AMA: Insurance industry consolidation is "unhelpful" to patients

[Winehole23]

Health Insurance Competition Vanishing: Study
(http://www.usnews.com/health/managing-your-healthcare/insurance/articles/2010/02/25/health-insurance-competition-vanishing-study.html)
Consolidation has not helped patients, says AMA president



THURSDAY, Feb. 25 (HealthDay News) -- Competition in the health insurance industry (http://www.usnews.com/health/managing-your-healthcare/insurance/articles/2010/02/25/health-insurance-competition-vanishing-study.html#) is vanishing, according to an American Medical Association report that looked at data from 43 states and 313 metropolitan markets.


http://s0.2mdn.net/viewad/817-grey.gif (http://ad.doubleclick.net/click;h=v8/3977/0/0/%2a/y;44306;0-0;0;46268512;32414-468/648;0/0/0;;%7Eokv=;kw=HealthDay;kw=healthinsurance;kw=insu rance;kw=health;sz=468x648;tile=2;pos=xxlA;%7Eaopt =2/1/50/0;%7Esscs=%3f)

In 24 of the states, the two largest insurers had a combined market share (http://www.usnews.com/health/managing-your-healthcare/insurance/articles/2010/02/25/health-insurance-competition-vanishing-study.html#) of 70 percent or more. Last year, 18 of 42 states had that type of market situation.


Among the other findings:


In 54 percent of metropolitan markets, at least one insurer had a market share of 50 percent or more -- up from 40 percent of metropolitan markets the year before.
In 92 percent of metropolitan markets, at least one insurer had a share of 30 percent or more -- up from 89 percent of metropolitan markets the year before.
Ninety-nine percent of metropolitan markets are highly concentrated, according to federal merger guidelines, compared with 94 percent the year before.

The report, Competition in Health Insurance: A Comprehensive Study of U.S. Markets, was released this week.


"The near total collapse of competitive and dynamic health insurance markets has not helped patients," AMA President Dr. J. James Rohack said in a new release. "As demonstrated by proposed rate hikes in California and other states, health insurers have not shown greater efficiency and lower health care costs. Instead, patient premiums, deductibles and co-payments have soared without an increase in benefits in these increasingly consolidated markets."


Rohack added that a lack of competition in the health insurance industry (http://www.usnews.com/health/managing-your-healthcare/insurance/articles/2010/02/25/health-insurance-competition-vanishing-study.html#) "is clearly not in the best economic interest of patients," and the AMA wants the U.S. Department of Justice and state agencies "to more aggressively enforce antitrust laws that prohibit harmful mergers."

The AMA also wants the Department of Justice to consider the following measures: a retrospective study of health insurance mergers; research to identify the causes and consequences of health insurance market power; and creation of a system for predicting the effects that health insurance company (http://www.usnews.com/health/managing-your-healthcare/insurance/articles/2010/02/25/health-insurance-competition-vanishing-study.html#) mergers will have on patients and health care providers.

[LnGrrrR]

Obviously, this is because of the health care bill.

/republicans

[Winehole23]

Health insurance reform as passed isn't likely to break the trend and may even help it along.

Why we put all our eggs in the basket of a middleman which is failing in its job as an intermediary (to use its clout to negotiate "regulatory bargains" on our behalf), is more than a little perplexing, if bringing down health care costs was the contemplated end.

In retrospect, I tend to doubt it was.

[boutons_deux]

"if bringing down health care costs was the contemplated end"

There is no serious effort of bringing down health care costs, because serious effort on costs would have meant a serious effort on health care industry profits. Harry-and-Louise would have been resurrected to kill the bill.

There are $Bs being made from the inefficiencies, over-treatment, and general insanities of the US health care. Any effort at reducing the $Bs will be met with 100 of $Ms of counter-effort, primarily buying comparatively cheap Congress votes.

[Winehole23]

I seldom agree with you, b_d, but in a broad sort of way I can go along with that.

[Winehole23]

Judge may rule by tomorrow on insurance dispute (http://www.boston.com/business/ticker/2010/04/judge_may_rule.html)

April 8, 2010 01:10 PM

By Robert Weisman


A Suffolk Superior Court judge today adjourned a two-hour hearing without ruling on a request by six Massachusetts health insurers to reinstate premium rate increases rejected by the state last week.



Judge Stephen E. Neel said he expected to rule by tomorrow or Monday on the insurers' request for a preliminary injunction that would allow them to go ahead with charging higher rates for individuals and small businesses.



Insurance commissioner Joseph G. Murphy's decision to reject the double-digit rate increases was "arbitrary and capricious," said Dean Richlin, an attorney representing the health insurers.


"Insurers are required either to submit to confiscatory rates or to go out of business," he said.


But assistant attorney general David Guberman said the court had no jurisdiction in the case because the insurers had not exhausted the administrative appeals process within the state division of insurance.



Last week, the state Division of Insurance rejected insurers' proposed base rate increases for individuals and small businesses averaging 8 to 32 percent, in what is known as the small group market. The category includes about 800,000 Massachusetts residents.


Prior to the state turning down the higher rates, the insurance companies posted them on the Commonwealth Health Insurance Connector Authority's website, www.mahealthconnector.org (http://www.mahealthconnector.org). The site was set up under the 2006 Massachusetts health care overhaul to help residents buy insurance. After the state refused to accept the higher rates, it ordered insurers to pull them from the site. The new rates were supposed to take effect April 1.


As a result of the standoff between the state and insurers, residents and small businesses shopping for insurance, as well as those seeking to buy new policies, have been unable to get quotes for new coverage this week.


Yesterday, Blue Cross Blue Shield of Massachusetts -- the state's largest health insurer -- and Tufts Health Plan said they will, as ordered by the Division of Insurance, resume making new policies available for the small group market -- using last year's base rates, not the requested double-digit increases rejected the state rejected. The companies said they were not sure the new prices will be ready by tomorrow, as the state wants.



Harvard Pilgrim Health Care and Fallon Community Health Plan have not committed to offering new rates by tomorrow -- despite the insurance commissioner's stern warning that the law requires them to do so.

