On the opacity, I have one informative anecdote. I had a single blood test done awhile back and no one knew if insurance would cover it, or which of the dozen or so billing codes it involved (taking the sample, delivering the sample, testing the sample, etc.) might be covered. It was an expensive test so I spent days bouncing between the doctor's billing team and the insurance company until the settled answer was: No one knows, do the test and insurance will decide. So I did it and insurance denied covering the doctor-recommended test. The salaries involved for all the billing people (and my time) would have covered the cost of the test. </rant>
It's usually less than you think and often worth avoiding the insurance company hassle. Then you can just get reimbursed with your FSA or HSA anyway.
"Guess how much money you're spending in a year on healthcare! But beee caaareful: if you guess too high, YOU LOSE IT"
I still used mine while I still had access to one, but it was grumpy-making and was usually almost more trouble than it was worth.
Combined with the PITA level, there's no way I'm doing it again. I can't see how it's worth my time. One of these three options is very likely:
a) my income level is low, so every dollar counts, but my marginal tax rate is also low, so spending a ton of extra time on this is not worth saving ~ 15% on taxes for health care
b) my income level is high, so my marginal tax rate is high, but saving 40% of taxes for health care is not worth the time, because health care is not a meaningful amount of income
c) my health care spending is high relative to income, and I can deduct health care costs on my tax return. Then I can deduct a lot more than the FSA will reimburse for, and the records don't need to satisfy a third party, unless I'm audited by the IRS.
* It's only a deduction for income tax. FSAs let you save on FICA as well.
* It's an itemized deduction. You only benefit after your total itemized deductions exceed the standard deduction. Fewer people are itemizing nowadays because the federal standard deduction is large.
* There's a 7.5% of AGI floor: you can only count medical expenses that exceed this fraction of your income.
If you underestimate the amount you spend by more than the rollover limit, you can't get that money back.
So on top of the broken employer-tied health insurance system, we have gamified the financing of out of pocket medical expenses.
On top of that, if you lose your job part way through the year, you lose the balance of any FSA funds remaining (they belong to your employer - I found that out the hard way).
Why shouldn't the institutions that do this all day and claim it as their special expertise handle all of this? Why should I even be /capable/ of losing money due to my lack of experience with the system?
The money is forfeited back to the employer. There should be a law that money is now taxed and forwarded to the employee in their regular payroll.
This system is designed to screw over regular consumers.
Indeed. I don’t understand why they cant just make medical expenses tax-deductible up to a certain amount. The effect would be the same. Why do I need a separate account for it, and why do I have to guess how much I’ll need every year (as you pointed out)?
I guess at least part of the answer is that the companies administering FSAs make money out of this system. Sigh.
We have that, although the deduction only starts after a certain amount which makes it useless to almost everyone.
Unless you have a bunch of other things to deduct, it's often the right choice to just use the standard deduction.
As someone who does deal with enough medical stuff to clear the deductible (and sometimes the OOP max) on their normal health plan annually, it’s still much more convenient, again because the money is all there at the beginning of the year when the expenses are highest
"To contribute to an HSA, you'll need to be enrolled in an HSA-eligible health plan, also called a high-deductible health plan (HDHP)."
[1]: or so it seems, I tried to figure this out earlier in the year and the data is just lacking in order to make a perfect decision.
There are cases where it doesn't make fiscal sense. One employer covered 1x premium/employee(spouses and kids were full rate).
And it's a time suck.
And if you have an HSA, you have a high deductible plan.
Me: "Okay, what if we don't go through insurance?"
Pharmtech: "$45 for the prescription."
Me: "That's a bit higher than last time."
Pharmtech: performs some sort of incantation "Okay, $12."
Me: "How did we go from not at any price to $12?"
for those of you keeping score at home, the medicine was generic colchicine which costs $.30/dose (https://pmc.ncbi.nlm.nih.gov/articles/PMC7851728/), and I was getting 12
$45 was probably cash price, the they can let it go for if they do their ordering through a pharmacy supply group.
$12 may be a price with a discount program like GoodRx applied. Data changes hands behind the scenes to make the lower price at the till possible. Don't know how GoodRx works, but been around long enough to know you're probably the product.
You'll be amazed the complexity of the pharmacy benefits management complex.
t. Been there, seen it, tried to fix it best I could, left in abject horror.
You don't really factor into it except as an actuarial data point. But you might have kicked off an overpayment check back to the consumer in 12 months because golly gee, those pesky regulations! Don't worry though, you can hand it back because the premiums went up again!
"I'm just outside town, so I should be there in fifteen minutes...actually, it's looking more like six days...No, wait, thirty seconds"
Sounds like that guy got a job setting prices for prescription medicine.
