EDIT: One more interesting detail from the podcast and the book it's based on: Those deals between PBMs and pharma companies are secret. Not even the insurance companies know the details of what's in there.
It's also fun to point out that typically this is everyone involved in a consumer getting their drug: * the consumer * the consumer's employer who selects the insurance * the insurance * a PBM who get a Pharma benefit plan for the insurance * the Pharma company that manufactures the drug * the pharmacy you actually buy the drugs. On top of that the actual payment apparently happens often months after you received the drug.
Edit2: Clarifying "PBM"
[1]http://www.econtalk.org/robin-feldman-on-drugs-money-and-sec...
Of course the vending machine was full of junk food, and the contract was with the same company that controlled the pharmacy. These people need to be put out of business.
In some cases pharma co.'s created their own PBMs.
There is a long and storied history of litigation on American drug pricing. If you want to understand the Rube Goldberg machine, I recommend searching the keywords "Average Wholesale Price" or "AWP".
In terms of consumer protection, some states are better than others. Maine was a leader in this area. However it looks like the pharma industry has prevailed.
https://www.policymed.com/2011/06/maine-set-to-repeal-unfair...
If you are desperate and your life is at risk, they can literally strip you naked - just see how many unscrupulous people become rich during wars.
When you are in a medical emergency, and you need a treatment right there and right then - no time to shop around - why should an unregulated, shareholder value maximising business, not extract from you as much as you can afford?
In a free market, you'd also have choice via competition to drive that price down. Right now, hospitals can literally veto their competition by claiming "there isn't enough demand to justify another hospital in this area". So bing, no new hospital, no competition.
And of course, this assumes your provider is out to screw you at every turn. This turns out to not be the case for obvious reasons; your provider still wants your business in the future. In the case of a single hospital/provider (a la regulation) they've got your business no matter what.
Competition is a key force in markets, and regulation in the medical industry provides huge barriers to competition.
Not really though. Like, if I am having a heart attack the correct answer to "Which hospital do I go to?" is always going to be "The closest one equipped to handle it". Well technically the one I get can to the fastest that can handle it but you see my point.
This kind of choice via competition would work for things like optometrists and GPs (assuming you live in an area with more than one general practice) but just plain doesn't for emergencies.
An because it's so obvious, people will want to be prepared for it. By having insurance (real insurance, not the bizarre "health insurance" construct we have today), or subscribing to some service like you do for when you car breaks down etc.
I'm not sure what exactly would happen, but I'm certain it won't be that people will just never think about this until they all, one by one, have a medical emergency and have to unexpectedly pick a hospital on the spot.
Because if hospital B isn't my choice but I'm closer to it when the emergency happens I am going to hospital B
But that is not at all what I'm asking about. You clearly didn't read the post I commented on.
If my basement is flooding and I sound rich and dumb to the plumber I call, I might get quoted triple the price of one of his regular customers, sure.
But there won't be a Plumbing Benefit Manager company as a middle man that has a "negotiated special hourly $800 rate" with the plumber so I don't have to pay the "official $9340 rate".
That sort of complex plunder reeks of regulation to me. I can't imagine how it arises. Which is why I asked.
Gouging related to temporary situations is a laughable comparison.
The comparison isn't laughable at all.
Send out a flier in the Sunday newspaper and the margins on medicine will reduce to as close to zero as possible just like food.
I worked for a time in pharma and believe me direct to consumer was seen as a boon to profit margins, not a constraint.
Public transparent pricing that will drive consumers to pick and choose their health care providers would do great things for the ridiculous situation we are in.
But I never see ads for cheap drugs.
So I think you're talking about different things.
I'm sure this analysis[0] has plenty of critique waiting to pounce, but it's something to consider.
[0] https://www.peoplespolicyproject.org/2019/04/08/us-workers-a...
A less nuanced explanation is to agree that in an unregulated market, this type of excessive rent seeking would not exist. The old and sick would simply die in the streets. (Actually that's not quite fair since in an unregulated market we wouldn't have streets.)
Obamacare alone added 20,000 pages of regulations.
https://open.live.bbc.co.uk/mediaselector/6/redir/version/2....
This kind of discrepancy makes these debates somewhat pointless as different sides talk past one another.
There are many reasons - high quality of medical staff, top notch equipment, just a good place to be. Also, Suisse is long term perceived as creme de la creme in many aspects of life, so this fits the overall picture, be it real or some wishful thinking (mostly real though).
In Utah I've gotten further, but usually if they knock off 20% I've had a good day. It's insanity. The market is completely messed up.
It’s a stupid game about who is the biggest bully. Not many people have the nerves for this.
I read somewhere that’s how to fix your credit rating, wonder if it’s also good for s discount ;)
Also interesting, e.g. what happens if you lose your job, decide to go indie or until you find another job... In other words, how safe you feel? (compared to living in Australia with their universal healthcare)
Unless your employer pays a portion for you, expect to spend $4,000 to $8,000 per year per person on health insurance premiums, depending on your age, plus up to $3,000 or so on out of pocket costs assuming you need medical care.
It’s just your lifetime’s, up to 65 or whenever Medicare (taxpayer funded care) kicks in, health costs amortized over your whole life and then discounted for age since younger people don’t need as much healthcare.
In America, the voters want doctors and hospitals and drug makers to provide everyone, no matter how destitute, with services and medicine. But the voters also don’t want any to pay any additional taxes, so this is all a work around to that.