[Wild Cobra]

Is everyone looking forward to these problems to go nation wide?

[boutons_deux]

"these problems to go nation wide"

lack of health-insurance competition is already nation-wide.

[Winehole23]

Private equity investors compromise public health and medical practice for profit.


MedPage Today (https://www.medpagetoday.com/opinion/second-opinions/93615): “Private Equity Is Ruining American Healthcare”

For-profit insurance companies have long been regarded as the ultimate offenders in medical -profiteering. However they distract from the goal of providing healthcare, it is the unscrupulous involvement of private equity (PE) in medicine, a similarly culpable and even more insidious economic titan.


In May 2021, an American Antitrust Institute white paper (https://www.antitrustinstitute.org/work-product/study-finds-private-equity-investment-accelerates-concentration-and-undermines-a-stable-competitive-healthcare-industry/) found private equity investment accelerates consolidation and “is fundamentally incompatible with a stable, competitive healthcare system serving patients and promoting the well-being of the population.”


The rise of private equity in medicine has resulted in a proxy war against insurance companies exclusively for the benefit of clandestine shareholders and investment fund managers rather than patients or clinicians.
https://www.nakedcapitalism.com/2021/07/private-equity-now-buying-up-primary-care-practices.html

[Winehole23]

PE is a unique and unregulated investment platform with the objective of aggressively generating short-term revenue for the firm and its investors without regard for long-term value to society, including public health much less the people of the organization.


PE firms typically operate on a 3 to 7-year cycle for the acquired company by an investment manager with funds from “limited partners” who can be institutional investors also. The company can be acquired in a leveraged buyout from which the resulting transaction saddles the company with high-interest debt needing to be paid back. The company bears the full risk of failure to become more profitable. A typical and ruthless tactic to insure profits is cost-cutting and personnel layoffs which cuts into the capabilities of the company.

In any case and regardless of outcome, the PE firm and manager become significantly wealthier due to exorbitant fees on such as assets under management.

[Winehole23]

If billing transparency would tend to expose ER docs to fraud charges, the clear implication is that the companies in charge of ER billing are routinely adding phony charges.



Private equity firms have spent hundreds of millions of dollars convincing emergency room doctors and patients that they are all on the same team, fighting the greed of evil insurance companies. But in a remarkable “saying the quiet part out loud” moment, the major professional organization representing emergency physicians just admitted that private equity greed may be leaving the ER doctors vulnerable to criminal fraud charges.

The admission came in a document (https://docs.google.com/document/d/1IDO-gQrtqMZ272xZHyj8tGKJpvhYvFdx/edit?fbclid=IwAR3SoeNI30nQlpVpuQWDxjC9-Ox-PQg9K6QSTi16Uf3lCj5b9qETzHwfWYs) the board of the American College of Emergency Physicians (ACEP) circulated to its roughly 400-member council in advance of its annual conference, which began earlier this week in Boston. Robert McNamara (https://medicine.temple.edu/robert-mcnamara), a Temple University medical school professor who has been working for decades to galvanize ER doctors in opposition to the “corporate practice of medicine,” had proposed a resolution that would essentially force all ER staffing companies seeking to do business with ACEP to periodically furnish their physicians with data on the services and procedures the company had billed for under their license numbers.

Buried in the middle of the otherwise mundane memo on past resolutions, the board addressed McNamara’s proposal. Unsurprisingly, the Board expressed extreme reluctance to adopting the proposal, noting that four separate attorneys it had consulted believed there was “substantial risk to implementing the resolution as written.” The ACEP brass had previously cited the (dubious) threat that forcing transparency could somehow invite an antitrust lawsuit, but this time they provided a new and eyebrow-raising concern.

“ACEP engaged outside counsel to advise on whether securing regular reporting of billing in a physician's name could inadvertently subject that physician to potential liability under the False Claims Act [emphasis added], since provision of this information could now leave them considered to be ‘knowing,’” they wrote.

In other words: emergency room doctors are better off not knowing what their private equity overlords are billing under their license numbers, because they are less likely to go to jail for Medicare fraud if they didn’t actually know they were committing it.
https://www.dailyposter.com/er-organization-admits-to-the-evils-of-private-equity/

[Winehole23]

“If emergency physicians saw what was being billed in their name they would be shocked,” McNamara says. “We know that these companies are regularly charging nine times the Medicare reimbursement rate, and we know we aren’t making that kind of money, but we don’t know what’s actually being charged in our names,.”

[Winehole23]

“What we should really be getting angry about is the fact that those same insurance companies we demonize are actually subsidizing the expansion of private equity controlled medicine, by giving companies like Team Health and Envision far higher reimbursement rates than independent practices,” says McNamara.

Indeed, a seminal research paper (https://www.nber.org/system/files/working_papers/w23623/w23623.pdf)on surprise ER billing found that hospitals that outsourced ERs services to Envision saw their charges for the same procedures immediately double, and that private insurers pay ER doctors a far higher average multiple of Medicare rates than their counterparts in virtually every other medical specialty.

“Physicians have no idea the insurance companies are paying them so much,” explains McNamara, “because they don’t see any of that money.”

[Winehole23]

The profit motive screws patients and delivers substandard care.


The email to the health care workers was like something out of “The Wolf of Wall Street.” “We are in the last few days of the month and are only 217 appointments away from meeting our budget,” the August 2020 memo stated. “Don’t forget the August bonus incentive for all patients scheduled in August! That’s the easiest money you can make. Get that money!!”
The “Get that money!!” entreaty wasn’t addressed to a bunch of hard-charging, coke-snorting stockbrokers. It went to Michigan-based employees of Pinnacle Dermatology, a private equity-owned group of 90 dermatology practices across America.



The memo was shared with NBC News by a former Pinnacle employee, Dr. Allison Brown, a board-certified dermatologist and dermatopathologist. Brown says Pinnacle terminated her shortly after she advised management of questionable practices that she contends were hurting patients.


