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Physician here. The problem with this law is it takes the medical reimbursement contract system and then shoots the physicians in the back. When insurance com

by riahi 7y ago

Physician here. The problem with this law is it takes the medical reimbursement contract system and then shoots the physicians in the back. When insurance companies are trying to get people to join their network, they offer competitive rates. Once they are large enough, they start to exert downward pressure on physician reimbursement to both existing and new medical service providers (hospitals and physicians). The only way to counteract their pricing power is to be willing to walk. Physicians do not like going out of network; the insurance companies make it incredibly painful, refuse to pay you, and instead send the check to the patient who is expected to deposit it and forward it to the patient (if they pay at all). However, what has happened post-ACA is massive consolidation across the medical services sector so that large staffing companies would deliberately go out of network to force better rates strategically. It was no longer the individual physicians choice whether or not to out of network; rather their employers'. However, these laws are a huge gift to the insurance companies. They remove the physician/hospital's ability to negotiate, and already, we are seeing insurance carriers refuse to negotiate or offer rates greater than 125% of Medicare. It also completely eliminates the incentive for insurance carriers to even bother creating a provider network. This is not the intent of the law and fundamentally is acting as a wage-cap. Medicare rates are intentionally set by fiat and often below the cost of goods sold. 125% of Medicare is an arbitrary "sounds good" number that is not helping anyone but the insurance companies. Instead, a better version of the law would be to have payments indexed to the FAIR health claims database [https://www.fairhealth.org https://www.fairhealth.org]. Yes, I agree the medical reimbursement system in the US is not ideal; however, this is tantamount to price fixing which in EVERY thread on compensation for software engineers, people think what Google/Apple/et Al did to prevent wage increases and poaching was unethical and unfair to workers. I don't think this is any different.