It's adding 3rd parties like "insurance" (which only works as insurance in very limited catastrophic circumstances) and government plans that create the nightmare of the Mystery Price Only Knowable After Service Has Been Rendered.
I doubt your doctors office can commit a cash price for the lab they sent you blood too.
And try doing that at a hospital and see where it gets you
You go to your doctor, you have a suspected tick bite with a bullseye pattern around it and a red streak running away. Your doctor is concerned about tick born illnesses and the red streak suspecting the start of sepsis. They need to determine asap if they can treat you with docycline or if you need IV antibiotics. They need to assess your blood for a CBC to determine immediate risk factors like sepsis. They also need to asses for pathogens like Lyme disease, alpha-gal syndrome or that other tick disease I can't remember. This will determine what antibiotics will be effective, and if eating red meat will make you anaphylaxic, and you need to see an allergist if you ever want to eat red meat again
There's a place in town that can do the CBC, the test for alpha-gal is only done by two labs in the country, nearest one is in south Carolina two states away. There's more, but not many more that test for the other two diseases, the closest one is almost the whole country away in salt lake city.
You have to know ASAP to determine your next course of action.
In your proposal, do you call south Carolina and then fly there? Do you do the same to salt lake city? You've still got to find and negotiate with someone local for a CBC. Salt lake city doesn't have the same balance billing law your home state does, you could pay more than your cash price there if they involve another provider.
What do you do? Gotta act fast, or you could wind up with life long neurologically symptoms or even die.
I do believe it gets you gigabytes of text, copy protected PDFs, unsearchable PDFs, and other horseshit due to https://www.cms.gov/priorities/key-initiatives/hospital-pric...
Outside of certain procedures which are used to cash payers (dentists, lasik, plastic surgeons, imaging) this is nearly impossible in my experience.
Ummm
I lived in both systems. In a single payer system, the state essentially decide what is allowed and what is not. And with the state as a single payer, they also go back and forth on price with the hospitals.
It still is a better system overall but there is no places where you can just spend as much as you want on healthcare without some type of centralized supervision.
Usually if the state decides you are not eligible for something (for example, some examination), you can just pay and get it anyway.
I had a test recommended once that was not covered, but my Dr explained this in advance and the cash price to me was $110. There are no 'surprise' denials after the fact.
this is the crucial difference.
It's absolutely fine (and required even) that single payer public healthcare doesn't cover every conceivable thing under the sun. It should cover the most common, easily scaled and mass produced items.
For the remainder, the patient should be told and know what to expect price wise - private or self-paid etc. And this also allows competition between entities offering this thing that's not covered.
Having opaque and unknown pricing (until after you've done it) is basically a form of highway robbery.
That and there is often a 'gap' that needs to be covered for GP and specialist services, although that tends to be balanced out by much cheaper prescription costs. (Prescriptions in Canada for example easily cost 2X as much).
However, Australia has a two-tier system where you can buy private insurance cover that can cover the costs of gaps and allow you access to private hospitals. This insurance is much cheaper than the equivalent US versions.
It's only after hours of scouring my EOBs and being on the phone with my insurance that I then come back to the practice's office with evidence in hand, and they dismiss the charges.
I'm pretty sure this is just a racket because they expect most people not to put up a fight and just pay, or get sent to collections hell.
The amount of work you need to do as a patient in our health system is so dumb.
Oh, someone knew but the doctors office wanted to do the expensive thing and get paid (either by you or the insurance)
Not saying the blood test was unnecessary but we have no idea what communication happened between the doctor and insurance company. Did they possibly recommend a less expensive test and the doctor decided that'd make him less money so he went forward anyway?
However, I could tell the insurance customer service person a code, then they could tell me if it was classified as a covered preventative service.
So I, the insurance company’s customer, Googled medical procedure codes and found some on random PDFs, and checked which ones were covered, and then I asked the doctor to provide me the services for that code.
That is American healthcare.
On the flip side, I also had a doctor’s office try to bill my insurance $25 for towels used to wipe the ultrasound jelly off my wife’s belly. My insurance didn’t pay, so the doctor’s office sent me the bill for what insurance didn’t cover, so I called the doctor’s office and asked why I am being charged $25 for the few pieces of paper towel (not even linen towel), and the receptionist said they would waive the charge.
So, moral of the story is bring your own paper towel roll when you expect to get messy at the doctor’s office.
Malicious compliance engaged.
Start with code “1” and go to “99999999999999999” until they tell you it’s covered.
This is not just because of the capriciousness of insurance adjusters, but because they have to deal with all the 273 different variations of insurance plans that people who come through their offices might have.
In general, a doctor's primary goal will be to get you good care.