Among the practices Brown alleges: overlooked diagnoses, lost patient biopsies, questionable quality control in the company-owned lab and overbooking of patients without sufficient support staff.
https://www.nbcnews.com/health/health-care/get-money-dermatologist-says-patient-care-suffered-private-equity-back-rcna9152

[Winehole23]

Focus back on insurers: employer based plans mean lost wages for employees


The... excessive cost of health care is largely absorbed by employer-based plans that insure approximately 160 million Americans. That these health plans are funded by employees’ lost wages (“lost” because this money would otherwise be paid to workers), Case and Deaton argue, substantially explains decades of lost jobs and stagnant wages particularly hard felt among lower-wage workers. Beyond the negative effect excessive costs have on care, the burden on low-wage workers constitutes a reverse Robin Hood effect that exacerbates already substantial economic inequality. As Case and Deaton conclude, “the industry that is supposed to improve our health is undermining it” and “our government is complicit.”https://www.statnews.com/2021/12/29/deaths-of-despair-unrecognized-tragedy-working-class-immiseration/

[SnakeBoy]

The profit motive screws patients and delivers substandard care.

https://www.nbcnews.com/health/health-care/get-money-dermatologist-says-patient-care-suffered-private-equity-back-rcna9152

Corporate medicine sucks for the pt and the Dr.

The solution is booming tho
https://www.yahoo.com/lifestyle/biggest-perks-concierge-medicine-works-232327341.html

[DMC]

ST Left: Employer provided HC coverage doesn't work!
also
ST Left: ICUs are overrun with patients! Hospitals at their breaking points!

Conclusion: If we just had socialized medicine where everyone could go to the hospital without concern for cost, there'd be so much more available ICU space and hospitals wouldn't be stuffed to the breaking points.

:lol ST Left

[ElNono]

ST Left: Employer provided HC coverage doesn't work!
also
ST Left: ICUs are overrun with patients! Hospitals at their breaking points!

Conclusion: If we just had socialized medicine where everyone could go to the hospital without concern for cost, there'd be so much more available ICU space and hospitals wouldn't be stuffed to the breaking points.

:lol ST Left

Not really. You would just be able to go to the doctor regularly and discover/fix problems before they get so bad that you have to hit the ER. This is not theoretical either, see:

While the discussion about the health of citizens in the US and EU is a topic for another time, we can compare stats about how emergency medicine is handled across borders using several notable studies .

To begin with a big issue, the US has the highest rate of deaths which could be avoided by routine healthcare interventions compared to those in the EU.

https://www.duvasawko.com/us-healthcare-system-compared-to-other-countries/

[ChumpDumper]

DMC: HURR-DURR THE LEFT

The Left: lol

[DMC]

Not really. You would just be able to go to the doctor regularly and discover/fix problems before they get so bad that you have to hit the ER. This is not theoretical either, see:

While the discussion about the health of citizens in the US and EU is a topic for another time, we can compare stats about how emergency medicine is handled across borders using several notable studies .

To begin with a big issue, the US has the highest rate of deaths which could be avoided by routine healthcare interventions compared to those in the EU.

https://www.duvasawko.com/us-healthcare-system-compared-to-other-countries/

If COVID is the cause of overcrowding and "elective" care is denied due to it, how would these people be better off? In fact, the people in the ICUs are there largely due to COVID (so the narrative goes) so how would catching it earlier have prevented that (never mind the insane wait times for medical care in other countries).

Do these avoidable death people choose to not be seen? It's like pulling teeth to get older people to do routine checkups. It's not because of the cost, but because of the fear of what will be found coupled with the inconvenience of going and the fact that the PCP is a pusher who just wants to fill their night stand with copious amounts of scripts they don't actually need.

[ElNono]

If COVID is the cause of overcrowding and "elective" care is denied due to it, how would these people be better off? In fact, the people in the ICUs are there largely due to COVID (so the narrative goes) so how would catching it earlier have prevented that (never mind the insane wait times for medical care in other countries).

Do these avoidable death people choose to not be seen? It's like pulling teeth to get older people to do routine checkups. It's not because of the cost, but because of the fear of what will be found coupled with the inconvenience of going and the fact that the PCP is a pusher who just wants to fill their night stand with copious amounts of scripts they don't actually need.

But you weren’t talking about COVID, you were talking about employee sponsored healthcare.

And I disagree, cost plays a significant role. Even for a good chunk insured people, high deductibles means paying out of pocket for initial visits and followups. Another factor is actually requesting and getting the time off. And yet another factor is some insurances demanding that you visit an in-network doctor or foot a chunk of the bill. Then there’s copays… and all that is if you’re insured at all.

COVID is a health emergency, and everybody understand it as such. That’s why you don’t get charged for vaccines, for example. Though if you do end up hospitalized and you don’t have solid insurance, good luck.

[DMC]

But you weren’t talking about COVID, you were talking about employee sponsored healthcare.

And I disagree, cost plays a significant role. Even for a good chunk insured people, high deductibles means paying out of pocket for initial visits and followups. Another factor is actually requesting and getting the time off. And yet another factor is some insurances demanding that you visit an in-network doctor or foot a chunk of the bill. Then there’s copays… and all that is if you’re insured at all.

COVID is a health emergency, and everybody understand it as such. That’s why you don’t get charged for vaccines, for example. Though if you do end up hospitalized and you don’t have solid insurance, good luck.

Since people with health insurance fill up the available spaces already, how does free HC for all even make sense? There wouldn't magically be open ICUs suddenly. Hospital waiting rooms wouldn't suddenly be empty. They'd be even more full of kids with runny noses and every other person dragging the entire family in for testing weekly.

Not sure you remember but there was a time when there was no copay for emergency room visits (but there was a copay for PCP visits). People would simply not go to their doctors for small shit, they'd go to the emergency room because it was free. Then insurance companies wised up a bit and set a copay for ER visits, even a modest one like 25 dollars at the time (more now). That stopped most of it right away. Where you'd see whole families in waiting rooms during any visit, you now saw only people who had emergencies (for the most part).

You cannot convince me that 25 dollars made the difference between needing emergency care and being able to wait. Socialized medicine is that free ER especially if the PCP has a waiting list.

I'm all for free shit for everyone but it's not really free. It's just free to them.

