<p>My employer’s benefits director is swamped, can’t keep up with changes, and never knows the internals of plans. Our only saving grace is that we always hit the maximum out-of-pocket early in the year, and then we pay nothing. But I think the major impact of that (globally) is that hospitals, doctors, surgeons, etc., can pretty much get away with charging what they want, and then they get involved in endless fights with the insurance company - in which they try (but don’t succeed) to involve us.</p>
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<p>What business isn’t trying to make money?</p>
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<p>I think you need to look at it the other way first. The insurance companies choose what they want to pay so the provider has to inflate prices. 75% of $200 is more than 75% of $150… And those providers have their bills to pay too…</p>
<p>Best healthcare on the planet; worst healthcare system on the planet . . . .</p>
<p>We’ve had excellent care and service from UHC though they are just one of the benefits managers for our company - we self-insure and that may make some difference.</p>
<p>My employer’s benefits director is swamped, can’t keep up with changes, and never knows the internals of plans.</p>
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<p>Do they have a benefits consultant mini? That is what the firm I work for does … we help the benefits manager when necessary. If your company has a broker/consultant, the benefits manager should use them & get his/her money’s worth.</p>
<p>We’ve had excellent care and service from UHC though they are just one of the benefits managers for our company - we self-insure and that may make some difference. </p>
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<p>That can make a difference, since the plan decides what to cover … but they are still beholden to UHC’s general rules/regulations. Self insured plan managers very often are more on top of claims administration than when the plan is fully insured, though.</p>
<p>Insurance companies can tell you how much costs will be up front, or at least, ball park. Just get the CPT code for the procedure and give them a call. If you have Aetna you can even look up procedures on their website.</p>
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<p>What hospitals and docs charge is for the most part irrelevant because if they’re a participating provider, which is usually the case, they’re bound to accept the fee schedule that’s agreed upon, and are forced to adjust off the excess charge. For self-pays, what’s charged is also a moot point because there is so much written off anyway because of inability to pay.</p>
<p>The place where we are out of control is over the amount & type of treatment that is done for a condition (usually in outpatient settings), and there’s no magic bullet.</p>
<p>One thing about UHC - in the last year or so, they have very aggressively begun audits of claims, requiring supporting documentation, in far greater proportion than other insurers.</p>
<p>Like VeryHappy said, It is the best of healthcare, it is the worst of healthcare; the former for those who can afford, the latter for those who cannot. A tale of two groups of people, yet one country. A country at or near the bottom among first-world nations in a variety of healthcare indicators, including cost (per capita or as % of GDP), % of citizens with basic healthcare or better, infant mortality rates, efficiency (% of healthcare system dollars actually spent on healthcare), and the list goes on. And related to the thread title, a country practically alone in the use of for-profit health insurance providers.</p>
<p>^^ Absolutely alone as far as I know. There’s no place else in the developed world where you can go bankrupt from an illness. It’s barbaric.</p>
<p>World New Tonight (Monday) ran a story about the tremendous cost disparities routinely charged by hospitals for basically identical procedures. Same hospitals. Same procedures. Wildly different costs. Here’s a link to video of the report:
[Medical</a> Costs Vary Wildly From Hospital to Hospital, Says Study - ABC News](<a href=“Patients in the Dark on Medical Costs, Study Finds - ABC News”>Patients in the Dark on Medical Costs, Study Finds - ABC News)
It’s illuminating. And infuriating!</p>
<p>fignewton, that’s actually not what I said. We have the best medical care – but the worst system of getting it paid for.</p>
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<p>Except that they are not complying with this nicety any more. They take the agreed upon in-network amount from the insurer, then turn around and have bill collection agencies hound the patients/consumers to pay more. It is going on more and more. The patient then has to figure out if their credit rating will be damaged by insisting that the providers accept the in-network fees. Many capitulate. Many are busy with their own jobs and it becomes a full time job to navigate the labyrinth of bills, payers, providers, etc.</p>
<p>We need to get some really good minds at work to come up with a better payment model. One that encourages us to be careful with our usage. We want people to take care of their health, but not overuse services.</p>