An insurance company's only goal nowadays is to make as much money as possible for as little effort as possible.
How can that be true when their profits are capped on collected premiums? Look up the Medical Loss Ratio (MLR) rule to see what I'm referring to. If you wanted to squeeze money out of people, health insurance would be the least appealing industry to do that in since you're required to spend 80-85% of premiums on medical care.
So which is it? Insurers unfairly denying reimbursement for what should be valid claims, or insurers unfairly increasing spending on claims so they can increase their profits.
Also, go look at 5, 10, and 15 year returns for the big insurers (UNH/Elevance/CVS/Cigna/Humana/Molina/Centene) if you think health insurance is a good business for earning money. Spoiler alert: they’re less than desirable, stick with SP500.
That's the goal of almost every business and person
It was not designed to make money. It was designed to cost less, in the same way the USSR was designed to make workers rich - it simply failed spectacularly.
Neoliberals dislike both regulation and public ownership, but made a Faustian bargain where they replaced public ownership with more regulation, thinking that regulation was the lessor of the two evils. In reality, it's not - like in the USSR where they had corporatised but heavily regulated "companies". A heavily regulated company doesn't make money by offering better value to customers, it makes money by finding loopholes in regulations, and regulators will always lose the cat and mouse game of closing these loopholes.
Neoliberals end up creating a system that's actually a lot like the USSR (if the famous "Well intentioned Commissaire" essay is representative of the USSR) - heavy regulations, with corporate entities outsmarting the regulators to enrich their owners (or managers) while minimising the value they create. Neoliberals deny the need for pubic management, but are forced to badly reinvent it (via heavy regulation). Communists deny the need for incentives, and are forced to badly reinvent it (once again via regulation), ending up not a million miles away from where neoliberals end up - with endless regulation and lost efficiency.
It's worth noting that the US spends far more tax dollars (per capita) than Australia on health (Australia has a hybrid public / private model). Medicare, Medicaid and the VA costs about as much as Canada's expensive public system (per capita) since the US is so insanely inefficient.
(edit: The essay I mentioned - https://highered.blogspot.com/2009/01/well-intentioned-commi...)
Let's say I draft an insurance contract that says for any treatment if >5 of 10 randomly selected doctors agree that the procedure was warranted, then I have to pay out the cost of the procedure, no questions asked. This contract is less hassle, clear, and doesn't require arguing with an insurance company since it specifies how disputes are resolved.
But I'm not going to give it to you for free. I need to know the expected payout in order to come up with a price and sell it to you. You know, like how all other insurance works. There is a price that is positive EV for me, but better aligns with your risk tolerance, and is therefore positive utility for you as well. In America, pricing it is illegal. I cannot, by my own methods, determine a fair price and sell it to you.
That's why we can't have nice things, because it's illegal for two people to agree on a price and terms and create a good deal for themselves.
I go to a particular doctor and I'll see a bunch of random things on the bill that don't seem to have anything to do with my visit. Like a thousand dollars worth.
But then insurance rejects them, but I still don't have to pay a cent -- the doctor never actually charges me.
It seems quite clear they're just trying to throw things at the wall and see what sticks.
Everything about American healthcare is bad.
Except the part where you are cared for by a competent clinician?
I've heard this "US healthcare is expensive but at least it's good" thing a few times, but never with any particular evidence, and from the few numbers I remember seeing, healthcare outcomes are generally no better.
Due the usefulness of the diseases classification coding based on ICD, it's also being used in many part of the world especially in US for healthcare insurance claim purposes.
[1] International Classification of Diseases 11th Revision: The global standard for diagnostic health information:
[2] ICD-11 vs. ICD-10 - a review of updates and novelties introduced in the latest version of the WHO International Classification of Diseases:
I doubt the insurance company would downcode the diagnosis, just the procedure.
I'm also not surprised that some providers will try to figure out which codes they can use to get the most revenue. ("Hey, if I do procedure A instead of B, I get paid more, so why would I do B?")
That being said, I also wouldn't be surprised if many of these turn into lawsuits, or ultimately push to revise the whole "fee for service" system.
The more shady the industry, the more everyone involved is shying awaa from sunlight.
1. Sitting in a Urgent care. They get you in the exam room. You sit there for 15 mins, doctor comes and sees you for 5 mins (mostly rushes the exam), do a blood draw, ask me to sit around while they run the test, doctor leaves, as soon as 45 mins are over the nurse comes over to let me know it’s taking longer to run the test so I can go home and they’ll call when the results are out. A month later charge thousands of dollars to insurance for a 45 min Urgent Care visit that doesn’t cover the lab work.
