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There certainly is cost shifting to private pay as a result of low Medicaid, Medicare (and of course charity care) reimbursement. "Costs" are also inflated to allow for more bad debt to be written off. Remember, no one ever pays charges. But I don't think our issue with costs can solely be attributed to govt programs or a lack of supply of docs. If so, why are prescription drugs so expensive? We have lots of competition there. There are more drug stores than McDonalds in the US.

But, lets remember, Medicare is single payer in the US and even with this model, we spend more on Srs than any other country with single payer. We get so caught up on price per unit/drug/procedure that we lose focus on increases as a result of the amount of care we consume. Again, our single payer system is more expensive than the rest of the world. Why is this? Id argue our reimbursement model to pay docs is so flawed. We pay on a per unit FFS basis. Plus all docs get the same $. Good, bad or horrible. Everyone gets paid the same. Thats a flawed model.

I agree a part of this is how far removed the patient (and provider) are from what things costs which only drives utilization. Im a huge fan of mandating fee schedules being posted for everything along with requiring there to be cost share on every service, even if its modest. Im also for paying base don outcomes that look at the total cost of care.

Im just a shill though.
 
Remember, no one ever pays charges.

Unless you try to self pay

Id argue our reimbursement model to pay docs is so flawed. We pay on a per unit FFS basis. Plus all docs get the same $. Good, bad or horrible. Everyone gets paid the same. Thats a flawed model.

That's not true everywhere. The hospital system I work for charges significantly more for services than surrounding hospitals and has negotiated higher reimbursements with insurance companies,at least in part because of our size and name recognition. All our docs are salaried though.
 
Good post CH. I definitely think the reimbursement FFS model is bad news. The whole system including Medicare spend more than it should and gets no better macro level results.

I think more info to patients is a good thing, but ultimately i don't believe that there can ever be a functioning consumer level market for health services. The knowledge gaps are too huge, most markets are monopolized, and the urgency of the need for care kills the ability to even try to access competitive services or price shop.

The consumer will always need a sophisticated intermediary to interface with the health system. The question is how to structure that in a cost effective way. A lot of other countries are clearly doing that a lot better than us.

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Good post CH. I definitely think the reimbursement FFS model is bad news. The whole system including Medicare spend more than it should and gets no better macro level results.

I think more info to patients is a good thing, but ultimately i don't believe that there can ever be a functioning consumer level market for health services. The knowledge gaps are too huge, most markets are monopolized, and the urgency of the need for care kills the ability to even try to access competitive services or price shop.

The consumer will always need a sophisticated intermediary to interface with the health system. The question is how to structure that in a cost effective way. A lot of other countries are clearly doing that a lot better than us.

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For some services sure, but if we want to tackle costs for non emergency care, I think there is a ton of ways to get info to consumers or at least structure benefits to align better to control costs. There is no one magic bullet to controlling costs.

My broader theme here is consumers have no incentive to control costs/spend and the ACA worsens that trend.
 
Unless you try to self pay



That's not true everywhere. The hospital system I work for charges significantly more for services than surrounding hospitals and has negotiated higher reimbursements with insurance companies,at least in part because of our size and name recognition. All our docs are salaried though.

My bad, I was referring to Medicare. Medicare varies reimbursement by regional factors etc. But as a general rule there aren't differences based on quality, outcomes or even exp or not, god help 'em. ereince.

If anyone pays retail, private pay or not, god help 'em. Who pays sticker price? If you just whip your CC out, they will drop it 20%...
 
Take prostate cancer for example. For most patients, there are 3 treatment options that can be considered standard of care: surgery, prostate seed brachytherapy, or external beam radiation therapy (generally with IMRT, though some centers are trying to use the much more expensive proton therapy). As far as we know, all three methods are equally effective in treating the cancer (though demonstrating the difficulty of comparative effectiveness research, every randomized trial that has been attempted has failed). The differences in treatment modalities lie in their side effect profiles and cost (brachy is cheaper than surgery which is cheaper than IMRT, as a general rule). As it stands now, care is often directed by the urologist, because they generally see the patient first and make the diagnosis. At my center, patients are presented with all the options and make the decision themselves. That said, "how much do they cost" is never part of that decision making process, because their insurance will cover each procedure regardless. I'm not sure what the best solution is, and US patients are certainly used to having a choice.

