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First, a story from Kaiser Health News

Many doctors are disturbed they will be paid less -- often a lot less -- to care for the millions of patients projected to buy coverage through the health law’s new insurance marketplaces.

Some have complained to medical associations, including those in New York, California, Connecticut, Texas and Georgia, saying the discounted rates could lead to a two-tiered system in which fewer doctors participate, potentially making it harder for consumers to get the care they need.

I saw this story posted over at Corrente Wire. In the comments, Dromaius, who's been extremely informative on the whole issue of narrow networks and did this helpful survey of the dearth of specialists offered on plans in her state, chimes in with her 2 cents:
I've been saying this all along. Obamacare and its narrow networks have given insurance the power to run the show. It's extortion.

And I've been saying that it's not that those evil hospitals and providers aren't cooperating. It's that insurers are paying less in reimbursements, sometimes a whole lot less than they do with traditional plans. They frequently pay less than Medicare which is already reimbursed pretty low. And unlike Medicare/Medicaid, the reimbursements are NOT regulated.

In my state, the only way insurance companies would agree to participate on the Exchange is if they could offer narrow network plans. I believe that when insurance says they are "under pressure," they are lying.

The Kaiser article backs up her claim about lower reimbursement rates:
Physicians are uncomfortable discussing their rates because of antitrust laws, and insurers say the information is proprietary. But information cobbled together from interviews suggests that if the Medicare pays $90 for an office visit of a complex nature, and a commercial plan pays $100 or more, some exchange plans are offering $60 to $70. Doctors say the insurers have not always clearly spelled out the proposed rate reductions.
This should be surprising. We already know insurance companies are shifting costs onto consumers, per Olenick's spreadsheet of Exchange plan payouts, we shouldn't be surprised they're also shifting costs onto doctors.

Insurance costs are going to continue to rise in this country over the long term (assuming the economy improves). They're already way higher than any other industrialized nation. The reason is clear: the health industry (including not only insurance but also pharmaceutical and medical device companies) is extracting massive profits. The Affordable Care Act bargained away any chance of controlling this rentier behavior, and so it's only chance to control costs comes from shifting them onto us.

We shouldn't have let this happen. We shouldn't continue to let this happen. We need to remove profit from the field of human health; market forces, even if you believe in their efficacy, aren't going to come into play when one economic actor is bargaining for their life. People will pay anything to save their lives or the lives of their loved ones and so, if you allow the bandits-in-suits that make up the for-profit health complex take advantage of them, they will.

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Comment Preferences

  •  You will see narrow networks as payers (5+ / 0-)

    try to contain costs, but this:

    information cobbled together from interviews suggests
    is hardly data.  What will be public data are the actual number of participating physicians in the "narrow networks" once they are formed and contracted.
  •  Yes (10+ / 0-)

    "We need to remove profit from the field of human health"

    THAT is the starting point.

  •  No, that's not it (9+ / 0-)
    The reason is clear: the health industry (including not only insurance but also pharmaceutical and medical device companies) is extracting massive profits.
    Costs are out of control in this country because reimbursement is (mostly) on a "for procedure" basis (ensuring many needless and sometime completely counterproductive procedures are carried out) instead of a more sane basis (such as "keeping people healthy").
    •  Yes, docs are compensated by frequency of (6+ / 0-)

      visits and diagnosis and not by quality of such.  Single payer won't fix that - instead it will institutionalize graft.

      "The way to see by faith is to shut the eye of reason." - Thomas Paine

      by shrike on Sun Nov 24, 2013 at 03:12:13 PM PST

      [ Parent ]

      •  Why are per capita costs so much lower (8+ / 0-)

        in countries with a single-payer system, then?

