<p>“But the big problem historically with our system of health care delivery is that the people who can pay get charged extra for the costs incurred by the people who can’t. And apparently Childrens’ pricing model includes shifting the cost of highly specialized care onto their charges for routine procedures. That’s probably not something that middle income parents of healthy, normally developing kids ought to have to pay extra for.” </p>
<p>Okay, I’m not understanding this as a pro-ACA argument. This objection to cost-shifting is precisely what ACA does. Love it or hate it - It’s cost-shifting.</p>
<p>My big problem with specialized hospitals is not that that some patients get charged extra for the costs incurred by very sick people. That’s cost shifting. If everyone was insured there shouldn’t need to be any cost shifting. </p>
<p>The issue to me is the total cost. American medicine costs too much. Some patients get charged extra for the costs of things that shouldn’t be charged for because they shouldn’t exist: price gouging by specialists; paying for expensive medical equipment that the hospital doesn’t need, or doesn’t need in duplication; paying for lavish luxuries.</p>
<p>Supporters and opponents of the ACA can agree that American medicine costs too much and we have to rein in costs. One patient can’t stand up to a medical provider and negotiate prices; they don’t have enough power, but worse, they don’t and can’t have enough knowledge. But an insurer can bring market forces to bear and negotiate.</p>
<p>In the case of Children’s, I think the original article I saw talked about equipment and procedures, and some additional checks and balances, oriented toward the high-needs/high-risk kids they are designed to serve. The appendectomy doesn’t cost 23k because there is a line on the bill labelled “Surcharge: $9,000.” It is not a “pro-ACA” argument. It is further discussion of why SC has “standard” charges much higher than some other hospitals. And why an insurer might balk at automatically paying those, for kids who do not need to be treated at SC. </p>
<p>Sure, but excluding access to those hospitals is a very big problem when you need one of those hospitals. That’s been discussed.</p>
<p>All hospitals cost-shift primarily to cover non-payment which is still expected to be an issue even with ACA since estimates show it still leaves 30-million uninsured along with many more who can’t cover their deductibles and continued ER abuse since it’s convenient and getting in to see a doctor is reportedly becoming a big issue.</p>
<p>Insurance is cost-shifting. Subsidies are cost-shifting. I suppose they are trying to drive down costs by refusing to pay them but if doctors are not liking this plan and refusing to participate that seems like a big deal. The provider lists are old and outdated and people who are buying this insurance are not really buying much in some places. And, some are paying more for it. That’s not good. imho. </p>
<p>I would say that calling subsidies “cost-shifting” is misleading and imprecise. They are cost-shifting in the broad sense that any government spending is cost-shifting, but otherwise I don’t think it’s any more accurate to call an insurance premium subsidy “cost-shifting” than to call federal highway spending “cost-shifting.”</p>
<p>Excluding access is bad. Putting the cart before the horse is also bad. Trusting that some article is “the truth, whole truth and nothing but the truth,” just because, is bad. Right now, we really don’t know the extent of the mass “excluding” some predict with such certainty. We don’t know what other facts led to some snafu cited here, what timelines or what the details of the contention even were. Nor the other options available in those anecdotes or how easy access to those options actually is.</p>
<p>Not only to cover no-pays. You might like to pore through a hospital annual report. (Seems we crazy folks on CC are curious sorts.)</p>
<p>Isn’t college tuition also some shifting? And, in our daily lives, we underwrite all sorts of services we may not use or need or have caused. </p>
<p>Yes, I am concerned about illegal aliens. No, I don’t think we have expertise to predict.</p>
<p>“Seattle Children’s CLAIMS that the kids they perform routine surgery on are sicker than the usual. But I don’t believe them. That is to say, some of the kids they give appendectomies to may be somewhat sicker, but I’m certain they also handle plenty of kids who are just normally sick, and they charge their jacked up prices to all kids.”</p>
<p>No, they don’t charge their jacked up prices to all kids. They treat Medicaid patients for routine issues, I’m sure at low reimbursement Medicaid rates. Certainly their higher rates charged to other patients reflects the cost of treating Medicaid patients. It would be wise if they’d refuse to treat children with routine problems that they are getting little reimbursement for, and send them to other hospitals. People shouldn’t have to pay higher costs to cover the costs of others who don’t need to go to a specialty hospital.</p>
<p>The problem is, since Medicaid patients can get treated anywhere at no cost to themselves, they have no incentive to search for cheaper options like everybody else. Why not get the best if someone else is paying?</p>
<p>The exact same argument applies to Goldenpooch. He wants to get the best, with someone else paying, and he complains when his insurance company searches for cheaper options. </p>