I walked into a hospital in Australia just like that, stuffed with people with runny noses and sore fingers and shit. The attending told me it was like that every day because it was free to them. They'd often see the same family a couple times a week.

[ElNono]

Since people with health insurance fill up the available spaces already, how does free HC for all even make sense? There wouldn't magically be open ICUs suddenly. Hospital waiting rooms wouldn't suddenly be empty. They'd be even more full of kids with runny noses and every other person dragging the entire family in for testing weekly.

Not sure you remember but there was a time when there was no copay for emergency room visits (but there was a copay for PCP visits). People would simply not go to their doctors for small shit, they'd go to the emergency room because it was free. Then insurance companies wised up a bit and set a copay for ER visits, even a modest one like 25 dollars at the time (more now). That stopped most of it right away. Where you'd see whole families in waiting rooms during any visit, you now saw only people who had emergencies (for the most part).

You cannot convince me that 25 dollars made the difference between needing emergency care and being able to wait. Socialized medicine is that free ER especially if the PCP has a waiting list.

I'm all for free shit for everyone but it's not really free. It's just free to them.

I walked into a hospital in Australia just like that, stuffed with people with runny noses and sore fingers and shit. The attending told me it was like that every day because it was free to them. They'd often see the same family a couple times a week.

I’ve been in 4 different countries with government-covered HC (Buenos Aires, São Paulo, Paris, Alberta) where I made visits to doctors and/or hospitals for different reasons, and it works. I suspect the NIH in the UK is not much different as well. I’m pretty sure they all have different models and different standards of care, but right now the US actually spends more money in healthcare per capita than they do, while they provide very close to full coverage.

Now if your argument is that a change like that would also require a cultural shift in the US, I agree, and it probably wouldn’t be overnight as well. In January 1st, a new law here in the US kicks in that prevents ‘surprise’ billing from out of network providers, which apparently are so common that we need a law to stop that. It’s another band-aid that comes too late to a system that’s uniquely expensive and broken.

We discussed this topic over the years a million times, and at some point when we go down the rabbit hole we all end up on the same spot: the reason we have Medicaid, or Reagan’s law that hospitals can’t turn away patients, is that the profit motive sometimes simply doesn’t align with what’s best for patients. Before the law, hospitals would load up sick people into busses or actual chopper and ship them out of town. That’s actually what triggered that law.

At some point we have to face the fact that for some things, there’s more than just the profit motive (we already recognize that it the military, for example, where NatSec prevails over making a buck). Healthcare is not different, you’re either ok with poor people dying on the street (political suicide) or just stop with the pretense that the free market will suddenly have a solution to this specific problem when it never has.

[DMC]

I’ve been in 4 different countries with government-covered HC (Buenos Aires, São Paulo, Paris, Alberta) where I made visits to doctors and/or hospitals for different reasons, and it works. I suspect the NIH in the UK is not much different as well. I’m pretty sure they all have different models and different standards of care, but right now the US actually spends more money in healthcare per capita than they do, while they provide very close to full coverage.

Now if your argument is that a change like that would also require a cultural shift in the US, I agree, and it probably wouldn’t be overnight as well. In January 1st, a new law here in the US kicks in that prevents ‘surprise’ billing from out of network providers, which apparently are so common that we need a law to stop that. It’s another band-aid that comes too late to a system that’s uniquely expensive and broken.

We discussed this topic over the years a million times, and at some point when we go down the rabbit hole we all end up on the same spot: the reason we have Medicaid, or Reagan’s law that hospitals can’t turn away patients, is that the profit motive sometimes simply doesn’t align with what’s best for patients. Before the law, hospitals would load up sick people into busses or actual chopper and ship them out of town. That’s actually what triggered that law.

At some point we have to face the fact that for some things, there’s more than just the profit motive (we already recognize that it the military, for example, where NatSec prevails over making a buck). Healthcare is not different, you’re either ok with poor people dying on the street (political suicide) or just stop with the pretense that the free market will suddenly have a solution to this specific problem when it never has.

Per capita :lol

Why do I care about per capita? That's just saying person A pays for person B and the per capita is they paid the same amount.

About medicaid

Payer Trends
Previous analyses have shown that utilization of the ED is also related to insurance coverage (for
instance, Sun et al. 2018 and National Center for Health Statistics 2019 are two examples). Adults under
the age of 65 with Medicaid were approximately twice as likely to report having gone to the ED in the
past year compared to those who are privately insured (National Center for Health Statistics 2019).

Previous work has shown that between 2006 and 2015, the share of ED visits for children was highest
among those with Medicaid and increased substantially, while the share covered by private insurance
declined. Similarly, among adults 18-64, the share of ED visits covered by private insurance decreased
and the share covered by Medicaid increased for most years between 2006 and 2015 (Sun et al. 2018;
Moore et al. 2017).

[ElNono]

No, per capita means dividing the entire price tag over your country’s population. That’s how you compare costs between countries with disimilar amount of population. How else would you compare it?

[ElNono]

Per capita :lol

Why do I care about per capita? That's just saying person A pays for person B and the per capita is they paid the same amount.

About medicaid

Payer Trends
Previous analyses have shown that utilization of the ED is also related to insurance coverage (for
instance, Sun et al. 2018 and National Center for Health Statistics 2019 are two examples). Adults under
the age of 65 with Medicaid were approximately twice as likely to report having gone to the ED in the
past year compared to those who are privately insured (National Center for Health Statistics 2019).

Previous work has shown that between 2006 and 2015, the share of ED visits for children was highest
among those with Medicaid and increased substantially, while the share covered by private insurance
declined. Similarly, among adults 18-64, the share of ED visits covered by private insurance decreased
and the share covered by Medicaid increased for most years between 2006 and 2015 (Sun et al. 2018;
Moore et al. 2017).

But that’s the point. The premise is that all of those people needed care (they wouldn’t go to the ER otherwise) but only people with insurance coverage (in this case Medicaid) are more likely to go (hence, healthcare cost is indeed a big factor, since all insurance does is cover costs).

