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The people who get screwed the hardest are the underinsured (in all cases) and those who have high-deductible plans with coinsurance and HSAs (and have some acu

by pc86 5y ago

The people who get screwed the hardest are the underinsured (in all cases) and those who have high-deductible plans with coinsurance and HSAs (and have some acute issue). I work in radiology and entered a few common procedures I see a lot in our data on https://turquoise.health/ https://turquoise.health/ (also linked in the Twitter thread). Then I entered information for our own HDHP+HSA plan. Guess what, having insurance costs you 40-60% more if it's an acute issue. So if you're healthy, you have zero incentive to use your insurance if you suddenly need a CT of something. The rub of course is if you pay cash, it doesn't count toward your multi-thousand dollar yearly deductible, so if it turns out to be a chronic issue you just shot yourself in the foot. But if it doesn't, you just burned thousands by using your insurance when you didn't have to. It's a complicated issue and anyone who says they have the solution, including "just make it free / just have the government pay for everything," is either being disingenuous or doesn't understand the problem. As was stated in the Twitter thread, running a hospital 24/7 is astronomically expensive. Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements. Attending physicians as resident-run hospitals will sleep overnight while getting paid literally half a million dollars a year. Insurance companies will just decide not to pay something and will spend years in court to defend their right to pay whatever they want, down to and including $0. Vendors will charge tens of millions of dollars to implement monolithic thick-client applications where everything is so configuration-heavy that you literally can't have a test environment because it won't match. Interoperability is managed by a text-based standard named HL7 that if you're not familiar with, will make you rip your hair out. The standard itself is ignored by every organization who ends up with their own flavor, so every app needs to be configured to support nearly any value in nearly any field. Hospital IT is staffed by people making $40k/yr who don't understand modern computing, and run by executives with no technical background. Every single entity and company involved in healthcare is complicit in the end result, which is skyrocketing patient costs with at best no change in patient care or patient outcomes.

atlasunshrugged 5y ago
Thank you for sharing this, really helpful to hear from someone inside the industry and of course, the issue is super nuanced and complex. I just wonder if/when something will give in the U.S. But you said something that stood out - "Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements." Given the rising prices, why isn't the pot getting bigger? What do you think of Epic systems and EHR stuff?
- pc86 5y ago
  I have friends that work at Epic but I don't do a lot on the EHR side. I will say I went several years ca. 2010-2019 or so without utilizing healthcare at all, and went from having doctors laugh at me when I asked for my chart and telling me that I wasn't allowed to see it from being able to log in to my doctor's portal and see my actual Epic chart, complete with their shorthand, typos, etc. The first time I logged in, after the initial shock, I was able to correct two errors in my medical history from when I was in HS. So from a consumer standpoint I am 110% pro-EHR. I think the pot is getting bigger but it's getting bigger for gigantic organizations like Kaiser (not calling them out specifically but it's a name everyone knows). Someone pointed out, either here or in the tweet thread, that the 2011-2020 price increases are just going to Stanford. The physicians don't see any of that because they have their own reimbursement, and the patient gets their own bill. When we ran billing in-house it was not uncommon for patients to call us with billing issues because they didn't understand (nor should they have had to) that our radiology service bill was separate from the hospital. Which was separate from the anesthesiologist. Which was separate from the lab. Etc. I see the pot getting bigger mainly for insurance companies, and large hospital systems, in that order. Some docs in some specialties are doing as well or better than they were ten years ago but a lot of the primary care specialties just get whatever the Medicare reimbursement is and don't have any control over it. Insurance companies will pay them whatever they decide to pay them. So short of increasing the cash price on that minority patients, all of whom are going to be very price sensitive, the independent docs and small practices can't do much to move the lever. Healthcare software vendors seem to be making out like bandits because their clients are typically the large systems and insurers who are flush with cash.
hazmazlaz 5y ago
>just have the government pay for everything How does almost every other country in the world manage to do exactly this then? Clearly it's a feasible solution elsewhere, so why not in the US? As much as I'd like to believe we're exceptional, I know that in the end we're really not.
- pc86 5y ago
  I'm not saying that couldn't be part or most of the solution. But there is a decided air of "well all these other countries do it, you idiot, so it's clear we just need to snap our fingers and do it too and everything will be perfect with exactly zero unintended consequences" whenever someone says we "just" need to have universal healthcare and everything else will work itself out. There are some extremely good elements of American healthcare. Our healthcare education system with all its flaws is among the best in the world. We're a global center of medical and pharmaceutical research. Changes to the provider side need to take that into account or the entire world could suffer as a result.

by pc86 5y ago

atlasunshrugged 5y ago

Thank you for sharing this, really helpful to hear from someone inside the industry and of course, the issue is super nuanced and complex. I just wonder if/when something will give in the U.S. But you said something that stood out - "Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements." Given the rising prices, why isn't the pot getting bigger? What do you think of Epic systems and EHR stuff?

pc86 5y ago
I have friends that work at Epic but I don't do a lot on the EHR side. I will say I went several years ca. 2010-2019 or so without utilizing healthcare at all, and went from having doctors laugh at me when I asked for my chart and telling me that I wasn't allowed to see it from being able to log in to my doctor's portal and see my actual Epic chart, complete with their shorthand, typos, etc. The first time I logged in, after the initial shock, I was able to correct two errors in my medical history from when I was in HS. So from a consumer standpoint I am 110% pro-EHR. I think the pot is getting bigger but it's getting bigger for gigantic organizations like Kaiser (not calling them out specifically but it's a name everyone knows). Someone pointed out, either here or in the tweet thread, that the 2011-2020 price increases are just going to Stanford. The physicians don't see any of that because they have their own reimbursement, and the patient gets their own bill. When we ran billing in-house it was not uncommon for patients to call us with billing issues because they didn't understand (nor should they have had to) that our radiology service bill was separate from the hospital. Which was separate from the anesthesiologist. Which was separate from the lab. Etc. I see the pot getting bigger mainly for insurance companies, and large hospital systems, in that order. Some docs in some specialties are doing as well or better than they were ten years ago but a lot of the primary care specialties just get whatever the Medicare reimbursement is and don't have any control over it. Insurance companies will pay them whatever they decide to pay them. So short of increasing the cash price on that minority patients, all of whom are going to be very price sensitive, the independent docs and small practices can't do much to move the lever. Healthcare software vendors seem to be making out like bandits because their clients are typically the large systems and insurers who are flush with cash.

hazmazlaz 5y ago

>just have the government pay for everything How does almost every other country in the world manage to do exactly this then? Clearly it's a feasible solution elsewhere, so why not in the US? As much as I'd like to believe we're exceptional, I know that in the end we're really not.

pc86 5y ago
I'm not saying that couldn't be part or most of the solution. But there is a decided air of "well all these other countries do it, you idiot, so it's clear we just need to snap our fingers and do it too and everything will be perfect with exactly zero unintended consequences" whenever someone says we "just" need to have universal healthcare and everything else will work itself out. There are some extremely good elements of American healthcare. Our healthcare education system with all its flaws is among the best in the world. We're a global center of medical and pharmaceutical research. Changes to the provider side need to take that into account or the entire world could suffer as a result.