2. Go to PCP with cold symptoms that haven’t cleared in 10 days. I insist it’s a sinus infection, they send me back with no antibiotics and ask to schedule and online appointment in 2 days. I insist I come in in person, but they schedule an online appointment anyway. Nothing gets better and I see the doctor online after 2 days, they say I’ll have to come in so that they can evaluate me in person and prescribe antibiotics. I go in person, get antibiotics and get cured. Insurance gets charged for 3 separate hour long visits ($750 each and none of them lasted more than 10 mins).
Or it was viral after all and you cleared it on your own.
Doctors who specialize in this have a hard time accurately distinguishing bacterial infections from viral. There’s no reason to trust your own opinion on the matter. It’s too easy to fool yourself.
If doctors prescribed antibiotics to every person who came in insisting they have a bacterial infection, we’d all be in for a bad time.
It was a bacterial infection. That was the correct diagnosis. Flu (viral) doesn’t get progressively worse after 10 days and then get better immediately after a couple doses of antibiotics. My symptoms were in line with a sinus infection (I’ve had them before just like I’ve had flu before) and even if they are not able to diagnose correctly after 10 days, there are other tests that can be prescribed that weren’t and there was absolutely no reason to schedule an online appointment when they clearly knew that they’d need an in person check anyway.
Afaik any other country with mandatory health care also puts a ceiling on prices. In germany, there is a price catalog for any service, with only few exceptions, and doctors/hospitals cannot legally charge anything else for these covered services. Now guess what the US does not have, even thought obama had foreign consultants explicitly advising for it.
Health ensureance companies are certainly not the most altruistic but any profit oriented company trying to cut cost where ever possible is hardly a supprise.
Well, we sort of do: we have Medicare's reimbursement rates, which are indeed a price catalog for every service... but only if you're covered by Medicare, of course.
I've heard that price negotiations between private payers and providers are often done with reference to the Medicare rate: "I'll pay you 20% over Medicare for this."
I wonder what would happen if we moved the "medically necessary" requirement burden of proof from the doctor/patient to the insurer. So the insurer would be required to pay out a claim regardless of whether the insurer thought it was medically necessary, but their recourse could be to try to claw it back post-payment.
If you're saying they need to be forced to pay whatever invoice comes to them and start legal battles for each suspect case then yeah... that doesn't seem feasible.
1. pay out claims slowly
and/or
2. deny or downcode claims outright?
Really? That to me would imply that doctors/patients are submitting a huge amount of incorrect claims.
> That to me would imply that doctors/patients are submitting a huge amount of incorrect claims
UnitedHealthcare says that 10% of claims go through additional review for various reasons[0].
I don't know if there are stats for the industry as a whole, but my guess is that they deal with a lot of errors.
0: https://www.uhc.com/news-articles/newsroom/how-many-claims-a...
Doctors would still have a Duty to Code Services Accurately and a Duty to Maintain the Medical Record (which would clearly enable an insurer to prove a non-medically necessary therapies). There would be plenty plenty of evidence for an insurer to immediately respond.
So claims could be rejected on the basis of failing to code accurately or lack of record.
If insurance companies underpay, doctors should treat that no differently. Don’t appeal through the insurance company itself. Imagine I go to a store and pay less than the full amount at the register, and then the grocery store appeals to ME to decide whether I actually should have paid the correct amount. It’s absurd.
Doctors should treat the insurance companies like anyone else who owes them money and isn’t paying in full on time.
Proving this sucks bc smaller practices have horrible staff turnover, the EMRs are dog shit and the contracts are who knows where and in what format.
Recovery is beyond the scope of most small practices.
Its a nightmare where providers are often shorted millions of dollars and that ends up coming out of the patient’s pocket.
Everyone yammering about upcoding on this thread is blissfully clueless.
Seems like a business opportunity. Could probably work very similar to other collections agencies where they either buy the debt for pennies on the dollar or take a percentage of the collected amount.
IMHO, in office care should be more of a time and materials billing than billing based on procedures done. Of course, then the doctors' billing office would aggressively measure time the doctor spent, and the insurance company would suggest the doctor took too long for whatever.
Who do you think is easier to squeeze the money from? A mega-insurance corporation or your sick grandma?
The total industry wide profit numbers aren't relevant at all if you're running a small clinic going up against an insurance provider. Heck even if a single clinic made more money than an insurance provider, it would barely matter - the insurance providers have the power to stop covering your practice and kill it, a clinic does not have any such power over insurance providers.
I recently did an in-depth sleep study, got a CPAP machine prescribed to me, free replacement filters and replacement tubes + mask for it whenever I need them. I also got xrays and CT scans because of a foot injury around the same time. I also got comprehensive blood tests done.
