3 ms·

When you look at the costs between US and European healthcare, the difference isn't in gov't regulation. In the US each private healthcare company creates it's

by dv_dt 8y ago

When you look at the costs between US and European healthcare, the difference isn't in gov't regulation. In the US each private healthcare company creates it's on medical billing codes and private health providers each need to employ specialists to decipher the codes of each insurer. In europe, governments generally regulate costs (and indirectly provide unified medical billing codes), and a variety of public/private entities all use the same codes... The "amount" of regulation is mostly a red herring. One needs the right regulation.

dragonwriter 8y ago
> In the US each private healthcare company creates it's on medical billing codes In the US all public and private insurers are required by law (HIPAA) to use a specified sst of standard billing transaction formats and code sets. Well, at least if they do billing electronically, as virtually all of them do.
- dv_dt 8y ago
  So they at least have a common language of sorts on what is being done, but not how much it costs nor if it's covered or accepted. https://en.wikipedia.org/wiki/Healthcare_Common_Procedure_Coding_System https://en.wikipedia.org/wiki/Healthcare_Common_Procedure_Co... Implemented in 1996, but had a Level 3 for "local" interpretation, only disallowed in at the end of 2003 with electronic records only required in 2012 under the ACA... so I think the US is still making it's way to "standard".
- specialist 8y ago
  By analogy, like with most standards, those formats and codes are syntax, the semantics are continuously debated.
  - dragonwriter 8y ago
    The mandated standard code sets are actually mappings of code values to prescribed meanings, so they are in fact prescribed semantics and not just bare syntax. Likewise the mandatory transaction standards prescribe semantics and not just syntax.
fitchjo 8y ago
Historically, the US used CPT, which was different than the rest of the world, but since they adopted ICD-10, they use the same billing/procedure codes as the rest of the world. The entire time, though, any provider in the US was using the same set of billing codes.
- dv_dt 8y ago
  https://en.wikipedia.org/wiki/ICD-10#United_States https://en.wikipedia.org/wiki/ICD-10#United_States > The implementation of ICD-10-CM has been subject to previous delays. In January 2009, the date was pushed back by two years, to October 1, 2013, rather than an earlier proposal of October 1, 2011 > The US has used ICD-10-CM since October 1, 2015 > The US also has the ICD-10 Procedure Coding System (ICD-10-PCS),[35] a coding system that contains 76,000 procedure codes that is not used by other countries. The nice thing about standards is that there are so many to choose from. The corollary is you know you've got a great standard when it gives you that choice within the standard itself...
- jtmcmc 8y ago
  as someone going through some medical shit right now I can tell you I keep being given CPT codes to talk to my insurance company about
  - no_identd 8y ago
    Can you elaborate a bit on that?
- ubernostrum 8y ago
  The "which procedure code standard do they use" bit is a red herring. The billing arms race is much more relevant. Suppose that this year, Insurer A pays $100 to Doctor B for performing Procedure 12345. Next year, they may only pay $95, and a couple years after that they may only pay $80. The doctor's costs are not going down in that time; if anything, the overhead of being in business (rent, wages for staff, etc.) will increase, at least at the nominal 2% rate of inflation. So the doctor has higher costs year over year but is getting paid less by the insurer for rendering the same service. What does the doctor do? Turn to the codes! The doctor finds a creative interpretation of the procedure which allows billing it as two codes, let's say 23456 and 34567. Each of those pays out $50 from the insurer. So the doctor switches to billing that way. Now the doctor gets the same payment as before for the same service as before. Of course, the insurer will start ratcheting down payments for those codes pretty soon, now it's an arms race: how creatively can the doctor find alternative ways to describe the procedure, in order to get paid the same as before, and how quickly can the insurer catch on and reduce its payments? Except the doctor doesn't have time to do this, so the doctor hires billing-code specialists to come up with the creative ways to describe the procedures. And the insurer expands its department of billing-code specialists to figure out what the doctors are coming up with, and dispute or reduce payments. And the cycle goes on and on. My first job out of college was at a company that processed health claims, and (manually) handling those claims was part of what I did there. And for the past few years I've been in health care again, on the software side (some of it at an insurer, some of it at a provider). I've gotten to watch this happen, and wondered what the reduction in cost would be if they cut, say, 90% of the billing specialists out of the system entirely and just went back to prior levels of payment.

