The Reno specialist made her a follow-up appointment in June. The Carson City specialist saw her in 4 days.
Etc, etc.
We're our own LLC, and we got our own group health plan, as a function of being self-employed and having experienced the employment-related gaps in health insurance coverage.
None of this is interesting, but it's stupid and risky. This system has to be changed.
Funny! Pointed too.
Getting the best dealz runs in basic conflict with needing to stay alive.
This is why markets do not work well for primary care. They can work well higher up the chain where life basics are not really in play.
Last year, I paid $4000 more than my $6500 out of pocket maximum, because I had a heart procedure and the heart rehab following the procedure was an exception to the out of pocket maximum, a fact I discovered only after incurring the costs. You see, if you clearly follow the asterisk and the footnote references in the policy, then it's very clear that these expenses would not have been covered.
Health care is an inelastic good, we need it. So this is a market (much like having a military) that really benefits from the government stepping in and making things sane.
Let users watch a series of videos and choose what kind of risk and benefit they tolerate/want and how much they’re willing to spend.
It’s morbid, but we do such assessments constantly. Do I come to a complete stop and waste a few seconds and ml of gas, or roll through it and be really careful about it?
The difference in your "every day" scenarios is recoverability. Your actual health put at risk means you die, unrecoverably.
Then there is always people not being able to spend. So they just die?
A poll on that policy would be instructive.
Obviously the advanced directive solution is largely irrelevant in a 100% coverage/public system. The insurer then makes those decisions for you. But for as long as you have a system with uninsured, there’s value in having decisions made in advance as a “just in case”.
In simpler times, a city able to provide clean water was a city of note. Worthy destination. This has been true for ages.
Flint fucked for how long now?
Our national priorities are insane! Bat shit wrong and health care, food, water, housing are all right at the top of reform agendas for damn good reason.
We can do better, and we need to.
The uninsured are uninsured because they are unable to spend. Put whatever the fuck anyone wants on that paper and it does not matter one lick.
Might as well write, "yeah, let me die, k?"
Frankly, there is zero value in the idea, and a lot of harm potential in the norms being changed for the worse: "but they consented..."
Anyone who wants to make a directive can do so today. Expecting people to do it because our system is fucked makes zero sense.
It is long past time we get our priorities in order so conversations like this are laughable, not morbid.
I always wonder if you libertarians are doing a bit, because it sure seems like it.
It’s a solution to the problem of “I continued to choose to live in an environment without health insurance, how do I handle the situation of not being in a position to negotiate?”
This extreme libretarianism stuff is pure BS, health care services in an emergency cannot exist as a free market.
As for those uninsured that just broke their ____ and are not in a position to start calling around, having pre-negotiated rates for the best pricing against all hospitals within a reasonable time’s transport would save a pile of cash. There’s no shortage of hospitals or excess capacity in the US.
The reality is you need an M.D. to make a reasonable evaluation. This is why at an HMO we have primary care physicians. Or in any other country, GPs. They decide if you need specialized care. However, how am I supposed to pick one of them? It's Russian nesting doctors.
It's probably the most complicated thing we have to deal with in our non-professional lives.
Seriously though in general managers have worked in and around technical people before, and their role in the process is to evaluate qualitatively. Are they a good communicator? Do they seem like awful people? They use feedback from the engineers to estimate if they're good engineers. I don't have a deep bench of M.D.s to lean on to figure this stuff out.
With a bank, Bank of America has terrible service - so I just don't use them, with a doctor though... what if I'm paying a premium price but receiving substandard care, given how complex human bodies are most illnesses compound over time and only in very select circumstances could you get a doctor to come in post defacto look at an X-Ray and say "This doctor was terrible, that's totally a tumor" maybe the real issue is that a tingling in your finger tips when you sit down that you asked your doctor about went unnoticed and twelve years later your heart gave out over totally preventable causes.
Same way you would pick anything else? I shopped around for my GP and changed several.
Some factors were: years of experience, user feedback, spoken languages, any red flags for the whole practice, how they respond to my concerns and questions in conversation, etc.
