It's the opposite, Medicare establishes the fee schedule each year in October and implements it January 1st, then most groups make their adjustments to their fee schedules for January implementation. 

 

Insurance contracts generally run 2 to 4 years and are based on some formula of a particular year of the Medicare fee schedule. For instance, Aetna will negotiate this year for a 3 year deal that pays 104% of the 2015 year Medicare fee schedule. Any new codes that are added by Medicare are addressed by contract language that spells out how Aetna will pay them, usually at a lower rate that the 104% they've agreed to for established codes. Contract rates aren't uaually affected by the annual Medicare changes except in which codes are new and which ones are no longer valid.

 

For anyone who cares, the Medicare Fee Schedule is comprised of procedure codes that identify the service performed by the provider. The procedure codes are linked to diagnosis codes that must be present for the procedure to meet "medical necessity." The codes are priced by what's called Relative Value Units, or RVUs. These RVUs are made up of 3 components: the work RVU, the expense RVU and the malpractice RVU. The RVU is mulitplied by a Geographic Adjustment Factor that exists to balance the differences in operating cost by region of the country. For instance, the GAF is higher in New York City than in Birmingham, Alabama because of thedifferences in the cost of living.

 

As JackCity was asking about cost, the answer for professional services (doctors and other clinicians) is that Medicare pays for each level of service based on the RVUs assigned to the service code the physician provides. Your doc sees you for a cold, bills Medicare a 99213 code for the office visit and Medicare pays $73.93 nationally for the service when provided outside a facility. The regional Medicare contractor who processes your claim then applies the GAF and you end up with a higher or lower amount based on where you are located. Where I work that number is $73.17. That's the results of all that math I described up above. 

 

Facilities have differing rates because their overhead is structured differently. Most hospital stays are paid using Diagnosis Related Groups (DRGs) to calculate the cost. As mentioned above, the reimbursement for a Gall Bladder surgery for a facility is the CMS calculation of the RVUs of that procedure and all the supportive and ancillary care that goes with it. The facility is paid a flat rate for the DRG and has to made due with that amount. Again, the amount paid is calculated by the government and then that number is used by the commercial plans for negotiation. 

We are talking about the same thing from different angles. It doesn't matter what the hospital decides to bill, medicare sets the rate. Also medicare will reduce the rate of reimbursement based on patient satisfaction Hospital acquired infections and so on. In 2009 they deliberately choose things like bed sores, because they are nearly impossible to prevent in a bed bound patient (a large proportion of nursing home and hospitalized patients). So if a hosp tries to bill at say 100% of the rate, medicare will say no, you had a patient have a fall or bedsore or complain or w/e and just pay less. But good talk on RVU's tho, obviously someone is a little bit more intimate with them than I am at this moment. I enjoyed it.

---

Yes, it's improvement, but it's Blaine Gabbert 2012 level improvement. - Pirkster

http://youtu.be/ouGM3NWpjxk The Home Hypnotist!

http://youtu.be/XQRFkn0Ly3A Media on the Brain Link!
 

Peyton must store oxygen in that forehead of his. No way I'd still be alive after all that choking.

 

That's what I've seen. The providers and the insurance companies are gaming the system. The whole concept of insurance is part of the problem, since it's really not insurance against catastrophe, but an unlimited use fee. Medical costs would be a lot lower if people paid out of their own pockets and insurance just covered catastrophic problems. There's no competition for price when insurance companies just follow Medicare price controls.


To answer the original question, here are some ideas:


 

1. The ACA should be scrapped, completely. It's too flawed to fix.


 

2. Most company-provided insurance will cover pre-existing conditions if the person had prior coverage when the condition was discovered. This is a reasonable thing to codify into law.


3. Individuals should get full tax credit for heath care costs including insurance. Corporations should pay no taxes (the customers actually pay the taxes through higher prices anyway), so a corporate tax write off would not be a factor. This would move the responsibility for health insurance to the individual, resulting in more competition and lower rates.


4. Eliminate the requirement that hospitals have to treat non-citizens. Health insurance costs in California are way higher than they are in Florida for this very reason.


