Dignity Health deserves a special mention though. They obfuscate their billing as much as possible. The initial bill indicated they'd give me a cash discount and wanted something like $2500. Then they sent me another bill for $1800 if I paid promptly, with lots of weasel words to make it seem like I really owed more than $1800. So, of course I paid but I had no real idea if $1800 would be sufficient (in fact their online payment portal hinted it wouldn't be). The best part was getting a survey about the quality of their billing statements right after.
Imagine if every time you went grocery shopping you had to pay for the people stocking the shelves, putting the carts back if you used one, the cashier, and each wholesale distributor. It's crazy and senseless. Just the way they like it so they can get away with so much more.
Well, yeah, that's true by the definition of “subcontractor”, which doctors in hospitals often are not.
OTOH, healthcare isn't the only place where you might pay a fee to a facility for use of the facility and a fee to a service providers associated with the facility for services they provide in the facility. It's perhaps an inconvenient arrangement, but by no means unique.
Where else does this occur?
Event facilities (for weddings, etc.) often have established partners for various event services that you pay directly rather than through the facility, which you also rent.
Dance studios where the dance instructor is affiliated but not an employee of the studio (especially where the affiliation is non-exclusive) will sometimes (especially for private lessons rather than group classes) charge a floor fee which you will pay to the studio, while the instructor is paid directly.
Fairs, etc., often charge you a gate fee, while you pay for goods and services inside to vendors directly (which vendors are also paying the fair for the privilege of being there, too.)
Arguably, residential real estate leases without included utilities is a closer analogy than any of those: there are a number of non-optional service providers you pay separately, on top of paying the landlord to occupy the premises.
BUT STILL, weddings are a really bad example here.
The people getting married get to chose from whom they want the table and chair covers, flowers, singer/band, catering, belly dancers/entertainment, lights people, AV people.
Those are choices you got to make and the bills will obviously come separate since there is clear distinction of entities. Heck, the venue and the singers might not even of said a word to each other, let alone have a billing agreement.
...why?
Most (all?) states forbid whats called the "Corporate Practice of Medicine." The idea is that profit motive of a corporation can lead the corporation to manage physicians contrary to the interests of their patients. To mitigate this, states only allow certain business models for physicians:
* Sole Proprietorships - they can work for them selves
* Professional Corporations - a restricted sort of corporation that requires all shareholders and executives to hold a license for the profession the corporation practices (ie, they all must be physicians)
* Some states have exceptions for research universities, public hospitals, non-profits, and other sorts of organizations.
The exact restrictions of course vary from state to state. Here's a state-by-state rundown: [1]
Its my understanding that analogous restrictions are common for other licensed professions such as law and accounting, but I know much less there.
[1]: http://archive.healthlawyers.org/google/health_law_archive/p...
But businesses and some consumers do want things to be under one roof - no surprises on in vs out of network, they don't like separate bills from each doctor that sees them, easy referrals, etc.
Kaiser is sort of a funny workaround.
The Kaiser Foundation Health Plan, the Kaiser Foundation of Hospitals and The Permanente Medical Group = Kaiser Permanente
The win for the patient is everything in-network and under one roof. If you are in a Kaiser facility EVERYONE is basically in network (with the exception of some state mandated providers that have to go through their own state flows - yes, that's why sometimes you need to repeat info on forms even at Kaiser)
The win for doctors is you really don't have denied claims or the billing pain you might in private practice.
CMA I think has really fought these setups before, but now oddly (in part because of medical malpractice and EHR overheads etc) working for Kaiser isn't considered a dump job anymore.
Bad news, obamacare put demand through the roof at Kaiser (even though they are not the cheapest plan) so they are shortstaffed I think.
If you do or know anything about medical billing - medical providers probably hate it as much as you do. A patient with primary coverage through Kaiser and secondary through Medi-cal - just to bill Medi-cal for $40 - you could spend hours on that as you hoop jump.