Also I think it's not really fair to take full lifetime costs into consideration at once. As you get older you'll be looking at those much more expensive treatments and covered by expensive insurance but the insurance tends to be of a higher quality when it comes to reducing sudden costs - I am more concerned about younger people who generally have terrible insurance and may get hit with 4 months of 20k physio due to a sudden injury but generally have low "normal" costs.
The UK has periodically had a back and forth on whether the outcome ratio numbers which are collected for internal statistical measures should be published.
ie should we make it easy to get a number that says 4.6 for Mr Able, 5.2 for Ms Awesome and 3.8 for Mr Good?
At one extreme the reality may be that Mr Good isn't good and his numbers are low because he's a bad surgeon, he makes a lot of mistakes, his technique is not what it should be, he's using an approach that's outdated... that's a real problem, and maybe "patient choice" is a fix where colleagues may be reluctant to say "Fire Mr Good" because he's a good guy, he's not _terrible_ at his job, but yeah they would not themselves choose to be treated by him.
At the other extreme the reality may be that Mr Good is the only guy who'll take patients that Ms Awesome thinks are too high risk. She thinks it's better to say "No", he thinks if they seek medicine he should do his part. Maybe they're obese, or they won't stop smoking, or they won't stop doing the sport that's wrecking their body. And Ms Awesome is right that Mr Good's patients are higher risk, but that's not because he's doing a bad job, he's playing what was dealt.
Every time patients are asked to rate the quality of the care, they consistently rate simple feel-good care like massages, chiropractice, or just therapy as very good, but saved-your-lfe-operations get rated very badly, because the experience and recovery is often miserable. You live, but you don't feel good, so you rate the quality of the care after how you feel, even though you ought to rate it Five-star, A++++, would transplant a failed heart again!
So the rational person abandons subjective ratings and look at objective ratings, what's the medical outcome for a provider? Sure, that's better, but the quality of the outcome is incredibly dependent on the quality of the patients! It's a well-known fact that a positive attitude helps immensely with recovery, how do you measure that? How do you integrate that with an outcome measurement?
On the other hand, if a provider is charging too much, they shouldn't be included in the plan in the first place, as they're simply a bad option.
The principle idea is that because they have to pay some, they'll be more sensitive to pricing and more willing to shop for an affordable provider, which is exactly the efficiency argument.
And in this particular case I agree, even. Though the fact that this has to be done by individuals (who are sick!) sort of makes a hash of the moral notions of "the market" being the solution here. We're buying efficiency at the cost of individual grief, and that has value too.
Oh you went to an in-network hospital, but this one doctor walked into the room for five minutes and she was out-of-network, so now your bill is 10x higher than it otherwise would be, etc. etc. It's ridiculous.
This is less difficult than it sounds. Move to Texas, and keep all your assets in retirement accounts, home equity in your primary residence, and possibly annuities if you've made too much money for that all to hold everything. Note that this should be done before possibly incurring debts.
Wouldn't it be easier instead for healthcare billing not to contain so many gotchas?
Sure, but improving your BATNA helps your negotiations even if you don't need to exercise it. The bill gets handled with opening a dispute and sending a "give me documentation for an implied regulatory complaint" letter. If things devolve into a lawsuit or threat thereof, I tell them my financial situation and what they can expect from a lawsuit and offer to settle for a nominal amount.
>Wouldn't it be easier instead for healthcare billing not to contain so many gotchas?
Well yeah, but I can't change the healthcare billing system, while I can change how my finances are structured.
Debt collection follows a combination of state and federal law, and Texas state law is unusually favorable to debtors. Specific important pieces:
1. Your primary residence is protected from forced sale to satisfy general creditors, up to 10 acres (urban) or 100 acres (rural).
2. Garnishment of wages is limited to certain special circumstances, such as nonpayment of taxes or child support.
3. IRAs have unlimited protection from creditors (other states have a cap).
>And how can you put everything in retirement account?? 401k is 19k/year and IRA is 5k? What do you do with the rest of your money?
Home equity is a very significant part of this. If you borrow $300k to buy a $400k home, the $100k you have tied up in your house is protected from creditors. If you have an extra $50k you want to save, you pay down your mortgage more aggressively and creditors can no longer come after it.