 

5. Make most drugs non-prescription. That would eliminate numerous otherwise unnecessary trips to the doctor.
Amoxicillin for childhood ear infections is a prime example
of this. It was absurd that Prilosec was suddenly found out to be safe as a non-prescription drug just as the patent expired.


6. The US should limit the drug prices to the lowest price a company charges among the ten highest GDP countries where a drug is sold. If a company claims it can't sell the drug profitably at that price, then they can raise the price elsewhere (or not sell it there if the other country balks at an increase) to compensate.

1. I agree, there are only two clauses I like, preexisting conditions and 26 insurance.

 

2. This is/ was the law if you take away ACA, it hurts a lot of people who loss their job due to illness and now can't get another one or insurance for 2 years till they qualify for disability. This particular thing would bankrupt people, just like it used to in the past.

 

3. all medical costs should definitely be write-offs, I agree.

 

4. This is something I don't agree with for emergency situations. Yes it is abused frequently by our neighbors to the south, but that is an immigration, not a healthcare issue. We have a quid pro quo for other countries with emergency tx, and I believe that is how it should be.

 

5. That is a really bad idea. Unlimited access to antibiotics for our meat and poultry is a big reason we have superbugs. It absolutely should be limited to provider prescription. People have zero idea whether an infection is viral, parasite, fungal or bacterial, and would end up causing more problems. 

 

6 I like this thought, and is what a lot of other countries do. Funny how the ACA didn't allow medicare to do this directly, despite it being a big talking point during the campaign trail. We subsidize the world in drug prices.

---

Yes, it's improvement, but it's Blaine Gabbert 2012 level improvement. - Pirkster

http://youtu.be/ouGM3NWpjxk The Home Hypnotist!

http://youtu.be/XQRFkn0Ly3A Media on the Brain Link!
 

Peyton must store oxygen in that forehead of his. No way I'd still be alive after all that choking.

 

except they really dont...every filed an appeal for denial of services? you can expect to wait for months before they take any action...I need an MRI for my back but to get an MRI I have to either attend pain management sessions or physical therapy for 6 weeks...I waited 2 weeks for an opening in pain management only for them to tell me I can't do pain management without having an MRI, so I waited another week for an opening in physical therapy who said they can't treat me because I need a firm diagnoses of my condition because they don't want to cause more damage to my back by doing the wrong exercises, so I can't do psychical  therapy without an MRI...Filed an appeal, about 6 weeks later the insurance company claimed it's not a medical necessity at this time because they have found that physical therapy often relieves back pain without the need for an MRI, so it went back to the arbitration board...  

This is the other crappy part of our insurance system. I hate that. My father is currently dealing with a DoS for a surgery he had. They denied it morning of, and he had the surgery still cause surprise, after years [BLEEP] around with the insurance he needed the treatment. He went through all the hoops and then they still threw him under the bus at the last second. I think he will end up paying cash. The surgery actually worked great, but no he didn't need it. No one needs to swallow food. (sarcasm)

---

Yes, it's improvement, but it's Blaine Gabbert 2012 level improvement. - Pirkster

http://youtu.be/ouGM3NWpjxk The Home Hypnotist!

http://youtu.be/XQRFkn0Ly3A Media on the Brain Link!
 

Peyton must store oxygen in that forehead of his. No way I'd still be alive after all that choking.

 

1. Here in Jacksonville 3 health care systems have been fighting over who gets to build a hospital in the Southwest area of the region. St. Vincent's, Baptist and HCA all applied for a CON to build but St Vs was approved and the other two told they couldn't build. Demand is irrelevant, the government decides who does and doesn't get to build their facilities in that neighborhood. Here's an article about the Baptist denial and the reasons outlined for telling them no.

 

http://jacksonville.com/community/clay/2...y-hospital

 

2. There are dozens of minor health care issues that we currently use physicians for that could be accomplished without their oversight. The cost of becoming a physician and the salary and benefits of being one means that they as a whole are ragingly protective of their market share and territory. As a result we now have a severe shortage of providers at every level because doctors do work that doesn't require them and we strangle the supply from medical schools.