Poor people and old people get subsidized by Medicaid and Medicare (taxpayers) and they pay less or nothing at all, so the providers go after everyone else (middle class) for as much as they can. The bigger employers who have negotiating power can do well for themselves, but the smaller employers/individuals on healthcare.gov get screwed because they don’t have enough negotiating power to prevent getting taken for all they have.
Everyone assumes if youre dirt poor you get Medicaid. But at least for some states as I’ve found out that’s far from true. In Florida for example (we have a poor friend there who is sick) non disabled adults do not ever qualify even if they earn zero dollars.
https://www.benefits.gov/benefit/1625
> To qualify for this benefit, you must:
> Be over the age of 64; or > Be pregnant or have a child 18 or under; or > Be blind or disabled; or > Have a child, parent, or spouse in your household who is blind or disabled
By suggesting my friend needs proper motivation do you mean she should get pregnant so as to qualify?
Re avoiding treating people with chronic conditions, my understanding is that used to be a (state-by-state) thing that the ACA federally outlawed. We live in NYC where the state had already outlawed it, so even if the ACA is rolled back we should be fine.
We have very good insurance atm. I would go so far as to say, ignoring the general craziness of dealing with the US system and the occasional billing frustration, we have better coverage now than we did in Australia because _almost everything_ is covered (even most things Australia would consider "elective" and hence one would pay for out of pocket). We pay a token $1/month for premiums because law says we have to contribute and my employer pays our deductible. As long as we stay in-network we have basically no out of pocket costs.
If I lose or leave my job I have to find a new one and transfer my visa within 30 days, or leave the country within another 90 days after that. There's a thing called COBRA which allows you to pay a relatively low fee (iirc it's ~$700/m) to continue with exactly the same insurance post-employment for a short period (I think 9-12 months? Unsure exactly). Otherwise we'd just move back to Australia. We're both Australian citizens and we aren't really interested in making the transition to being US permanent residents.
Boy, are you going to be in for a surprise if you ever utilize COBRA. If there's a "we" involved, plan on about double that, because you will pay the full, undiscounted premium. They don't want you on that plan, and they only do it because of federal law, so they're going to make it as unappealing as possible.
insurance post-employment for a short period (I think 9-12 months? Unsure exactly)
18 months.
What I think we need, however, is a model that doesn't depend on single-pricing to work, because the real world isn't single-buyer.
People tried to solve it by creating healthcare savings accounts, but the solution itself is very complex, and the end user is often in situations where they don't have the ability to negotiate (e.g. emergency health care). So in practice, the financial benefits seem to accrue with low-care patients, not low-cost-of-service patients, meaning it doesn't affect the system in the right way.
Ultimately, I think the only way to fix it is to start adding negative pricing pressure in small ways to the system, not trying to tackle the whole problem at once.
For example, waive deductibles for treatments which are billed below average (mean? median? in any case, this has to be independent of list price). That creates a financial incentive for insured patients to both seek out billing information, and to lower it.
What's great about that (for insurers) is that you're specifically altering behavior of your most cost-conscious customers, who tend to be your lowest margin customers, without mucking about with the profit margins on your most valuable customers.
Why is "use less, pay less" a bad thing?
Going a bit deeper, however, it will most likely increase health care costs over time. This is because it splits the population into two separate risk pools (low-risk low-use, and high-risk high-use).
To save myself the time of explaining it in full, just compare it to the current state of the credit card market. When Discover pioneered the idea of splitting the risk pool (by offering cash back rewards to low risk clients), then it created upwards pressure on credit card fees (because the general risk pools slowly became high-risk pools, meaning that existing risk fees didn't cover the necessary spread). The traditional cards now started charging more to merchants, which left room for larger rewards for the low-risk pool in a vicious cycle.
Sorry no.
Long term unemployed people in the US qualify for free medical care, celphones and basic dental work. The process is arduous, yes, but it is comprehensive. I had entire recurring blood panels, multiple MRIs, neurological impairment tests , every hospital visit and all of my prescriptions provided for free.
Lumping all levels of poor together is just lies that obfuscates larger issues.
https://www.theguardian.com/news/2016/nov/23/enormous-pop-up...
And other articles too. People inside the USA, travelling ( sometimes for days) to queue (sometimes for days) for a dentist. Why are there organistations in the US whose purpose for existence is to travel around, providing free dental care to any and all comers? Like a medical mission to a country suffering enormous poverty.
Programs: California Medi-cal (which covered all of my medications, tests, etc), Denti-cal (all dental work thats not cosmetic), my obama phone, calfresh (for ebt food) and calworks (cash monthly stipend) are the only programs I can speak to.
I'm grateful for what I had to fight to receive during a bad period of my life and hate seeing misrepresentations like this being spread without specific context.
Had I not been able to finally get working again, I would have eventually qualified for free housing, utilities and all the other benefits available from programs that are funded from various sources. I made several friends through the course of going to these offices over a long period of time who were admittedly worse off than me (mentally) but somehow knew all the inside information on how to game the system. (Ex: if you are considered impaired you can get free bus/subway/van service card, which they all knew how to easily acquire). I had to ride my bicycle or walk everywhere to get back and forth from these appointments.
https://www.marketwatch.com/story/no-other-state-comes-close...
https://www.kff.org/health-reform/state-indicator/state-acti...
An anecdote I like to share with friends back home is related to a routine blood test that she has every few months. The price the provider bills varies significantly, but one time they billed $2900. Our insurance paid them $27 like they usually do and the remainder was written off.
Imagine being sick, having no insurance, maybe no job, and receiving that bill in the mail with absolutely no way for you to know that they would probably accept over 100x less than billed. I can understand why medical expenses are the #1 cause of bankruptcy in this country.