4 ms·

"What I want from NYT is an article which really examines the situation, and not just sensationalizing numbers." Steven Brill, in Time, wrote an excellent arti

by dalke 12y ago

"What I want from NYT is an article which really examines the situation, and not just sensationalizing numbers." Steven Brill, in Time, wrote an excellent article on just that topic. The subscriber access is at http://time.com/198/bitter-pill-why-medical-bills-are-killing-us/ http://time.com/198/bitter-pill-why-medical-bills-are-killin... while a no cost version is at http://www.uta.edu/faculty/story/2311/Misc/2013,2,26,MedicalCostsDemandAndGreed.pdf http://www.uta.edu/faculty/story/2311/Misc/2013,2,26,Medical... . See also an interview with him at http://www.pbs.org/newshour/bb/health-jan-june13-healthcare_02-25/ http://www.pbs.org/newshour/bb/health-jan-june13-healthcare_... . Brill's thesis is that with most medical care it is impossible to do the comparison shopping that you emphasize should be possible "even in an emergency." You hypothesize that "private insurers are hugely subsidizing Medicare by paying 100x the price." As http://www.medscape.com/viewarticle/521175_2 http://www.medscape.com/viewarticle/521175_2 comments, "U.S. hospitals now receive abut [sic] 31 percent of their net revenues from Medicare." Moreover, if you start to read about the US system you would realize that Medicare is prevented, by US law, from negotiating drug prices. Private insurers, on the other hand, can do so. The Brill piece covers that detail. Since your hypothesis doesn't match reality, it must be incorrect. I am not well informed of this topic, and my knowledge is mostly limited to the popular press. I cannot therefore point to any critical research. There was a recent posting here on HN, at https://news.ycombinator.com/item?id=8304019 https://news.ycombinator.com/item?id=8304019 , concerning "The Cost of My Mother’s Cardiac Care in the United States and India." The actual article is at http://www.annfammed.org/content/12/5/470.long http://www.annfammed.org/content/12/5/470.long , which starts "When my mother fell ill while visiting me in the United States, I had the opportunity to compare costs of surgical cardiac care in the United States and India. I faced challenges in making well-informed decisions in the United States due to the lack of cost transparency and the minimal flexibility offered in choice of care, whereas in India costs are readily available and allow most people to freely choose their preferred type of care." It sounds like you are saying that NYT should, in every piece about a topic, give the full details to justify its arguments. That's not how newspapers work. They often give many different pieces; some of which examine the situation, and others which help flesh out details. This is one of the latter. You are supposed to read the newspaper over time to get a better sense of the whole. Otherwise, you need to look towards the specialist literature, like review papers on the economics of the US health system, to get the answers you're looking for. BTW, you like the word "should" - you used it three times. The many observations show that the US health care system isn't the way you think it should be. There is no legal framework like what you asserted. This suggests you are basing your opinions more on wishful thinking, rather than trying to understand what is actually a quite complex and well-discussed issue. I hope those links I gave help provide a beginning for you.

