out the initiative personally, providing some counterprogramming to the second day of impeachment hearings while showing his willingness to take on powerful interest groups like hospitals and insurers.

 
 

Mr. Trump was “taking historic action to make health care prices transparent for consumers, yet the coverage on all the cables remains on the impeachment inquiry charade,” his press secretary, Stephanie Grisham, tweeted. “Dems should get back to work — just like our” president.

The hospital industry, which has long kept its negotiations with insurers secret, said it would challenge the rule in federal court. “This is a very radical proposal,” said Tom Nickels, an executive vice president with the American Hospital Association, a trade group.

Hospitals say the administration does not have the authority to compel them to disclose their private negotiations and compared the order to forcing private parties to reveal trade secrets.

But if the rule survives, “it’s a game changer,” said John Barkett, a former Obama administration official who is now a health policy expert at Willis Towers Watson. Knowing the price of a colonoscopy or knee surgery before it takes place “would be hugely helpful,” he said.

The administration’s decision to aggressively tackle the secrecy surrounding hospital prices came amid widespread concern about rising costs for medical care. Democrats have also been campaigning on soaring health care costs, and both parties fear entering the 2020 campaign season with unfulfilled promises to gain control of out-of-pocket health spending.

 
 

People “are increasingly exposed to the crazy pricing of health care,” said Chas Roades, one of the founders of Gist Healthcare, a consulting firm in Washington. “We are overdue for a public airing of how all of this works.”

While the hospitals’ legal challenge may succeed, they are vulnerable to the increasing public outcry over high prices, Mr. Roades said. “It’s not a good look for the industry to push back on transparency on prices.”

Mr. Trump seemed to relish taking on powerful interest groups. “I don’t know if the hospitals are going to like me too much anymore with this, but that’s O.K., right?” he asked. About health insurers, he quipped, “they’ll be thrilled.”

The new rule requires hospitals to make a range of prices easily available, such as prices negotiated within an insurer's network, what hospitals are paid if their care is out of a patient’s insurance network, and what the hospital would accept for the treatment if paid in cash.

Administration officials, employers and others have criticized hospitals and insurers for keeping the deals they strike a secret, making it challenging for patients to seek less expensive care. They argue that by making it easier for people to find the actual prices that insurers pay — and not just the standard list prices for various services, which the Trump administration started requiring hospitals to post earlier this year — hospitals will be under more pressure to compete on prices.

The rule has the potential to roil the health care industry, which critics argue use the secrecy of their negotiations to keep prices high. A recent study showed that private insurers pay some hospitals two to three times more than the federal Medicare program pays for the same care. Even employers say they have little visibility into the prices being paid by the insurers on behalf of their workers.

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Proponents of the rule say it will create a working health care market in which hospitals compete on price and quality. People will be able to look for hospitals that give them the best value, said Cynthia Fisher, a health care entrepreneur and the founder of the group Patient Rights Advocate. “It will be aggregated and assimilated in a way that people can have ready access to it,” she said.

 
 

Both the hospitals and health insurers say they should not be required to make public what they consider proprietary information, and they are expected to mount legal challenges to any mandated disclosure. In Ohio, a state law requiring price transparency that was passed two years ago is still waylaid in the courts.

Hospitals say that disclosing prices would lead to higher costs, not reduce them, because each institution would know the prices of its competitors and could be reluctant to settle for less.

Health insurers, which have voiced similar concerns, said they were evaluating the rules.

“Transparency should be achieved in a way that encourages, not undermines, competitive negotiations to lower patients’ and consumers’ costs and premiums,” said Matt Eyles, the chief executive of America’s Health Insurance Plans, which represents insurers, in a statement.

Alex M. Azar II, the health and human services secretary, called that “a canard.”

But the legal challenge ahead is real. When the Trump administration tried to require pharmaceutical companies to disclose the list price of their drugs in their television ads, the courts blocked the regulation. A federal judge ruled last summer that the Department of Health and Human Services exceeded its regulatory authority with the rule, which was seen as largely symbolic since list prices are not what patients typically pay.

“We may face litigation, and we feel we are on a very firm legal footing,” said Mr. Azar, who emphasized the information is already being made public to patients on what is called an explanation of benefits form — but after they go to the doctor or get a medical treatment.

Mr. Nickels from the hospital association said information about all of a hospital’s negotiated prices with individual insurers is not currently available. “That isn’t public information given to everyone, given to competitors,” he said.

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mpu


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