Oh, also, from reading into things, it looks like if you buy a 2 to 4 unit house, then even the non-owner-occupied units remain protected. So you can extend things somewhat that way by having a more expensive home that cashflows.
>Do you setup and LLC or trust?
LLCs are more for business-related liabilities, and trusts are weird and expensive enough that I haven't looked into them. Besides which, there's a perfectly reasonable alternative to a trust - annuity and insurance products. Both their value and payments to you are exempt from attachment and seizure in Texas, again with the exception of child support payments and "fraudulent transfers" made after incurring the debt. So essentially, if an insurance company is holding your money and giving it back to you in a structured way, creditors have a really hard time getting at it.
It is absolute insanity that this is even a thing to consider.
The funniest thing about it is that if you do this, you are effectively socializing your personal losses and letting everyone else insured through your provider bear the cost for your healthcare. If that's not an argument for actually socializing healthcare costs for everyone, I don't know what is.
But, unfortunately, it's currently impossible to set a maximum price you could wind up owing due to receiving medical care. Any provider you go to could end up incurring out-of-network charges and wind up balance billing you. The only fix is to cap the actual damage of creditor judgements in general.
Of course, because demand for healthcare is infinite, so you could wind up costing the insurance company an infinite amount of money. And if their expenses are uncapped, they're not going to cap how much you can pay them.
And if they cap their expenses on your behalf, it's not really insurance, it's just a shitty payment plan.
[0] https://www.cbsnews.com/news/out-of-network-anesthesiologist...
That's why I think full free market healthcare simply won't work. It's far too much at odds with people that need medical care, made worse if you need timely medical care.
If you have a M4A, you have less choices not more.
> That's why I think full free market healthcare simply won't work
The last thing I would call healthcare in the us is free market.
Insurance companies want to contract with the healthcare providers with the highest quality outcomes that don't have overprescription, relapses, and readmissions.
Search terms: "narrow networks"
2) Make insurance company that reimburses 1$ per visit
3) Profit
There are multiple reasons why this doesn't work for healthcare even in theory.
- Emergency care can't be substituted without massive cost. Providers compete on distance not on price.
- Emergency care can't be denied (or at least we don't want this) on the basis of price.
- Health is not insurable like cars, etc. You can't predict in advance when you are going to get in a car wreck so you better buy insurance when you get the car. If you could, the price of the insurance would be the price of the car, and therefore worthless. But you could just wait until you feel sick to get health insurance. This is why the ACA has to be paired with the individual mandate to work properly.
There is HUGE price discoverability capacity in healthcare. But the US is not a free market: every single player has some sort of regulatory capture to mess it up, including workers, that get tax benefits and are blind to price through employer provided insurance.
Price sensitivity does work for high deductible plans, pointing to the basic economic principal-agency problem of the current system: if you have low copays and you cant choose insurances because your employer pays for it, you are a price insensitive patient.
My favorite example is OneMedical: one of the biggest complains patients have is "why do I have to pay 150 a year", while their healthcare plan is thousands A MONTH and a single doctor visit costs 300 U$S!
> have little option in substitution (if my appendix is ruptured my substitution to getting surgery is dying!)
Emergency healthcare is a small fraction of overall healthcare spending, and it is NOT expensive because of insurance, its expensive because hospitals are expensive. It doesn't make sense to complain to an auto-insurance company that fixing cars is expensive, its completley out of their hands, and they actually work in your favor to reduce costs if they can.
And medicine has PLENTY of substitutes. From cheaper drugs, to less accessible and lower quality healthcare. It's called the Iron Triangle of Healthcare: cost-quality-access. You can find your place in the triangle.
Just yesterday I sent in the paperwork to roll over my HSA from one bank to another-- the punchline is, my insurance provider didn't change and my insurance login was the same (Premera ConnectYourCare), but it looked like the 15k in my HSA account inexplicably disappeared. Needless to say, this was concerning.
A few phone calls later, and I come to find out that my 15k with Bank_0 was available on the backend, but since Bank_1 was preferred by my new employer, Premera shows Bank_1 on the frontend. Keep in mind, all interactions with your HSA bank account are abstracted away from you. So you must track down your Bank_0 and Bank_1 account numbers (I used my tax paperwork) and mail in honest to god physical signed forms authorizing the rollover.