        •  Because those countries put limits (11+ / 0-)

          on care -- the whole "rationing" argument.  In other words, in this country, when you have an 80 year old with a significant medical condition, and he could either die or a $100,000 medical condition has a 20% chance of extending his life 3 months, most families demand that care (they want the doctors to "try everything"), and there's typically not a panel to say, "that's a hugely expensive procedure for an outcome that has less than a 1 in four chance of being successful, and success is only a short increase in his life, not a cure, so it's not financially worth it."

          Also, some expensive elective procedures which simply increase quality of life near the end of life may be denied to certain patients.  

          We do a little choosing of who will get what care under what circumstances (who gets heart transplants is literally a life and death decision, since there aren't enough donor hearts to meet demand).  But in cases where the government has more control over medical care, more of those kinds of decisions are made.  The ACA sets up the IPAB which can do some of that kind of thing (by setting extremely low Medicare reimbursements for disfavored treatments, for example), which is why Republicans called it a "death panel."

          The majority of medical spending is for care at the end of life.  Countries that control medical spending have to get control over those expenditures.  Culturally, the U.S. is not accustomed to being told, "there's a last chance procedure that has a 1 in 10 chance of keeping Grandma alive, but because it has a low outcome Medicare won't pay for it."  

          •  Ah, so if conservatives don't like something (6+ / 0-)

            we should just give up on it. Cool. I'll just go throw the EPA, Social Security, and the 8 hour workday in the garbage then.

            Don't be daft. There's no difference between your "death panel" or the "market" when it comes to granting care. Denial from either one still kills your grandma.

            The difference is, you're not going to get equality or justice out of a market. You are likely to get your pocket picked, though.

            •  Your mistake: (3+ / 0-)
              Don't be daft. There's no difference between your "death panel" or the "market"
              But Medicare has no price controls now so therefore that model is unsustainable on a general basis.

              "The way to see by faith is to shut the eye of reason." - Thomas Paine

              by shrike on Sun Nov 24, 2013 at 03:51:25 PM PST

              [ Parent ]

            •  I was talking about Medicare (3+ / 0-)
              Recommended by:
              VClib, nextstep, Pi Li

              which is not "the market," but is a single payer system.  

              That's why Medicare, as currently constituted, is completely unsustainable.  See the latest Medicare Trustees Report, pdf here.

              •  Medical cost curve is changing dramatically (6+ / 0-)
                Recommended by:
                quill, Tonedevil, myboo, ybruti, worldlotus, JesseCW

                That report, constrained by law to do simple projections, is already out of date. The projection that Medicare would eat the economy were always unrealistic, but now they are completely absurd:

                Medical cost curve shifting

                Fear-mongering about the unsustainability if Social Security and Medicare was fairly mainstream a few years back, but facts don't support it.

                Promoting the need to "reform" (meaning cut) Social Security and Medicare does not seem like a Progressive Democratic position.

                •  Don't be fooled by short-term numbers. (3+ / 0-)
                  Recommended by:
                  Pi Li, Roadbed Guy, howarddream

                  Yes, the 2013 report showed a short-term improvement, if you read it.  The date it becomes insolvent was extended a year or two.  But it showed long-term unsustainability, even considering the cost cutting in the ACA.  The 2013 Report said that if Congress never again did the "doc fix," things were just unsustainable.  If Congress did the "doc fix" (which everyone assumes they will), the long term outlook is horrible.  

                  The very point that you pointed out  -- the better short term outlook -- was addressed by the Medicare Trustees in an article that you can find reprinted here.

                  Here's what the Medicare Trustees say about that:

                  There is no reason to believe that the recent reported slowdown in health care cost growth will improve the long-term picture significantly relative to current projections. At our press conference announcing the release of the trustees’ report, I was surprised to hear questions asking in effect whether a recent slowdown in health care cost growth might have a significant effect on the outlook and debate surrounding the Medicare program. To my ear the questions reflected an incomplete understanding of the factors underlying current projections. It would be mistaken to conclude that the recent slowdown in health care cost growth (partially though not wholly attributable to the recent recession) should relax pressure for much-needed Medicare reforms.

