Another pitting of the US health ”care” system

My husband and I are on Medicare, (USA) and are lucky to have a good supplement that covers anything Medicare does not cover, and is very affordable. My two grandchildren have Medicaid. All govt insurance, IOW. I am very happy with the care we all receive at the hands of the so called socialist medicine. Medicaid in this state, MO (not one of the better states) has paid for everything for grandkids, including their dental care and we did have to pay some vision, but no big deal. So, in a sense, we experience what it would be like to have universal healthcare. It is great.

However, it is also unstable bc one must meet certain income and age criteria to receive these benefits. Also, it seems we will be at the mercy of the politicians, if they have their way (some of them).

US healthcare is a abomination, that says it all. (Though the care itself is quite good, just costly).

After many years overseas, I can confirm it is all an illusion. There are many parties who have inserted themselves in between you and the medical provider who do nothing at all to improve your care and who exist solely to take a cut. Remove all of them, and the cost of care falls off a cliff.

I guarantee that’s exactly what’s going on.

My gallbladder surgery’s “rack rate” - the amount billed to insurance - was something like 50,000 dollars. Insurance’s negotiated rate was less than a tenth of that.

A friend’s daughter had a colonoscopy. The clinic was in-network. The anesthesiologist was NOT. They got a bill for 4,000 dollars.

Having some experience with this precise procedure: my anesthesiologist bills insurance something like 1,300 dollars - and gets maybe 300.

The friend’s bill got almost entirely written off.

Nicely coincidental timing for a new development:

As the FTC’s diagram (embedded in the article) makes clear, it’s not just a bunch of unaffiliated middlemen scraping out their cut at each step, it’s also giant vertically integrated megacorps that present themselves as separate companies, inflating prices along the way so the parent benefits. Absolutely maddening.

Odds are that under tax-funded UHC you would pay materially less.

But then how would the folks who aren’t involved in diagnosis, treatment or patient care make any money? And what about the yacht salespeople who depend on them? Do you want them to STARVE?

What kind of monster are you?

(/s, in case anybody’s wondering.)

The worst for me was when the NICU at the in-network hospital where I gave birth was out of network. $17,000 if you want your newborn to live! USA!

That was years ago, now, but recently my employer did something to our prescription benefits plan that makes it almost impossible to obtain less than a 90-day supply of anything. Seems they want every prescription to go through an online pharmacy.

At about the same time, a local independent pharmacy opened up so I moved my one long-term prescription from Walgreens (a nightmare!!) to them. When the local pharmacist kindly called to ask for my insurance I realized I had no idea anymore about my benefits, so I asked what the uninsured cost would be. $20 or so for 90 days. No fucking problem!

I recently got a short term prescription for my now-teenager. Again, the kind pharmacist calls to ask about insurance. Uninsured cost is $7.52.

I realize that my family is really lucky, but fuck my employer (and me, I guess, for not reading every email?) because I have no idea what I’d do if the pharmacist said “that’ll be $12,000”

But if she said “that’ll be $120, I’d be fine. I hate paperwork so much. I kind of want to experiment with “uninsured” for a while. What would any given doctor or pharmacist charge directly for any given routine procedure or med? And would paying directly undercut some of the horrifying grift?

This also gives me some hope that maybe I can afford to basically self-insure with low-cost catastrophic coverage. And that, in turn, means that maybe I am not tied to my always-confusing and ever-decreasing employment benefits.

P.S. I realize that it’s a bit of a dick move to talk about “experimenting with being uninsured” in the USA.

I recently went through something similar. A short term medication would be $10/month for the full 3 month course from Walgreens, which insurance requires I use, but they refused to cover it. Turns out insurance will only cover that medication if I have a very slow test done. So, if I wanted insurance to cover it, I’d have to go back to the doctor, pay for the test, and wait 6 weeks for results.

I had the doctor send the prescription to Costco, which doesn’t take my insurance, and it was $20 for the full 90 day supply.

The doctor and I had actually discussed the test at the initial appointment, and her recommendation was to skip it. She was 99% sure of the diagnosis, and recommended to just get on with the very low risk treatment.

My blood pressure medications mail ordered from a Canadian company cost less for a 90 day supply than my copay for a months worth in the US. including shipping.

I don’t know that it’s fair to just tar all non-clinical personnel with the same brush. Even if you were to do away with all the PBMs, third party administrators, and all the other middle-layer nonsense in the US healthcare system, there would still be a huge need for a lot of administrative and technological people. You’d still need office/practice management staff, IT people, software developers, utilization review people, and so forth. Some would shift to the government’s side of things under UHC, but some wouldn’t, and either way, they’d be needed.

