Is a crucial part of health care reform that every provider must charge the same for every customer?

[HamdenRice]

I've been trying to think through this whole clusterfuck of a reform by disaggregating (ie separating) various parts of the problem.

I was reading another thread that contrasted the Medicare reimbursement for what private insurers pay, and what cash paying customers pay.

This occurs because providers, especially hospitals, are playing financial games shifting costs. If Medicare or private insurance won't pay the full cost of procedure X, they recoup that cost from cash paying schlub Smith.

Wouldn't a crucial part of reform simply be: Any provider must charge exactly the same price for the same procedure no matter how the procedure or service is financed? Can there be any reform or even a public option if this cost shifting is allowed to continue?

[rurallib]

1. The crucial part of health reform is that every citizen be able to get

the medical care they need without fear of bankruptcy or losing everything. That every American no matter what their status in life is able to access health care without fear of consequences.

[HamdenRice]

2. There needs to be many, many reforms other than the basic financing

That should be obvious from the scope of the bills emerging from Congress. As the new system is taking shape -- severe regulation of private insurance plus a public option -- it seems that many other reforms have to go along with that.

So the question remains, given the overall shape of the new system, should providers be required to charge everyone the same price for the same procedure or service?

[sinkingfeeling]

3. Let's start with something even more basic. Health care providers need to justify their 'costs'.

I just saw the itemized bill for 33 IMRT (radiation treatments). Cost $86,422.00 or something like $1960 for 10 10 second 'hits'. Now this was at a place that has 2 IMRT machines, a CT scanner, and a PET scanner, plus other standard medical equipment. They operated both machines from 9am until 4PM, treating about 30 patients a day. The equipment was more than paid for. Easy to cover the salaries of the technicians. Why so much?

[HamdenRice]

4. That's really the issue

Providers are just trying to get as much revenue as they can without regard to cost. The question to them isn't, how much did it cost to provide this service, but what can I get through the system that is trying to chisel me. If I can't get it from an insurer, I'll get it from the poor schlub who came in here without insurance and doesn't have a lawyer or staff to fight this, and then I'll sell the "receivable" to a collection agency.

No matter what we do in terms of overall financing, we have to have rational pricing.

And sadly, it's irrational Medicare and Medicaid pricing that has cause the providers to side against reform, even though it's in their interest.

[NYC_SKP]

11. $22 for a Tylenol. Yes, there needs to be truth in costing every detail.

They get whatever they can get from whomever walks in the door.
It might be the poor sucker w/o insurance but who has assets and a dream to pay the rent and keep his car so he can get to work.
Or it might be the working person with the shittiest plan and high deductible.

The reform we need needs to be thorough and go far beyond just providing a plan to everyone.

[flyarm]

13. understand this..it is not just the person paying cash, anyone with private health insurance is

paying approx the same as those paying cash..sometimes more!
and that is on top of paying the highest rates for insurance!

[panader0]

5. Perhaps the public option would stop the practice you are referring to.

Besides the insurance industry, I'd also like to have the issue of doctor and hospital fees addressed. Do doctors really need to be millionaires? Sure, their education costs a lot, but some doctors make unbelieveable amounts of money. Like 2 grand for 20 minutes of work? And hospitals? Do they need to be so rich? What about not-for-profit hospitals? My point is that health care costs are out of reach of the average person, but not just because of insurance.

[HamdenRice]

14. "Do doctors really need to be millionaires?" -- Now you're asking a really hard question

I was listening to news-talk radio on a liberal station yesterday and a guy called in who was somewhat right wing, but he made one good point (then a lot of stupid points).

He said that 40 years ago, when health insurance was still relatively new, it was mostly for catastrophic illness, and your regular family doctor visit was usually paid out of pocket.

I definitely remember being a student over the summer without insurance around 1982 and getting chicken pox. I went to the neighborhood doctor who treated me for $20 -- and even at that, his attitude was like, hmmm how about you just give me twenty bucks or whatever you can afford.

Now even counting inflation, few people can afford even a routine check up! It's way more than the equivalent of $20 in 1982 dollars.

There are 2 distinct components of health insurance now: actual insurance for big expenses like surgery; and a savings component which is just a way of putting away money every week for routine health care.

The dirty little secret of this debate is that in any system, almost everyone who is working class and above in income is going to pay for his or her own routine health care. The system can help you save up for it, but it won't pay for it. It's kind of like a Christmas club savings account.

But this isn't fair unless the routine care is something an average person can pay for.

I also remember back around 1979 when my then university announced that doctors had surpassed MBAs in projected earnings. (That changed after the explosion of Wall St in the 80s). But the point is that I remember in the 1960s, doctors made about as much as elementary school principles. Now they almost all expect to be millionaires, and we can't afford the routine component of care if the person we are going to expects to make a million a year.