jcrben 7y ago
If physicians are not going to get on board with solving the problem, then I'm not too sympathetic when it doesn't work out well for them. Physicians who see patients while out-of-network without asking permission are outrageously unethical. And if someone is unconscious or dying, then you can't ask permission.
- leot 7y ago
  I have direct knowledge of an ophthalmologist splitting surgeries over two days that could have been done in one session, because it nearly doubles their billings. They justify it by pointing at their less educated yet better-compensated college buddies working in finance. I've seen similar bad money-optimizing behavior from PCPs (e.g. it was insisted to me that I schedule an appt for lab results, which was justified by a lie about HIPAA preventing me from being able to get them over the phone). The rot goes deep.
  - riahi 7y ago
    Or you could not have insurance play games where they pay less because something is done on the same day. We used to have this in Radiology. If a patient came in for a Cancer restaging CT, payers could pay 100% of the chest, 50% of the abdomen, and 25% of the pelvis. Just because these were done on the same day doesn't mean it's any faster or cheaper to interpret each of those portions. Yes there's some savings in the technical components (placing the IV etc), but it takes me just as long to read the three scans if they are done on one day or 3. Why should I take a 125% hit when I'm providing a convenience for the patient by doing all their scans on the same day?
    - ikiris 7y ago
      The entitlement in this single post is staggering. You are part of the problem.
    - Alkim 7y ago
      "Why should I take a 125% hit when I'm providing a convenience for the patient by doing all their scans on the same day?" You don't see what is wrong here? If your mechanic told you he wanted you to come to the shop 3 times instead of one for his convenience, you would find another mechanic. I'm from the US and I've lived in Singapore and the UAE for many years. And I've had to deal with the US system from time to time as well. Medical services cost a fraction in Asia and the Middle East compared to the US and the paperwork is much simpler. And most of the doctors are educated in Europe. And lately I've seen more US doctors moving abroad simply out of frustration. One time I was in West Virginia with my family and I had trouble catching my breath so we went to the ER. 1.5 hours of waiting, literally a 5 minute visit from the ER doctor and a 3600 USD bill. No treatment. No meds. Later I had to negotiate with the hospital over the bill. Eventually they told me that the insurance reimbursement rate for my vist would have been 600 bucks, but because I had no insurance, I was expected to pay 3600. I eventually got it down to 2200 after much angst and effort. Sick people don't need this aggro. Nor do they need the pain and discomfort for visiting the medical facility 3 times instead of 1 because of the vagaries of the US insurance/hospital billing system. The US system is broken.
CPLX 7y ago
> we are seeing insurance carriers refuse to negotiate or offer rates greater than 125% of Medicare... fundamentally is acting as a wage-cap. Sounds good to me. Sorry I feel your pain but medical costs are out of control and you’re part of the problem. Consult with your friends in the industry and figure out how to make billing reasonable and fair or it’s going to be imposed on you.
- riahi 7y ago
  Right, I'll get on repealing Medicare, EMTALA, and now Balance Billing legislation before I can legally offer a sane bill. /s The proposed solution to balance billing is linking the "out of network rate" to the FAIR health claims database. It keeps the insurers honest and allows competition at the market rate. If you gut everyone, hospitals will close and access to care will shrink.
  - ratsmack 7y ago
    The big problem with healthcare in general is administrative churn that eats away at the money available for actual Health Care [1]. [1] https://www.americanprogress.org/issues/healthcare/reports/2019/04/08/468302/excess-administrative-costs-burden-u-s-health-care-system https://www.americanprogress.org/issues/healthcare/reports/2... Everyone pays for the bloated administrative machine that is the elephant in the room that no one seems to ever talk about.
  - jcrben 7y ago
    FAIR Health is a claims db. It doesn't have a single price. You think every doctor should be paid at what percentile - 90th? Doesn't make that much sense to me. I know that's typical UCR. Also, you don't have to do everything, but you could start by doing something other than complaining about doctors who have ruined many people's lives getting paid less. I'm working on setting up a Bay Area chapter of https://rightcarealliance.org/ https://rightcarealliance.org/ (which is national) for grassroots healthcare organizing - feel free to hit me up if you'd like to participate.
    - 7y ago
subhobroto 7y ago
> It also completely eliminates the incentive for insurance carriers to even bother creating a provider network. This is extremely disingenuous. The reason for the regulation was precisely because most physicians never bothered joining a provider network knowing that doing so would cap their income and the ability to hold the patient hostage. Hey - it's ok to make money. But it's not OK to make it unethically. You are extremely lucky that people dont think too deeply about the root cause of the outrageous costs of healthcare in U.S. and get quickly distracted, blaming insurance companies and the govt. about their crippling medical debt - because when they do actually run the numbers, look at the statistics, the invoices, the claims, they realize the root cause are the providers themselves. It's very likely though, that some here in the HN crowd will come to this realization because they do think deeper. There is 0 reason for an insurance company to charge more than absolutely necessary. The cheaper the premiums are, more volume they have. Here are my thoughts: Nothing stops a provider from telling a patient "Hey, I will cost you $10000 at most. Do you want me to treat you?". The provider does not have to know what network the patient is in, what their deductible is. Whether the patient is employed or not. All they have to know is that the maximum they have charged for stitching a cut, that this patient in front of them, has, is $10000 and that is what they inform them. If a provider thinks that this question distracts them from providing the best of care, nothing stops them from joining an insurer's network and continue to do the good work. Provider does not want to handle money at all? Fine - work at a hospital that has someone willing to do that. To have the numbers ready. Or even have an estimate printout in a new minutes. Computers do that now. Do you, personally, think this is a fair expectation? No one is asking a provider to quote down to the last two decimal places what a visit might cost. The expectation is to know, atleast, what the maximum financial liability could be: $500? $2000? $10000? $50000? Crickets. Indifference at best. Instead - here's what providers have been doing: They explicitly try and stay OON to extract the maximal possible revenue from patients who were in a desperate situation with 0 leverage. > It was no longer the individual physicians choice The bulk of the individual physicians NEVER chose to be in network in the first place. Not when they were independent. Not now. The American people are hurting from the thousands of dollars in medical debt foisted on them without them even being told what they are getting into. Thousands of dollars in surprise bills from tens of different providers in addition to the tens of thousands of dollars from the hospital after spraining an ankle, dislocating an elbow, getting a cut. I am not talking about blood gushing out of an open wound. I am not talking about a head cracked open. Nickle, dimed and harassed by collection agencies that add on fees and interest rates multiples of prime if you can't settle in full. I understand the medical education system in the U.S. is expensive and long but I, as your customer, should have the ability to know, UP FRONT, how much seeing you, might get me into debt so I can make a decision whether I should work with you or not. NOT after the fact. Do you, personally, think this is a fair expectation? Not a SINGLE doctor in the WHOLE of California has ever come forward to answer this question of mine, which at this point is more than 3 years old: https://www.quora.com/How-do-I-find-a-general-physician-in-San-Diego-who-is-known-for-helping-people https://www.quora.com/How-do-I-find-a-general-physician-in-S... All this question asked (details can be found in comments for those logged in) was: Is there any general physician in San Diego that will provide an estimate (NOT a guarantee) of a visit planned weeks in advance with their staff. I have found tens of doctors in Mexico who were more than happy to provide a quote down to the last two decimal places and they went beyond what was expected of them. Yet, 0 responses so far from the WHOLE of California sans one extremely disingenuous, snarky Anonymous remark that stood up a strawman argument that I somehow wanted the estimate for free (which I did not and was more than happy to pay for) Every regulation is a response to societal pain. This pain has been cutting in too deep for far too long.
PhasmaFelis 7y ago
Honest question. If I ask a doctor "will I be billed for this procedure," and they straight-up can't or won't answer me, what's going on? Whose fault is that?
- riahi 7y ago
