Affordable Care Act Scene 2 - Insurance Premiums

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<p>That’s a different story, LF. Aetna is talking about what happens when you have a heart attack and end up being taken by ambulance to the nearest hospital, which is not in-network for you. </p>

<p>I’m talking about when you go to the emergency room at a hospital that is in your network, are admitted, and then get seen by a hospitalist who is not in your network, and then you get slammed with out of network charges even though you took care to go to a hospital in your network. I say, if you go to a hospital in your network, you should pay in-network charges for everything that is done there.</p>

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<p>GP, I have a question for you. For as long as we’ve been discussing this, I’m still not sure what you believe.</p>

<p>Let’s talk about pre-ACA. You maintained continuous insurance coverage, and you ended up with a policy that was dirt cheap and had a great network. Imagine GoldenDouble, your imaginary neighbor. Suppose that GoldenDouble bought exactly the insurance you bought. Every time you changed policies, if GoldenDouble was able to buy that same policy, he did. He had an HSA, just like you. Ten years ago, he got cancer.</p>

<p>Do you believe that last year, GoldenDouble would have been paying the same rates you were paying? Do you believe that every time you changed your policy, GoldenDouble would have been offered the same policy at the same rates?</p>

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<p>“Hospitals, by federal regulation, are not allowed to have physicians as employees.”</p>

<p>Very technical, and only for those interested in this side bar:</p>

<p>Not precisely true. I think there was some misunderstanding there. First, the federal government has nothing to do with this issue - only the states do. (Why do so many people blame the federal gov’t for things the federal gov’t is not involved in??). Many states permit hospitals to employee docs. Many states do not, and prohibit what is called “corporate practice of medicine”. This doctrine prohibits corporations (and hospitals are corporations) from practicing medicine or employing physicians. </p>

<p>Some states, including Colorado, New York, New Jersey, and Illinois, allow exceptions, provided the corporation get approval from the state. </p>

<p>None of this in fact stops hospitals from “owning” physician practices. What the hospital does is have a friendly physician buy the practice using hospital funds, and execute a contract that effectively means that the hospital controls the appointment of the managing principal. These are called “captive PCs”. </p>

<p>The reasons for these corporate practice of medicine laws is to protect the professionalism of medical care and promote the sanctity of the physician/patient relationship. These states are also concerned that their licensing standards and regulatory control would be subverted if corporations take over the practice of medicine. </p>

<p>When you go into a hospital, you may run into both employed physicians and “voluntary attending” physicians (VAPs). You won’t be able to tell the difference. Both employed physicians and VAPs are credentialed by the hospital, and no physician can admit and attend to a patient without being afforded admitting privileges by the hospital. Hospitals will only credential physicians that 1) meet their quality assessment, 2) fill certain necessary needs (that is, a hospital won’t credential 50 cardiologists if they don’t have the patient load to support them), and 3) admit a sufficient number of patients that allow the physician to be familiar with the hospital’s procedures and protocols. </p>

<p>[I offer this last piece only as an aside, to explain a trend that’s going on and not to make a political statement: Many states have started passing laws that require doctors who perform abortions to have admitting privileges at a hospital. This is a way to prohibit all abortions, as most abortion doctors do not perform abortions on hospital premises. In an emergency, they just call an ambulance and the patient goes in through the ER. Therefore, according to almost all hospital credentials practices, they can’t qualify for admitting privileges.]</p>

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<p>As a side bar to my side bar (!!) I offer this in the spirit of FYI, not a political comment: many states have started passing laws requiring abortion doctors to have admitting privileges at a hospital. This is just a way to prohibit all abortions because, as you can see from the last paragraph of my previous post, doctors who primarily perform abortions don’t practice on a hospital premises and therefore do not qualify to be afforded admitting privileges at a hospital. </p>

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<p>People love to hate big, soulless insurance companies. I hate them myself. But, on the other hand, I kind of like having a big, soulless insurance company on my side to negotiate with a big, soulless for-profit hospital.</p>

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<p>So, what happens when something goes wrong on the abortion table? No hospital?</p>

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<p>Same thing that happens when something goes wrong at the oral surgeon’s office. The patient is taken by ambulance to the hospital and treated by the ED doctors. </p>

<p>X - posted hayden and Fang. Guess the answer’s pretty obvious. </p>

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<p>Actingmt, the same thing happens as when something goes wrong at a ambulatory surgery center - the patient goes to the ER. No one ever needs an admitting physician to go to the ER. </p>

<p>(Edited to correct the autocorrected spalling of actingmt’s name)</p>

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<p>Emergency room.</p>

<p>Do LASIK docs have admitting privileges at hospitals? I bet they don’t. How about other doctors who operate clinics outside the hospital, like some plastic surgeons?</p>

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<p>Some specialties operate in both an office or ambulatory setting, and a hospital setting. It depends on the complexity and acuity of the procedures they perform. </p>

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<p>That makes sense. Thanks.</p>