                  It’s important to understand that our long-term projections already assumed a substantial slowdown in health care cost growth relative to historical rates. This is because the projections are based on demonstrated trends in the elasticity of health care cost growth – in layman’s terms, how much people’s health care consumption patterns change as a result of factors that include health care prices, income levels, and insurance coverage. To put it more crudely, we have never expected that historical rates of health care cost growth will continue to the point where health care services absorb our entire economy. We are not going to have a society in which we are all walking around homeless, naked and starving but with impeccable health care.

                  Thus even before the 2010 passage of the ACA, we were assuming that health care cost growth would eventually slow down. Adding the ACA’s aggressive Medicare cost restraints to that assumption means that we are in effect assuming over the long term that Medicare expenses will actually grow more slowly per capita than our general economy. This assumption is one reason why many have questioned whether the ACA’s cost restraints will be sustainable over the long term. At the very most, one might argue that the recent slowdown in health care costs renders current projections slightly more plausible, but no one should be assuming that things are going to look much better.

                  It's not the rosy picture that some want to make it out to be.  

                  And I'm not trying to be "progressive Democratic" or "conservative Republican."  I'm reporting the facts, as outlined by the Medicare Trustees.  Anyone who is interested in actual facts should look at the full Trustees Report.  

                  We'll see when the 2014 Trustees Report comes out this spring.  

                •  The DailyKos far right travels in a pack and (2+ / 0-)
                  Recommended by:
                  Urban Owl, priceman

                  is utterly immune to logic.  They are opposed to most of the party platform.

                  There's really no point to trying to reason with them.  They do not share our goals. They participate here with the sole objective of attempting to forestall progress on issues ranging from a living wage to the right to organize to protecting social security to banking regulation to health insurance reform.

                  They're always  on message, and never on our side.

                  "I read New republic and Nation/I've learned to take every view.." P. Ochs

                  by JesseCW on Mon Nov 25, 2013 at 05:24:31 AM PST

                  [ Parent ]

              •  No, it's really not. (3+ / 0-)
                Recommended by:
                Chi, JesseCW, aliasalias
                That's why Medicare, as currently constituted, is completely unsustainable.
                Once we take money from the MIC and drones and wars and NSA spying and computers.
              •  Medicare isn't too expensive, America's private (4+ / 0-)

                for profit healthcare system is too expensive. Everything Medicare or private insurance buys, from aspirin to heart transplants, costs more here than in other country in the world.

          •  money doesn't need to be rationed (3+ / 0-)
            Recommended by:
            gooderservice, Chi, Pi Li

            A government sovereign in its own currency can print whatever amount of money it needs to.

            Doctors and health care professionals need to be rationed, medicines and technology need to be rationed. Those are real resources, they are finite, and they have to be managed carefully so that they aren't squandered and are directed with maximum effect.

            But money is not a resource, it is just a way of keeping score. You can't run out.

            You don't need to "control spending" as such under a single-payer program. You might have to control costs--maybe it's not desirable for other reasons to allow companies to charge too-high a price for medicines and technology--but not because you need to limit spending.

            The real question is not whether it's too expensive to approve a certain procedure for Grandma, that's a red herring. The question is whether it's a smart use of limited resources (medicine, tech, doctors, nurses, hospital beds) that could go to other patients who might have a better chance of making it if those resources were used to treat them.

            Antibiotic resistance is a classic dilemma of this type. Every use of an antibiotic on one patient decreases its effectiveness for other patients because it increases the chance of antibiotic-resistant bacteria.

            So when you're faced with a very sick older patient who probably won't live too much longer even if you cure him/her, should you use the powerful antibiotic and risk creating a strain of antibiotic-resistant bacteria that could kill or sicken many younger patients with a longer life expectancy?

            These are very hard decisions, much harder than trying to limit spending. Harder to quantify what the risks are and how care should be rationed. To weigh the abstract possibility of future patients dying from an antibiotic-resistant germ against the immediate and concrete certainty of a dying patient now is very difficult.