  It entirely depends on if they are independent and work for themselves, and therefore know their contracted rates with the insurance companies. If the physician in question is an employee or a member of a large health organization, it's entirely possible someone else does those negotiations on the person's behalf, so they would have literally no idea. By law, we can only charge one price to all payors. We cannot charge variable numbers; however, you can accept less money than charged. Medicare will pay what they pay; they don't care what my charge is. However, other payors (private insurance) will pay various amounts which are usually higher than Medicare. If I set my top price too low, I'm leaving money on the table. However, I cannot "enter the negotiation" even with a cash-paying-patient legally without charging the top-line price. These top line charges are called "Chargemaster" rates. I can probably get a hold of my institution's charge master schedule and figure out what they'd charge you, but as one of literally 200 radiologists in my current practice, I have no say in those rates at all.
  - subhobroto 7y ago
    > However, I cannot "enter the negotiation" even with a cash-paying-patient legally without charging the top-line price. Yes, this is true and if you try and settle with a cash-paying-patient who's insured, the insurance company can drop you as well as pursue breach of contract damages. > By law, we can only charge one price to all payors What law is it? because this is absolutely untrue in a country that does not follow an all payer rate set system and the U.S. ain't one. In the U.S. the VA pays one rate, Medicare another, private another, Indian Health Service (IHS) and Tribal Health another and so on. Here's a helpful chart for you that shows all the different parties each of who pays different rates for the SAME CPT CODE: https://qph.fs.quoracdn.net/main-qimg-72f33aa55c71c439fc4660b23333c55b-c https://qph.fs.quoracdn.net/main-qimg-72f33aa55c71c439fc4660... Infact a lot of avarice ridden providers refuse to treat Medicare patients, who need the most help, precisely because Medicare pays less than private party care. > one of literally 200 radiologists in my current practice, I have no say in those rates at all Oh yes you do. Most radiologists dont even attach themselves to a network because they can bill OON. Which is why 35 percent of adults have surprise bills for imaging services: https://www.radiologybusiness.com/topics/healthcare-economics/surprise-billing-imaging-services-survey https://www.radiologybusiness.com/topics/healthcare-economic... Let me quote another article: http://www.ncsl.org/research/health/counteracting-surprise-medical-billing.aspx http://www.ncsl.org/research/health/counteracting-surprise-m... > As an example, a woman seeks care for a broken limb. She is careful to go to a hospital that is in her health insurance plan’s network. She remits her copayment and receives an X-ray. Several days or weeks after the visit, the woman receives a bill for hundreds, possibly thousands, of dollars. Even though the patient was seen at an in-network hospital, the radiologist who read her X-ray was not in her insurance network. Still, the patient is responsible for picking up the out-of-network cost. No one is forcing a radiologist to be OON - it's their own decision and they do it exactly to have a say in their rates. It's fine to want to make money. Whats the big deal with all this smoke and mirrors? Here's how a business transaction outside healthcare in the U.S. goes: Party A: Hey B, you have X, which I need Party B: Yes. I have X, and I want $Y from you Party A: OK, but can you try and do it for a bit less, say $Z? Party B: Yes. Here's how a business transaction in healthcare in the U.S. goes: Party A: Hey doctor, you have X, which I need Doctor: Yes. I have X, and I accept your insurance! Party A: OK, here I am. $30 co pay, right? Doctor: Yup! Doctor (3 months later): Oh, turns out you owe me $250 for the local anesthetic and $1700 for use of the camera I shoved down your throat 3 months ago. Also the thing I did was surgery because I went inside your body so it's not a $300 in office visit but a $750 one. If you don't know what endoscopy is, it's your fault you ignorant slob. It's your fault you didn't know all of this. I didn't go to medical school for nothing, now pay up or I will repo your house and garnish your wages. The pain is showing now. People are really upset about how they have been and continue to be taken advantage of
avocado4 7y ago
If 125% of Medicare is below cost of goods sold then costs need to come down. Medicare reimbursement rates are too high compared to the rest of the world. Nobody needs to be paid $300 for a 5 minute visit to get a prescription for routine issue. 10 years of training is not necessary for most instances of routine care. Most of it can be done by a midlevel with 4 years of post-high school training. There's no need to require $500 MD visit ($150 from me, $350 from employer/taxpayers) to get tretinoin cream. I should just get it online for $20 like I would in the UK or Australia, no MD involved. Scope of practice laws need to be rewritten. Every instance of "you must have a medical license" should be replaced with "you must uphold standard of care". This will allow companies like CVS or even Amazon to provide a lot of routine care directly to patients through midlevels, software, and operations, with direct government safety oversight. Emergency care with inelastic demand should be federally regulated and socialized. Federal government should determine scope of practice and standard of care. MDs (all of whom are overtrained in the US) should focus on complicated cases and on pushing medical science forward. It's time to move away from archaic Flexner-era cartel.
- deleted 7y ago
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- riahi 7y ago
  You can't compare the US standard of care with the rest of the world's standard of care. If you want equivalent costs to the rest of the world, expect the US expectation of care, turnaround time, and time-to-service to decrease drastically. You have a habit of posting in healthcare threads and denigrating physicians. Your favorite replacement (midlevels) do not make less money. They are only paid less money; the hospital gets either equivalent (Oregon) or about 85% of that paid to a physician. You are getting WORSE care for the same price when you see an NP or PA. This is why I personally avoid seeing them. You have a huge trust in the US government that large swaths of the population simply do not have. Have you spoken to many veteran's about their experience in the VA healthcare system? Some VAs with academic affiliations are ok....many...are not. Do you think the government now doesn't already massively regulate healthcare through CMS mandates?
  - 7y ago
zbsnsbskd 7y ago
Correct me if I’m wrong, I’m not in the field. I thought the ACA put limits on insurance company’s profit margins, by saying that they had to pay out a certain minimum from the total monies collected. This is a perverse incentive for the insurance company to encourage the medical industry to increase costs. Am I wrong about the ACA?
- riahi 7y ago
  This is correct. Their profits are capped at 20%. If they make too much money, they have to refund premiums.
  - dehrmann 7y ago
    Even pre-ACA, I don't remember insurance companies having margins that big. Progressives like to paint insurance companies as villains, but they're not printing money, and definitely not like tech or financials. Not that insurance companies don't add bloat, but healthcare cost in the US is due to a lot of factors. - Overtreatment to mitigate liability - Overtreatment of the elderly - Poor end-of-life management - Insurance bureaucracy - Siloed providers - Intervention rather than prevention - Conflict with other policies (like the farm bill) The ACA tried to fix, um, not really any of them. But props to Michelle Obama for axing the food pyramid.
    - vkou 7y ago
      Insurers are absolutely villains (But not the only villains in this game). They are the reason that hospitals have such bloated billing departments, and who gets to pay for all that? Well, I, as the patient, do.
- jcrben 7y ago
  No, this is a terrible (but surprisingly common) argument. Most insurers operate in competitive markets - even if they let costs balloon, their competitor probably doesn't and can undercut them. There are a few that operate in non-competitive markets but the larger and startup insurers (e.g. Oscar Health) are aggressively entering new regions these days. Most insurers are pretty aggressive at managing costs thru managed care techniques (described at https://en.wikipedia.org/wiki/Managed_care#Techniques https://en.wikipedia.org/wiki/Managed_care#Techniques).
joshmn 7y ago
Why should the sick care whatsoever? Why do we need to have this discussion about competitive rates and charging these competitive rates to people who are in genuine need? And most of the time (for the doctors of this discussion), because they are in dire medical need. Provider networks are just artificial competition. They don't need to exist. They just drive up costs and sink people into pouring money in a system that already sucks. I've been dealing with it for the last 6 years with my mother. I wouldn't wish the added stress on anyone. It's ridiculous and wrong and backwards.
mantap 7y ago
Of course it's different. Being a programmer is just a job, whereas being a doctor is a privilege granted by society.
- dehrmann 7y ago
  > Being a programmer is just a job That's like saying building bridges is just a job. The word you're looking for isn't "privilege," it's "responsibility."
  - mantap 7y ago
    Access to doctors is something that every person needs be they rich or poor and something that must be accessible at a reasonable price. Being a doctor is a privilege granted by society on the understanding that society sets the rules of how the healthcare system works. Bridge engineers are free to charge what they want if they feel they are worth that much.
smsm42 7y ago