Then I come to find out that I should have done this anyway-- HSA accounts are laden with monthly account fees, paper billing fees and investment fees that my previous employer wasn't paying anymore, and these aren't covered by my current employer. HSA bank accounts are one hell of a moneymaking venture for the big banks-- 0 risk because employers send yearly contributions into the account; high likelihood that people will forget to roll it over and the account will drain via fees.
HSAs have the hugely hidden cost of managing this separate account+tax entity, and I did not know this when I signed up for one. I'm not even sure that my hours of labor on it are worth the tax savings.
I am either the luckiest person alive, or maybe there is additional benefits not obviously well represented here to working for a stable, revenue producing organization, but I don't seem to encounter what seems to be the well-represented insurance pains documented here (probably a little bit of both, in my guess).
The procedure was in December. After the procedure she received a 6-figure bill, which she then had to follow up with hours of phone calls back and forth to the insurance company, hospital, and doctor's office. They sent her a revised bill for somewhere around $8,000, and then another revised bill for around $4,000.
The insurance company says it's because the doctor coded the procedure incorrectly. The doctor says the hospital coded it incorrectly. She has had to file an appeal with the insurance company, and the only reason it looks like it will work out is because the insurance company records all phone calls and was able to get records of her original calls before the procedure asking if it would be fully covered. She has still been told to expect that they will deny her first appeal and she'll have to appeal a second time in order to get it covered. This has been causing her immense stress for the past 4 months as she does not have enough money to pay even the $4,000 bill out of pocket.
My experience is that your experience actually is extremely uncommon in America today. Most people who have to interact with the health care system beyond annual checkups have to deal with something like this.
My father currently undergoing treatment for lung cancer. He has medicare and supplemental coverage through Humana. Bills are still in excess of 150,000, so I definitely understand the other side of it.
When I go to the insurance site, it lists me with a $2k individual & $4k family deductible. It says my OOPM is $7.5k. Of course I hit my deductible this year, so I'm getting billed an extra thousand.
My employer and insurance company both swear it's the other one's fault and even filing a complaint with the state insurance commission doesn't seem to have helped. :(
For example, I recently got prescribed a medical device, but was then told that if I didn't have a follow up appointment between certain dates I'd be billed out of pocket for the device.
The prescribing physician, of course, has no open appointments until a couple months after the given follow up interval, despite knowing the potential issue and prescheduling the followup.
And of course the device provider, the physician, and the insurance company all tell me completely different things about the situation.
The current "solution" is "just see your primary care instead," not sure how it'll go.
On top of that insurance frustrates my wife so before we were married when she was on PhD student insurance I generally managed that too, plus her transition to my insurance after marriage.
So I'm definitely out-of-norm on this. If anything I like to think that means I'm more qualified to call out how bullshit the world of insurance is, atleast in terms of end-user UX, but obviously that's just my opinion.
I've worked for employers of varied sizes and profitability (self-employed, small nonprofit, very large health system [including its own insurance plans], midsize for-profit), and I haven't noticed a consistent pattern that would differentiate them in terms of health plan stability. In all cases, the goal is to minimize cost while providing an acceptable level of coverage.
Of course, job hopping and employer-provided coverage are a painful combination. My family had to reach our deductible twice last year, which wasn't fun (the increased salary and other benefits of the new job made it worth it).
I'd love to see health coverage detached from employment. If traditional Medicare-for-all isn't feasible, then let's go with Medicare-Advantage-for-all instead.
No matter what an individual’s stance is with respect to another individual’s professional history in terms of frequent changes or gaps, I don’t think that has to correspond to level of healthcare that the latter individual is able to obtain.
Imagine there's a single, private, insurance company, A.
Wouldn't the natural interest of A be to maximize health costs (i.e. make paying for health coverage expensive, as thus their insurance more desirable and more expensive in return)?
And if there were more smaller insurance companies competing with A, wouldn't it make sense for A to just eat them up to eliminate competition (so, having us end up with an even larger company)?
And if there were several equally large insurance companies aside A (say, B, C, D), wouldn't it make sense for them to collude and keep prices and profits high?