"For those who are not familiar with the Kaiser system, here is a very abbreviated explanation. Kaiser Permanente is an HMO, and consists of the Kaiser Foundation Health Plan (the Kaiser insurance) and the Permanente Medical Groups (the Kaiser doctors). The patients buy the Kaiser insurance and they are only allowed to see Kaiser doctors. The Kaiser doctors are salaried from the pool of insurance premiums and provide service only to the Kaiser patients. In the Kaiser model, services are prepaid, so there is no financial incentive or penalty to providing or receiving medical care."
Wouldn't it be fun if whenever somebody criticizes their government, they also state who they voted for to force them to open their eyes to the fact that it's their own fault.
People rationalize it by saying that voting for a 3rd party is "wasting" their vote, but in that sense, voting for anybody is wasting their vote because it never comes down to one individual's vote deciding things. Really they just have two driving forces - allegiance to whatever tribe they randomly found themselves feeling like a part of (and mysteriously agree with all the inconsistent aims of), and wanting to be on the winning team. Healthcare be damned.
Without a switch to range voting, approval voting, or one of the condorcet variants, the party system will remain broken into two corrupt halves.
It's actually worse than what people say. First past the post voting systems have a lot of problems, one of which is called the spoiler effect. By not voting for the major party you prefer you are actually voting against said major party.
Take this simple example: Major party A has 51% of the votes, while major party B hast 49%. Party A wins the election. Next election party C makes a big campaign at party A voters and convinces 3% to vote for them. Now we have A 48%, B 49% and C 3%. Party B wins the election. And if we look at the paper trails it probably doesn't surprise who funded party C's campaign.
Assigning this well studied behaviour of rational voters to simple tribalism is trivialising the core issue in the US: Elected officials are not representing the people. The way to fix this issue is to fix their voting system.
I guess I am stubborn but I will never vote for one of the two big parties. However it would be great if smaller parties got some kind of representation in Congress. It seems ridiculous that in the 90s Ross Perot got 20% of the vote but that resulted in zero representation.
Also, I find it curious that while our community has generally settled on "incremental improvement" approach, we expect different from our governments and want the "big bang" changes. Then we are surprised when things get worse.
It’s not. It sends a signal that there is a desire for something else.
The public memory is so short and so malleable, people forget things week over week let alone the entirety of an election cycle.
The issue with third party voting is a classic case of the problem of coordinated collective action.
Would-be voters don't participate out of perceived futility or participate in the dual party system for similar reasons.
I don't know how to solve it but there does seem to be growing agitation in the electorate with the current system as it stands, with the Electoral College under public scrutiny and with media support. To me that is a signal that times are changing.
In reality, voting for someone who didn't win the election is a "wasted" vote. But people will say that a particular candidate has no chance of winning the election, so voting for them is "wasting" your vote. Unfortunately, because most people follow this line of reasoning, it becomes a self fulfilling prophecy.
I'm going through this now! It is completely baffling! I went to the ER, and then I received a steady stream of bills over a period of months. They were so numerous and so devoid of useful context that I began to worry that they were illegitimate. The billing process is absolutely insane.
$$$$$$.
The Medical system is being used to transfer wealth from the working and middle classes to the capital class under the guise of "free market". That money is being used to shape legislation, buy politicians, influence elections and kill threats to the system, allowing for even greater wealth transfer.
The rigged markets of socialist Europe are far more transparent, fairer and free, whereas our "free market" is opaque, completely unfair, totally impossible to understand and offers very little in terms of real free market choice. Yet we are brainwashed to think that our system is superior, due to the propaganda the industry pumps out.
Second, I would require that all medical products and services must have their prices acknowledged by the consumer before service is rendered. Obviously there would have to be some exceptions for extreme medical emergencies, but emergency care only makes up about 1% of healthcare costs, so that can slide.
I would disband medical unions such as the AMA, which spent decades artificially limiting supply of medical workers to keep wages sky high.
I would ban employer provided health insurance, decoupling healthcare from employment.