I am not happy with this solution, but I must say medical establishment - maybe not physicians themselves, but certainly whoever takes care of pricing and billing - were doing everything for years to invite regulation. Because people can tolerate what's going on only for so long. When every time you go to a doctor, you never get a price on anything and then you get a flurry of bills with cryptic codes and unexplainable charges and are expected just to pay exorbitant sums and shut up - people will only go with it for so long. No other good is sold this way, and no other business is conducted this way. I am generally pretty laissez-faire guy, but even my blood starts boiling when I see how the business is conducted there. I tried a couple of times to figure out some of the medical bills, and I almost went crazy. The impression is literally nobody - or at least nobody mere mortal is able to talk to - knows how it actually works and is willing to tell me - who pays the freaking money for the whole charade! - what's going on. I know one medical area where it isn't this way. Dentistry. When I go to a dentist, whatever is the procedure, I can know upfront what are the costs, what I am paying for, and almost always (excluding rare exceptional cases, which usually also are handled by the dentist) which part is out of pocket and which will be covered by insurance. That is before we even start. But if I go into a non-dental clinic - suddenly billing is a riddle, wrapped in a mystery, inside an enigma, nobody can say anything - you just have to wait for the bills to come, and then you'd know. No wonder it ends up with the state coming in and putting the boot down. And no wonder it will be done in a ham-fisted way state regulation usually works. Because however laissez-faire I am, I cannot but see current situation is completely fubar. I'd prefer medical professionals and insurers and administrators and whoever they are figured it out and proposed me a market-based solution that doesn't make each visit to a doctor a reverse lottery - but that doesn't seem to happen (well, there are a handful of medical establishments with proper predictable pricing, but rare and far between). So, no wonder this is happening instead.
- hiram112 7y ago
  > When every time you go to a doctor, you never get a price on anything and then you get a flurry of bills with cryptic codes and unexplainable charges and are expected just to pay exorbitant sums and shut up - people will only go with it for so long. Nailed it, buddy. I just went through a bad few months of health issues that required numerous trips to see specialists, in-patient and out-patient care, etc. Even though I do have supposedly decent insurance which costs about $1K month between my employer and me, the bills just started piling up day after day. Cryptic codes on all of all of them and absurd costs which were reduced by the insurance company and then sent to me. I'd consistently see crazy, clown-world prices like a one-night hospital stay charged for $25K, reduced by the insurance company to $1200, and then billed to me for $500. It's like they just made up the prices as they went along. And even after doing my best to figure out which bills were valid and which weren't, I still had almost $10K of bills out of pocket, even though I have a deductible for $3K. Turns out the hospital who guaranteed me to be in-network allowed the use an out-of-network anesthesiologist (who billed me twice - once through the hospital where it took place and once through some anesthesiology company). If any other business or industry played these kind of games they'd be instantly bankrupted as consumers would refuse to play, force their credit card companies to make charge backs, or find alternatives. Any other industry with these type of practices would be instantly sued by the SEC and DOJ for RICO act violations and collusion. And while I know it's not just doctors causing the issue, they play a huge part. No sympathy from me if their whole industry were nationalized and they were forced to take government set salaries no higher than GS-15.
ikiris 7y ago
If all of your employeer's and most private doctors didn't try to systematically fuck over your patients and brag about it (I worked in major health management orgs), you wouldn't be getting the big regulation stick. I don't really have sympathy.
brianwawok 7y ago
As a patient I can’t disagree more. I have been hit by a $5000 fee because I was seen by a doctor who wasn’t in the right network, despite it not being a choice I was able to make. Doctors lose negotiating powers and are paid a lower wage? I am fine with that. Wait until we have universal health care. It’s not fair to extract full market value from users when the penalty from not paying is death.
gok 7y ago
Doctors lost the right to complain about wage fixing when they decided to be a cartel.
robomartin 7y ago
This is why I think our government should not have much to do with healthcare other than to look after safety, accountability and exercise regulatory control where absolutely necessary. They have made a mess out of the US healthcare system and healthcare is the last thing they address. BTW, my wife is also a physician and we have several additional physicians in our family both in the US and abroad. And, of course, through their respective networks you get to have interesting conversations with other physicians (I enjoy going to conferences with her for this reason). This is where my conclusion comes from. I developed this idea that we need to eject politicians from almost everything related to healthcare in the US save the areas I mentioned above. One example of this is the constant regurgitation of different hair-brained insurance schemes to "fix" healthcare. We don't have an insurance problem. No manipulation of insurance will fix healthcare. And, no, "Medicare for All" won't do it either, in fact, it will make a mess out of it. The problems we have are structural (at least that's my term for it). It starts with the cost of education. Government guaranteed loans have caused a situation where medical practitioners, at every level, graduate with massive debt. This establishes a floor on what they have to earn in order to not only make these payments but have a life, a family, enjoy life in general. Government needs to bug out of student loans, which would put significant downward pressure on the cost of an education. The next issue is equally large: Tort reform. Medical practitioners at every level have to carry very expensive insurance in order to protect themselves from often ridiculous lawsuits with equally ridiculous financial outcomes. Companies developing, manufacturing and selling any medical product have to allocate non-trivial costs to the potential of becoming entangled in brutally expensive lawsuits. Anyone who thinks a pair of forceps used in surgery is expensive has no idea how much of bringing that product to market was made expensive by the potential of unbounded litigation. Moving on, I would add to this an expensive (in time and money) regulatory infrastructure. Personal anecdote: I have had interest in developing innovative tools for the treatment of both Strabismus and SSD (single side deafness). These two afflictions, as far as I am concerned, are still in the stone age today. I actually developed prototypes a couple of decades back. And then I discovered it would cost tens of millions of dollars to put them through the regulatory process (only if you have a smooth straight path, far more if you stumble). So I moved on. Far easier to work in aerospace and robotics than to endure the financial torture and risk that an entrepreneur has to undertake to be in the medical industry. There's more, but I think the above are easily the top three. I would add to this the abject failure of not pushing through and having a solid nation wide medical information system that is efficient and patient focused. The fact that you can expect to have to fill out ten pages of the same questions at every doctor you visit is reprehensible at best. There is no amount of insurance or "Medicare for All" magic that will improve our healthcare system until we, at the very least, address the above, none. It's a farce. It's false promises for votes, I don't care who it is or which ideological extreme they come from. Notice that there is one thing in common with all of the above: They all address costs. Our healthcare system is ridiculously expensive because our costs are ridiculously high. Fix that and then any reasonable insurance scheme should be able to deliver access to excellent care at reasonable prices. And, yes, we should also be able to cover everyone in the process.
antiterra 7y ago
None of what you suggest addresses the absolutely criminal and despair inducing practice of a surprise out-of-network RNFA charging $40,000 for an hour procedure in order to milk as much as possible from an insurance company and patient.
sershe 7y ago
"carriers refuse to negotiate or offer rates greater than 125% of Medicare" ... "This is not the intent of the law and fundamentally is acting as a wage-cap." Having lived in both Canada and the USA, I think this is great. The doctors in the USA are vastly overpaid (that is why it is/was so hard to find a primary care doctor in Vancouver, they all moved south for the money), and the healthcare, both statistically and in my personal experience, is not better for it.
rmtech 7y ago
The US system is such a mess. It's supposed to be a free market, and yet the middlemen and the doctors are arguing about who should set the prices. Guys, this is not how capitalism is supposed to work. Imagine this model in any other sector - it would be illegal and also a total joke. How about scrapping insurance, scrapping medical licensing, clearly advertising prices at doctors' offices and requiring patients' signed consent for any costs incurred? That's what an actual free market solution looks like. It wouldn't be perfect but it would be a damn site better than what you have currently.
neoliberal_dad 7y ago
That's good. Doctor salaries need to come down. You're not entitled to be compensated arbitrarily more than Medicare.