<p>People could be asked to pay more for optional services, fancier equipment, etc. If people had the choice, they might forego some non-critical services. As it stands now, we don’t even know how to make the decision.</p>
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<p>I haven’t seen this yet. I think that the insurers would drop hospitals or doctors if they heard about this. UHC sends us a letter (maybe it’s an email now) when we get a service (or when they get a bill), basically asking us if we really received a service. UHC has received duplicate billings from some providers for the same service and lets us know when it happens. Sometimes, the second billing is a year or two after the service is performed and paid for. I don’t know if it’s bad recordkeeping or sending a bill that you’ll pay because you think that you may have forgotten to pay it and you wouldn’t be able to find it in your records if you looked.</p>
<p>I agree on being careful with usage - but it’s already such a pain to schedule appointments when working full-time.</p>
<p>“Except that they are not complying with this nicety any more.”</p>
<p>I ran into a variation of this for the first time last year. I was referred to a specialist, who immediately sent me a bill, payable at the desk prior to seeing him. I thought it was a mistake, so I called. No mistake. Patient pays prior to service and then negotiates with the insurance carrier for reimbursement. I canceled.</p>
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<p>Some states have legislation that prohibits providers from balance billing. We have it in MA. I believe there are other states as well. </p>
<p>I think a big issue in health care is to determine what a particular medical procedure “really costs”. I thought this news report on the findings of new study on cost variations across hospitals was quite interesting. Here’s the story I heard.</p>
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<p>Except that they are not complying with this nicety any more. They take the agreed upon in-network amount from the insurer, then turn around and have bill collection agencies hound the patients/consumers to pay more. It is going on more and more. The patient then has to figure out if their credit rating will be damaged by insisting that the providers accept the in-network fees. Many capitulate. Many are busy with their own jobs and it becomes a full time job to navigate the labyrinth of bills, payers, providers, etc. </p>
<p><a href=“http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/U/PDF%20UnexpectedChargesStatesAndBalanceBilling.pdf[/url]”>http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/U/PDF%20UnexpectedChargesStatesAndBalanceBilling.pdf</a></p>
<p>I think that this document is a few years old but it’s an interesting read on this practice. I haven’t seen it personally but I’ll watch for it.</p>
<p>Our dentist charges more than R&C but he has technology that only one other dentist in the state has so I’ve always paid the difference for his services. That’s a choice that we make - not something unexpected.</p>
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<p>My mother-in-law had more complex surgery than that appendectomy a few years ago and the surgery + three or four days in the hospital was something like $1,000 or $2,000 which was paid for out of pocket.</p>
<p>This was in Malaysia.</p>
<p>“We have the best medical care…”</p>
<p>I have seen diabetic care up close in the U.S. and in Chennai, India. It isn’t even close. (It’s far better in Chennai. Far better monitoring. Every appointment includes a nutrition component. Everything from footcare to eyes dealt with in a single appointment at a single location. Pharmacy on site - and they check drug interactions before dispensing any meds. Anyone who thinks that the “best care” is here hasn’t been around much these days.)</p>
<p>The best treatment for diabetes is prevention.</p>
<p>A good tennis friend of mine knew all about nutrition, exercise, and diet. Yet he was very heavy for the past two decades. He had tried surgery to reduce his weight and it worked for a while. He was diagnosed with diabetes late in 2011 and he immediately went on a diet and exercise program and lost 30 pounds in a few months. He and I both know that his diabetes was completely preventable. I told him how I lost weight and he knew everything that I did about diet and nutrition. He just didn’t act on it until it was too late.</p>
<p>He has more weight to lose and his immediate goal is to get off the medication that he’s on for it. Unfortunately, the US is not winning the battle on prevention.</p>
<p>The whole system is messed up, and has been for many years (I debated health care policy back in the late 70’s, when HMO’s were supposed to be the magic bullet). There is no doubt the system is inefficient and one of the problems is it is fragmented, it is regulated by the states while the health insurers are national, and health care treatment by its very nature is resistant to things like increases productivity to bring down costs (basically medical care is a custom service, because every case can be different, and it requires individual service that isn’t efficient…how do you mass do medical care? Maybe computer based electronic systems that scan and proscribe? I suspect the AMA wouldn’t like that too much).</p>