by dv_dt 8y ago

dragonwriter 8y ago

> In the US each private healthcare company creates it's on medical billing codes In the US all public and private insurers are required by law (HIPAA) to use a specified sst of standard billing transaction formats and code sets. Well, at least if they do billing electronically, as virtually all of them do.

dv_dt 8y ago
So they at least have a common language of sorts on what is being done, but not how much it costs nor if it's covered or accepted. https://en.wikipedia.org/wiki/Healthcare_Common_Procedure_Coding_System https://en.wikipedia.org/wiki/Healthcare_Common_Procedure_Co... Implemented in 1996, but had a Level 3 for "local" interpretation, only disallowed in at the end of 2003 with electronic records only required in 2012 under the ACA... so I think the US is still making it's way to "standard".
specialist 8y ago
By analogy, like with most standards, those formats and codes are syntax, the semantics are continuously debated.
- dragonwriter 8y ago
  The mandated standard code sets are actually mappings of code values to prescribed meanings, so they are in fact prescribed semantics and not just bare syntax. Likewise the mandatory transaction standards prescribe semantics and not just syntax.

fitchjo 8y ago

Historically, the US used CPT, which was different than the rest of the world, but since they adopted ICD-10, they use the same billing/procedure codes as the rest of the world. The entire time, though, any provider in the US was using the same set of billing codes.

dv_dt 8y ago
https://en.wikipedia.org/wiki/ICD-10#United_States https://en.wikipedia.org/wiki/ICD-10#United_States > The implementation of ICD-10-CM has been subject to previous delays. In January 2009, the date was pushed back by two years, to October 1, 2013, rather than an earlier proposal of October 1, 2011 > The US has used ICD-10-CM since October 1, 2015 > The US also has the ICD-10 Procedure Coding System (ICD-10-PCS),[35] a coding system that contains 76,000 procedure codes that is not used by other countries. The nice thing about standards is that there are so many to choose from. The corollary is you know you've got a great standard when it gives you that choice within the standard itself...
jtmcmc 8y ago
as someone going through some medical shit right now I can tell you I keep being given CPT codes to talk to my insurance company about
- no_identd 8y ago
  Can you elaborate a bit on that?
ubernostrum 8y ago
The "which procedure code standard do they use" bit is a red herring. The billing arms race is much more relevant. Suppose that this year, Insurer A pays $100 to Doctor B for performing Procedure 12345. Next year, they may only pay $95, and a couple years after that they may only pay $80. The doctor's costs are not going down in that time; if anything, the overhead of being in business (rent, wages for staff, etc.) will increase, at least at the nominal 2% rate of inflation. So the doctor has higher costs year over year but is getting paid less by the insurer for rendering the same service. What does the doctor do? Turn to the codes! The doctor finds a creative interpretation of the procedure which allows billing it as two codes, let's say 23456 and 34567. Each of those pays out $50 from the insurer. So the doctor switches to billing that way. Now the doctor gets the same payment as before for the same service as before. Of course, the insurer will start ratcheting down payments for those codes pretty soon, now it's an arms race: how creatively can the doctor find alternative ways to describe the procedure, in order to get paid the same as before, and how quickly can the insurer catch on and reduce its payments? Except the doctor doesn't have time to do this, so the doctor hires billing-code specialists to come up with the creative ways to describe the procedures. And the insurer expands its department of billing-code specialists to figure out what the doctors are coming up with, and dispute or reduce payments. And the cycle goes on and on. My first job out of college was at a company that processed health claims, and (manually) handling those claims was part of what I did there. And for the past few years I've been in health care again, on the software side (some of it at an insurer, some of it at a provider). I've gotten to watch this happen, and wondered what the reduction in cost would be if they cut, say, 90% of the billing specialists out of the system entirely and just went back to prior levels of payment.