by riahi 7y ago

jcrben 7y ago

If physicians are not going to get on board with solving the problem, then I'm not too sympathetic when it doesn't work out well for them. Physicians who see patients while out-of-network without asking permission are outrageously unethical. And if someone is unconscious or dying, then you can't ask permission.

leot 7y ago
I have direct knowledge of an ophthalmologist splitting surgeries over two days that could have been done in one session, because it nearly doubles their billings. They justify it by pointing at their less educated yet better-compensated college buddies working in finance. I've seen similar bad money-optimizing behavior from PCPs (e.g. it was insisted to me that I schedule an appt for lab results, which was justified by a lie about HIPAA preventing me from being able to get them over the phone). The rot goes deep.
- riahi 7y ago
  Or you could not have insurance play games where they pay less because something is done on the same day. We used to have this in Radiology. If a patient came in for a Cancer restaging CT, payers could pay 100% of the chest, 50% of the abdomen, and 25% of the pelvis. Just because these were done on the same day doesn't mean it's any faster or cheaper to interpret each of those portions. Yes there's some savings in the technical components (placing the IV etc), but it takes me just as long to read the three scans if they are done on one day or 3. Why should I take a 125% hit when I'm providing a convenience for the patient by doing all their scans on the same day?
  - ikiris 7y ago
    The entitlement in this single post is staggering. You are part of the problem.
  - Alkim 7y ago
    "Why should I take a 125% hit when I'm providing a convenience for the patient by doing all their scans on the same day?" You don't see what is wrong here? If your mechanic told you he wanted you to come to the shop 3 times instead of one for his convenience, you would find another mechanic. I'm from the US and I've lived in Singapore and the UAE for many years. And I've had to deal with the US system from time to time as well. Medical services cost a fraction in Asia and the Middle East compared to the US and the paperwork is much simpler. And most of the doctors are educated in Europe. And lately I've seen more US doctors moving abroad simply out of frustration. One time I was in West Virginia with my family and I had trouble catching my breath so we went to the ER. 1.5 hours of waiting, literally a 5 minute visit from the ER doctor and a 3600 USD bill. No treatment. No meds. Later I had to negotiate with the hospital over the bill. Eventually they told me that the insurance reimbursement rate for my vist would have been 600 bucks, but because I had no insurance, I was expected to pay 3600. I eventually got it down to 2200 after much angst and effort. Sick people don't need this aggro. Nor do they need the pain and discomfort for visiting the medical facility 3 times instead of 1 because of the vagaries of the US insurance/hospital billing system. The US system is broken.

CPLX 7y ago

> we are seeing insurance carriers refuse to negotiate or offer rates greater than 125% of Medicare... fundamentally is acting as a wage-cap. Sounds good to me. Sorry I feel your pain but medical costs are out of control and you’re part of the problem. Consult with your friends in the industry and figure out how to make billing reasonable and fair or it’s going to be imposed on you.

riahi 7y ago
Right, I'll get on repealing Medicare, EMTALA, and now Balance Billing legislation before I can legally offer a sane bill. /s The proposed solution to balance billing is linking the "out of network rate" to the FAIR health claims database. It keeps the insurers honest and allows competition at the market rate. If you gut everyone, hospitals will close and access to care will shrink.
- ratsmack 7y ago
  The big problem with healthcare in general is administrative churn that eats away at the money available for actual Health Care [1]. [1] https://www.americanprogress.org/issues/healthcare/reports/2019/04/08/468302/excess-administrative-costs-burden-u-s-health-care-system https://www.americanprogress.org/issues/healthcare/reports/2... Everyone pays for the bloated administrative machine that is the elephant in the room that no one seems to ever talk about.
- jcrben 7y ago
  FAIR Health is a claims db. It doesn't have a single price. You think every doctor should be paid at what percentile - 90th? Doesn't make that much sense to me. I know that's typical UCR. Also, you don't have to do everything, but you could start by doing something other than complaining about doctors who have ruined many people's lives getting paid less. I'm working on setting up a Bay Area chapter of https://rightcarealliance.org/ https://rightcarealliance.org/ (which is national) for grassroots healthcare organizing - feel free to hit me up if you'd like to participate.
  - 7y ago