I would attempt to reshape the health insurance industry to actually work like insurance instead of total coverage. If you get the sniffles, just pay the market rate to visit the NP at the CVS minute clinic, get your antibiotic or whatever, and be on your way. Insurance should not be involved in that, and should be reserved for major medical emergencies or serious conditions like cancer.
I would have serious patent reform, moving pharmaceuticals to generics at a faster rate, and expedite FDA certification for generics. I would work to create a system of partner countries for healthcare certification. If your drug is approved in France, you get a greatly expedited process in the US and vice versa.
If those things didn't dramatically bring down the price of healthcare to a reasonable rate, then I'd consider some socialization of risk.
I'd like to understand why healthcare doesn't bill using time & materials plus markup. All current pricing seems little more than make believe.
I also don't understand why different people are billed different prices. I get that different providers will likely (hopefully) have different billing rates. But isn't billing different prices for the exact same thing illegal?
Oh, America, you will never change.
Simply examine the way the issue was presented by frontrunners in the supposedly liberal party of the United States on the debate stage yesterday.
Two candidates call for true universal coverage, a few call for a public option but brand it as universal coverage to confuse viewers, and several (with moderator and broadcast sponsor support) outright mislead by stating that universal coverage that eliminates private insurance will threaten access to health care.
We have a long way to go.
...
Loss aversion is a powerful emotion with destructive effects on our politics.
Once enough people have something to lose from a change, change becomes extremely hard, even if the overall net effect would be positive.
Not only does this preserve bad policies, it turns some into a one-way ratchet--where it's easy to make things worse and very hard to make them better.
Examples
- Medical middlemen (insurance, insurance brokers, billing companies...) are pure waste. But they employ so many people and generate so much revenue that they are very hard to attack. The US has slowly climbed to ~2x the per-person medical spending of our peers... so now, any effort to reduce that to 1.9x will be met with fierce resistance.
- Prison guard unions are powerful nationally and in many states, including California. They fight any and all attempts to reduce incarceration. That was true in 1980 with ~100 prisoners per 100k population... and it's true now with ~650, by far the highest in the world.
- Realtors and car dealers essentially tax the two biggest purchases most people in America make, house and car. They have powerful lobbies in all 50 states.
There is no particular amount that will placate these rent-seekers. They just never want their income stream reduced.
Both parties are economically right wing. Third party is easily squished by tribalism and system being unbalanced.
If private insurance was allowed (in Canada), the elite would have expensive plans that had physicians only caring for a few people each, and so on. This worsens the care in the general system but more importantly, it splits the interests of the elite from the general public.
Becuase that's where I get stuck.
From a less selfish perspective, there but for the grace of God go you.
Hoy por ti, mañana por mi.
Specialized illnesses don’t discriminate by class. Those without means don’t receive the care they need. We are fighting so that the system centers that care instead of revolving around a third party private payer that has every incentive to deny that care.
But they would never be able to outcompete it.
https://www.uhc.com/employer/news/consultant/irs-sets-new-20...
https://www.cigna.com/assets/docs/about-cigna/informed-on-re...
But I’ve never heard of a deductible actually being set equal to out of pocket maximum or even anything close to it. Even the bronze family plans on healthcare.gov had deductibles of a few thousand.
For many procedures, we’ve just been avoiding going to the doctors. Doctors have been a hit and miss too. Most really don’t know what they’re talking about.
I’m kinda hopeful that someone will really commoditize common procedures and checks and will make them dirt cheap. May be amazon. Can’t say.
But shit like LapCorp and a whole swath of vulture physicians and insurance companies need to die.
US healthcare is really fucked up.
Another example was the birth of my child. We prepared for this by setting up an FSA, and having really good PPO coverage that year, supposedly, with a 10% copay. After all the billing shenanigans, my copay was about 30% and well above the out of pocket maximum. How does that happen? You can go to an in-network hospital, and be treated by a mix of providers, all of whom bill separately. Some will be in-network, others will be out of network, so you are in effect deducting against two out of pocket limits.
Medical billing is fraudulent. Medical insurance is fraudulent. These people are all acting in violation of tons of existing laws - I don't understand why this isn't prosecuted.