zaroth 12y ago
In the article they cite an example where private insurance paid 100x the Medicare rate. That's not to say private insurers pay, overall, 100x the Medicare rate. It's closer to 2x per procedure in the aggregate. I don't understand why a private insurer would ever pay 100x the Medicare rate in any case. The article went on to say how Dr. Mu, despite his title as Chief of Neurosurgery, does "probably not very lucrative" work due to low Medicaid rates. So this is a case where private insurance is subsidizing the public system. Cost shifting is well known in the industry. The 30% of the revenue paid by Medicare corresponds to significantly more than 30% of the services/cost. Operating a hospital is analogous to operating an airline, where you can sell 30% of seats at a price that would be grossly unprofitable if the whole plane sold that way. My hypothesis is that as more care becomes public, the price per procedure that Medicare (or whatever it's called then) will be dramatically higher, because there won't be anyone left to shift the costs onto. I was able to find some data which demonstrates this; 'Aggregate Hospital Payment-to-Cost Ratios for Private Payers, Medicare, and Medicaid, 1992 - 2012' - http://www.aha.org/research/reports/tw/chartbook/2014/chart4-6.pdf http://www.aha.org/research/reports/tw/chartbook/2014/chart4.... There's a subtle point that this data hides, that the article shows, which is although private payments exceed costs, in aggregate, by ~150%, the billing is highly selective. So some private payers may pay close to the Medicare rate (85% of cost) where some private payers are paying 10,000% the cost, like in the case in the article with Dr. Mu. It's exactly this highly selective billing which I think people should be protected from. Both from an Dr/ethical standpoint, to the necessary legislation which could more clearly protect against this, rather than relying on more general statutes. I don't really care to discuss "how newspapers work" but I do think while NYT is trying to tell a story about an industry, all I hear is anecdotes. Anecdotes are important, but in a story about industry billing practices, I also need to know if these anecdotes are crazy outliers, or everyday occurrences. You need to anchor your anecdotes with something if you want to tell a story bigger than the anecdote -- I think that's basic reporting, but yes, perhaps too much to expect.
- dalke 12y ago
  "They cite an example where private insurance paid 100x the Medicare rate" Is that the line "If the surgery had been for a Medicare patient, the assistant would have been permitted to bill only 16 percent of the primary surgeon’s fee"? If so, Dr. Mu received the $117,000 as a private check from Mr. Drier, and not from a private insurance company. There's nothing which says that Dr. Mu wouldn't have accepted the lower Medicare rate, or that someone else would have been the assistant if Dr. Mu's primary interest was the extra income, or that a private insurance company would had other preconditions in place to prevent a $117,000 bill. It's hard to have an idea in part because Dr. Mu did not respond. The only other 100x I can find is the out-of-network vs. in-network bills for a muscle and skin graft. But that's not the Medicare rate. "Probably not very lucrative" is quite far from "subsidizing the public system." If the doctor makes $120K/year with Medicare patients only, and $500K/year with only non-Medicare patients, and the hospital is profitable both ways, then where's the subsidy? While an extra $380K/year is very lucrative. If what you are saying is true, then there should be a mass wave of hospitals and doctors which don't accept Medicare. While some hospitals and clinics don't accept Medicare, they are relatively few. In fact, hospitals and medical centers will advertise that they accept Medicare. For example, this billboard for a clinic - http://www.yourwestvalley.com/topstory/article_73ac64db-fc44-5574-8c2e-cd66059bfa6f.html?mode=image&photo=0 http://www.yourwestvalley.com/topstory/article_73ac64db-fc44... . It's very hard for me to accept that the payment-to-cost ratio chart you linked to is meaningful. That appears to be the average cost across everyone. A better chart would be the cost of Medicare treatment vs. the reimbursement by Medicare, and the same for the private insurers. Otherwise, this could be showing that Medicare does a better job of cost containment than private insurers, so that private insurers end up paying for more medically needless but profitable procedures than Medicare. (For example, http://content.healthaffairs.org/content/22/2/230.full http://content.healthaffairs.org/content/22/2/230.full argues that Medicare is better at cost containment than private insurers.) Instead, I find papers like "How Much Do Hospitals Cost Shift? A Review of the Evidence" at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160596/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160596/ more persuasive than that chart. > Most of the analyses and commentary based on descriptive, industrywide hospital payment-to-cost margins by payer provide a false impression that cost shifting is a large and pervasive phenomenon. More careful theoretical and empirical examinations suggest that cost shifting can and has occurred, but usually at a relatively low rate. Margin changes also are strongly influenced by the evolution of hospital and health plan market structures and changes in underlying costs. Regarding newspapers, I'm saying that you are getting peeved because you don't understand how newspapers work. The old phrases are "if it bleeds, it leads" and "When a dog bites a man, that is not news, because it happens so often. But if a man bites a dog, that is news." and "You never read about a plane that did not crash." People read a newspaper in part because they want crazy outliers. The good papers try to fit it in a larger context, biased of course by the overall ideology of the editors and writers. (Eg, the WSJ is pro-market.) But complaining about the lack of complete context and details in a newspaper article is like complaining that the sky is blue.

