Quote:ok then, so now we don't have benefits, we have rights?
If the government tells your employer they must provide you with health insurance, what else is it but a right?
Isn't it the same as the "right to a living wage" that we call minimum wage?
Quote:Hospital fee schedules are based on prices provided by the Center For Medicare and Medicaid Services (CMS). Those prices are based on the Relative Value Unit structure where each procedure is priced based on three expense factors: labor, overhead, and malpractice. Health care facilities don't just pull numbers out of the air, they create their fees based on the CMS schedule.
In your particular anecdote, the cost to you for your pain pill is the cost of having a specific prescription delivered to you in the Emergency Department of a first world health care facility, the most expensive form of health care that exists in the world. The best way to curb this, aside from the individual market I already mentioned, is to create an intermediary care facility, like modern Urgent Care, that keeps non-life threatening cases out of the Emergency Room. That system wasn't really in place in 2002, but it's becoming more common as hospital systems invest in "ER Avoidance Programs" to lower their own costs. My own system is affiliated with a large Urgent Care network and we're currently developing agreements with several specialists to be "immediate care providers" who will accept same day referrals from PCPs that would normally go to the ER. Anytime we can provide care in a setting other than the ER it's a win in the "cost reduction" column, which really is good for everyone.
the value you mentioned is determined by whom? certainly ONE pill for $26 when a 30 day supply of the pill around $12 isn't of any value other than to the providing facility...I'm certain, the providing facilities would get the pills extraordinarily cheaper than I would for a 30 supply via prescription, so in my mind, that would be called price gouging....
Quote:If the government tells your employer they must provide you with health insurance, what else is it but a right?
Isn't it the same as the "right to a living wage" that we call minimum wage?
rights and benefits are not the same thing...and the employer only has to provide health insurance to employees to workers who work over a certain amount of hours, which is a big reason many small businesses and corporations are hiring only part time people nowadays
Quote:the value you mentioned is determined by whom? certainly ONE pill for $26 when a 30 day supply of the pill around $12 isn't of any value other than to the providing facility...I'm certain, the providing facilities would get the pills extraordinarily cheaper than I would for a 30 supply via prescription, so in my mind, that would be called price gouging....
CMS, a division of the federal government.
Quote:rights and benefits are not the same thing...and the employer only has to provide health insurance to employees to workers who work over a certain amount of hours, which is a big reason many small businesses and corporations are hiring only part time people nowadays
That's why I said "the view of the Left", they are working to get us to the point where fringe benefits are no different than the minimum wage, federally required because they are a "right."
Quote:CMS, a division of the federal government.
and how is this "value" determined? If this so called "value" is already controlled by the government, it should be regulated...A pill that costs the providing facility pennies or maybe even a fraction of a penny, should not be allowed to be sold to a consumer who ultimately (more than likely) will submit the claim to his health insurance provider for $26...That is an exorbitant percentage of profit per pill and the cost for the nurse to bring it to you certainly can't cost that much...If that is deemed acceptable by CMS, CMS needs to be audited and regulated
Quote:That's why I said "the view of the Left", they are working to get us to the point where fringe benefits are no different than the minimum wage, federally required because they are a "right."
if they are a right, wouldn't they have to amend the constitution?
Quote:if they are a right, wouldn't they have to amend the constitution?
Of course not, those are only the enumerated rights. We have plenty of rights that aren't listed in the Constitution, all protected by the 9th amendment.
Quote:and how is this "value" determined? If this so called "value" is already controlled by the government, it should be regulated...A pill that costs the providing facility pennies or maybe even a fraction of a penny, should not be allowed to be sold to a consumer who ultimately (more than likely) will submit the claim to his health insurance provider for $26...That is an exorbitant percentage of profit per pill and the cost for the nurse to bring it to you certainly can't cost that much...If that is deemed acceptable by CMS, CMS needs to be audited and regulated
The CMS process is extensive already, is open to public comment every year, and ultimately is approved by Congress. The fact that it's already over-regulated contributes to the cost problem.
Quote:
In your particular anecdote, the cost to you for your pain pill is the cost of having a specific prescription delivered to you in the Emergency Department of a first world health care facility, the most expensive form of health care that exists in the world. The best way to curb this, aside from the individual market I already mentioned, is to create an intermediary care facility, like modern Urgent Care, that keeps non-life threatening cases out of the Emergency Room. That system wasn't really in place in 2002, but it's becoming more common as hospital systems invest in "ER Avoidance Programs" to lower their own costs. My own system is affiliated with a large Urgent Care network and we're currently developing agreements with several specialists to be "immediate care providers" who will accept same day referrals from PCPs that would normally go to the ER. Anytime we can provide care in a setting other than the ER it's a win in the "cost reduction" column, which really is good for everyone.