subhobroto 7y ago

> It also completely eliminates the incentive for insurance carriers to even bother creating a provider network. This is extremely disingenuous. The reason for the regulation was precisely because most physicians never bothered joining a provider network knowing that doing so would cap their income and the ability to hold the patient hostage. Hey - it's ok to make money. But it's not OK to make it unethically. You are extremely lucky that people dont think too deeply about the root cause of the outrageous costs of healthcare in U.S. and get quickly distracted, blaming insurance companies and the govt. about their crippling medical debt - because when they do actually run the numbers, look at the statistics, the invoices, the claims, they realize the root cause are the providers themselves. It's very likely though, that some here in the HN crowd will come to this realization because they do think deeper. There is 0 reason for an insurance company to charge more than absolutely necessary. The cheaper the premiums are, more volume they have. Here are my thoughts: Nothing stops a provider from telling a patient "Hey, I will cost you $10000 at most. Do you want me to treat you?". The provider does not have to know what network the patient is in, what their deductible is. Whether the patient is employed or not. All they have to know is that the maximum they have charged for stitching a cut, that this patient in front of them, has, is $10000 and that is what they inform them. If a provider thinks that this question distracts them from providing the best of care, nothing stops them from joining an insurer's network and continue to do the good work. Provider does not want to handle money at all? Fine - work at a hospital that has someone willing to do that. To have the numbers ready. Or even have an estimate printout in a new minutes. Computers do that now. Do you, personally, think this is a fair expectation? No one is asking a provider to quote down to the last two decimal places what a visit might cost. The expectation is to know, atleast, what the maximum financial liability could be: $500? $2000? $10000? $50000? Crickets. Indifference at best. Instead - here's what providers have been doing: They explicitly try and stay OON to extract the maximal possible revenue from patients who were in a desperate situation with 0 leverage. > It was no longer the individual physicians choice The bulk of the individual physicians NEVER chose to be in network in the first place. Not when they were independent. Not now. The American people are hurting from the thousands of dollars in medical debt foisted on them without them even being told what they are getting into. Thousands of dollars in surprise bills from tens of different providers in addition to the tens of thousands of dollars from the hospital after spraining an ankle, dislocating an elbow, getting a cut. I am not talking about blood gushing out of an open wound. I am not talking about a head cracked open. Nickle, dimed and harassed by collection agencies that add on fees and interest rates multiples of prime if you can't settle in full. I understand the medical education system in the U.S. is expensive and long but I, as your customer, should have the ability to know, UP FRONT, how much seeing you, might get me into debt so I can make a decision whether I should work with you or not. NOT after the fact. Do you, personally, think this is a fair expectation? Not a SINGLE doctor in the WHOLE of California has ever come forward to answer this question of mine, which at this point is more than 3 years old: https://www.quora.com/How-do-I-find-a-general-physician-in-San-Diego-who-is-known-for-helping-people https://www.quora.com/How-do-I-find-a-general-physician-in-S... All this question asked (details can be found in comments for those logged in) was: Is there any general physician in San Diego that will provide an estimate (NOT a guarantee) of a visit planned weeks in advance with their staff. I have found tens of doctors in Mexico who were more than happy to provide a quote down to the last two decimal places and they went beyond what was expected of them. Yet, 0 responses so far from the WHOLE of California sans one extremely disingenuous, snarky Anonymous remark that stood up a strawman argument that I somehow wanted the estimate for free (which I did not and was more than happy to pay for) Every regulation is a response to societal pain. This pain has been cutting in too deep for far too long.

PhasmaFelis 7y ago

Honest question. If I ask a doctor "will I be billed for this procedure," and they straight-up can't or won't answer me, what's going on? Whose fault is that?

riahi 7y ago
It entirely depends on if they are independent and work for themselves, and therefore know their contracted rates with the insurance companies. If the physician in question is an employee or a member of a large health organization, it's entirely possible someone else does those negotiations on the person's behalf, so they would have literally no idea. By law, we can only charge one price to all payors. We cannot charge variable numbers; however, you can accept less money than charged. Medicare will pay what they pay; they don't care what my charge is. However, other payors (private insurance) will pay various amounts which are usually higher than Medicare. If I set my top price too low, I'm leaving money on the table. However, I cannot "enter the negotiation" even with a cash-paying-patient legally without charging the top-line price. These top line charges are called "Chargemaster" rates. I can probably get a hold of my institution's charge master schedule and figure out what they'd charge you, but as one of literally 200 radiologists in my current practice, I have no say in those rates at all.
- subhobroto 7y ago
  > However, I cannot "enter the negotiation" even with a cash-paying-patient legally without charging the top-line price. Yes, this is true and if you try and settle with a cash-paying-patient who's insured, the insurance company can drop you as well as pursue breach of contract damages. > By law, we can only charge one price to all payors What law is it? because this is absolutely untrue in a country that does not follow an all payer rate set system and the U.S. ain't one. In the U.S. the VA pays one rate, Medicare another, private another, Indian Health Service (IHS) and Tribal Health another and so on. Here's a helpful chart for you that shows all the different parties each of who pays different rates for the SAME CPT CODE: https://qph.fs.quoracdn.net/main-qimg-72f33aa55c71c439fc4660b23333c55b-c https://qph.fs.quoracdn.net/main-qimg-72f33aa55c71c439fc4660... Infact a lot of avarice ridden providers refuse to treat Medicare patients, who need the most help, precisely because Medicare pays less than private party care. > one of literally 200 radiologists in my current practice, I have no say in those rates at all Oh yes you do. Most radiologists dont even attach themselves to a network because they can bill OON. Which is why 35 percent of adults have surprise bills for imaging services: https://www.radiologybusiness.com/topics/healthcare-economics/surprise-billing-imaging-services-survey https://www.radiologybusiness.com/topics/healthcare-economic... Let me quote another article: http://www.ncsl.org/research/health/counteracting-surprise-medical-billing.aspx http://www.ncsl.org/research/health/counteracting-surprise-m... > As an example, a woman seeks care for a broken limb. She is careful to go to a hospital that is in her health insurance plan’s network. She remits her copayment and receives an X-ray. Several days or weeks after the visit, the woman receives a bill for hundreds, possibly thousands, of dollars. Even though the patient was seen at an in-network hospital, the radiologist who read her X-ray was not in her insurance network. Still, the patient is responsible for picking up the out-of-network cost. No one is forcing a radiologist to be OON - it's their own decision and they do it exactly to have a say in their rates. It's fine to want to make money. Whats the big deal with all this smoke and mirrors? Here's how a business transaction outside healthcare in the U.S. goes: Party A: Hey B, you have X, which I need Party B: Yes. I have X, and I want $Y from you Party A: OK, but can you try and do it for a bit less, say $Z? Party B: Yes. Here's how a business transaction in healthcare in the U.S. goes: Party A: Hey doctor, you have X, which I need Doctor: Yes. I have X, and I accept your insurance! Party A: OK, here I am. $30 co pay, right? Doctor: Yup! Doctor (3 months later): Oh, turns out you owe me $250 for the local anesthetic and $1700 for use of the camera I shoved down your throat 3 months ago. Also the thing I did was surgery because I went inside your body so it's not a $300 in office visit but a $750 one. If you don't know what endoscopy is, it's your fault you ignorant slob. It's your fault you didn't know all of this. I didn't go to medical school for nothing, now pay up or I will repo your house and garnish your wages. The pain is showing now. People are really upset about how they have been and continue to be taken advantage of