None of it cost me a penny other than the ~100 euros a month, the doctors and GPs are paid well, the quality of care I received was exceptional, and in the worst case scenario possible I would've only paid 375 euros max.
My mother in law has osteoporosis and a number of other chronic illnesses, so she has to see specialists quite often. The quality of care she receives is similarly excellent to the one I received, and due to her disability her healthcare is partially covered as well.
It's not perfect of course, but it sure does beat all the horror stories you often hear coming from across the pond of people ending up in lifelong medical debt should, God forbid, something happen to them that they realistically have no control over. So I'm sorry, but I don't buy that the for-profit fucked up system you guys have going on over there is the best of the lot, especially if you're an average Joe and not someone from SV earning obscene amounts.
Now, what happens is that the profits have to be kept in check, either via price controls or sufficient competition. It's not hard to argue that the choices made in the US are quite suboptimal, but it's far more of a regulatory problem than purely a matter of people making money. If nobody makes money, there's no healthcare.
Speaking of tax-funded healthcare, did you know that US residents pay more tax towards healthcare than residents of any other country? And in return for that, they don't get any healthcare so they have to pay a second time to buy their healthcare.
[1] https://www.novonordisk.com/content/dam/nncorp/global/en/inv... https://www.marketscreener.com/quote/stock/GSK-PLC-9590199/f...
Edit: I too agree the US healthcare system is flawed, I'm just saying you cannot compare it against EU's results without considering the above fact.
Uh, what? Other systems have their problems, but they're varying levels of functional, and the health and life expectancy of the populations in most other developed countries is higher than the US, all the while spending a fraction.
Most other developed countries have a mix of public and private insurance and/or delivery, with the better run systems being better rationalized in dealing with costs and having an actual market where it makes sense to form one (eg you can't practically shop around for ER care, but you can for elective or planable services). The French system is held in high regards in particular (though it isn't really replicatable due to their unique civil service setup).
What do you mean failed horrifically? Yes, some countries have long queues. That's because there are actually people getting served. That's just the latency/throughput tradeoff being tilted farther towards throughput - which is what you want, and it's not like people who come in with heart attacks don't get to skip the queue. In America, people get heart attacks and just choose to die so their family won't get bankrupted by an ambulance ride.
Are you possibly getting this information (that healthcare is a horrific failure in every other country) from propaganda sources, instead of information sources?
Have they?
i live in neither country but i know i'd rather have cancer in the UK than the US.
That Breaking Bad meme about Walter getting lung cancer in the UK comes to mind.
Not being for profit doesn't mean you don't pay people.
Further, I wonder how the Sixth Amendment works then? So many non-profit people working for... no money?
This "work for no money argument" is so incredibly weak, I had to make sure I quoted the argument so the person wouldn't change it.
No, "living paycheck to paycheck" means you're spending everything you get each month. There can be all sorts of reasons for that.
> That makes their wages an exchange of equal value, and thus not profitable.
This is true for all profit. If you lend me money and profit off the interest, we've decided between us that the time value of that money is worth that interest, and so it's an exchange of equal value.
This is a semantic punt to the word “reasonable.”
What? The IRS doesn’t regulate wages. They just care about getting their money. If I pay you $10bn a year to yell at my cat, the IRS is fine so long as I pay payroll and you income taxes.
Most insurances won't publish their fee schedules. So doctors don't know what they will pay. So what they do is bill insanely high knowing the insurance will come back with "Nah, we only cover $X". They'll collect $X, then write off the remainder. Because the fear is not getting the maximum money possible. If the doctor would bill $100 and the insurance pays up to $200, then the doctor "lost" $100.
Regardless of how much it actually cost the doctor to provide the service.
It's also why the "cash price" is usually much cheaper, because it's closer to what it costs the doctor to provide the service.
https://www.cms.gov/priorities/healthplan-price-transparency...
That's the insurance companies' stance. The work you performed is this and so our agreed upon rate is this.
(That’s because you’re a major, well-known insurer and pay an industry high 35%. The guy who mows the Medicare yard might pay 40 cents on the dollar. The person mowing the Medicaid yard has to file 87 forms to get paid his $6.)
Source: I’ve co-owned doctors offices.
The 12 y/o say ‘no you stink’ and hangs up. Then you send the landscaper a letter saying ‘sorry your peer to peer was denied’
( I know this is exaggerating a bit and made to sound funny but it mostly works like that in healthcare )
That's...not a lot of money.
If they get away with it for a few offices and a little money, it just becomes how they do business and grows.