Qualifying for Medicaid is also not simple unless you’re really poor (this is largely because States foot a part of the bill), and unlike Medicare, they can actually seize assets to recover payments later on. Another reason people avoid enrolling in Medicaid if possible.

[DMC]

But that’s the point. The premise is that all of those people needed care (they wouldn’t go to the ER otherwise) but only people with insurance coverage (in this case Medicaid) are more likely to go (hence, healthcare cost is indeed a big factor, since all insurance does is cover costs).

Qualifying for Medicaid is also not simple unless you’re really poor (this is largely because States foot a part of the bill), and unlike Medicare, they can actually seize assets to recover payments later on. Another reason people avoid enrolling in Medicaid if possible.

So you're saying people on medicaid need more medical care than people not on medicaid? The article seems to indicate that people on medicaid typically don't engage in preventive care, and only go to the ER because they feel it's a one stop shop, so lack of education as well.

How does putting the entire nation on medicaid resolve that?

[ElNono]

So you're saying people on medicaid need more medical care than people not on medicaid? The article seems to indicate that people on medicaid typically don't engage in preventive care, and only go to the ER because they feel it's a one stop shop, so lack of education as well.

How does putting the entire nation on medicaid resolve that?

Well, of course it is, people don’t sign up for Medicaid unless they really need the help, which normally happens when they’re already in the ER and in trouble.

Nobody I know suggested putting the nation on Medicaid, but having an option to buy into MediCARE. That’s generally what a ‘public option’ means.

[DMC]

Well, of course it is, people don’t sign up for Medicaid unless they really need the help, which normally happens when they’re already in the ER and in trouble.

Nobody I know suggested putting the nation on Medicaid, but having an option to buy into MediCARE. That’s generally what a ‘public option’ means.

I'm not suggesting people on medicaid should buy insurance. I am suggesting putting everyone one medicaid basically lowers the standard of care, it doesn't help those already on medicaid. The standard of care has to be lower because there are more people using it more often for things they could otherwise see their PCP for. Cost is cost, ER or PCP but the ER is a mission critical component of the hospital, it's not really a doc in a box clinic like you see in strip centers.

[ElNono]

I'm not suggesting people on medicaid should buy insurance. I am suggesting putting everyone one medicaid basically lowers the standard of care, it doesn't help those already on medicaid. The standard of care has to be lower because there are more people using it more often for things they could otherwise see their PCP for. Cost is cost, ER or PCP but the ER is a mission critical component of the hospital, it's not really a doc in a box clinic like you see in strip centers.

What PCP? 1 in 4 Americans don’t have one and that’s been on the decline as well (https://mobile.reuters.com/article/amp/idUSKBN1YK1Z4). Plus, sometimes it takes a month or more to get an appointment. This gets tilted further by the in-network/out-of-network nonsense, which reduces the pool of medical professionals you can go see.

If you do have one, something as simple as an infection can go from the doctor phoning in a prescription to your pharmacy without seeing you, to the guy that wants to charge the $150 for the visit. This is also where employment-based insurance can kick you in the ass and has even happened to my wife: you find a good doctor you’re comfortable with, but you switch jobs and suddenly this guy is out of network and you have to go hunting for a decent doctor again. That kind of shit is truly an America-only issue.

[DMC]

What PCP? 1 in 4 Americans don’t have one and that’s been on the decline as well (https://mobile.reuters.com/article/amp/idUSKBN1YK1Z4). Plus, sometimes it takes a month or more to get an appointment. This gets tilted further by the in-network/out-of-network nonsense, which reduces the pool of medical professionals you can go see.

If you do have one, something as simple as an infection can go from the doctor phoning in a prescription to your pharmacy without seeing you, to the guy that wants to charge the $150 for the visit. This is also where employment-based insurance can kick you in the ass and has even happened to my wife: you find a good doctor you’re comfortable with, but you switch jobs and suddenly this guy is out of network and you have to go hunting for a decent doctor again. That kind of shit is truly an America-only issue.

My point is that people with a PCP don't visit the ER as often. Put everyone on the universal ER waiting room list and that just makes it worse.

I just switched doctors but my daughter is a PA so her office is basically my primary. I used military doctors for a few years. Even with a card for the VA I won't go near it. My older PCP was my doc for 20 years but he was too focused on geriatrics and kids, steroids and antibiotics for everyone. My wife was an insurance administrator for most of her career, I've heard all about it forever.

[RandomGuy]

Corporate medicine sucks for the pt and the Dr.

The solution is booming tho
https://www.yahoo.com/lifestyle/biggest-perks-concierge-medicine-works-232327341.html

You think this is the solution to the problem? Expand on how that would work nationally. Always good to hear well thought out ideas.

[RandomGuy]

ST Left: Employer provided HC coverage doesn't work!
also
ST Left: ICUs are overrun with patients! Hospitals at their breaking points!

Conclusion: If we just had socialized medicine where everyone could go to the hospital without concern for cost, there'd be so much more available ICU space and hospitals wouldn't be stuffed to the breaking points.

:lol ST Left

Economics 101:
Subsidize anything, and you get more provided units than the naked demand/supply would normally dictate.

ST right: HAHA subsidies don't do anything.


:lol ST right

[DMC]

Economics 101:
Subsidize anything, and you get more provided units than the naked demand/supply would normally dictate.

ST right: HAHA subsidies don't do anything.


:lol ST right

Then Medicaid folks should have plenty ICU space. :lol

[ElNono]

My point is that people with a PCP don't visit the ER as often. Put everyone on the universal ER waiting room list and that just makes it worse.

I just switched doctors but my daughter is a PA so her office is basically my primary. I used military doctors for a few years. Even with a card for the VA I won't go near it. My older PCP was my doc for 20 years but he was too focused on geriatrics and kids, steroids and antibiotics for everyone. My wife was an insurance administrator for most of her career, I've heard all about it forever.

There are reasons people here don’t go visit their PCP (if they have one to being with). That’s what I was pointing out. It’s more than one, and include being able to take time off work for preventive care, having to pay out of pocket due to deductibles, not being able to foot the bill for super expensive medications, and others I mentioned before. Some of those things have made people avoid care until it’s an emergency, which at this point is a cultural problem that would also need to change, tbh.