I don't even just blame the doctors. An entire parasitic set of industries has grown around them. For example, Medical school tuition used to be within reach of working class parents. Now a medical student puts himself or herself in debt for hundreds of thousands of dollars -- the university, student loan parasites and other industries are blood sucking the doctors.

I was teaching in the 90s, and this professor who was "running" for dean was canvassing and came to my office. He made this pitch for why one of his platforms was that we had to charge way more for tuition -- which was already around $40,000. He said he had done calculations that showed that by graduating from our school, students would earn at least $1 million more over a lifetime than if they didn't graduate and --this was the shitty part -- the university had to capture more of that value added. In other words, universities are now pricing themselves to capture as much future income of graduates as possible.

My friend is a professor of medicine, and she says that between med school loans, and the ambition young doctors have to lead the good life right away by buying first homes on graduation, many start out life $1 million in debt. That's not a typo. Some young doctors are starting out $1 million in student loan, mortgage and credit card debt.

I don't see how we can unwind all of this shit, and I'm beginning to think the whole thing has been fucked up beyond our capacity to reform it.

[flyarm]

6. they also shift costs to people with private insurance ..meaning people with

straight up insurance, meaning .. not HMO's

Example..i have straight insurance ..i don't know the code....but not an HMO..

I go to the emergency room with a severe Migraine..The last time I went ..I get charged $450 dollars for the migraine care..and $1,700.00 for people who don't have insurance...it is like a penality for having really really good health care insurance..I am getting hit with fee's for people who don't have health care .

Now I do not begrudge those charges ..except..they come off my lifetime cap of health insurance..if that didn't occur ..i would have no problem with it..but we all have a lifetime cap ..some 1 million others 2 million depending on your insurance..

As you go to doctors and get care here and there..it is all coming off your cap..so when i am getting charged for other people..it is lowering my lifetime cap..so if i needed a huge expensive surgery..my cap is being shrunk by others who I don't even know!! At least if I knew them ..we could maybe have a cup of coffee together..since they now own some of my insurance.

Use my insurance ..but not my cap..

hope that explains some more to you.

[Cresent City Kid]

7. Good point

The focus has been on "how will we pay?" and not on "what do they charge?". Costs are high because excessive salaries of non-medical people like hospital administrators and insurance executives are baked into the system. I'm certain that they will look for a way to sustain this within the new system, the cost shifting as you suggest is the likely culprit.

[sui generis]

8. yes

Two critical factors:

Level health care bills without regard to cash or insurance as the method of payment.

The official line: for medical care, cash payments are typically lower than insurance because of the bill administration and R&C game. Conversely in pharma, cash buyers pay significantly more than the label cost (not the co-pay) for medicine, because officially insurance companies can negotiate on behalf of an arbitrary group of people using the formulary. What's left out is that cash payers are in and of themselves a group, they just don't negotiate prices as a group.

AND

Level insurance premiums without regard to acute or pre-existing conditions, chronic care requirements, pharmaceutical requirements, or any other excuse for jacking premium costs.

The official lines is that if you put a bunch of healthy people together in a group, their fully burdened costs are reduced by not having claims, and unworthy people can be lumped together to share the higher cost of their care. In practice, insurance companies would love to never pay a claim at all and to have everyone who is already paying for coverage additionally pay for the parts of the health care that are capped or excluded due to one feeble excuse or another.

Level the costs. Level the premiums. No exceptions. It's fundamentally the only way that public healthcare can be made sustainable.

[Winterblues]

9. IMO a good start would be for every major city to have a Government

Free clinic with Government salaried doctors and Government Salaried nurses and open to the General public 24 hours a day. If Emergency Rooms were freed up for just emergencies a major cost reduction would occur. One of the things (they say) that raise the costs of everyone's insurance is having to pay for the uninsured usage of Emergency Rooms. I think a real Government hospital or clinic would work well. People could either use the free clinic or pay for insurance and deal with what the Insurance Companies allow.

[TexasObserver]

10. Yes! We need massive regulation of costs for medical procedures.

This is what so many do not understand. I don't care if you have insurance that you think is awesome, just wait until you have a major medical problem, and wait until you find out which charges YOU will have to pay because your insurance doesn't. There are major shortfalls between what a hospital will charge and what insurance will pay. Each consumer is caught in a hopeless maze of insurance company policies and hospital charging and collection policies.

Regulate health costs. Set up limits on the amounts they can charge for any major procedure. Don't let holes exist between what coverage pays and what hospitals can charge.

If we don't impose our will on the health care industry, it will continue to run roughshod over every one of us.

[flyarm]

12. Interesting story at Firedoglake about this subject..but i would be leary of

AHIP campaign to shift blame..the insurance carrier i have is constantly doing "resonable and customary " crap..and we have no idea how they come about the reasonable and customary price for proceedures..nor are we allowed to know how they fix these ammounts..believe me i have spent exhaustive amounts of time trying to figure it out!

http://seminal.firedoglake.com/diary/7136