So, the answer to the problem is clear. Take over an insurance company and screw 51% of your customers. You can probably raise profits and get nice bonuses as you do so, before the backlash sets in.
If you mess up and screw only 49% of your customers, then no one has anything to complain about, right?
True, but with three qualifications.
First, the range for fraud is low, because every resident in Canada is entitled to medical treatment, and the doctors are the ones who decide if treatment is needed. If the doctor decides treatment is warranted, using their best professional judgment, that’s it: the doctor provides the treatment and bills for it. Medicare pays. There’s no insurance bureaucrat second-guessing the doctor and ex post facto denying the claim.
Second, since the doctor has the authority to decide if medical treatment is warranted, once the doctor puts in the claim, the person processing it has very little authority to review it. It’s just a simple administrative task, highly computerized, and with only one set of codes, they don’t need nearly the staff o process the claims as in an insurance model, where the processing clerk has a stronger mandate to review the claim.
Third, obviously when money is involved, there’s potential for fraud, human nature being what it is. But if Medicare officials become concerned that a doctor is over-billing, they can review the doctor’s practice and claims. If they conclude the doctor is over-billing, they can recover the excess by administrative set-off. If they conclude that it’s not just over-billing, but actual fraud, they report it to the police.
But that doesn’t result in the Medicare officials coming after the patient for reimbursement. It’s the doctor who is on the hook for the over-billing, not the patient.
I think this point is lost on many of our American friends, mainly because they simply cannot conceive of an insurance system that does not have functionaries and bureaucrats investigating claims. Yet the fact remains that if a qualified physician orders a treatment in Canada, that treatment is paid for, without being investigated by a non-physician bureaucrat.
Northern Piper, I believe it was you who once posted the differences between Canada’s single-payer model, and a traditional insurance model. As I recall, it was quite informative. Could you do the same again in this thread, just as a reminder to all?
I can conceive of an insurance system that does not have functionaries investigating claims. What I can’t conceive of is one that has no functionaries investigating claims *and * is based on a fee-for- service model and doesn’t have a lot of fraud. This article is mainly about power wheelchairs- but there are other scams as well. I basically think any medical device that advertises on afternoon TV that you can get the product at not cost through Medicare/Medicaid/insurance is a scam - power wheelchairs/scooter/oxygen concentrator /diabetes test strips, you name it . Maybe the US has more fraud than other countries or maybe we’re more suspicious - I’m not sure. And maybe when people outside the US talk about “paying for treatments”, they’re not really talking about fee-for-service specifically , but more generically mean the provider gets paid and not by the patient ( maybe by salary or capitation)- I’m not really sure about that either.
In my case there are two situations where I have paid for services with no fear of anybody denying a claim, no copay, no deductible:
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getting medical services outside of the Spanish public system and paying out of pocket. Biggest expense I paid like this was my LASIK: it was equivalent to five mortgage payments or three pairs of normally-priced glasses. Note that the price was set and completely transparent. No additional fees for the anesthesiologist, the nurse, or to make sure the clinic’s cat hadn’t been into the surgery room that day.
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getting medical services outside of whichever country I happened to be living in. File for reimbursement or not even bother. Get reimbursed, if I did bother. I say “whichever country” because this applied being both under Spain’s UHC and under Switzerland’s UHC.
Now that we have European UHC, there’s a card you can get with your “EU Medical Number” (your country code plus your usual number), but it’s valid only for six months; after that you’re understood to have moved wherever and should get under their system. For people like me who are always outside our base country but not really moving to another, getting an insurance which works on a reimbursement basis for non-catastrophic coverage is just more convenient than having to get the card every six months (catastrophic situation, they pay directly). If I use that same insurance in Spain or in a country in which they also work they pay directly; I’m currently in France and my insurer happens to have a French presence, so I can just hand either my EU-UHC card if I had it or my private insurance card since I do have it over to the nice lady at the counter and she’ll handle everything.