<p>If Seattle Childrens shouldn’t be treating Medicaid patients for routine problems (and I quite agree-- why should Medicaid pay for specialized equipment and training sitting around unused when a child is being treated for a routine broken arm) they also shouldn’t be treating privately insured patients for routine problems. Why should my insurance company pay for specialized equipment and training sitting around unused while some little brat whose parents insist on “the best” is being treated for a routine broken arm on my dime?</p>
<p>But Seattle Childrens would resist this kind of triage, because they don’t nearly have enough patients unless they treat routine broken arms… at cancer prices. A better answer is for Seattle Childrens to charge cancer prices for cancer, and broken arm prices for broken arms. That would given them the incentive to have just enough specialized equipment for cancer, but not excess equipment sitting around unused while broken arms are being treated.</p>
<p>I don’t know their prices, cf, but maybe they do treat routine broken arms at cancer prices.</p>
<p>As far as GP wanting the same thing, I think that is totally different. He wants access to the very best care if he needs it, and his premiums will probably reflect that. Totally different than people going to top hospitals for routine care, at taxpayer and other patients expense. As far as complaining, perhaps a little much, but somebody has to balance out the “ACA is absolutely wonderful, nothing is the fault of the ACA” crowd.</p>
<p>In the general case, the most expensive hospitals don’t provide the “best” care, necessarily. If your child has a broken arm, they’re not necessarily better off at Seattle Childrens than at some community hospital that treats kids’ broken arms all the time.</p>
<p>GP wants access to the most expensive hospitals, and he wants to be the one who determines whether he needs to be there. But very few people are willing to pay for an insurance policy that is available to all comers, and that lets any subscriber go to the most expensive providers any time they want. </p>
<p>I think GP should be able to go to the super-expensive specialists if he has a rare condition that only the super-expensive specialist knows how to treat. I think Medicaid patients, and all other patients, also should have that ability. But rare conditions are rare, so it makes sense that there be a gatekeeper who says, “A broken arm is not a rare condition, and we’re not paying for Seattle Childrens to set the bone at cancer prices. If Seattle Childrens wants to be reimbursed for setting broken arms, they have to charge broken-arm prices, not sarcoma prices.”</p>
<p>Trouble is, GP wants the “very best” care – which he believes can only be found at ultra-expensive hospitals – but he’s upset about being charged a higher premium for that choice. </p>
<p>GP can defend himself and I have no doubt that he will, repeatedly. But that is not quite an accurate portrayal of his wants. He wants the specialty hospital on his plan in case he needs it. Honestly, don’t we all? The exchange policies are going to a problem when people get really sick and that’s when insurance is critical. Nobody is going to lose their house over a broken arm.</p>
<p>The very example you guys showed to demonstrate this problem actually demonstrates the opposite. The insurance company agreed to pay for Seattle Childrens’ unique services for the sick kid.</p>
<p>That was not my example and that family found a way around it. Good for them. There are plenty of examples of cancer patients and other sick people losing care providers under their new plans. In the Seattle case, they likely wouldn’t have had that problem at all prior to ACA or if they were on Medicaid, which is another interesting twist. Medicaid covers more than exchange insurance.? That is crazy.</p>
<p>Yes, Flossy and Busdriver described my situation accurately. I want a plan with a robust network and, believe me, my current premium reflects it. I doubt I will ever qualify for subsidies so any comparison to Medicaid is bogus. </p>
<p>I guess it all comes down to how one views insurance. I try to assess the worst case scenario and then purchase a policy to protect my assets from such an occurrence. In health care, a catastrophic diagnosis requiring specialty care from many providers may cost hundreds of thousands or even millions of dollars. This is I want insurance for, not the broken arm, flu or garden variety ailment. So Obamacare doesn’t meet my needs at all. Instead, it does a pretty good job with what they call essential benefits or routine/preventative care (although that remains to be seen) but with these narrow networks and formularies, it absolutely doesn’t protect you from a catastrophic diagnosis, where most of us will want to avail ourselves of the best care possible.</p>
<p>I can promise you that if you looked at the amount of premiums I have paid over the years and the insurance reimbursements from my health insurance policies, the insurance companies have made a huge profit from me. To say that I some kind of mooch, looking to get expensive care at someone else’s expense, is totally specious. </p>
<p>Even if I qualified for an Obamacare subsidy, I would be the last person signing up for an exchange plan. It would be like buying auto insurance that doesn’t cover accidents with other Porsches, Mercedes and BMW cars on the road. Precisely the coverage I need.</p>