avocado4 7y ago

If 125% of Medicare is below cost of goods sold then costs need to come down. Medicare reimbursement rates are too high compared to the rest of the world. Nobody needs to be paid $300 for a 5 minute visit to get a prescription for routine issue. 10 years of training is not necessary for most instances of routine care. Most of it can be done by a midlevel with 4 years of post-high school training. There's no need to require $500 MD visit ($150 from me, $350 from employer/taxpayers) to get tretinoin cream. I should just get it online for $20 like I would in the UK or Australia, no MD involved. Scope of practice laws need to be rewritten. Every instance of "you must have a medical license" should be replaced with "you must uphold standard of care". This will allow companies like CVS or even Amazon to provide a lot of routine care directly to patients through midlevels, software, and operations, with direct government safety oversight. Emergency care with inelastic demand should be federally regulated and socialized. Federal government should determine scope of practice and standard of care. MDs (all of whom are overtrained in the US) should focus on complicated cases and on pushing medical science forward. It's time to move away from archaic Flexner-era cartel.

deleted 7y ago
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riahi 7y ago
You can't compare the US standard of care with the rest of the world's standard of care. If you want equivalent costs to the rest of the world, expect the US expectation of care, turnaround time, and time-to-service to decrease drastically. You have a habit of posting in healthcare threads and denigrating physicians. Your favorite replacement (midlevels) do not make less money. They are only paid less money; the hospital gets either equivalent (Oregon) or about 85% of that paid to a physician. You are getting WORSE care for the same price when you see an NP or PA. This is why I personally avoid seeing them. You have a huge trust in the US government that large swaths of the population simply do not have. Have you spoken to many veteran's about their experience in the VA healthcare system? Some VAs with academic affiliations are ok....many...are not. Do you think the government now doesn't already massively regulate healthcare through CMS mandates?
- 7y ago

zbsnsbskd 7y ago

Correct me if I’m wrong, I’m not in the field. I thought the ACA put limits on insurance company’s profit margins, by saying that they had to pay out a certain minimum from the total monies collected. This is a perverse incentive for the insurance company to encourage the medical industry to increase costs. Am I wrong about the ACA?

riahi 7y ago
This is correct. Their profits are capped at 20%. If they make too much money, they have to refund premiums.
- dehrmann 7y ago
  Even pre-ACA, I don't remember insurance companies having margins that big. Progressives like to paint insurance companies as villains, but they're not printing money, and definitely not like tech or financials. Not that insurance companies don't add bloat, but healthcare cost in the US is due to a lot of factors. - Overtreatment to mitigate liability - Overtreatment of the elderly - Poor end-of-life management - Insurance bureaucracy - Siloed providers - Intervention rather than prevention - Conflict with other policies (like the farm bill) The ACA tried to fix, um, not really any of them. But props to Michelle Obama for axing the food pyramid.
  - vkou 7y ago
    Insurers are absolutely villains (But not the only villains in this game). They are the reason that hospitals have such bloated billing departments, and who gets to pay for all that? Well, I, as the patient, do.
jcrben 7y ago
No, this is a terrible (but surprisingly common) argument. Most insurers operate in competitive markets - even if they let costs balloon, their competitor probably doesn't and can undercut them. There are a few that operate in non-competitive markets but the larger and startup insurers (e.g. Oscar Health) are aggressively entering new regions these days. Most insurers are pretty aggressive at managing costs thru managed care techniques (described at https://en.wikipedia.org/wiki/Managed_care#Techniques https://en.wikipedia.org/wiki/Managed_care#Techniques).

joshmn 7y ago

Why should the sick care whatsoever? Why do we need to have this discussion about competitive rates and charging these competitive rates to people who are in genuine need? And most of the time (for the doctors of this discussion), because they are in dire medical need. Provider networks are just artificial competition. They don't need to exist. They just drive up costs and sink people into pouring money in a system that already sucks. I've been dealing with it for the last 6 years with my mother. I wouldn't wish the added stress on anyone. It's ridiculous and wrong and backwards.

mantap 7y ago

Of course it's different. Being a programmer is just a job, whereas being a doctor is a privilege granted by society.

dehrmann 7y ago
> Being a programmer is just a job That's like saying building bridges is just a job. The word you're looking for isn't "privilege," it's "responsibility."
- mantap 7y ago
  Access to doctors is something that every person needs be they rich or poor and something that must be accessible at a reasonable price. Being a doctor is a privilege granted by society on the understanding that society sets the rules of how the healthcare system works. Bridge engineers are free to charge what they want if they feel they are worth that much.

smsm42 7y ago

I am not happy with this solution, but I must say medical establishment - maybe not physicians themselves, but certainly whoever takes care of pricing and billing - were doing everything for years to invite regulation. Because people can tolerate what's going on only for so long. When every time you go to a doctor, you never get a price on anything and then you get a flurry of bills with cryptic codes and unexplainable charges and are expected just to pay exorbitant sums and shut up - people will only go with it for so long. No other good is sold this way, and no other business is conducted this way. I am generally pretty laissez-faire guy, but even my blood starts boiling when I see how the business is conducted there. I tried a couple of times to figure out some of the medical bills, and I almost went crazy. The impression is literally nobody - or at least nobody mere mortal is able to talk to - knows how it actually works and is willing to tell me - who pays the freaking money for the whole charade! - what's going on. I know one medical area where it isn't this way. Dentistry. When I go to a dentist, whatever is the procedure, I can know upfront what are the costs, what I am paying for, and almost always (excluding rare exceptional cases, which usually also are handled by the dentist) which part is out of pocket and which will be covered by insurance. That is before we even start. But if I go into a non-dental clinic - suddenly billing is a riddle, wrapped in a mystery, inside an enigma, nobody can say anything - you just have to wait for the bills to come, and then you'd know. No wonder it ends up with the state coming in and putting the boot down. And no wonder it will be done in a ham-fisted way state regulation usually works. Because however laissez-faire I am, I cannot but see current situation is completely fubar. I'd prefer medical professionals and insurers and administrators and whoever they are figured it out and proposed me a market-based solution that doesn't make each visit to a doctor a reverse lottery - but that doesn't seem to happen (well, there are a handful of medical establishments with proper predictable pricing, but rare and far between). So, no wonder this is happening instead.

