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Old 04-27-2019, 12:14 PM
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"All Payer rate Setting" Healthcare Plan?


"All-payer rate setting: America’s back-door to single-payer?"

For the sake of discussion in this thread let us assume that a one step to Medicare for All is not going to happen with any Congress that is likely to be elected this next cycle and that we are looking at possible paths to get farther there.

One approach is opt-in at various lowered ages with the long term plan to build up the medicare system to handle that larger volume and give real world experience to more people that it works thus building support over a few years to expand the opt in further.

"All Payer Rate Setting" appears to be another proposed option, one that Buttigieg endorses as a stepping stone to single payer.

As described -
Quote:
In all-payer rate setting, all of the insurers negotiate jointly with all of the health care providers, and set on one specific price for each procedure. In that system, private insurers wouldn't pay more than Medicaid when a patient went in for an MRI. Everybody would pay the exact same price. ...
Advantages allegedly include better bargaining power and decreased administrative costs.
Quote:
It's a misconception that all the countries with national health-care systems use single payer. Many like the idea of having consumers pick and choose between different private insurers so there's competition and innovation around service, disease management, and more. But they tend to use all-payer rate setting to hold down costs.

France, Germany, Japan, the Netherlands, and Switzerland all use some version of all-payer rate setting
Reality would run into the fact that different populations often end up costing more than others, based on a variety of risk factors, from identifiable medical co-morbidities, to membership in soicioeconomically disadvantaged communities.

And it seems to ignore the move away from pure fee-for-service to a rise of so-called "value-based" shared population level risk products (inclusive of within Medicare) which have gotten healthcare systems/groups to innovate on providing better quality at lower cost.

This approach is of course not mutually exclusive with opt-in to Medicare, which of course would likely continue to allow the purchase of Medicare supplement insurance products.

Not sure what I think of this approach. Any thoughts?
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Old 04-27-2019, 01:32 PM
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I would hope there was some provision that non-insured patients could get the same prices. And given that the price would be the same, I'd hope there'd be no more of the nonsense that you go to the emergency room of an in system hospital and find that the doctors there are employed by a private company and are not in system so you're stuck with the entire cost.
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Old 04-27-2019, 01:51 PM
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Originally Posted by OldGuy View Post
I would hope there was some provision that non-insured patients could get the same prices. And given that the price would be the same, I'd hope there'd be no more of the nonsense that you go to the emergency room of an in system hospital and find that the doctors there are employed by a private company and are not in system so you're stuck with the entire cost.
The former : even if there was a 20-100% penalty applied (to discourage healthy people forgoing insurance) it would still leave prices at something approaching sanity. These days it's extremely common for a bill to be 25-50k for something medicare would only pay 2-3k for. (I had 2 screws removed from my leg. A few minutes of general anesthetic, 2 tiny incisions, 1 stitch each. 25k was what the clinic demanded..per screw. My insurance paid a tiny fraction of that of course)

As for the latter: that is obviously included. The way medicare does it, they decide on what the prices are, and they add a multiplier for geographic areas due to higher or lower costs to operate. Medicare will not pay into scams like the one you describe, because the work item those private doctors performed is still the same billing code.

Last edited by SamuelA; 04-27-2019 at 01:52 PM.
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Old 04-27-2019, 06:40 PM
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As I have said in prior threads, the Medicare rate is akin to the indigent criminal pay rate in most states. Doctors (and in my case lawyers) accept the rate because it helps pay the bills, but if everyone paid that rate, them and we would go out of business because you cannot pay employees at such a reduced rate if it was the sole income.
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Old 04-27-2019, 08:45 PM
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Originally Posted by UltraVires View Post
As I have said in prior threads, the Medicare rate is akin to the indigent criminal pay rate in most states. Doctors (and in my case lawyers) accept the rate because it helps pay the bills, but if everyone paid that rate, them and we would go out of business because you cannot pay employees at such a reduced rate if it was the sole income.
Perhaps so. The mechanism would have to be responsive in some way to the actual supply demand relationship. Also you could remove bottlenecks on supply. While there appear to be more attorneys being trained than jobs for them, there appears to be both a doctor and a nurse shortage at present. Neither training pipeline is wide enough. A sane set of government policies would fix this.