More egregious are the urorads centers, where essentially surgeons and radiation oncologists collude to combine as many treatment modalities as possible to maximize reimbursement. Because there is no truly defined standard of care, they can get away with it, and aggressively market their combined approaches without any good evidence their outcomes are any better.
 
Kino
For some services sure, but if we want to tackle costs for non emergency care, I think there is a ton of ways to get info to consumers or at least structure benefits to align better to control costs. There is no one magic bullet to controlling costs.

My broader theme here is consumers have no incentive to control costs/spend and the ACA worsens that trend.

I don't agree that consumers have no incentive to control costs or spending. I work with Medicare members every single day and nearly all of them would like to spend less or need less medical services and medicine. The costs of medical services and medicines are simply not available to people pre-purchase. I personally haven't heard of any of the members I speak with every day having been discouraged by a provider from expensive procedures or medications. From my perspective it seems that if medical providers and the Insurance industry really want to blame consumers for high costs through overconsumption, they should work harder on a solution to inform customers of costs pre-service
 
Kino

I don't agree that consumers have no incentive to control costs or spending. I work with Medicare members every single day and nearly all of them would like to spend less or need less medical services and medicine. The costs of medical services and medicines are simply not available to people pre-purchase. I personally haven't heard of any of the members I speak with every day having been discouraged by a provider from expensive procedures or medications. From my perspective it seems that if medical providers and the Insurance industry really want to blame consumers for high costs through overconsumption, they should work harder on a solution to inform customers of costs pre-service

you would think that it would be in teh insurance company's best interests to try and incent their insureds to pick cheaper treatments and educate them on cost. they do this to some extent with their approved drug lists and networks, but it's not at all transparent to the consumer. somewhere there's a messed up incentive or thumb on the scale in the marketplace but I don't know enough about it to understand what it is.
 
you would think that it would be in teh insurance company's best interests to try and incent their insureds to pick cheaper treatments and educate them on cost. they do this to some extent with their approved drug lists and networks, but it's not at all transparent to the consumer. somewhere there's a messed up incentive or thumb on the scale in the marketplace but I don't know enough about it to understand what it is.
Its like you said, insurance companies do this to a small extent, but to my knowledge, there is no publicly available list of Medicare approved drug costs. Really sick people are just now hitting the donut hole and all they have available to guide them on drug costs are co-insurance rates. Do you think a 60 year old person with MS should do without their $2200 medication for the overall good of the insurance industry? Because they're a burden, driving up everyone else's costs? The problem is that a large group of tax payers are unwilling to face the facts that you can't 1. Provide for the needy 2. Keep taxes down 3. Maintain a free market for the health care industry. You can only do two of those things at a time.
 
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Kino

I don't agree that consumers have no incentive to control costs or spending. I work with Medicare members every single day and nearly all of them would like to spend less or need less medical services and medicine. The costs of medical services and medicines are simply not available to people pre-purchase. I personally haven't heard of any of the members I speak with every day having been discouraged by a provider from expensive procedures or medications. From my perspective it seems that if medical providers and the Insurance industry really want to blame consumers for high costs through overconsumption, they should work harder on a solution to inform customers of costs pre-service



This is a hotly debated topic in the industry, esp when you factor in total cost of care...No provider wants to be shown as high cost. And of course none want to be high cost and mediocre quality. Id love for there to be a push in this direction.
 
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you would think that it would be in teh insurance company's best interests to try and incent their insureds to pick cheaper treatments and educate them on cost. they do this to some extent with their approved drug lists and networks, but it's not at all transparent to the consumer. somewhere there's a messed up incentive or thumb on the scale in the marketplace but I don't know enough about it to understand what it is.

We try and haven't done this nearly well enough but are making progress on this front. There is a lot of push back from providers and patients. Many patients just dont want this info coming from their insurers, which I get. And every provider I meet is the best / most efficient out there.

Im a huge fan of network tiering based on cost/quality data. Give people an incentive to find the best deal. But I think thumb here are benefits. If you are researching where to get a $20,000 surgery and the range is $15k to $25k but you will only pay $3,000 OOP, what do you care?
 
I can understand emergency life saving procedures being billed after the fact, but I can't think of anything other than healthcare where you make a purchase without knowing the cost. Even the dentist tells you upfront.
 