hiram112 7y ago
> When every time you go to a doctor, you never get a price on anything and then you get a flurry of bills with cryptic codes and unexplainable charges and are expected just to pay exorbitant sums and shut up - people will only go with it for so long. Nailed it, buddy. I just went through a bad few months of health issues that required numerous trips to see specialists, in-patient and out-patient care, etc. Even though I do have supposedly decent insurance which costs about $1K month between my employer and me, the bills just started piling up day after day. Cryptic codes on all of all of them and absurd costs which were reduced by the insurance company and then sent to me. I'd consistently see crazy, clown-world prices like a one-night hospital stay charged for $25K, reduced by the insurance company to $1200, and then billed to me for $500. It's like they just made up the prices as they went along. And even after doing my best to figure out which bills were valid and which weren't, I still had almost $10K of bills out of pocket, even though I have a deductible for $3K. Turns out the hospital who guaranteed me to be in-network allowed the use an out-of-network anesthesiologist (who billed me twice - once through the hospital where it took place and once through some anesthesiology company). If any other business or industry played these kind of games they'd be instantly bankrupted as consumers would refuse to play, force their credit card companies to make charge backs, or find alternatives. Any other industry with these type of practices would be instantly sued by the SEC and DOJ for RICO act violations and collusion. And while I know it's not just doctors causing the issue, they play a huge part. No sympathy from me if their whole industry were nationalized and they were forced to take government set salaries no higher than GS-15.

ikiris 7y ago

If all of your employeer's and most private doctors didn't try to systematically fuck over your patients and brag about it (I worked in major health management orgs), you wouldn't be getting the big regulation stick. I don't really have sympathy.

brianwawok 7y ago

As a patient I can’t disagree more. I have been hit by a $5000 fee because I was seen by a doctor who wasn’t in the right network, despite it not being a choice I was able to make. Doctors lose negotiating powers and are paid a lower wage? I am fine with that. Wait until we have universal health care. It’s not fair to extract full market value from users when the penalty from not paying is death.

gok 7y ago

Doctors lost the right to complain about wage fixing when they decided to be a cartel.

robomartin 7y ago

This is why I think our government should not have much to do with healthcare other than to look after safety, accountability and exercise regulatory control where absolutely necessary. They have made a mess out of the US healthcare system and healthcare is the last thing they address. BTW, my wife is also a physician and we have several additional physicians in our family both in the US and abroad. And, of course, through their respective networks you get to have interesting conversations with other physicians (I enjoy going to conferences with her for this reason). This is where my conclusion comes from. I developed this idea that we need to eject politicians from almost everything related to healthcare in the US save the areas I mentioned above. One example of this is the constant regurgitation of different hair-brained insurance schemes to "fix" healthcare. We don't have an insurance problem. No manipulation of insurance will fix healthcare. And, no, "Medicare for All" won't do it either, in fact, it will make a mess out of it. The problems we have are structural (at least that's my term for it). It starts with the cost of education. Government guaranteed loans have caused a situation where medical practitioners, at every level, graduate with massive debt. This establishes a floor on what they have to earn in order to not only make these payments but have a life, a family, enjoy life in general. Government needs to bug out of student loans, which would put significant downward pressure on the cost of an education. The next issue is equally large: Tort reform. Medical practitioners at every level have to carry very expensive insurance in order to protect themselves from often ridiculous lawsuits with equally ridiculous financial outcomes. Companies developing, manufacturing and selling any medical product have to allocate non-trivial costs to the potential of becoming entangled in brutally expensive lawsuits. Anyone who thinks a pair of forceps used in surgery is expensive has no idea how much of bringing that product to market was made expensive by the potential of unbounded litigation. Moving on, I would add to this an expensive (in time and money) regulatory infrastructure. Personal anecdote: I have had interest in developing innovative tools for the treatment of both Strabismus and SSD (single side deafness). These two afflictions, as far as I am concerned, are still in the stone age today. I actually developed prototypes a couple of decades back. And then I discovered it would cost tens of millions of dollars to put them through the regulatory process (only if you have a smooth straight path, far more if you stumble). So I moved on. Far easier to work in aerospace and robotics than to endure the financial torture and risk that an entrepreneur has to undertake to be in the medical industry. There's more, but I think the above are easily the top three. I would add to this the abject failure of not pushing through and having a solid nation wide medical information system that is efficient and patient focused. The fact that you can expect to have to fill out ten pages of the same questions at every doctor you visit is reprehensible at best. There is no amount of insurance or "Medicare for All" magic that will improve our healthcare system until we, at the very least, address the above, none. It's a farce. It's false promises for votes, I don't care who it is or which ideological extreme they come from. Notice that there is one thing in common with all of the above: They all address costs. Our healthcare system is ridiculously expensive because our costs are ridiculously high. Fix that and then any reasonable insurance scheme should be able to deliver access to excellent care at reasonable prices. And, yes, we should also be able to cover everyone in the process.

antiterra 7y ago

None of what you suggest addresses the absolutely criminal and despair inducing practice of a surprise out-of-network RNFA charging $40,000 for an hour procedure in order to milk as much as possible from an insurance company and patient.

sershe 7y ago

"carriers refuse to negotiate or offer rates greater than 125% of Medicare" ... "This is not the intent of the law and fundamentally is acting as a wage-cap." Having lived in both Canada and the USA, I think this is great. The doctors in the USA are vastly overpaid (that is why it is/was so hard to find a primary care doctor in Vancouver, they all moved south for the money), and the healthcare, both statistically and in my personal experience, is not better for it.

rmtech 7y ago

The US system is such a mess. It's supposed to be a free market, and yet the middlemen and the doctors are arguing about who should set the prices. Guys, this is not how capitalism is supposed to work. Imagine this model in any other sector - it would be illegal and also a total joke. How about scrapping insurance, scrapping medical licensing, clearly advertising prices at doctors' offices and requiring patients' signed consent for any costs incurred? That's what an actual free market solution looks like. It wouldn't be perfect but it would be a damn site better than what you have currently.

neoliberal_dad 7y ago

That's good. Doctor salaries need to come down. You're not entitled to be compensated arbitrarily more than Medicare.