But instead we arguably live with a government primarily designed to serve the richest 1 percent. Those folks can afford the best private criminal defense attorneys- this is why the public funding for 'indigents' is so poor. Ditto the available doctors- this is why not enough doctors are trained nor are there enough hospital beds for everyone - because it gives the top 1 percent a discount on their taxes.
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Old 04-29-2019, 12:01 AM
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I believe Maryland is the only state that uses all payer rate setting and I believe they've had lower medical inflation due to it. However I don't know details beyond that.

Setting rates at medicaid levels would bankrupt hospitals and clinics though. They can't survive on medicaid rates.

Do all payer systems eliminate in network and out of network issues? Or balance billing? Those are major flaws in our health system.
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Last edited by Wesley Clark; 04-29-2019 at 12:04 AM.
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Old 04-29-2019, 01:18 AM
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Do all payer systems eliminate in network and out of network issues? Or balance billing? Those are major flaws in our health system.
How can it not. "balance" billing and "pay 10x as much because you are "out of network"" is charging way more than the all-payer negotiated rate for a service. In the balance/out of network situations, the medical provider didn't do any more work, did they?

Last edited by SamuelA; 04-29-2019 at 01:18 AM.
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Old 04-29-2019, 08:59 AM
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Originally Posted by SamuelA View Post
How can it not. "balance" billing and "pay 10x as much because you are "out of network"" is charging way more than the all-payer negotiated rate for a service. In the balance/out of network situations, the medical provider didn't do any more work, did they?
Does Maryland have in network and out of network issues or balance billing?

You could still have networks sadly becsuae they drive up supply to certain medical facilities.
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Old 04-29-2019, 11:17 AM
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They did a study last year that showed after 3 years of the program at suburban hospitals it did not reduce hospital usage or cost.
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Old 04-29-2019, 12:07 PM
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I would hope there was some provision that non-insured patients could get the same prices.
Heh. When I went to my cardiologist for a one year follow-up after my stent placement I (and the women in the office) was surprised to discover that my insurance co-pay was more than what I would have been charged if I did not have insurance. That sucked, and there was no work-around. Added to that was the fact that, after a one hour wait, the doctor asked me if I'd been experiencing any chest pain and my "No" answer and a quickie auscultation of my chest ended my exam.

Have not been back.
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Old 04-29-2019, 08:01 PM
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Originally Posted by puddleglum View Post
They did a study last year that showed after 3 years of the program at suburban hospitals it did not reduce hospital usage or cost.
All payer global budget is not all payer rate setting.
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Old 04-30-2019, 02:20 PM
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Originally Posted by UltraVires View Post
As I have said in prior threads, the Medicare rate is akin to the indigent criminal pay rate in most states. Doctors (and in my case lawyers) accept the rate because it helps pay the bills, but if everyone paid that rate, them and we would go out of business because you cannot pay employees at such a reduced rate if it was the sole income.
Do you mean Medicaid in this post? Because I'm reasonably sure that my wife (and many others in Long-Term Care practices) are almost entirely paid Medicare rates and they do just fine.

A quick glance shows that extremely simple follow-up visits are reimbursed at about $50 (these would be probably <10 minutes of a doctors time) and anything more complex can go up to $300 if you are in an ICU or on a ventilator in a hospital room.

Private insurance certainly pays more, and there is no doubt doctors (especially specialists) would take a sizable haircut if Medicare prices were the standard, but they would be a far cry from going out of business.

Lots of good data here if you want to read a PDF of a 2017 study: https://www.cbo.gov/system/files/115...esentation.pdf
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Old 05-01-2019, 09:41 AM
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I'm sorry, but I read the OP title as 'All Prayer rate setting'. I thought, yeah, that's what we should expect from this administration.
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Old 05-02-2019, 01:48 PM
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Originally Posted by Jas09 View Post
Do you mean Medicaid in this post? Because I'm reasonably sure that my wife (and many others in Long-Term Care practices) are almost entirely paid Medicare rates and they do just fine.
The quote from the OP mentioned Medicaid rates, so maybe that is what he meant.

But if he did mean Medicaid, his point stands. Medicaid pays even less than Medicare.
Regards,
Shodan
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Old 05-02-2019, 02:15 PM
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Quote:
Originally Posted by DSeid View Post
"All-payer rate setting: America’s back-door to single-payer?"

For the sake of discussion in this thread let us assume that a one step to Medicare for All is not going to happen with any Congress that is likely to be elected this next cycle and that we are looking at possible paths to get farther there.