In defense of the ACA, this is what they were trying to address by requiring all Americans to be insured: that people would use insurance for preventative care - say removing a stone-infested gall bladder involving an easy outpatient procedure -instead of going to the emergency room with a burst gall bladder and requiring 3 weeks in an ICU.
Which said uninsured patient would then skip paying, driving insurance up for the rest of us.
You want to know why that emergency room pill costs so much? Because the uninsured can't afford to pay their emergency room bills. Thus, they charge the insured enough to cover the bill, and most of the time, create a healthy albeit modest profit.
Quote:In defense of the ACA, this is what they were trying to address by requiring all Americans to be insured: that people would use insurance for preventative care - say removing a stone-infested gall bladder involving an easy outpatient procedure -instead of going to the emergency room with a burst gall bladder and requiring 3 weeks in an ICU.
Which said uninsured patient would then skip paying, driving insurance up for the rest of us.
You want to know why that emergency room pill costs so much? Because the uninsured can't afford to pay their emergency room bills. Thus, they charge the insured enough to cover the bill, and most of the time, create a healthy albeit modest profit.
I understand what you are saying, but that huge percentage of buy to sell ratio should be illegal...For a pill that costs pennies or a fraction of a penny to be sold at $26 is undeniably price gouging...I can understand trying to recoup lost revenue, but grossly overcharging for services rendered like that is flat out wrong and should be illegal...Not to mention the fact that most hospitals nowadays can not refuse service due to lack of ability to pay, therefore some sort of plan is in place to compensate for non paying users of the facilities
Quote:I understand what you are saying, but that huge percentage of buy to sell ratio should be illegal...For a pill that costs pennies or a fraction of a penny to be sold at $26 is undeniably price gouging...I can understand trying to recoup lost revenue, but grossly overcharging for services rendered like that is flat out wrong and should be illegal...Not to mention the fact that most hospitals nowadays can not refuse service due to lack of ability to pay, therefore some sort of plan is in place to compensate for non paying users of the facilities
Just wondering if you were paying out of pocket?
Quote:In defense of the ACA, this is what they were trying to address by requiring all Americans to be insured: that people would use insurance for preventative care - say removing a stone-infested gall bladder involving an easy outpatient procedure -instead of going to the emergency room with a burst gall bladder and requiring 3 weeks in an ICU.
Which said uninsured patient would then skip paying, driving insurance up for the rest of us.
You want to know why that emergency room pill costs so much? Because the uninsured can't afford to pay their emergency room bills. Thus, they charge the insured enough to cover the bill, and most of the time, create a healthy albeit modest profit.
While that makes sense to most of us, there are newly insured folks who still won't be seen for preventative care because that's money (co-pays, lab tests, unpaid time from work to go to appointments, etc.) out of their pocket and possible job loss if their employer frowns on taking time off for such things. So they still end up in the ER and while their insurance will help knock down some of the cost, it's still expensive. And not too many employers can or will say much if you've been in the ER so there's less of a chance of getting fired or getting negative marks in your personnel file.
So in a way, that shiny new insurance doesn't really do much for folks who aren't used to having it. They'll stay with their mindset because that's what they're used to.
Quote:While that makes sense to most of us, there are newly insured folks who still won't be seen for preventative care because that's money (co-pays, lab tests, unpaid time from work to go to appointments, etc.) out of their pocket and possible job loss if their employer frowns on taking time off for such things. So they still end up in the ER and while their insurance will help knock down some of the cost, it's still expensive. And not too many employers can or will say much if you've been in the ER so there's less of a chance of getting fired or getting negative marks in your personnel file.
So in a way, that shiny new insurance doesn't really do much for folks who aren't used to having it. They'll stay with their mindset because that's what they're used to.
$5000 deductibles don't help either.
Quote:Just wondering if you were paying out of pocket?
no, but that brings up another point...the healthcare facilities charge so much because they know insurance companies will pay it...kind of like gas, we have to have it so they can charge whatever they want to for it...I fully understand your argument, but I still say to charge such exorbitant fees is nothing more than corporate greed...The healthcare industry needs to be revamped and regulated to ensure that consumers and insurance companies are not gouged with ridiculous fees for services because no one else can provide this service...
Quote:$5000 deductibles don't help either.
So true. Ours went way up this year. Pretty much unreachable at this point unless there's a hospital stay or surgery or something. I'm thankful I have insurance due to some back and foot issues I've needed treatment for, but as a whole the insurance industry scores right up there with all politicians in my book. And that's NOT a good thing. I guess since they have a symbiotic relationship it's to be expected that one is just as foul as the other.
Quote:no, but that brings up another point...the healthcare facilities charge so much because they know insurance companies will pay it...kind of like gas, we have to have it so they can charge whatever they want to for it...I fully understand your argument, but I still say to charge such exorbitant fees is nothing more than corporate greed...The healthcare industry needs to be revamped and regulated to ensure that consumers and insurance companies are not gouged with ridiculous fees for services because no one else can provide this service...