And since A (a single large) or A+B+C+D (several large) companies surely have considerable clout (money gives you that) isn't it their natural interest to spend on buying politicians, media, etc, to make sure things get even more in their favor?
All those seem inevitable (and profitable) in a market economy. How would insurance being a private market make it "make it more efficient for the sake of maximizing profit"?
A, an insurance company, is the one fighting to get the cost down from B, the healthcare provider.
> And if there were more smaller insurance companies competing with A, wouldn't it make sense for A to just eat them up to eliminate competition
Monopolization is more dangerous from the healthcare provider side, though it happens both ways. Basically, insurances compete against each other at state levels, while hospitals only fight the nearest hospital, maybe.
> And if there were several equally large insurance companies aside A (say, B, C, D), wouldn't it make sense for them to collude and keep prices and profits high?
You can see that health insurnace companies are not really profitable. They have lower margins than auto-insurance.
> And since A (a single large) or A+B+C+D (several large) companies surely have considerable clout (money gives you that) isn't it their natural interest to spend on buying politicians, media, etc, to make sure things get even more in their favor?
Noone has more interest than to implement national health insurnace than politicans. It's the biggest political boon plus almost unlimited spending they could get. If something like M4A passed, the state would grow in the order of 10% of GDP.
> ow would insurance being a private market make it "make it more efficient for the sake of maximizing profit"?
By keeping at bay provision costs vs quality. In Healthcare there is something called the Iron Triangle: Access vs Quality vs Cost. If you unleash access, you need to lower quality or increase cost.
If the healthcare cost is zero or negligible the need for insurance is also zero. You just pay it out of pockets.
The insurance company might want to lower their bills (when they do pay for your treatment), but they have a counter-incentive to health costs being lowered too much, and a positive incentive to get health costs higher for the uninsured.
Tautologic, of course, the service insurance gives is precisely the individually unforeseeable cost of disease.
> The insurance company might want to lower their bills (when they do pay for your treatment), but they have a counter-incentive to health costs being lowered too much, and a positive incentive to get health costs higher for the uninsured.
The great enemy of insurance companies is direct-to-provider pay (and insurance one of the historically great political enemies of doctors as well). It's been unfortunately regulated from its inception, but its an intuitive proposition to say that insurance companies win by how efficiently they apply the actuarial model, and how they control the risks and the payouts. Insurance companies that pay more to providers and restrict less coverage of their patients will soon be out of business.
Sure, but as an insurer they don't have any control over health care costs. They could bid prices up, I suppose, but that eats into their profits; such a strategy would cost them more than they could possibly gain.
> And if there were more smaller insurance companies competing with A, wouldn't it make sense for A to just eat them up to eliminate competition ... ?
The smaller companies would have to agree to that. Some of them could be co-ops or other organizations structured to represent their members and not interested in being bought out by a company which doesn't share the same principles.
> ... wouldn't it make sense for them to collude and keep prices and profits high?
Cartels are notoriously unstable. Every member has an incentive to cheat on the cartel to gain market share. And then you have the aforementioned co-ops and others who wouldn't be interested in joining the cartel.
> ... isn't it their natural interest to spend on buying politicians ... ?
And here we come to the real issue. Not that companies are interested in buying politicians—that's only to be expected, under the circumstances—but rather that (a) there exist politicians with the power to forcibly interfere in the market without being branded as criminals, and that (b) these politicians are willing to be bought and to support laws actively harmful to their nominal constituents.
In order to have a private market for either health care or health insurance you must first get the politicians out of the market.
It's friction costs for splitting up the decision-making process into multiple entities. For any bill, the insurance company pays $X, the patient pays $Y, and the provider has $Z in costs. The $X that the insurance company pays is what they optimize for, not $Y and certainly not $Z. This has the side effect of somewhat optimizing $Z, since $Y is limited by how much money people have and if $Z is consistently bigger than $X + $Y, the healthcare provider loses money and goes out of business.
Honestly, the way to go is to treat the entire process as interaction with hostile bureaucracy. Document everything, and look like you'll generate a regulatory incident if you don't get what you're legally entitled to. Otherwise the insurance company will happily reduce their costs by offloading it onto you or the healthcare provider through pulling bullshit stunts.
The insurance companies profit massively from the confusion they have created.