            "In America, the law is king." --Thomas Paine

            by limpidglass on Sun Nov 24, 2013 at 04:09:52 PM PST

            [ Parent ]

          •  End of Life care is not the cost driver (7+ / 0-)

            You assert that the differences in healthcare costs per capita are due to differences in end of life care, but cite nothing to back that up.

            A recent PBS interview with Harvard's David Cutler lists 3 reasons for Americans paying more for healthcare, and your story about other countries just letting grandma die isn't on the list.

            Why American healthcare costs so much

        •  Clever Handle - because we practice medicine (5+ / 0-)

          in a completely different manner than any other country in the world. The reason that our costs per capital are 2X the other countries in the G8 isn't because of a lack of single payer, or because insurance companies take too big a cut, or that we don't let the federal government negotiate with drug companies, or have a fee for service system, or even that our healthcare professionals earn more. Changing all of those things would help some, but they aren't the big reason we spend more, yet have poorer outcomes. In the US we teach and practice medicine in a manner unlike any other country in the world, even the other highly developed first world countries in the G8. If we want to move our cost per capita to be more in line with the rest of the G8 we would need to start teaching a different way of practicing medicine in our medical schools, and even then it would take a generation for a different way to practice medicine to become the new standard of care.

          If you entered a healthcare facility in New York or London complaining of chest pain the protocol for the diagnosis and treatment of your chest pain would be radically different. That's why our healthcare costs so much more.

          "let's talk about that"

          by VClib on Sun Nov 24, 2013 at 04:04:03 PM PST

          [ Parent ]

          •  That sounds vague and spurious (5+ / 0-)

            What exactly about the way we teach medicine results in higher costs?

            •  One thing is the students end (1+ / 0-)
              Recommended by:
              JesseCW

              up loaded with massive debt, which is then used to justify much higher salaries (both compared to other countries, and the "massive" debt incurred in their education . . .).

            •  CH - I have been involved in healtcare for (0+ / 0-)

              nearly 30 years both in the US and Europe. If our mythical patient with chest pains presented at a hospital or clinic each attending physician would pull down a computer screen with a check list and a suggested diagnostic and treatment path. The one in London would be different from the one in New York. It would obviously have some overlap, but they are different in a fundamental way.

              "let's talk about that"

              by VClib on Sun Nov 24, 2013 at 06:04:27 PM PST

              [ Parent ]

              •  Okay. (2+ / 0-)
                Recommended by:
                JesseCW, aliasalias

                1) How are they different? How does that difference result in higher costs?
                2) How big of a cost increase does it cause?
                2) Why will this take a "generation" to undue? Can't you just change what comes up on that computer screen? Why will the doctor have to unlearn and relearn all the medical knowledge they learned at medical school?

                •  You can't just change what is on the computer (5+ / 0-)

                  screen because what is on the New York screen is the standard of care for US physicians and patients. The London screen has been shaped by decades of policy and experience of the NHS. For our New York physician to deviate from the US standard of care requires him/her to expose themselves to professional and legal risks. The US standard of care is the result of hundreds of peer reviewed articles and a consensus of the various US medical societies.

                  In the UK, and the rest of Europe, they have developed a standard of care that involves less technology, particularly less expensive technology and more observation and touch and feel by the physician. In the US it's easier using high tech diagnostics to reach a conclusion quicker. It's also more expensive. In terms of therapy the UK and EU will do less intensive and invasive cardiac procedures in the cath lab for a patient with the same systems. And per capital they use fewer stents and perform less open heart surgery. In the last fifty years the practice of medicine in the UK and EU have been structured to be very cost efficient. Budgets for the single payer systems are always under political pressure and it significantly influences how medicine is practiced. At times it may put the patient at more risk, and not be as satisfying as in the US, but it costs a lot less.