 

3. Insurers already do that by how they contract with health systems and physicians and by choosing to leave states entirely. As always happens when government is involved, we have a huge bureaucracy full of redundancy and red tape that drives prices upward with a crippling effect on the service.

This was true/maybe is still true. But it won't be in 10 years. New medical schools are popping up like flies (especially DO's) we will actually have more American grads than residency spots within 5-10 years. And most new residency are primary care. Plus NP's and PAs are also proliferating like bunnies. Our system will change, I just hope I can be ahead of the curve instead of behind it for once.

---

Yes, it's improvement, but it's Blaine Gabbert 2012 level improvement. - Pirkster

http://youtu.be/ouGM3NWpjxk The Home Hypnotist!

http://youtu.be/XQRFkn0Ly3A Media on the Brain Link!
 

Peyton must store oxygen in that forehead of his. No way I'd still be alive after all that choking.

 

Actually you're wrong about pricing. It's against the law for any health care entity, pharmacy included, to price their drugs or services differently because of the insurance status of the customer. They can contract with insurance for lower reimbursement, but they cannot have a different list price, it has to be the same all the time. What's different is the amount of the contractual discounts from that price, those vary payer to payer and even contract to contract from the same payer.

 

Additionally, drug costs are reimbursed by insurance companies based on the Average Wholesale Price document produced by CMS each quarter. Most contracts are set in stone at the AWP so you don't negotiate them, you just get paid what the document says plus a small percentage. If the pharmacy is giving you a number it's the out of pocket expense which varies, not the shelf or list price because that really doesn't.

Against the law perhaps but with all that legal mumbo jumbo, it happens. 

---

Calling Deshawn Watson a future bust since 3/19/17. If I eat crow, I will keep this in here and proclaim JackCity a genius. 

Against the law perhaps but with all that legal mumbo jumbo, it happens.

If you get caught the fine is 10k-25k per instance extrapolated by claim volume.

---

“An empty vessel makes the loudest sound, so they that have the least wit are the greatest babblers.”. - Plato

1. Here in Jacksonville 3 health care systems have been fighting over who gets to build a hospital in the Southwest area of the region. St. Vincent's, Baptist and HCA all applied for a CON to build but St Vs was approved and the other two told they couldn't build. Demand is irrelevant, the government decides who does and doesn't get to build their facilities in that neighborhood. Here's an article about the Baptist denial and the reasons outlined for telling them no.


[url=]http://jacksonville....county-hospital[/url]



I can't say I see what the big deal Is. They had clear requirements and failed to produce the relevant documentation. That's not governments fault.

---

This was true/maybe is still true. But it won't be in 10 years. New medical schools are popping up like flies (especially DO's) we will actually have more American grads than residency spots within 5-10 years. And most new residency are primary care. Plus NP's and PAs are also proliferating like bunnies. Our system will change, I just hope I can be ahead of the curve instead of behind it for once.

Are you also in the Public Health/Medical profession?

---

This was true/maybe is still true. But it won't be in 10 years. New medical schools are popping up like flies (especially DO's) we will actually have more American grads than residency spots within 5-10 years. And most new residency are primary care. Plus NP's and PAs are also proliferating like bunnies. Our system will change, I just hope I can be ahead of the curve instead of behind it for once.

Medical schools can sprout up but what is restraining the output is number of residency seats available here in the US, which is regulated by the ACGME. This issue of #medical students to #residency slots available is already occurring. 

 

DO's can enter a DO residency, as well as an MD residency (but is generally harder for the higher-tier specialties).

---

1. Here in Jacksonville 3 health care systems have been fighting over who gets to build a hospital in the Southwest area of the region. St. Vincent's, Baptist and HCA all applied for a CON to build but St Vs was approved and the other two told they couldn't build. Demand is irrelevant, the government decides who does and doesn't get to build their facilities in that neighborhood. Here's an article about the Baptist denial and the reasons outlined for telling them no.

<a class="bbc_url" href=''>http://jacksonville....county-hospital</a>



I can't say I see what the big deal Is. They had clear requirements and failed to produce the relevant documentation. That's not governments fault.

