Only a few small changes needed for equitable health care (CAP and CARE)--Single payer not required

[andym]

After some thought I believe I have come up with just a few small changes that would ensure equitable health care, and hold down costs.

1) No one can be denied basic insurance. (already included in proposed reform)
*2) Premiums for basic insurance can not exceed some reasonable percentage (eg 5 %) over the cost (as determined by Medicare rates) as averaged per person over all users of health care. This would limit profits to a maximum of 5% for insurers, saving a fortune. Essentially there would be a maximum reasonable price for basic insurance. Many for-profit providers would leave the business. (This is the CAP)
3) Premiums subsidized on an income basis. (already included in proposed reform)
4) All tests/treatments requested by Doctors must be covered.
5) Preventive care, and Drug benefits included with reasonable maximum cost to patient built-in(see 7)

CAP to be regulated by the federal government.

Some other possible useful tenets:

6) Hospitals/Doctors to be paid on flat fee basis per patient (saves money, but could cause treatment problems). Patient would have to be treated as long as necessary.
7) Maximum charge for prescription drugs to be negotiated by govt with big Pharma.
8) Create clearinghouse to limit complexity of billing process-- make insurers pay for the clearinghouse to encourage simplified billing.
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In this case, no single payer needed. Just regulations and enforcement.

So how does this fit into the current debate. All we need to do is add #2 as an amendment (at the last minute perhaps) to the current reform and we will have a multipayer system like France. Will there be disruptions? Of course, but this is one sensible way to control costs, get everyone involved and cut out the middleman. In this case, technically one wouldn't even need a public option. In reality, a public option, or a some non-profit organization would be needed to take over, when the for-profits pull out.


Only a few small changes needed for equitable health care (CAP and CARE)--Single payer not required

This would only apply to those under 65. Medicare being a great program would remain as it is. Of course, it would be simpler still to just expand Medicare to everyone, but I am proposing an alternative which is perhaps compatible with the current political environment. I do think free-market advocates would probably oppose rule #2 with as almost as much force as they oppose single-payer.

[stray cat]

1. So many DUers are against these really excellent ideas if they can't get a public option

its a shame. Once more the progressive value is that if it can't be perfect - nothing should be done. The insurance companies don't need lobbyists they have dems who will vote against their regulation if there is not private option.

[Cleita]

2. So how does this help the doctors and health care providers who

want to simplify their billing? They still have to deal with a myriad of health plans with varied health coverages? Part of the reason for single payer is not only to cut costs for the government and the patient, but for the health care provider too.

[andym]

5. Good point. But if flat rates are implemented, billing will be simplified.

It's a good point, because billing is an important source of waste.
Two answers:
1) Billing will be simplified from what exists today if providers are paid on a flat rate.

2) It would be useful to create a central billing clearinghouse (so I added it to the list-#8). It won't be as clean as single-payer, but it would simplify things immensely. Basically, any bills that required a non-flat rate would go there, they would then make sure everything was OK and forward payment as needed. Essentially providers would bill the clearinghouse via the patient, which would then bill the insurers.

Each health care organization would then not need to maintain a complex expensive billing department. Probably the clearinghouse should be government run. Some very small percentage of the premium would go to fund the clearinghouse.

[Cleita]

7. Have you ever done medical billing?

It's a maze of codes and benefit allocations that varies with each company. I don't think that will simplify the billing.

[andym]

9. It would significantly simplify billing, because the new rules would eliminate complexity

To be in compliance, the insurance company would have to issue insurance which followed these new rules.
Especially if we required flat fee payments on a per patient basis, much of what the complexity would disappear.

However, let's say that some complexity remains. The beauty of the clearinghouse is that it takes the billing burden away from the providers and puts it in a centralized organization. At least half of the cost would be dealt with there. In thinking about it, the clearinghouse should be paid for by the insurers! That way it will be greatly in their own interest to simplify billing, since it will come out of their potential 5% margin. It would be their problem.

[Cleita]

11. Okay let me try this again. It's the insurance companies who make the

billing rules for what they require not the doctors or the politicians.

[andym]

12. Understood. But they will be restrained two-fold here

Today the insurance companies make the billing rules unencumbered. However, it is still the health care providers that invoice them. The providers are forced to deal with the insurers' complex billing requirements.

In the proposed system, the insurers would be restrained by the new rules. Basically they have to cover everything important. They will be forced to cover at a flat rate per patient. So politicians will have limited their ability to create complex billing rules. And the insurers will be responsible for paying for all of the complexity of their billing requirements (where ever they can find loopholes or for extras) out of their legally limited margin.

The only complexity will come when the offer extra services (not sure what that would even be, since all basic care is covered). They would have to simplify billing in order to not lose money. Because of the clearinghouse, the providers will not see any of the complexity. The clearinghouse will work out any problems, and the more effort it takes them to work out the problems, the more the insurers lose, since it comes out of their margin (5% or whatever).

[lildreamer316]

3. Interesting.

I'll be waiting to see what others have to say, but as you've explained it that would be pretty workable. However, I'm still inclined to push for Single Payer because I feel in the end it would be simpler to deal with. I can see your point, however.

[bkkyosemite]

4. Would what Medicare recipients pay go by their income too. As they pay for Medicare B out of their

Social Security checks and if they have the poorly made Medicare D. Also they probably have a supplemental that is over $300 for a couple and have to pay a retirement fund say $150 for vision, dental (only pays 50%) and prescriptions if Medicare D does not cover said prescriptions. Or they are on a advantage plan with $150. premiums but with co-pays.


So a couple on a fixed income is now paying $96 each plus $150 plus $317 to just cover them but not totally for vision or prescriptions or dental.

So another couple on a fixed income is now paying $96. each plus $150 plus $63 and $75 and they are not covered totally.

Their income let's say is $30,000 a year. Would they qualify for less premium payments for the above scenario. I wonder.

[andym]

6. Medicare would remain, this program would be for those under 65. nt.

[demodonkey]

8. #6 already being done under Medicare. It's called "Prospective Payment".

Your age, sex, and diagnosis are run through a computer program which determines the "average" number of days of treatment a person like you needs, and the provider is paid that amount regardless of whether you are there three days or thirty-three. Of course the goal is to push people out around the time the computer says (or before, leading to profit.)

Prospective Payment causes horrible problems if you need more than the average number of days of therapy, rehab, or nursing care.

For example, my mother was in a rehab hospital and doing great in stroke rehab (starting to walk.) But after so many days she was told "you aren't making enough progress" and she was put out to a nursing home where she became contracted and lost everything she had gained at the rehab hospital. She can not walk at all and has had horrible problems because of this. Plus she was trying hard to get better and it devastated her to be told she wasn't doing enough.

Since then she has had one episode after another, fighting for her care after bumping up against the prospective payment. I know about it now and call bullshit on them when it happens; knowing about this and standing up against it usually leads to a little longer care time in a facility.

So no, I am not in favor of anything that includes Prospective Payment. If the facility could be somehow forced to be honest and keep treating the patient as long as needed, maybe.

[andym]

10. I am aware of some of the problems.

I've added that treatment must be continued as long as medically necessary.

[bkkyosemite]

13. Sorry to hear the terrible time your mom has had. hugs to her.