                  So that's why it is a hard problem to solve. These are procedures and protocols developed over many decades and engrained into the teaching curriculum of the medical schools in the US and those in Europe. There is no easy fix.

                  "let's talk about that"

                  by VClib on Sun Nov 24, 2013 at 07:43:35 PM PST

                  [ Parent ]

                  •  It seems like this description is (1+ / 0-)
                    Recommended by:
                    VClib

                    consistent with what I posted above (or somewheres in these nested threads) about how the fault of the US system in making it very expensive is that it is overly procedure based.

                    It seems like that's pretty much exactly what you're saying here.

          •  I suggest writing a diary about your ideas (0+ / 0-)

            so we can see and discuss the changes you recommend.

            •  I am not sure it's possible to change (1+ / 0-)
              Recommended by:
              Roadbed Guy

              The way we practice medicine here is something that has developed over the last half century. It is so ingrained into the culture of medicine I don't know if it can be changed. And if it could be changed it would take a generation to implement.

              To do a really thoughtful job would take a major effort. I don't really have the time and doubt people would really care, so it's hard to put in the effort. I may retire some time in 2014 and if I did I'd have the time to write diaries on topics like this.

              "let's talk about that"

              by VClib on Sun Nov 24, 2013 at 06:00:24 PM PST

              [ Parent ]

              •  what about Canada? I lived there for years (0+ / 0-)

                my son and two daughters were born there and have always lived there, so I've seen a lot of the difference between the US of $ and Canada.

                One of my grandsons will need physical therapy for long time and last night speaking with one of my daughters she told me about her recent health issues. All of which she attended to by getting an appointment and seeing a couple of doctors...all of that was done without her ever once having to think about money.
                This side of the border they wouldn't be paying monthly mortgage payments to keep their lovely home, that money would all be going to some insurance company for them to dole out to health care people.

                without the ants the rainforest dies

                by aliasalias on Mon Nov 25, 2013 at 11:50:26 AM PST

                [ Parent ]

                •  aliasalias - I am not defending the US system (0+ / 0-)

                  just trying to help people understand why change would be so difficult and that the difference in cost isn't because of single payer versus fee for service.

                  Canada represents a good model for the US, but even if we adopted it tomorrow it would not solve the reason why healthcare in the US is so much more expensive than the EU.

                  "let's talk about that"

                  by VClib on Mon Nov 25, 2013 at 02:30:34 PM PST

                  [ Parent ]

        •  They are lower just about everywhere (1+ / 0-)
          Recommended by:
          JesseCW

          And even in the US, the components of our health care system that are single-payer (Medicare, Medicaid, VA) also have per capita costs higher than other countries.

          "Well, I'm sure I'd feel much worse if I weren't under such heavy sedation..."--David St. Hubbins

          by Old Left Good Left on Sun Nov 24, 2013 at 04:32:31 PM PST

          [ Parent ]

      •  only if you think that a Medicare for All (7+ / 0-)

        program would not have rules about what services will and won't be compensated and safeguards against fraud. I don't think anyone is proposing the government simply pay for every service anyone requests from a doctor.

        Right now undercare, caused by insurers wanting to hold on to every single dollar of insurance premiums, is a bigger problem than overcare, caused by doctors charging for extra services in order to line their pockets. Many doctors are specialists anyhow who make their money off of rich old (often white male) patients who pay cash.

        Although of course the fee-for-service model must be reformed to avoid physician abuses.

        Suggesting that we need private insurers because we need gatekeepers to do triage rather misses the point. They have no interest in a sensible rationing of health care, only in grabbing every single dime. If they had their druthers, they'd ration care by denying it to everyone. They're coming pretty damn close to that already.

        I would much rather have a democratically accountable government organization performing this triage function, rather than private, for-profit entities.