FYI, my wife is an RN. I also worked on medical systems with doctors for many years. Doesn’t mean I know more or less than anybody else, but I’ve seen the nitty gritty of running a practice.

[Winehole23]

https://pbs.twimg.com/media/Fei-k88WQAAaBeq?format=jpg&name=900x900https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html

[Winehole23]

Medicare Advantage is a scam that benefits insurance companies and harms the public.

In return, insurance lobbyists shower the US Congress with campaign cash.



1580538366663147521

1580538369645236224

1580538372073787392

1580538375643144193

[Winehole23]

more PE bill padding shenanigans


KHN reviewed the bills of a dozen patients in five states (https://www.documentcloud.org/documents/22415516-master-file-of-obed-patient-documents?responsive=1&title=1) who said they were hit with surprise emergency charges for being triaged in an OBED while in labor. That included a woman in Grand Junction, Colorado, who said she felt “gaslit” when she had to pay $300 in emergency charges (https://www.documentcloud.org/documents/22415516-master-file-of-obed-patient-documents#document/p7/a2148882) for the care she received in the small room where they confirmed she was in full-term labor. And in Kansas, a family said they were paying $400 for the same services (https://www.documentcloud.org/documents/22415516-master-file-of-obed-patient-documents#document/p19/a2148889), also rendered in a “very tiny” room—even though HCA Healthcare (https://fortune.com/company/hca-holdings), the national for-profit chain that runs the hospital, told KHN (https://www.documentcloud.org/documents/23120698-masterfile-of-company-responses#document/p2/a2157937) that emergency charges are supposed to be waived if the patient is admitted for delivery.


Few of the patients KHN interviewed could recall being told that they were accessing emergency services, nor did they recall entering a space that looked like an emergency room or was marked as one. Insurance denied the charges (https://www.documentcloud.org/documents/22415516-master-file-of-obed-patient-documents#document/p40/a2148897) in some cases. But in others families were left to pay hundreds of dollars (https://www.documentcloud.org/documents/22415516-master-file-of-obed-patient-documents#document/p56/a2148904) for their share of the tab—adding to already large hospital bills. Several patients reported noticing big jumps in cost for their most recent births compared with those of previous children even though they did not notice any changes to the facilities where they delivered.
https://fortune.com/2022/10/12/obstetrics-emergency-departments-private-equity-staffing-hospitals-routine-births/

[Winehole23]

Clara Love and Dr. Jonathan Guerra-Rodríguez, an intensive care unit nurse and an internist, respectively, found a charge for the highest level of emergency care (https://www.documentcloud.org/documents/22415516-master-file-of-obed-patient-documents#document/p23/a2148890) in the bill for their son’s birth. It took months of back-and-forth—and the looming threat of collections—before the hospital explained that the charge was for treatment in an obstetrics emergency department, the triage area where a nurse examined Love before she was admitted in full-term labor. “I don’t like using hyperbole, but as a provider I have never seen anything like this,” Guerra-Rodríguez said.

[Winehole23]

ER docs fighting back against the corporate practice of medicine, which is technically still illegal in 33 states.


A group of emergency physicians and consumer advocates in multiple states are pushing for stiffer enforcement of decades-old statutes that prohibit the ownership of medical practices by corporations not owned by licensed doctors.

Thirty-three states plus the District of Columbia have rules on their books against the so-called corporate practice of medicine. But over the years, critics say, companies have successfully sidestepped bans on owning medical practices by buying or establishing local staffing groups that are nominally owned by doctors and restricting the physicians’ authority so they have no direct control.

These laws and regulations, which started appearing nearly a century ago, were meant to fight the commercialization of medicine, maintain the independence and authority of physicians, and prioritize the doctor-patient relationship over the interests of investors and shareholders.

Those campaigning for stiffer enforcement of the laws say that physician-staffing firms owned by private equity investors are the most egregious offenders. Private equity-backed staffing companies manage a quarter of the nation’s emergency rooms, according to a Raleigh, North Carolina-based doctor who runs a job site for ER physicians. The two largest are Nashville, Tennessee-based Envision Healthcare, owned by investment giant KKR & Co., and Knoxville, Tennessee-based TeamHealth, owned by Blackstone.

Court filings in multiple states, including California, Missouri, Texas, and Tennessee, have called out Envision and TeamHealth for allegedly using doctor groups as straw men to sidestep corporate practice laws. But those filings have typically been in financial cases involving wrongful termination, breach of contract, and overbilling.

Now, physicians and consumer advocates around the country are anticipating a California lawsuit against Envision, scheduled to start in January 2024 in federal court. The plaintiff in the case, Milwaukee-based American Academy of Emergency Medicine Physician Group, alleges that Envision uses shell business structures to retain de facto ownership of ER staffing groups, and it is asking the court to declare them illegal.https://khn.org/news/article/er-doctors-call-private-equity-staffing-practices-illegal-and-seek-to-ban-them/

[pgardn]

Private insurers practicing the good old art of capitalism and the red team fails to cry "death panels" ?

Im not getting the disconnect.
Oh, its hypocrisy again.
Solved.
The red team does not actually examine their stances in any sort of critical or credible manner.

[Winehole23]

Insurance companies are the real death panels.

1622032718732337153

[Winehole23]

Fucking ghouls at UHC


When McNaughton’s mother reached a United customer service representative the next day to ask why bills that had been paid in the summer were being denied for the fall, the representative told her the account was being reviewed because of “a high dollar amount on the claims,” according to a recording of the call.https://www.propublica.org/article/unitedhealth-healthcare-insurance-denial-ulcerative-colitis

[Winehole23]

The US pays way more, for worse outcomes.


https://www.pgpf.org/sites/default/files/How-Does-The-U.S.-Healthcare-System-Compare-To-Other-Countries-chart-1.jpg

[Winehole23]

1631096068833259522

[Winehole23]

1639586528920838144

1639587163477090306

[boutons_deux]

The US pays way more, for worse outcomes.

Ain't Capitalism great?