Its not the government's fault that the government allows or prevents a business from starting? Really? Who else's fault is it then?

---

“An empty vessel makes the loudest sound, so they that have the least wit are the greatest babblers.”. - Plato

Its not the government's fault that the government allows or prevents a business from starting? Really? Who else's fault is it then?

Baptist's fault.


The agency said Baptist failed to meet the requisite criteria to demonstrate that the hospital is needed. Baptist didn’t establish that Clay residents lacked the availability or accessibility to health care — which was a necessary component to warrant approval of the application.


“In addition, the Agency did not find that the applicant [Baptist] demonstrated the extent that the proposed project would foster competition and promote quality and cost-effectiveness to all residents of Clay County,” according to the decision contained in a 64-page document obtained Wednesday by the Times-Union.

---

Baptist's fault.


The agency said Baptist failed to meet the requisite criteria to demonstrate that the hospital is needed. Baptist didn’t establish that Clay residents lacked the availability or accessibility to health care — which was a necessary component to warrant approval of the application.


“In addition, the Agency did not find that the applicant [Baptist] demonstrated the extent that the proposed project would foster competition and promote quality and cost-effectiveness to all residents of Clay County,” according to the decision contained in a 64-page document obtained Wednesday by the Times-Union.

Are you intentionally missing the point? Barrier to entry by regulation is the point. A business shouldn't have to prove to government a need before they can open for business. Because they do we have a hampered economy.

---

“An empty vessel makes the loudest sound, so they that have the least wit are the greatest babblers.”. - Plato

Are you intentionally missing the point? Barrier to entry by regulation is the point. A business shouldn't have to prove to government a need before they can open for business. Because they do we have a hampered economy.

The only barrier was Baptist's own negligence. What's your proof of a hampered economy?

---

The only barrier was Baptist's own negligence. What's your proof of a hampered economy?

No, the regulation is the barrier. Geez, for a smart guy you sure miss the obvious.

---

“An empty vessel makes the loudest sound, so they that have the least wit are the greatest babblers.”. - Plato

No, the regulation is the barrier. Geez, for a smart guy you sure miss the obvious.

It's like applying for a grant or for a publication. If you don't meet the criteria you get rejected. You don't blame the governing body though. Maybe your proposed work lacked details or clarity, or wasn't a wise investment.

---

It's like applying for a grant or for a publication. If you don't meet the criteria you get rejected. You don't blame the governing body though. Maybe your proposed work lacked details or clarity, or wasn't a wise investment.

Still you just dont get it. If the government forbids you from opening a business then they are interfering in the market. Its not about about successfully applying, it's that you have to apply at all.

---

“An empty vessel makes the loudest sound, so they that have the least wit are the greatest babblers.”. - Plato

Still you just dont get it. If the government forbids you from opening a business then they are interfering in the market. Its not about about successfully applying, it's that you have to apply at all.

If that's the best example you have of government interference I'd say you have your work cut out.

---

If that's the best example you have of government interference I'd say you have your work cut out.

Seriously? Its a core principle of the free market completely neutered by government interference. If you don't get that you should avoid discussions of economics in the future.

---

“An empty vessel makes the loudest sound, so they that have the least wit are the greatest babblers.”. - Plato

Baptist's fault.


The agency said Baptist failed to meet the requisite criteria to demonstrate that the hospital is needed. Baptist didn’t establish that Clay residents lacked the availability or accessibility to health care — which was a necessary component to warrant approval of the application.


“In addition, the Agency did not find that the applicant [Baptist] demonstrated the extent that the proposed project would foster competition and promote quality and cost-effectiveness to all residents of Clay County,” according to the decision contained in a 64-page document obtained Wednesday by the Times-Union.

 

Why should someone proposing to build a hospital have to prove to some government bureaucrat that it's "needed?" Can't a better hospital with lower fees be good for everyone, whether or not there is already a hospital in place?

---

                                                                          

"Why should I give information to you when all you want to do is find something wrong with it?"

Can't a better hospital with lower fees be good for everyone, whether or not there is already a hospital in place?

You know for a fact there would be lower fees?

---