Bit of both, as far as the UK NHS is concerned. Certainly the latter, in that in general hospital staff are salaried and GP practices are paid by capitation. But also the former, in that hospital/specialist budgets are established by local NHS organisations contracting with them in a nominal market supposedly competing on quality, with national tariffs for each complete type of treatment, rather than per item of service per patient. It seems to me to stand to reason that if you charge for every separate pill/bandage/test/brow-mopping, each with its own mark-up for overheads, you’re going to get inflated total bills.
I’m not talking about the patient paying and getting reimbursed. I’m talking about what
actually means . Fee-for-service means that each individual service is billed and paid for - under that sort of system , a doctor gets paid more for seeing a patient more often and performing more procedures. There are other ways to pay doctors- for example, when I was pregnant , my insurance company paid a set fee to my ob/gyn which covered all appointments and the delivery . There was no financial incentive for a c-section or to see me weekly instead of monthly as there would have been under a fee-for-service system where a doctor bills and is paid $X every time he see a patient and and additional payment of $Y every time blood is drawn. and so on.
There are other systems where a doctor is paid a set fee per patient every month (capitation) and of course doctors who work in government-run clinics and hospitals are often paid a salary. And when people simply say “treatment is paid for” or “they pay directly” it’s not clear to me which system is in use - the one where the doctor gets a salary , or the one where he is paid $X per month per patient registered to his practice (whether he sees that patient no times or ten times in a given month) or the one where he gets paid more for seeing the patient and ordering a blood test every week than he would for ordering one every month. One of those systems is more susceptible to fraud/overcharging than the others.
In my case whenever it was the insurance paying directly, me paying and getting reimbursed or me paying out of pocket, it has been fee per service. The fee was set, known beforehand and complete, but if it was the insurance who paid it directly I didn’t even ask what it was. That’s been in Spain, Italy, Costa Rica, Germany and France.
When I talk about me not paying OTOH, and no private insurance being involved, I’m talking about the Spanish UHC system. There is no fee per service either for the patient or for the personnel*. Those places which are privately-owned but part of the public network negotiate comprehensive fees; large monthly payments, rather than a payscale and a system to get paid according to that scale. The amount of people treated and the kind of treatments done are tracked but seen by Finance only once aggregated globally; the charts go on the table when negotiation comes around.
- “The only ones who get paid fee for service are whores and plumbers, and do I look pretty enough to be a plumber?”
Well, as the saying goes, prepare to be surprised. 
The vast majority of health care in Canada is based on fee-for-service, there are no functionaries investigating [individual] claims, and fraud rates are low. And I have to stress again that the absence of scrutiny of individual claims, which amounts to essentially second-guessing the doctor’s recommended treatment, embodies two foundational concepts in health care, not just in Canada but in most countries: clinical autonomy in the doctor-patient relationship, in which the insurer plays no role, and the principle that all medically necessary procedures will always be covered.
I’m not knowledgeable about the fraud prevention methods employed by the various provincial health agencies, but my guess is that when there is just one payer for all medical services, as is the case everywhere in Canada, then fraud would be relatively easy to identify as an unusual pattern of claims, and in fact the agencies might even use sophisticated AI techniques to ferret out those patterns, the way credit card companies do. Fraud might stay hidden if it was very small, but then you’d have to have doctors willing to take very big risks for very small gains. You might get marginal cases of doctors making unnecessary referrals for tests performed by labs in which they have a financial stake, but I think this is at least partially mitigated by the fact that testing and lab work is not the financial bonanza here that it is in the US, and moreover, we don’t have a defensive excessive-testing culture verging on paranoia as the US does, driven by a combination of profiteering and malpractice concerns.
Capitation instead of fee-for-service has been looked at from time to time but to my knowledge has a very minimal role in Canadian health care. Other than the predominant FFS model, Ontario does have alternative payment models but I have yet to encounter them. These are “enhanced fee-for-service” where in addition to standard FFS, doctors have a group of enrolled patients for whom they receive bonuses and premiums for certain ongoing services. There is also a blended capitation model in Ontario in the form of Family Health Networks and Family Health Organizations, but it’s not something I’ve encountered, either. These organizations are paid by FFS but also receive capitation for enrolled patients with the idea that it will optimize things like preventive services and chronic disease management. More about primary care payment models in Ontario here.