Philosophy of the shittiest possible product for the highest possible price.

[Winehole23]

1639587533720829954

[Winehole23]

1648809675897307137

[Winehole23]

1659029235233873921

[Winehole23]

privatization, working as intended.

die faster, plebs.


As the privatization of Medicare via insurer-owned Medicare Advantage plans expands to half of Medicare beneficiaries — 31 million people — care denials by Medicare Advantage insurers are threatening the foundational premise of the government’s health care safety net for seniors and people with disabilities: that people in Medicare should get the care that is recommended by a doctor.


A 2022 investigation (https://oig.hhs.gov/oei/reports/oei-09-16-00410.pdf) by the Inspector General of the Department of Health and Human Services found that in 2019, 13 percent of the total prior authorization requests denied by Medicare Advantage plans would have been covered under traditional Medicare, leading to an estimated 85,000 additional care denials. That year, Medicare Advantage plans also wrongly denied 18 percent of payment claims — covering an estimated 1.5 million claims — reducing the likelihood that doctors will recommend the costliest yet often most effective care, for fear of not being paid.


In the subsequent two years, as total Medicare Advantage enrollment increased from 22 million to 27 million, such denials have reportedly skyrocketed. A February report from the Kaiser Family Foundation found that two million (https://www.kff.org/medicare/issue-brief/over-35-million-prior-authorization-requests-were-submitted-to-medicare-advantage-plans-in-2021/) prior authorization requests had been denied by Medicare Advantage in 2021, more than triple the 640,000 (https://oig.hhs.gov/oei/reports/oei-09-16-00410.pdf) prior authorization requests these plans denied in 2019, according to an estimate in the Inspector General’s report.
https://www.levernews.com/care-denied-the-dirty-secret-behind-medicare-advantage/

[Winehole23]

raking fees from their own payments to doctors


Almost 60% of medical practices said they were compelled to pay fees for electronic payment (https://www.mgma.com/data/data-stories/more-than-half-of-medical-practices-report-being-f) at least some of the time, according to a 2021 survey. And the frequency has increased since then, according to medical clinics. With more than $2 trillion in medical claims (https://www.nacha.org/news/healthcare-eft-claim-payments-rise-2022-nacha-encourages-providers-use-ach) being paid electronically each year, these fees likely add up to billions of dollars annually.


Huge sums that could be spent on care are instead being siphoned off to insurers and middlemen. The fees can cost larger medical practices $1 million a year, according to an April poll by the Medical Group Management Association, which represents private medical practices. The figure sometimes runs even higher, according to a 2020 complaint to CMS (https://www.documentcloud.org/documents/23905049-adventhealth-complaint-to-cms-regarding-zelis) from a senior executive of AdventHealth, which has 53 hospitals in nine states: “I have to pay $1.8M in expenses that I could use on PPE for our employees, or setting up testing sites, or providing charity care, or covering other community benefits.” Most clinics are smaller, and they estimated annual losses of $100,000 or less. Even that figure is more than enough to cover the salary of a registered nurse.


The shift from paper to electronic processing, which began in the early 2000s and accelerated after the Affordable Care Act went into effect, was intended to increase efficiency and save money. The story of how a cost-saving initiative ended up benefiting private insurers reveals a lot about what ails the U.S. medical system and why Americans pay more for health care (https://publichealth.jhu.edu/2019/us-health-care-spending-highest-among-developed-countries) than people in other developed countries. In this case, it took less than a decade for a new industry of middlemen, owned by private equity funds and giant conglomerates like UnitedHealth Group, to cash in.


How these players managed to create this lucrative niche has never previously been reported. And the story is coming to light in part because one doctor, initially incensed by the fees, and then baffled by CMS’ unexplained zigzags, decided to try to figure out what was going on. Dr. Alex Shteynshlyuger, a urologist who runs his own clinic in New York City, made it his mission to take on both the insurers and the federal bureaucracy. He began filing voluminous public records requests with CMS.
https://www.propublica.org/article/the-hidden-fee-costing-doctors-millions-every-year

[Winehole23]

What he discovered in internal emails and government documents, which he shared with ProPublica, was a picture sharply at odds with the image of CMS as a hugely powerful force in health care. The records showed, again and again, federal officials deferring not only to a single company, but to a single executive.


Over the past five years, CMS adopted that company’s positions on fees. Shteynshlyuger discovered that, when it comes to the issue he cares about, the most powerful decision-maker wasn’t a CMS official. It was the chief lobbyist for a middleman company called Zelis. And that man just happened to be a former CMS staffer who had authored a key federal rule on electronic payments.

[RandomGuy]

There are reasons people here don’t go visit their PCP (if they have one to being with). That’s what I was pointing out. It’s more than one, and include being able to take time off work for preventive care, having to pay out of pocket due to deductibles, not being able to foot the bill for super expensive medications, and others I mentioned before. Some of those things have made people avoid care until it’s an emergency, which at this point is a cultural problem that would also need to change, tbh.

FYI, my wife is an RN. I also worked on medical systems with doctors for many years. Doesn’t mean I know more or less than anybody else, but I’ve seen the nitty gritty of running a practice.

.. and I have seen the HMO/insurer side.

How much simpler would single payer be, if the providers didn't have to hire armies of billing people to figure out who covers what and for how much?

[Thread]

.. and I have seen the HMO/insurer side.

How much simpler would single payer be, if the providers didn't have to hire armies of billing people to figure out who covers what and for how much?

If we can afford to give to Ukr/Nazi's we can certainly afford to give it to Americans.

[Winehole23]

weeding out patients with AI, punishing employees who buck against it on behalf of patients


The nation’s largest health insurance company pressured its medical staff to cut off payments for seriously ill patients in lockstep with a computer algorithm’s calculations, denying rehabilitation care for older and disabled Americans as profits soared, a STAT investigation has found.

UnitedHealth Group has repeatedly said its algorithm, which predicts how long patients will need to stay in rehab, is merely a guidepost for their recoveries. But inside the company, managers delivered a much different message: that the algorithm was to be followed precisely so payment could be cut off by the date it predicted.