- (user incentive to reduce cost) insurance is structured as co-pay of [20+]% on all expenses, no exceptions
- (price transparency) require healthcare providers to quote upfront for care, via API/website/phone/in-person. Price paid by anyone is the same except for expenses related to billing. E.g
- (create competition) enable creation of small scale clinics, testing facilities, and laboratories
And for God's sake, get the government out of it!!
One (social) system that may work well is the South Korean one: private provision of healthcare services; government run insurance scheme with mandatory payments by those that can afford to pay
https://en.wikipedia.org/wiki/Healthcare_in_South_Korea
I love markets, but health insurance really is a tough one given the govt can't seem to let people make their own mistakes on healthcare, so I think it might make sense to make it govt run.
Edit: the thing to acknowledge here is that it probably won't push the frontier of healthcare as much as the current US system does, but at least it would be high quality and affordable (not people's largest or second largest expense item).
This is a solved problem in two dozen countries and it’s been working for many, many decades.
> One (social) system that may work well is the South Korean one: private provision of healthcare services; government run insurance scheme with mandatory payments by those that can afford to pay
But then you suggest using the South Korean system where the government runs the insurance.
And you say; "so I think it might make sense to make it govt run."
So which is it?
Have health sharing plans been successful? Those require a religious affiliation IIRC.
I exclude single payer solely because it’s impossible with our current leadership.
I’m surprised there isn’t a Costco like medical group that’s nationwide, has a membership, and works solely to provide care efficiently.
It is beyond me why my employer is paying an insurance company anything at this point. Kaiser should be selling me an annual plan where everything at Kaiser is covered, maybe up to a point, and then they have insurance-like network relationships with e.g. other ERs in the area, if you need them, plus out-of-area addons for when I'm traveling.
This is, fundamentally, in Kaiser's interest to sell (again, I don't live near Kaiser Permanente, I'm just using them as an example; every population center has networks of healthcare providers like this). They hate dealing with insurance as much as their patients do. But only recently have these healthcare mega-conglomerates achieved so much monopolistic integration that they could actually do this and people would be interested.
Also, interestingly: My dentist does not accept insurance; direct pay. My eye doctor also does not accept insurance. This is also a new thing; it wasn't long ago that I recall them actually asking for it, but nowadays they just bill directly. It hasn't gotten more expensive (beyond the fact that my employer is paying for useless dental and vision insurance, but at least those are only like $1-$4/paycheck).
Idk, my point is, I think things are changing and will continue to change faster than you might think. I'd love to see government-ran single-payer, but even admitting that is very unlikely to happen on the near term, there's just so much excess, waste, and bureaucracy in the medical system that some kind of short-circuiting direct-to-consumer play, by someone, will happen. Once a major healthcare provider chain can prove that this D2C model works (and it would work), the dominoes will fall.
If you’re trying to solve them problem, why on earth do you propose such an expensive, convoluted and strange solution?
Two dozen countTies have solved this. It works very, very well. People pay less and get better outcomes. What more do you want?
One model that has shown promise is "bundled payments." For example, imagine that a certain insurance company switches to a bundled model for childbirth. They say, "we will pay a hospital $X to cover everything related to this patient's childbirth. Maybe it will be a very simple birth and the hospital will make a lot of money on it. Maybe it will be more complex/expensive, and the hospital will make less money. In some rare cases, the hospital will actually lose money."
Why is this a better model? Well, 2 reasons:
1. the hospital has an incentive to provide care efficiently, rather than trying to churn out as many procedures as possible so they can bill more
2. there's just fewer numbers for providers and payers to haggle over
What you are describing is an HMO, which hasn't had that much lower costs historically. Theoretically, you pay once and then they take care of you, but in practice costs haven't been that much lower.
Many medical administrations do everything they can to upcode in order to bill for more money.
The whole system is a mess.
My boss wants insurance to be expensive - if I could afford it I would be more willing to quit (retire early).
Finding cheaper services isn't in my interest - I'm not paying any bills anyway.
Insurance companies like the complexity because it means I can't understand the system and so I have to use them.
Doctors don't really care as they just have administrators play the game for them. Once in a while they look at the game and say something, but really this is just they don't understand how the game is played (they shouldn't - they are doctors, they should be looking at medical issues not administrative ones).
This proverb seems to also apply to health insurance and the things they do/don't cover.
Putting routine stuff under the purview of insurance is stupid regardless of context. There are other cheaper, faster, simpler and more transparent ways of doing that.
And having lived 10 years in Canada and 10 years in the US and used both their healthcare systems quite a bit, I have seen both sides. Let me just say I moved to the US for healthcare 10 years ago and we do not regret it one bit. The US is easy to point and laugh at, but that just comes from ignorance.