We try and haven't done this nearly well enough but are making progress on this front. There is a lot of push back from providers and patients. Many patients just dont want this info coming from their insurers, which I get. And every provider I meet is the best / most efficient out there.

Im a huge fan of network tiering based on cost/quality data. Give people an incentive to find the best deal. But I think thumb here are benefits. If you are researching where to get a $20,000 surgery and the range is $15k to $25k but you will only pay $3,000 OOP, what do you care?

I don't really disagree with anything in this post but I may draw different conclusions. modern health care is extremely expensive. American expenses are inflated but in any country major surgery is so expensive that the great majority of the population cannot realistically be expected to pay a significant percentage of the cost. So insurance in some form is required. We are not going to be able to put cost pressure for anything major directly on the consumer, it must be handled through the insurers. The point being, since that is the case, we need to be looking around the world to see which insurance systems control cost best. Hint: it ain't ACA. It might be some unfettered free market insurance solution but I am unaware of any country that has such a system. Instead of reinventing the wheel (whether with ACA or some Libertarian plan) why aren't we taking the ideas that are proven to work from other countries that are outperforming us?


That's a rhetorical question of course, the answer is because it would cost too many powerful people too much money. So we have to limp along with a stupid system.
 
I don't really disagree with anything in this post but I may draw different conclusions. modern health care is extremely expensive. American expenses are inflated but in any country major surgery is so expensive that the great majority of the population cannot realistically be expected to pay a significant percentage of the cost. So insurance in some form is required. We are not going to be able to put cost pressure for anything major directly on the consumer, it must be handled through the insurers. The point being, since that is the case, we need to be looking around the world to see which insurance systems control cost best. Hint: it ain't ACA. It might be some unfettered free market insurance solution but I am unaware of any country that has such a system. Instead of reinventing the wheel (whether with ACA or some Libertarian plan) why aren't we taking the ideas that are proven to work from other countries that are outperforming us?


That's a rhetorical question of course, the answer is because it would cost too many powerful people too much money. So we have to limp along with a stupid system.

Good post & discussion. Thanks.
 
I don't really disagree with anything in this post but I may draw different conclusions. modern health care is extremely expensive. American expenses are inflated but in any country major surgery is so expensive that the great majority of the population cannot realistically be expected to pay a significant percentage of the cost. So insurance in some form is required. We are not going to be able to put cost pressure for anything major directly on the consumer, it must be handled through the insurers. The point being, since that is the case, we need to be looking around the world to see which insurance systems control cost best. Hint: it ain't ACA. It might be some unfettered free market insurance solution but I am unaware of any country that has such a system. Instead of reinventing the wheel (whether with ACA or some Libertarian plan) why aren't we taking the ideas that are proven to work from other countries that are outperforming us?

That's a rhetorical question of course, the answer is because it would cost too many powerful people too much money. So we have to limp along with a stupid system.

Can we work the metric system into this "things that have proven to work elsewhere" implementation plan?
 
Oh OK. So the reason that health costs are high is that medicare pays too little. I see. That makes total sense. Does your grand theory also explain why ever other country with more public /single payer options spends far less on health care, with similar and often better outcomes, than the the us?

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My "grand theory" is pretty simple. At one time health insurance was cheap. Government got involved heavily by providing some populations "free" health care and forcing insurance companies to include things in their insurance that previously people had chosen to pay out of pocket in order to keep costs low. This drove up demand for health care beyond where it would otherwise have been and costs skyrocketed.

It then became politically correct for government to pay providers less than a market rate while requiring them to jump through costly bureacratic hoops. Providers, predictably, responded by figuring out ways to game the system, sometimes including fraud, but always shifting costs to private payers, making insurance unafordable for many people. To imply that Medicare and/or Medicaid are "efficient" or "cost effective" or that health care would cost more without these abominations is. in my view, foolish. People should be allowed to choose what they want covered by insurance without being harassed by special interests with friends in government. And no one should ever be forced to pay another person's bills.
 
You're so full of shit. "Some populations", "free healthcare" "people had chosen to pay" "forced to pay someone else's bills"... ugh
 
Your "grand theory" is absolutely, cliche-filled bullshit.

I feel dumber having read it, and I'm forcing you to pay for my visit to the hypnotist to remove the memory of it.
 
You do seem dumber having read it. Thanks to you and your friend with his dick in his hand for sharing your tolerance for opinions that differ from yours.
 
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