Internal documents show that a UnitedHealth subsidiary called NaviHealth (https://archive.ph/o/sNafJ/https://www.statnews.com/2023/03/13/medicare-advantage-plans-artificial-intelligence-select-medical/) set a target for 2023 to keep rehab stays of patients in Medicare Advantage plans within 1% of the days projected by the algorithm. Former employees said missing the target for patients under their watch meant exposing themselves to discipline, including possible termination, regardless of whether the additional days were justified under Medicare coverage rules.
https://archive.ph/sNafJ#selection-1283.0-1303.365

[Winehole23]

STAT previously reported UnitedHealth began limiting employees’ discretion to deviate from the algorithm (https://archive.ph/o/sNafJ/https://www.statnews.com/2023/07/11/medicare-advantage-algorithm-navihealth-unitedhealth-insurance-coverage/) after it bought NaviHealth in 2020. The newly obtained documents show that, since then, executives have sought to almost entirely subordinate clinical case managers’ judgment to the computer’s calculations. That has resulted in inflexible coverage decisions that legal experts say may violate longstanding case law and regulations that govern Medicare benefits.


Three former case managers said the individual stories behind the algorithmic denials were haunting: An older woman found in the laundry room by her grandson after a stroke, her right side paralyzed, was allotted 20 days of rehab by the algorithm, when the average for severely impaired stroke patients is almost double that (https://archive.ph/o/sNafJ/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902754/). A 78-year-old legally blind man who needed care for a failing heart and kidneys, and then fell in the nursing home, was granted 16 days. Another older man nearing his discharge date after knee surgery was expected to learn how to “butt bump” up and down stairs. If case managers disagreed, and tried to extend a patient’s stay, they ran the risk of missing their targets.


The final call on whether a patient receives more care — or a payment denial — is left up to one of NaviHealth’s physician medical reviewers. The case managers working underneath them are in charge of assembling the medical records, running the algorithm, and deciding whether to press for additional care or recommend to the medical reviewer that the patient get a denial. With a 1% target over their heads, former case managers said, making that decision too often meant choosing between their job performance and their conscience.


“By the end of my time at NaviHealth I realized — I’m not an advocate, I’m just a moneymaker for this company,” said Amber Lynch, an occupational therapist and former NaviHealth case manager who said she was fired earlier this year for failing to meet performance goals. “And that is not why I went into health care. I went into health care to help people, not to say, ‘Well, we’ve got all the money, see you later.’”

[baseline bum]

weeding out patients with AI, punishing employees who buck against it on behalf of patients

https://archive.ph/sNafJ#selection-1283.0-1303.365

Hard to imagine Medicare Advantage is getting even shittier by the day. When my mom was about to turn 65 I told her under no circumstance should she pay attention to any of the plethora of ads on TV about Medicare Advantage as it's just a scam for private insurance to loot your Medicare benefits. So picked out a Part G and Part D plan for her that have stayed relatively sane on premiums without having to worry about denials and out of network charges you get from privatized insurance. Just disgusting that half of Medicare recipients are now getting their benefits looted by Medicare Advantage, what a joke of a system but with a great name for conning seniors.

[Thread]

Hard to imagine Medicare Advantage is getting even shittier by the day. When my mom was about to turn 65 I told her under no circumstance should she pay attention to any of the plethora of ads on TV about Medicare Advantage as it's just a scam for private insurance to loot your Medicare benefits. So picked out a Part G and Part D plan for her that have stayed relatively sane on premiums without having to worry about denials and out of network charges you get from privatized insurance. Just disgusting that half of Medicare recipients are now getting their benefits looted by Medicare Advantage, what a joke of a system but with a great name for conning seniors.

That's American Democracy, bum.

Betcha by golly wow the Nazi's in Ukraine have fine coverage provided by America & again thru American Democracy.


You & your mom have to scramble for your's though.

[baseline bum]

That's American Democracy, bum.

Betcha by golly wow the Nazi's in Ukraine have fine coverage provided by America & again thru American Democracy.


You & your mom have to scramble for your's though.

Nothing democratic about America cubby.

[Thread]

Nothing democratic about America cubby.

Sad, but bitterly true.

[ElNono]

This is the shit we have going on... "If it doesn't save us money now, fuck it"

There are huge health care savings to be had from reducing obesity, which is associated with a host of chronic conditions including cardiovascular disease, but people may realize those savings decades later when they are enrolled in Medicare or with another employer’s plan. In effect, private insurers may invest in these drugs only to see public payers reap the rewards.

“That’s where employers and health plans are doing this cost-benefit analysis of where does the payoff start to take place, and is it likely that that enrollee is still going to be on our health plan when we do start to see any cost benefit?” Cox said.

...

The value of the drugs to patients’ health outcomes should matter more to states than the potential cost burden, Cutler added, especially if the medications can extend a person’s life.

“The plans are saying, ‘Why should I pay for this when I’m not going to benefit?’ And the short answer is of course your patients will benefit, but the cost savings which may occur, when they occur, will accrue to Medicare,” he said.

https://www.politico.com/news/2023/11/15/weight-loss-drugs-00127203

[Winehole23]

1682204024475652098Related, in the NYT yesterday:


The rate of serious medical complications increased in hospitals after they were purchased by private equity investment firms, according to a major study of the effects of such acquisitions on patient care in recent years.

The study (https://jamanetwork.com/journals/jama/fullarticle/2813379), published in JAMA on Tuesday, found that, in the three years after a private equity fund bought a hospital, adverse events including surgical infections and bed sores rose by 25 percent among Medicare patients when compared with similar hospitals that were not bought by such investors. The researchers reported a nearly 38 percent increase in central line infections, a dangerous kind of infection that medical authorities say should never happen, and a 27 percent increase in falls by patients while staying in the hospital.

“We were not surprised there was a signal,” said Dr. Sneha Kannan, a health care researcher and physician at the division of pulmonary and critical care at Massachusetts General Hospital, who was the paper’s lead author. “I will say we were surprised at how strong it was.”
https://www.nytimes.com/2023/12/26/upshot/hospitals-medical-errors.html