One approach is opt-in at various lowered ages with the long term plan to build up the medicare system to handle that larger volume and give real world experience to more people that it works thus building support over a few years to expand the opt in further.

"All Payer Rate Setting" appears to be another proposed option, one that Buttigieg endorses as a stepping stone to single payer.

As described -
Advantages allegedly include better bargaining power and decreased administrative costs.

Reality would run into the fact that different populations often end up costing more than others, based on a variety of risk factors, from identifiable medical co-morbidities, to membership in soicioeconomically disadvantaged communities.

And it seems to ignore the move away from pure fee-for-service to a rise of so-called "value-based" shared population level risk products (inclusive of within Medicare) which have gotten healthcare systems/groups to innovate on providing better quality at lower cost.

This approach is of course not mutually exclusive with opt-in to Medicare, which of course would likely continue to allow the purchase of Medicare supplement insurance products.

Not sure what I think of this approach. Any thoughts?
What will be done with a nonprofit that is the insurer and provider, like Kaiser Permanente?
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Old 05-07-2019, 02:05 AM
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I'd rather see a law enacted that online funding sites may not be used to gather financial resources to pay for medical care.
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Old 05-07-2019, 07:33 AM
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I would hope there was some provision that non-insured patients could get the same prices....
++++. As someone who was uninsured, and paying higher prices than insurance companies paid I found myself wanting to scream at the designers of healthcare reform: "Your blather is all about helping the uninsured? If you're sincere then, as a first step, let us pay the same prices as the insurers pay."
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Old 05-07-2019, 08:12 AM
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Man, the tangled messes you create, in the attempt to avoid copying stuff that works from other nations.
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Old 05-07-2019, 08:52 PM
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I'd rather see a law enacted that online funding sites may not be used to gather financial resources to pay for medical care.
Serious question: Why would this law be beneficial?

Is it a counter-flag thing to force more people to realize that health care in this country has reached insane levels?

I'm truly puzzled by the motivation here.
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Old 05-07-2019, 10:30 PM
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Originally Posted by Zakalwe View Post
Serious question: Why would this law be beneficial?

Is it a counter-flag thing to force more people to realize that health care in this country has reached insane levels?

I'm truly puzzled by the motivation here.
I can't speak for SOJA but to me its more about making all these desperate run arounds illegal so we are forced to confront the problem head on.
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Old 05-08-2019, 01:39 PM
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I'm not a fan.


Quote:
Originally Posted by DSeid View Post
"All Payer Rate Setting" appears to be another proposed option, one that Buttigieg endorses as a stepping stone to single payer.

As described -
Advantages allegedly include better bargaining power and decreased administrative costs.

Reality would run into the fact that different populations often end up costing more than others, based on a variety of risk factors, from identifiable medical co-morbidities, to membership in soicioeconomically disadvantaged communities.

And it seems to ignore the move away from pure fee-for-service to a rise of so-called "value-based" shared population level risk products (inclusive of within Medicare) which have gotten healthcare systems/groups to innovate on providing better quality at lower cost.

This approach is of course not mutually exclusive with opt-in to Medicare, which of course would likely continue to allow the purchase of Medicare supplement insurance products.

Not sure what I think of this approach. Any thoughts?
I'm not a fan*. The big problem here is that you are tipping the balance of power towards insurance companies, to the disadvantage of providers. Currently, each provider or hospital negotiates with each insurer. All-payer rate setting usually means each provider or hospital negotiates with all the insurers combined. Which means insurers make an offer that the provider must accept, or the provider literally loses every single customer.

Buttigieg seems to have a different idea of all-payer rate setting. Instead of each provider negotiating with all insurers at once, all providers negotiate with all insurers at once. Smart, but not too smart. There are geographic variations in the cost of living and one rate for a service will not work nationwide. Even Medicare does not have a national fee schedule for provider services, they set different rates for each locality. A provider in New York City making what we make here in Florida won't be able to afford his food, let alone rent.

So then you have some quasi-all-payer rate setting system, where localities of providers negotiate with all insurers. I'm not sure if you accomplish much with that aside from the administrative burden of getting everyone together; insurance companies already approach my office with offers like "I can't pay more than X% of the Medicare rate for your region".

*full disclosure, I manage a medical office.

~Max
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