by dalke 12y ago

zaroth 12y ago

In the article they cite an example where private insurance paid 100x the Medicare rate. That's not to say private insurers pay, overall, 100x the Medicare rate. It's closer to 2x per procedure in the aggregate. I don't understand why a private insurer would ever pay 100x the Medicare rate in any case. The article went on to say how Dr. Mu, despite his title as Chief of Neurosurgery, does "probably not very lucrative" work due to low Medicaid rates. So this is a case where private insurance is subsidizing the public system. Cost shifting is well known in the industry. The 30% of the revenue paid by Medicare corresponds to significantly more than 30% of the services/cost. Operating a hospital is analogous to operating an airline, where you can sell 30% of seats at a price that would be grossly unprofitable if the whole plane sold that way. My hypothesis is that as more care becomes public, the price per procedure that Medicare (or whatever it's called then) will be dramatically higher, because there won't be anyone left to shift the costs onto. I was able to find some data which demonstrates this; 'Aggregate Hospital Payment-to-Cost Ratios for Private Payers, Medicare, and Medicaid, 1992 - 2012' - http://www.aha.org/research/reports/tw/chartbook/2014/chart4-6.pdf http://www.aha.org/research/reports/tw/chartbook/2014/chart4.... There's a subtle point that this data hides, that the article shows, which is although private payments exceed costs, in aggregate, by ~150%, the billing is highly selective. So some private payers may pay close to the Medicare rate (85% of cost) where some private payers are paying 10,000% the cost, like in the case in the article with Dr. Mu. It's exactly this highly selective billing which I think people should be protected from. Both from an Dr/ethical standpoint, to the necessary legislation which could more clearly protect against this, rather than relying on more general statutes. I don't really care to discuss "how newspapers work" but I do think while NYT is trying to tell a story about an industry, all I hear is anecdotes. Anecdotes are important, but in a story about industry billing practices, I also need to know if these anecdotes are crazy outliers, or everyday occurrences. You need to anchor your anecdotes with something if you want to tell a story bigger than the anecdote -- I think that's basic reporting, but yes, perhaps too much to expect.

dalke 12y ago
"They cite an example where private insurance paid 100x the Medicare rate" Is that the line "If the surgery had been for a Medicare patient, the assistant would have been permitted to bill only 16 percent of the primary surgeon’s fee"? If so, Dr. Mu received the $117,000 as a private check from Mr. Drier, and not from a private insurance company. There's nothing which says that Dr. Mu wouldn't have accepted the lower Medicare rate, or that someone else would have been the assistant if Dr. Mu's primary interest was the extra income, or that a private insurance company would had other preconditions in place to prevent a $117,000 bill. It's hard to have an idea in part because Dr. Mu did not respond. The only other 100x I can find is the out-of-network vs. in-network bills for a muscle and skin graft. But that's not the Medicare rate. "Probably not very lucrative" is quite far from "subsidizing the public system." If the doctor makes $120K/year with Medicare patients only, and $500K/year with only non-Medicare patients, and the hospital is profitable both ways, then where's the subsidy? While an extra $380K/year is very lucrative. If what you are saying is true, then there should be a mass wave of hospitals and doctors which don't accept Medicare. While some hospitals and clinics don't accept Medicare, they are relatively few. In fact, hospitals and medical centers will advertise that they accept Medicare. For example, this billboard for a clinic - http://www.yourwestvalley.com/topstory/article_73ac64db-fc44-5574-8c2e-cd66059bfa6f.html?mode=image&photo=0 http://www.yourwestvalley.com/topstory/article_73ac64db-fc44... . It's very hard for me to accept that the payment-to-cost ratio chart you linked to is meaningful. That appears to be the average cost across everyone. A better chart would be the cost of Medicare treatment vs. the reimbursement by Medicare, and the same for the private insurers. Otherwise, this could be showing that Medicare does a better job of cost containment than private insurers, so that private insurers end up paying for more medically needless but profitable procedures than Medicare. (For example, http://content.healthaffairs.org/content/22/2/230.full http://content.healthaffairs.org/content/22/2/230.full argues that Medicare is better at cost containment than private insurers.) Instead, I find papers like "How Much Do Hospitals Cost Shift? A Review of the Evidence" at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160596/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160596/ more persuasive than that chart. > Most of the analyses and commentary based on descriptive, industrywide hospital payment-to-cost margins by payer provide a false impression that cost shifting is a large and pervasive phenomenon. More careful theoretical and empirical examinations suggest that cost shifting can and has occurred, but usually at a relatively low rate. Margin changes also are strongly influenced by the evolution of hospital and health plan market structures and changes in underlying costs. Regarding newspapers, I'm saying that you are getting peeved because you don't understand how newspapers work. The old phrases are "if it bleeds, it leads" and "When a dog bites a man, that is not news, because it happens so often. But if a man bites a dog, that is news." and "You never read about a plane that did not crash." People read a newspaper in part because they want crazy outliers. The good papers try to fit it in a larger context, biased of course by the overall ideology of the editors and writers. (Eg, the WSJ is pro-market.) But complaining about the lack of complete context and details in a newspaper article is like complaining that the sky is blue.