It’s that middle layer between the insurers, providers, and patients who are the real leeches in the whole thing.

I don’t think that’s meant about non-clinical people so much as it is about non-clinical entities. When I read

I assumed that everyone working at my doctor’s office was “involved” in patient care - that’s the function of the office and everyone working there supports that mission. Someone has to make appointments and check people in in order for patients to receive care.

With UHC, some versions will allow you to get rid of most of the functions insurance companies currently perform.

I remember reading a study from, I think, the Harvard School of Public Health that hospitals and clinic spend twenty percent of their budget on billing and working with the various insurance companies. Meanwhile the insurance companies are searching for ways to deny coverage. Some of that overhead would be reduced (though perhaps not eliminated) in a single-payer system.

And has anyone else here noticed that people who actually do those kind of jobs never seem to post online?

My mother used to work for a health insurance company, processing claims. However, she retired many years ago.

I kinda sorta did. I worked for a company that made clinical software, which included medical billing. And I mostly supported the medical billing portion, and to do so effectively I taught myself how to do medical billing, at least so far as to fill out reimbursement requests. Because it’s a huge advantage if a customer tells me that our software screwed up the totals on a HFCA 1500, and I can look at what they filled out and point out their mistake.

I found the process extremely tedious though. Definitely not my cup of tea. And then there’s the coding portion, and deal with insurance providers. Just let me fix computers thanks.

I used to work for one of the country’s largest occupational health clinic companies, and while a big chunk of our company was indeed clinicians and clinic support staff, there were still thousands of us who worked in the HQ and did various things that were not necessarily clinical, but definitely necessary.

There were, I’ll admit, a large contingent of people who did all the normal business functions that are necessary for for-profit service businesses - marketing, account relations, sales, business development, legal, etc… as well as a not small number of people employed on the billing side of things who mostly dealt with stuff like state agencies, insurance companies, TPAs, PBMs, etc.

Of all that, the main places that would be mostly redundant in a UHC type situation would be the billing and the customer-facing normal business function people. And that would be dependent on how the occupational health (i.e. workplace injuries/diseases) would be handled; right now, it’s something the companies pay for, either directly or through insurance, and as such, have a large degree of control over where their injured workers are treated. Under UHC, I’m not sure how that would work; I’m sure the government would still prefer companies foot the bill for people hurt on the job.

Which jobs can be eliminated with UHC is going to greatly depend on what sort of UHC - there are different models and in a fee-for-service, Medicare-for-all type, you will still need people to handle billing and payment. You won’t need those people if the government runs the clinics and hospitals and the doctors are employees. If people get assigned to clinics based on their address ( like zoned schools) there’s no need for marketing or sales. I actually don’t see much in the way of marketing currently - I’ve seen some ads for giant companies like Lenox Hill Radiology or Schweiger Dermatology and the occasional ad in the very local weekly for some smaller groups but that’s it.

There are loads of people who don’t provide clinical services who are necessary no matter how those services are paid for - and I don’t think this

was referring to the people behind the front desk, or the HR people or the IT people or the practice /office manager at the doctor’s office or hospital. It was referring to the insurance companies that don’t provide care but simply pay for it (or not, which means they must employ people to make that decision) or the PBM that doesn’t actually provide the services of a pharmacist but again, decides whether or not to pay for a prescription.

You have divined the subjects of my sarcasm admirably, and I thank you.

I managed a small doctor’s office for 8 years.

ETA: For example one of the things we had to deal with was, in order to accept major insurers, they offered us the going rates on a take it or leave it basis. That is, BCBS, United healthcare, etc. Our input to the actual negotiation of base rates consisted of writing our national association for our specialty, or in practice, just leaving it to them to lobby on our behalf.

Smaller insurers we had a little room to negotiate pricing but it might not be as you think. Nobody came to us with a fee schedule where we’d go line by line and check costs. The way it works is they propose X% of Medicare prices and we counteroffer Y% of Medicare prices. Only new or obscure insurers would offer prices over Medicare amount. Sales rep goes to Manager and asks if they can still turn a profit with these prices and relays back to us. In turn, Medicare prices are set by a national body with regional multipliers. So a new patient office visit in central FL might cost $250 but in central New York it might be 2x, 3x that price.

There was some negotiation for a couple newfangled biologics we administered in-office but that was not with the insurer directly, it was with the specialty pharmacy the insurer contracted with i.e. Express scripts or CVS Care mark. And the manufacturer had a monopoly on these new drugs so they were really expensive, we’d have to pay out of pocket for the inventory and then get the drug approved on a per-patient basis.

~Max

I have no idea what @nearwildheaven was suggesting there either.