The market is doing its job perfectly well maximizing the value defined by government constraints and influence (since govt is the largest payor).
But I tell you one thing that really affects why insurance sucks: that you get sweet tax exemptions if you get it through an employer, and to be an insurance that works through an employer you need to overcome massive regulatory hurdles.
Welcome to the world of regulatory capture.
That subsidy should die and healthcare should be finally decoupled from the employer. That would unleash massive market forces.
One of the fallacies in play is buying insurance is put in one category. Whereas paying taxes for insurance is another. The first is 'good' because it's 'free market' and the second is 'bad' because it's the government taking your money's.
Well, I'm in favor of socialized healthcare and generally receptive to increased taxation, so that's definitely not the implication I was going for. But it is true that there doesn't need to be a categorical consideration at all. A more sound statement would be "I as a consumer am willing to pay dollars equal to twice my current premiums to get healthcare coverage while avoiding hassles while receiving routine healthcare"
In truth I'm not making a blanket argument for any government-run healthcare system because alleviating my pain points necessarily depends on said system being efficient and well implemented. But I KNOW that the free market isn't suddenly going to start improving on these pain points without introduction of regulations to manage issues like competing doctor networks, confusing healthcare coding and opaque pricing, etc, and I have no trust that the free market types in congress have any interest in regulations of any kind, so I personally err on the side of socialized healthcare on this one.
Ah, but are you willing to force everyone else pay twice as much so that you can get the health care you want? That's the real question. You said you were in favor of socialized healthcare, so I would guess the answer to that question is "yes", but let's at least be honest here—the private vs. public debate is never about how much you are willing to pay. Under a private system you're free to buy as much healthcare as you can afford. The point of socializing healthcare is making other people pay.
Comparisons to other (first-world) countries with socialized healthcare systems suggest that it shouldn't be necessary for everyone to pay twice as much. If everyone paid exactly the same amount as they currently do (in tax + insurance premiums) there should be plenty to fund a first-world-standard national health system.
> you're free to buy as much healthcare as you can afford
It's difficult to know what you can afford when you can't find out even an approximate price until it's over and the bill arrives.
Right. Regardless of whether health care is paid for privately or via taxes, it's obvious that the problem isn't that we're not spending enough money.
> It's difficult to know what you can afford when you can't find out even an approximate price until it's over and the bill arrives.
I agree that prices and billing should be more transparent. It's crazy that they expect you to agree to pay whatever they might choose to bill, months or years after the fact, without even the courtesy of a binding estimate. I think a good argument could be made that these are not valid contracts and you should be able to walk away from them without penalty; they only get away with this sort of borderline-fraudulent behavior because the law grants health care providers special status. This situation is not improved by changing things so that health care providers don't even need your formal consent, or any interaction at all for that matter, to bill you via the IRS, with no contractual obligation on their part to provide any services whatsoever in return.
Yes. Especially you personally. Honestly, I don't even care about socialized healthcare as long as your tax rate is > 90%. Think of it as a "stupid libertarian tax".
I think most people will be in support of this measure, as hopefully it will force you to work so hard you don't have time to make inane internet comments.
The state is incentivized to be a political boon for politicians, not to give "healthy outcomes".
If you have a high deductible, you already chose to pay less. Revealed preferences and all that.
In reality, it's less efficient.
So then if it's supposedly more efficient, why do I waste multiple hours dealing with insurance bullshit literally every few months?
Start a new job at a startup, need to go to trainings to understand the health care options and choose one, get new cards and website logins, update my info at every provider
New dentist is having difficulty getting my routine care billed to insurance and calls me every week asking for my insurance information again.
Wifes doctor didn't do something correctly when I updated insurance so now I need to call and deal with this big medical bill that I shouldn't have gotten.
Startup got acquired so I get another training for the new insurance options. And get new cards and logins and update with all providers again
Planning to get a surgical operation but nobody can tell me how much it will cost, doctor says "probably whatever your deductible is" except I have a high deductible plan so is it really going to cost me $2500?
Etc cetera. There's no end to the nuisance. If I could choose to just pay more in taxes (hell I'll pay way more than my current premiums) and never deal with insurance again, I would do it in a heartbeat.