Providers benefit from possibly the best PR of any industry. Insurance companies are the "Ticketmaster" of the healthcare industry. Their entire objective is to be the punching bag for wasteful healthcare providers.
> The problem, doctors say, is that lower and lower reimbursements mean reliable community doctors, like Wagner, could have to make choices that are inherently bad for patients, like cramming more patient visits into a single day to make up for lost revenue, dropping patients on certain insurance plans, or selling their practices altogether.
I can quickly see something like this turning in an AI arms race between insurance and the provider with each auto-approving/denying/disputing the other. All the while locking out smaller players because they can't afford the 3rd party disputotron.
I recently created an application called EMpowerAI that uses AI to analyze clinical notes and assign appropriate billing codes based on medical complexity or documented time. It also can enhance the Assessment/Plan to justify higher billing codes if the note content supports it.
I presented it at the HRX conference in Atlanta on 9/4/2025 in the top 5 abstracts session. Here is the abstract: https://www.heartrhythmopen.com/article/S2666-5018(25)00291-...
As a Cardiac Electrophysiologist, I optimized the application for cardiology and EP, though it is scalable to other specialties. I am looking for beta testers and would appreciate any feedback. Here is a link to the app:
http://em-billing-assistant.onrender.com/
Leave your name and email here if you would like to receive updates:
The data is a disaster. Turnover is high, errs everywhere. Disputing is the easy part. Hard part is finding the contracts lol.
Edit: in case the reference isn't clear -- https://en.wikipedia.org/wiki/Cost_Plus_Drugs
And I think it is a sad state of affairs when the government has been so villified that we have to depend on billionaires for basic public good works.
https://knowyourmeme.com/memes/were-all-trying-to-find-the-g...
Doing nothing but flipping the burden, doctors get paid whatever they invoice and insurance have to claw it back would make a lot of this stonewalling bullshit go away. But with an openly corrupt government paid by insurance it'll never happen.
They have a cool blog at https://yuzu.health/blog that gets into the dynamics of this stuff. Legacy insurance is cooked.
They billed my insurance for over a thousand dollars.
> Flunkies, ...
> Goons, who act to harm or deceive others on behalf of their employer, or to prevent other goons from doing so, e.g., lobbyists, corporate lawyers, telemarketers, public relations specialists; <-- YOU ARE HERE
> Duct tapers, ...
> Box tickers, ...
> Taskmasters ...
The US insurance system doesn't seem to be giving us low prices, but let's not pretend it's all their fault. It's just a complex market where it's hard to compare providers, and therefore is prone to a lot of inefficiency.
The dental industry gets no defense from me as I've been subject to attempts at swindling and coercion more times than I can remember, as if it's standard practice.
So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's unlikely someone else will if they have to pay on your behalf.
Essentially, place yourself in the role of each participant:
- patient: wants to maximize care, money no object since it isn't theirs
- medical practice: wants to maximize money spent on care
- insurer: wants to minimize money spent on care
Normally, the first two would be happy to collude to charge the third any amount of money since they'd both get what they want. And that is indeed what happens. So you get the natural result that the insurer doesn't want to support certain payments even if they were kind and pure-hearted. That they don't want to when they're neither should then not be a surprise.
You can remove that pressure by turning the interaction into:
- patient: wants to maximize care with minimized cost
- practice: wants to minimize care with maximized cost
The pressures between the two parties are now opposite and you can find the market equilibrium. With this opposition you'll suddenly find that patients start complaining about doctors ordering unnecessary procedures and so on, just like insurers claim in the other model.
You can also work through with the other versions to model where equilibrium will set in and see if it's where it does. Most of the time you don't need to assume any moral valence for the participants. They might as well be machines. It is their roles that determine how they act, not their personalities.
Ok, hear me out for a minute.
What if I wanted to pool with several people, so that if any of us had unexpected medical needs, it wouldn't bankrupt any of us. Knowing that most of us would not need it.
And then, since we're all on the hook for each other's general health, we also agreed to share the cost of preventative care, because it was literally cheaper for us to all pay for preventative care than to try to just solo it and then hit the group with the cost of terminal cancer care instead of catching it early and doing a small excision. (and other such examples.)
And then what if we made the pool HUGE, to even further spread out the costs?
Sure wish there was a system that just did that, without trying to also generate insane profits off it.
Health insurance companies in the US must pay 80% of premiums to providers. All their overhead (e.g. their accountants and actuaries and so on) comes out of the remaining 20%. What's left is their profit. People have this fantasy that all the money we spend on healthcare is secretly going to greedy insurance companies while doctors struggle to get by. But insurance company profits are a drop in the bucket.