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<p>CF, every time I changed policies, except for one time when I changed insurance companies (in retrospect I wish I hadn’t), I did not have to go through underwriting. Generally speaking, it was because I was transferring to a policy with a higher deductible or one the insurance company considered less generous than the one I had. So if GoldenDouble had done the same thing as I did, I do not think he would have been paying different rates than me (or is it I?). </p>

<p>I was in the individual market for 25 years and only had to be underwritten twice. The first time and when I voluntarily changed companies, which I shouldn’t have done. I probably made 3 or 4 other changes without underwriting. Usually these changes were made after premium increases, but I never had any problem finding alternative policies that I found attractive. My last policy had a deductible of $5,200.</p>

<p>Maybe I was getting a good deal but so were hundreds of thousands of other people in Ca. I still don’t think paying $8148 a year in premiums (and having a total of $10,400 in deductibles) was that great of a deal. I don’t think the insurance company, which I am sure found my policy to be very profitable, thought I was taking advantage of them.</p>

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<p>You say that you never had trouble finding policies that were attractive, but you also say that being on the hook for 18K a year wasn’t a great deal. </p>

<p>Sounds like you did exactly what we did – as premiums skyrocketed, you were forced down the ladder. We were never underwritten either when we stepped down. Obviously. Why would they? The problem came if you wanted to improve your coverage. That’s when they underwrite. </p>

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<p>I don’t like this trend of doctors selling their practices to hospitals. This article which CF linked to in a post earlier today expresses my concerns very well. I do think Obamacare is accelerating this consolidation of the healthcare industry, which is not going to be good for consumers in the long run.</p>

<p><a href=“Hospitals Are Going On A Doctor Buying Binge, And It Is Likely To End Badly”>http://www.forbes.com/sites/scottgottlieb/2013/03/15/hospitals-are-going-on-a-doctor-buying-binge-and-it-is-likely-to-end-badly/&lt;/a&gt;&lt;/p&gt;

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<p>LasMa, CF asked me if her imaginary friend could have paid the same rates I did if that person had been afflicted with cancer ten years ago. My answer is “yes”. You’re just looking for any excuse to justify this law regardless of the facts.</p>

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<p>Oh, gottlieb’s article is a year old and misrepresents some terms. </p>

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<p>What’s really the special “unknown” about your policy/policies, GP? Such that a person with cancer could transfer to a new plan with no issue, no difference in rates from what you (presumably healthy) were offered? If you are so certain in your position, you don;t need snarky comments, btw. If you’ve got facts, give them. (I did say, facts.) Just sayin’.</p>

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<p>So then the answer is NO, GoldenDouble would not have the same insurance payments as you, because GoldenDouble at the very least would not have gotten the same rates as you did when you underwent underwriting.</p>

<p>Now I’m curious about the times you changed plans but kept the same insurance company. As I understand it, you did that several times. Your insurance company had your health records, because you were an existing customer. When they accepted you for the new plan, is it your contention that they forgot all about your good health? And that if GoldenDouble had applied to change plans, they would have forgotten all about his cancer, even though they knew about it? </p>

<p>Any existing customer, no matter how poor their health, would have been able to purchase the new plan at the very same rate you purchased it at, that’s your belief, even though the insurance company knew that in taking on this customer for this plan, they’d be losing money? I’m pulling out Fang’s Razor here, and saying that the insurance company is not composed of idiots, and they aren’t going to sell a new policy to a known money-loser if they don’t have to.</p>

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<p>Edited: This is in response to GP’s cited Forbes article.</p>

<p>I agree with lookingforward. I read most of the article and couldn’t finish it. I wouldn’t even know where to start with where I disagree. </p>

<p>One thing I will address though are the accountable care organizations. They may or may not be successful, that remains to be seen. But the whole thrust of ACOs is to allow physician practices to work with hospitals WITHOUT being purchased by hospitals. Obamacare structured ACOs to lower the barriers between independent physicians and hospitals, so that they could legally form these structures as joint ventures between docs and hospitals and allow the groups to share quality measures, be on the same electronic medical record platforms, and work jointly to improve patient outcomes. They share grants from the gov’t if they show improved patient outcomes, and the grants are shared among the hospitals and independent physicians. </p>

<p>Essentially, the financial structure of the ACO is supposed to improve economies of scale, put doctor and hospital on the same side of the table instead of adversarial relationships, and give the doctors the benefits of sharing back office expenses without becoming employed. I told Sen Cardin and strongly believe it’s one of the best parts of the ACA. But of course they’re new, and there’s always a chance they’ll fail. </p>

<p>The ACO was designed to preserve the independence of private practice, not weaken it. Now it may not work, we don’t know yet. And we won’t know for a while. One of the largest independent medical partnerships in my region absolutely loves the idea as supporting their independence and in fact they think it gives them even a stronger seat at the table with hospitals as they need each other to form medical homes for their patients. On the other hand, the CEO of the nearby healthcare system feels ACOs will fall apart. It will take a few years to figure it all out, but I can assure you Obamacare was not designed as an attack on private physicians. </p>

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<p>GP, I was simply making an observation about the interesting adjective you applied to a plan with a $10K deductible. </p>