Sorry, yes it was IPAB, not IPAC (darn fingers can’t type). It was the acronym for what became labeled by Republicans as the death panel, and they never staffed it with actual people. Eventually, the Pubs killed it off in 2018.
I could list many more ways to cut costs that don’t involve going to single-payer. Patent reform, Malpractice reform, Giving medicare bargaining power, electronic record keeping, all of these and many more that can be googled in seconds.
As for community-rating, I’m aware the ACA doesn’t have community rating. But it did restrict what companies could do, in order to protect consumers, and I think it was well-written. The main thing the ACA needs is richer subsidies, not full-blown community rating.
The problem in the US is not private insurance (where 70% of Americans who have private insurance like it, and where 85% who have private insurance like their care). It’s politics, particularly the Republican party. That’s the problem. That’s the only reason we don’t have UHC.
For that reason, as I’ve stated repeatedly, the next step is for a few blue states to make the logical changes that will achieve UHC in their states. We have a few blue states with 2 to 4% uninsured, where some technically easy changes could get the number down to about zero (not sure if we’ll ever get undocumented immigrants covered, but that’s another topic altogether). When that happens, and I think it will happen in the next 5 years, we will have a model that can be replicated over and over.
The “fix” won’t come from Washington. That much is certain.
Speaking of Canada, the attached doesn’t paint a very flattering picture of older-aged Canadian satisfaction with their healthcare.
The US doesn’t look all that great, particularly on costs or being economically vulnerable, etc. But I was surprised that Canadians age 65+ are less satisfied with their healthcare than most other countries and even the US. About 1/3 were not satisfied, compared to about 1/4 in the US in this link. And the Commonwealth Fund is not some Trumpist right-wing think tank.
Want to comment on that? Why is that the case in your view? Canadians in their older ages don’t seem pleased in relation to most other advanced nations.
This seems like it’s undermining your argument that subjective individual satisfaction is an essential part of healthcare decision making.
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I read a Forbes article that suggested that the UHC/ single payer was not twice as good at half the price as some here contend. In fact, healthcare expenditures in the USA are generally the same as other industrialized countries until the 65+populace starts to be factored in. At that point, the USA healthcare expenditures increase dramatically more than the UHC/ single payer systems. I suspect UHC/ single payer does a wonderful job providing healthcare for people who generally don’t need too much of it. For the elderly, not so much. It also may be that the elderly of the USA have more chronic diseases related to lifestyle such as diabetes that dramatically raise expenditures.
Is this the post you were thinking of? I was comparing the situation of Tee, an American poster, and me.
With single payer health plans, whither insurance companies?
Sure, whenever human nature is involved, there’s the potential for theft and fraud.
But, the single-payer system has an advantage that the multi-payer doesn’t: the complete data set for all physicians in the system, and their billing practices.
To clarify, when I’m talking about the Canadian system, it is the third option: I go to the med clinic, the doctor sees me and provides medical services, and then the doctor’s staff bills the provincial medicare system for that visit.
So why is that not susceptible to fraud? Because of payer-profiles. Take my GP. The provincial medicare system has the payer-profile for every single GP in the province. They can run a computerized check on the profile of any specific doctor, and compare it to the general profile for all GPs; or all GPs in that city; or all GPs in that particular clinic.
If the payment-profile spikes for a particular doctor, that’s when functionaries start to look at it; not on an “every single claim” basis, but when the profile of a particular doctor stands out. It may be that there’s a good reason for the profile of that particular doctor; or it may be a sign of over-billing. And if that’s the case, then the medicare office can use administrative set-offs to reclaim the over-payments.
But, again, that doesn’t affect the individual patient. It’s between the Medicare commission and the doctor.
Please find where I said that Canadian health care was perfect and needed no improvement. I try to understand and sometimes actively engage with government initiatives that are always trying to make it better.