<p>The free market seems like a great idea, but with health insurance, for example, you don’t enter the field as a start up, because you need large resources to enter the field. And between medical procedures and outcomes being unknown, how do you compete on costs? How could a doctor be like earl Scheib and say “Heart problems? Bypass surgery, 10,000 dollars, any person, any time”…it doesn’t work. I have seen some point to things like laser eye surgery and dental implants, where they advertise set prices, or boob jobs and tummy tucks and such and then point to that as showing the market at work. What they leave out is of all medical procedures, those are ones that are serialized, doing breast implants or a nose job or a tummy tuck or dental implants tends to be standard, which most medicine is not…would a cancer center ever advertise “we will treat breast cancer, 10,000 dollars” or even give you a valid estimate, when there is no way to know how long or what in the end will work (or not…). </p>
<p>State regulation of insurance companies is a problem. There are very few health insurance companies in any given region, generally there are maybe 3 or 4 big providers in any market and they know that. If a state makes a regulation, for example, that says a women cannot be discharged the next day after having a baby, health insurers will threaten to pull out of the state, and often it means legislation gets canned. If regulation is done nationally, the health insurers can’t pull tricks like that; likewise, health insurers can do things like refuse to pay for things that should be covered, and have the patient end up paying the cost which of course makes them more money…and even if the state protects against that, they often ignore the regulation…if these things were federal, what would they do, threaten to leave the US? </p>
<p>Want another cute one? I went in several years ago for gall bladder surgery. The hospital was in network, and they assigned the doctors that treated me. Being part of the network, they are supposed to use doctors in the network, but guess what? At least one of the doctors was out of network, and i ended up paying several thousands of dollars because of that, and when I complained to the health insurance company, they told me to talk to the hospital…because frankly they didn’t care, saved them money. I had a schmuck doctor in their network do an evaluation on something that might or might not be covered by the plan (it could be considered either reconstructive surgery or cosmetic, the latter not covered), the doctor told me it wasn’t covered, got a fee out of me for the evaluation, but then had the B***s to bill the insurance company…and the health insurance company said that’s my problem (even though he billed them as well)…</p>
<p>There is an article in Today’s times that talks about another scam, the reasonable and customary costs used in out of network billing. The HI companies agreed to establish a comprehensive database of reasonable and customary costs, by region…and guess what? They don’t use it, instead they are using medicare re-imbursement rates, which is a joke.
<a href=“Health Insurers Switch Baseline for Out-of-Network Charges - The New York Times”>Health Insurers Switch Baseline for Out-of-Network Charges - The New York Times; And guess who pays?</p>
<p>I remember when they passed the banking bills, and all the people bloviating on talk radio were saying this was needed, that people filing for bankruptcy were people who had run up credit cards to buy expensive things, loans for expensive cars, etc, etc…when in reality, most bankruptcies by far are due to medical bills. </p>
<p>As far as the CEO of United Healthcare making 46 million, poor baby, not too many years ago he made 100 million. That too is part of the problem, CEO compensation these days is based on stock price, which in turn is based on what stock analysts say (think some 26 year old snot nosed kid out of wharton or harvard actually care what health insurers are doing to their client? All they care about is how many numbers they like on the balance sheet…). One of the things you are seeing with insurance companies across the board is they have shifted their model of revenue as well. Once upon a time most insurance companies, if you compared premiums to payouts, were neutral (i.e payouts=premium revenue) or even negative (payouts > revenue), but they didn’t care because insurance companies made their money investing the ‘float’ (money not currently owed in claims) in the markets. With the crash in markets, health insurers are using a different model. They are now operating where they want to make 20% more in premiums then they pay out, and to do so they have been raising rates higher then inflation and also doing everything they can to deny payout.</p>
<p>I don’t know what the answer is, but where we are heading is where health care once was, if you were well off you paid for it, if you didn’t you better hope you can find someone willing to treat you and accept whatever you can pay. Too many hands in the pot, too many conflicting interests, and I don’t buy that it is the fault of the consumer, and I find that also asinine. If I want to get a car repaired, I can shop around, get estimates and have them do it, but if you have cancer, heart disease, etc, would you settle for the guy who gives you the lowest cost and perhaps cost you your life, of the guy who has shown results?</p>