The real villains are the doctors who recommend expensive MRIs and act like it's a complete surprise that the bill they give you is so high. And then go lobby the government to limit their competition. I would love to have a doctor in france look over my radiology and tell me if I have cancer. But that's illegal, I need to hire an American. Coincidentally, the average radiologist in San Francisco makes $660,000/year (about $400/hour).
> "Health insurance companies in the US must pay 80% of premiums to providers."
How was that figure decided upon, and why isn't it higher? Why isn't it "pay overheads and salaries, and return the rest to the customers"?
But to answer your question, there are many people looking to invest their time and money into profitable enterprises. Because insurance is a good that is very beneficial for society, we want people to invest in making it a thing. Therefore, we set up a system where the people who invested in its creation get a tiny fraction of the benefit it generates. There are many areas of life where this works great, like providing food and shelter, and I guess it wasn't obvious that insurance would be an exception for some reason.
The outliers drain the coffers
In HealthPartners' case, they do deny claims despite having the structure you mentioned. I think if you wanted to run such a pooled insurance company that advertised that it would pay any and all claims made to it and would deny precisely zero claims, you could and you would find it very easy to onboard both patients and providers to it, at least so long as its fund was solvent.
- patient: wants to maximize care, money no object since it isn't theirs
- medical practice: wants minimize care since money is based on number of patients not care
- insurer (government): wants to minimize money spent on care while maximizing care because money comes from healthy citizens who pay taxes
In Medicare, this incentivizes maximizing patients on 'recurring revenue procedures' like dialysis.
In the UK NHS (which I know better), it leads to the government denying certain kinds of care depending on the Adjusted QALYs / pound spent that the intervention will provide.
TANSTAAFL after all, but yes, perhaps the interesting thing about the government being in that model is that patients can control government in a way that they cannot control insurance companies (i.e. they're not strictly oppositional) and consequently when the insurer is the government you get spend-bias in the direction of who has government power. In the US, that turns out to be old people. Additionally, governments have non-health-related sources of revenue so a government health plan can be used as a redistribution mechanism.
But I think it leads to these outcomes predictably with a splitter placed on how much control the government exerts over the practice and how much control the patients exert on the government.
Still, this would be better than the current system. Even when you don't know if the doctor is telling the truth you can go by their reputation for telling the truth. Reputations will matter more, and doctors will care about maintaining their reputations in their community.
If you can pay. You're still required to have insurance anyways. Which is a regressive tax and harms the people most in need of these services. It's a cruel joke.
Those living paycheck to paycheck are screaming at you right now.
Because anyone can afford that, right?
Oh, and by the way, if you are in Texas abortion is illegal. In case you didn't actually __decide__ to get (yourself, your partner) pregnant.
So it's either 40-80K or 40 years. Easy choice.
System seems fine, though I think I'd prefer if we completely subsidized childbirth and 12 months after for all (because those are people who will keep us solvent in the future).
Healthcare practices want to maximize revenue and push up the “level” of a doctors visit and they can do it with just adding one or two extra little questionnaires or an extra test or two that you might not pay attention to so they can get an extra several hundred dollars a day for billing higher level cases daily.
When a provider rips off an insurer it's invisible to the general public.
Also, incidentally, when people talk about fraud in Medicare/Medicaid, the providers are almost always where that happens (yet that's often not pointed out).
Of the multiple times my insurance has declined to cover one thing or another, not once have I ever gotten a reason. The claim is just billed to the patient, directly. I'm then left wondering things like "Hey, your plan documentation says 'preventative care is 100% covered'. This was preventative care. Why is it being declined?"
If I want to know, it's an hour of my time, at least, going back & forth with insurance to learn "Oh, '100% covered' … except in these cases."
They're at least as likely to fuck something up (curiously, always in their favor, not yours) as insurers, from what I've seen. And they're almost as unpleasant to deal with—at least they don't generally keep you on hold for literal hours, but it's still not great.
And one of the ugliest public-facing roles in all of American medicine has to be the insurance-vultures whose job is to hover about emergency rooms pestering very-sick people for their billing information. Fucking gross.
17% of the US GDP is healthcare, now obviously there's a lot of nurses and random courier drivers and all sorts of other stuff in there, but they would all need to take some amount of haircut for us to get fleeced less.
The GDP contribution of slavery was ~13% just preceding the civil war and credible moves (i.e. electing Lincoln) to make them take a haircut caused, you know, the civil war.
There is likely no "clean" way to fix this problem other than a century long frog boiling exercise
https://www.azcentral.com/story/news/local/arizona-health/20...
They don’t. They want to increase profits by pushing more and more cost to the patient while squeezing providers. The patient is always the loser in this system. One reason is that most patients don’t even have a choice of insurance because their employer picks the insurance that’s best for the employer.