        "In America, the law is king." --Thomas Paine

        by limpidglass on Sun Nov 24, 2013 at 03:47:39 PM PST

        [ Parent ]

    •  That's one of the many reasons costs are high, yes (5+ / 0-)
      Recommended by:
      quill, gooderservice, Chi, JesseCW, aliasalias

      But it's not the only or even major one. Look at how much more drugs cost here than just across the Canadian border. Look at how much higher medical device costs are here than in countries where the national health system negotiates for lower rates.

      •  Those things are much less due to (2+ / 0-)
        Recommended by:
        nextstep, OrganicChemist

        "massive profits" than the willingness of reimbursers to pay for virtually anything the FDA approves (for safety) rather than efficacy, much higher physician salaries, and the such.

        Drug costs are something like 1/7th of all health care costs, so you could eliminate them entirely (not the just profits) and we'd still be above international norms.

        •  You're talking about two sides of the same coin (3+ / 0-)
          Recommended by:
          quill, JesseCW, aliasalias

          Yes, they overcharge because they can get away with it. That doesn't change the fact that they're overcharging, and that overcharging results in massive profits.

          And I made it pretty clear I'm not just talking about drug costs. Profit is baked into the entire health system.

          The best way to clear the whole system out is through a real National Health System.

          •  But there are not massive profits (1+ / 0-)
            Recommended by:
            nextstep

            per se.

            Services  * are * being rendered, etc - my point is that a very large number of these services are not necessary and would not be done under a "national health plan"  (so maybe on that we agree)

            •  I have a feeling we agree in principle (2+ / 0-)
              Recommended by:
              quill, JesseCW

              and maybe this is a semantic point, but yes, there are massive profits in the current system. Maybe we are using a different definitions of the word? Because there being services rendered doesn't invalidate there being profits; indeed, it's necessary. If there wasn't some kind of exchange going on, there wouldn't be any profits in the first place.

        •  We can say that about most items taken alone. (1+ / 0-)
          Recommended by:
          aliasalias

          The Insurance Skim adds about 20% to our health costs.  Take it away entirely and run a program with the overhead of Medicare and we're still only about a fifth of the way there.

          "I read New republic and Nation/I've learned to take every view.." P. Ochs

          by JesseCW on Mon Nov 25, 2013 at 05:33:18 AM PST

          [ Parent ]

    •  Roadbed Guy - that's actually a small part of the (0+ / 0-)

      problem. See my longer comment in this thread.

      "let's talk about that"

      by VClib on Sun Nov 24, 2013 at 04:07:13 PM PST

      [ Parent ]

      •  There's fairly compelling evidence (1+ / 0-)
        Recommended by:
        JesseCW

        that's it is a substantial part of the problem; for example pilot programs that do not use the fee for service model provide care for patients at 1/3 to 1/2 the cost with equally good or better outcomes.

        Some argue that the patients involved are skewed towards being healthier or sicker, so the comparisons are not perfect (for example, the physicians involved also forgo their usual money-grubbing ways . . . .).

        •  But they still practice US brand medicine (0+ / 0-)

          There is no doubt that outcomes based medicine can be less expensive. The challenge is getting everyone into an integrated health management system so that the economics work for all the clinicians. And that is a very big challenge. How do you do that in the US? However, they will still practice US medicine and that is a much more expensive style of medical practice.

          "let's talk about that"

          by VClib on Sun Nov 24, 2013 at 05:53:38 PM PST

          [ Parent ]

        •  I'm not sure people are understanding... (1+ / 0-)
          Recommended by:
          Roadbed Guy

          There are several issues here. First, people are all complaining about the accelerating profits of the insurance companies. The ACA did put caps on that and there have been refunds because of that. I don't see how limiting doctor networks to dramatically increase profits would work under the ACA because of the threshold required rebates.

          Medicare is not able to negotiate for drugs (which as stated previously is not a high cost factor), but they do set reimbursement rates for doctors, hospitals, etc. and everyone always agrees that those rates need to be raised because too many institutions stop accepting Medicare patients when the rates are too low. So even though Medicare does have some cost containment powers, when they are used, everyone complains (especially patients) and they are then ignored (by Congressional actions). Same thing with Medicaid - but just to an even greater extent.