But if you honestly want my opinion on that report, I would begin by asking why you posted a report that is such a total indictment of the poor quality of health care for seniors in the US. I didn’t see much (or anything, really) that rates Canada at less than about average among the 11 first-world countries, except completely subjective questions like rating “dissatisfaction with health care quality”. I don’t know, maybe some elderly Canadians are impatient with having to wait for their gerontologist appointments! Seriously, people can be “satisfied” or “dissatisfied” for the most frivolous reasons. (Just read some product reviews on Amazon – "I would have given the product a 5, but the shipping carton was torn, so I gave it a 1! :D) And for what it’s worth, which is as much or as little as any anecdote is worth, the claimed dissatisfaction is completely contrary not only to my own experience, but to the experience of elderly relations that I’ve looked after, some of whom have needed a great deal of medical care.
The reality is that Canada ranks high in quality of life for seniors and I’ve seen academic studies that attribute seniors having longer, more comfortable, and happier lives in Canada to being generally healthier (due to no-cost access to health care earlier in life) and to free access to health care in their senior years, compared to their American counterparts, many of whom soon discover how sadly inadequate Medicare really is.
Instead of cherry-picking some subjective point that you like, you really should pay attention to the overall summary at the end of the report in your own link. The last page summarizes the “Lessons Learned from 2017 International Health Policy Survey”, and the #1 lesson learned was the following: “U.S. seniors are sicker, more economically vulnerable, and face greater financial barriers to medical care and social care than elderly in the 10 other countries”.
Those are the conclusions that one reaches from a balanced assessment of objective observations, and it’s a damning indictment.
Another good objective one is “Potential years of life lost (PYLL)”, defined in this CIHI report as “a major population-level outcome indicator that estimates the additional years a person would have lived had he or she not died prematurely (before age 70, as defined by the OECD).”
In comparison with 17 other high-income countries, Canada (again) maintained a middle-of-the-pack performance on this important metric, so it’s good by first-world standards but there’s room for improvement. But the US? Absolutely dead last, as one might have expected from the above conclusions. For example, some typical PYLL numbers expressed as absolute numbers per 100,000:
Sweden 2,487; Australia 2,853; Canada 3,113; US easily in last place at 4,629.
I have not seen that article. But one problem the US has is definitely lifestyle diseases. Obesity drives problems with heart disease, strokes, diabetes, & cancer. This lowers life expectancy & increases costs. The Standard American Diet is a killer.
You didn’t answer my questions. I’m asking you why Canadian senior citizens are less satisfied with their healthcare than other developed countries, including the US. Answer it.
Also, while you’re at it, what’s up with Canadian health care and prescription drugs? Seems like most people have to get private supplemental coverage or employer coverage to get their Rx filled. Some Canadians have to pay full price with no drug coverage at all.
Quoting from the link:
*About 700,000 Canadians – many of them in precarious or lower-paid jobs – have no prescription drug coverage at all, while another 3.6 million are believed to have coverage that falls short of allowing them to afford medications, according to estimates from the government.
“What we do know is that far too many Canadians are going without medication,” said Yussuff. “Studies have indicated they’re splitting their medication, they’re sharing their medication and in some cases not taking it.”
*
I answered your question, and gave you additional pertinent data. If you didn’t like the answer, that’s on you. I have no further insights. But you would be well served to consider the information I did give you.
What’s up with prescription drug coverage is that outpatient prescription drugs have never been generally within the scope of the Canada Health Act or the single-payer plans in the various provinces, mainly because virtually every employed person has a trivial supplemental plan that covers it. Once a person reaches retirement age, however, drugs are covered too, and there are various other programs for those in need. If you didn’t know that you must know almost nothing about Canadian health care or its coverage priorities and the reasons for them.
I think there has been a certain amount of talking past each other - because I understood “no functionaries investigating claims” to mean just that, that every bill was paid , no questions asked of anyone ever , not even at the level of “and why is it, Dr Pediatrician , that every visit without exception includes a charge for venipuncture?” and that was what I couldn’t imagine. It appears that what was meant was something a little more nuanced , something more like “even if we decide later that the doctor over-billed , the patient doesn’t get stuck with the bill” and that’s not hard to imagine at all.
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