Actually, hospital payments rates are contracted for the majority of their patients. Medicare, Medicaid and Tricare are government programs, so you don't get to negotiate a rate, you simply take what they offer or don't participate. Commercial payers like Blue Cross, Aetna and United Healthcare negotiate individual contracts with physicians and facilities that pay on some percentage of the Medicare rate (good rates are 110 - 120% of Medicare, bad ones can be 80% or lower). Once the service is rendered the insurance company has the leverage because they can (and do) simply deny the claim and not pay it short of a judge forcing them to. They also deny claims for illegitimate reasons or say the service is the patient's responsibility and force the physician to rebill the claim costing labor time and a delay in cash flow or force the patient to spend time on the phone demanding they pay the claim. You've not seen corporate greed until you've seen how an insurance company works to hold on to their dollars!
The contracted rates also affect the hospital's fee schedule because the fee you send to the insurance company on the claim has to more than the contracted rate or they only pay the amount you bill. That constantly drives the fee schedule rates up because providers/hospitals are only allowed to have one fee schedule by law, therefore the fee has to be more than the highest contracted rate across your contracts.
All of these things factor in the administration of the health care and the need for this support is one of the largest influences on cost. In large provider groups the billing support staff requires at least 1 person for every 3 doctors. That's after the cost of the location, clerical staff, clinical staff, and supplies. But what choice do they have, either pay for staff to collect the money they're owed or go out of business. The same goes for hospitals but they gauge their staff need on number of beds and dollars in revenue. And none of this even covers government audits, insurance companies who take back the money they've paid by reducing or withholding payment on a different patient, the cost of IT in the new world of electronic medical records, or the cost of continuing education and compliance with ever-changing government requirements. One of my employees spends almost 2 months each year just reviewing and communicating the annual updates from CMS and ACHA to the Medicare and Medicaid programs. The bureaucracy of healthcare is something to behold and incredibly costly to the entire industry.
Quote:Actually, hospital payments rates are contracted for the majority of their patients. Medicare, Medicaid and Tricare are government programs, so you don't get to negotiate a rate, you simply take what they offer or don't participate. Commercial payers like Blue Cross, Aetna and United Healthcare negotiate individual contracts with physicians and facilities that pay on some percentage of the Medicare rate (good rates are 110 - 120% of Medicare, bad ones can be 80% or lower). Once the service is rendered the insurance company has the leverage because they can (and do) simply deny the claim and not pay it short of a judge forcing them to. They also deny claims for illegitimate reasons or say the service is the patient's responsibility and force the physician to rebill the claim costing labor time and a delay in cash flow or force the patient to spend time on the phone demanding they pay the claim. You've not seen corporate greed until you've seen how an insurance company works to hold on to their dollars!
The contracted rates also affect the hospital's fee schedule because the fee you send to the insurance company on the claim has to more than the contracted rate or they only pay the amount you bill. That constantly drives the fee schedule rates up because providers/hospitals are only allowed to have one fee schedule by law, therefore the fee has to be more than the highest contracted rate across your contracts.
All of these things factor in the administration of the health care and the need for this support is one of the largest influences on cost. In large provider groups the billing support staff requires at least 1 person for every 3 doctors. That's after the cost of the location, clerical staff, clinical staff, and supplies. But what choice do they have, either pay for staff to collect the money they're owed or go out of business. The same goes for hospitals but they gauge their staff need on number of beds and dollars in revenue. And none of this even covers government audits, insurance companies who take back the money they've paid by reducing or withholding payment on a different patient, the cost of IT in the new world of electronic medical records, or the cost of continuing education and compliance with ever-changing government requirements. One of my employees spends almost 2 months each year just reviewing and communicating the annual updates from CMS and ACHA to the Medicare and Medicaid programs. The bureaucracy of healthcare is something to behold and incredibly costly to the entire industry.
I understand the contract thing...That's why they have the separate fee schedule for in network and out of network providers...In network providers generally agree to accept whatever payment the insurance company pays and not bill for the difference between what was billed and what was paid...
I maintain that the healthcare system grossly overcharges in certain areas and that it is unfair and unethical, and should be illegal...I know a large portion of the billing goes to cover overhead and malpractice insurance, but the insurance companies don't need any help in finding an excuse to raise premiums...
I don't know how to solve the problem completely, but putting a realistic cap on the amount they can charge for dispensing medications at the ER, would be somewhere to start...
It was mentioned earlier that some people use the ER as a primary doctor facility and I know that's a fact...It's also a fact that some people use it as an excuse to get out of work...They don't want to work on a certain day, so they go to the ER and get a note saying they were seen at that facility and they have an excused absence. There is a lot of abuse of the health care system, and I think a major overhaul is what needs to happen...
It seems Canada's free health care system works pretty well, (although it's not completely free) but I doubt we could ever make a system like that work here because they jerk faces in Washington would find a way to screw it up and make it a pain in the rear