          What VClib is saying (and people are ignoring or not understanding) is that medicine in this country is practiced in a very high tech, instant diagnosis, throw everything at a problem kind of way and patients get really upset (and frequently sue) if they don't think that every possible medical miracle was delivered to them to effect their cure. This is simply unknown in much of the world - in Europe as VClib apparently has experience and in Africa, Asia and Australia where I have experience, there is a much greater empathetic and "let's wait and see" kind of approach. The first thing a non-USA educated physician does is not necessarily order a whole slew of tests and scans just to make sure he has covered everything. Also, the amount of drugs that are prescribed after a diagnosis is dramatically lower in many countries then here in the United States. Historically, doctors in France, England and Germany have tolerated higher blood pressure and cholesterol levels before they will begin prescribing. They will really try to work with the patient to use lifestyle changes before resorting to drugs - and will even tolerate higher levels than here in the United States. US patients  freak out if they don't get their little script for their instant cure after a doctor visit. Non-US patients have not been trained to expect this treatment.

          The whole medical malpractice, sue - sue -sue is a very American thing that doesn't exist in most other countries. Although studies show this "only" adds 3 - 5 % to the cost of medical care, when the medical care bill is as high as it is in the US, this is really serious money.

          People have a much easier time of "letting go" in many other countries. Again, in the US we demand that every last trick be tried to keep someone alive for those last few weeks. In many other countries, it is quite usual for someone with a terminal illness to just go home and spend their last days with family or to a hospice situation where those are available. People seem to accept their mortality in a better way and don't demand Fort Knox Hail Mary attempts to extend a life.

          In many countries, people in the medical professions simply don't have the standard of living they do here. They are paid far less and lead far simpler lives.

          In many other countries, the patient experience is not nearly as individual or luxurious as in the US. Private or semi-private rooms are rare. Hospital wards are the norm. People are not scheduled for nearly as many face-to-face meetings with a physician - especially follow-ups. A call by an aid to check on how things are going after various surgeries and other procedures is quite common. In many hospitals in Asia, families bring the meals to the patients - the hospital does not feed them.

          Many people here seem to think that if we could only kill off all of the insurance companies and the pharmaceutical companies, then nirvana would be upon us. That is way too simplistic a way to think. Real health care cost containment in this country will require a radical change in thinking and management by insurance companies, the government, doctors, medical facilities and patients. Until that happens, we will just be scratching around the edges. I think that is what VClib is attempting to iterate.

          •  Sorry. Just as many meds prescribed per person (2+ / 0-)
            Recommended by:
            aliasalias, priceman

            in the EU.  That dog don't hunt.

            "I read New republic and Nation/I've learned to take every view.." P. Ochs

            by JesseCW on Mon Nov 25, 2013 at 05:36:03 AM PST

            [ Parent ]

            •  That's really not the case for many countries (0+ / 0-)

              Even for many countries in the EU, there is a very big difference in the prescribing of drugs - particularly in the areas of psychotropics, antibiotics and statins. For children and psychotropics it is 2 -3 times in the US compared to many other countries.

          •  Too bad not everybody can be like (1+ / 0-)
            Recommended by:
            OrganicChemist

            you and be an organic chemist - since I was reading on the internet how such people had a longer life expectancy than expected.

            Although they say that effect is dwindling now that mouth pipetting is increasingly being frowned upon.

            •  Mouth pipetting...lol (1+ / 0-)
              Recommended by:
              Roadbed Guy

              I actually remember doing that now and then way back in my college years. I only did it for salt solutions and some of the non-noxious stuff, but some of my classmates did it for a lot more than that. I can very clearly remember everyone sloshing around benzene and getting it everywhere. There was a small warning label on the bottles about potential adverse effects because of skin contact, but in the rush of getting lab work done, lots of students just sloshed it around. Now you need to do hood work with gloves and other protective gear if you use it.

              Times so change. I heard that the prof who did all the early work with thallium lost his hair and had all kinds of dental problems - so did many of his doctoral students. Now we know that thallium is a pretty toxic metal.

  •  As my children used to say, "Duh." (8+ / 0-)

    The insurance companies are trying to maintain profits?  I'm shocked, SHOCKED I tell you.  

    Yes, that was sarcastic, but the point is, this is the inevitable result of the ACA, as it was structured, doubling down on the for-profit insurance model.    Three points:  

    1.  The ACA does put some limits on profits.  Insurers must pay at least 80% in the small and individual markets, 85% in the large markets, on actual medical care.  Presumably, all non-medical overhead involved in running a company (including the executive salaries) and profit has to come out of the rest.  

    2.  The ACA took away the insurers biggest tools for assuring that they remained profitable -- the ability to write a large number of different types of policies (you could write policies where all routine medical costs would come out of pocket, and insurance would only kick in if there was something catastrophic, or policies that excluded maternity care, pediatric care, non-catastrophic mental health care, for example, for people who did not want to pay extra for those) and the ability to charge those who were lower risk (younger, healthier, without pre-existing conditions) significantly less, and the higher risk significantly more.  Any sane person knew that those limitations meant that the insurers would then look to make up those profits elsewhere.  And right now, they are looking to (1) higher premiums and deductibles;  (2) narrower networks, and (3) lower reimbursements as a way of making up profits.  All of this is exactly what every sane person EXPECTED would happen when you looked at the ACA as a whole.  No sane person thought the insurance companies would simply say, "Ok, you cut our ability to make profits, that's fine, we won't try to find other ways to make profits."  

    3.  I strongly suspect that if the ACA continues in largely its present form, we will turn into a two tier medical system.  There will be one system for the ordinary people -- the less well known hospitals, doctors who can't command the highest payments, etc. -- and a separate system for those who can pay more for extra benefits plus perhaps can pay something on top of what the insurance pays.  I've already seen doctors, if you want to keep that doctor, to pay an up-front "annual fee retainer" ($1200 a year is a number I've seen here in New Orleans).  In other words, you'll pay an "access fee" and they'll agree to accept your insurance reimbursements if you have something really significant you need them for.  If you don't need them, or if you only need your annual checkup, they keep your $1200.  In exchange, you get them, you get shorter waits for appointments, you get them to spend more time with you when you come in.  The most prominent doctors and hospitals will demand -- and get -- this.  The most prominent hospitals will be limited to the well off who can pay the extra, over and above insurance.  The less well off will be relegated to the second tier of hospitals and doctors.

    I don't like that system, but I've seen moves in that direction already.  

    •  Two tiers (1+ / 0-)
      Recommended by:
      VClib

      That's going to be inevitable under any approach toward unversal care, whether single payer, insurance, etc. Rich folks will find ways to get better care and will pay for it. an interesting take on that issue from Britain is here

      Private insurance in a single payer, government run healthcare system is a funny animal: one part incest, one part conflict of interest, and three parts strange bedfellows. And it’s infinitely fascinating. Here’s how it works:

      “Texas is a so-called red state, but you’ve got 10 million Democrats here in Texas. And …, there are a whole lot of people here in Texas who need us, and who need us to fight for them.” President Obama

      by Catte Nappe on Sun Nov 24, 2013 at 04:03:36 PM PST

      [ Parent ]

      •  The problem we have is that people here (1+ / 0-)
        Recommended by:
        OrganicChemist

        are used to the "average" person, with employer provided insurance, is used to getting to see the doctors he/she wants, and going to the hospital he/she wants. For example, I'm in New Orleans, and many people here diagnosed with some serious form of cancer choose to go to M.D. Anderson in Houston.  You hear about that regularly.  

        It may well be that, five years from now, people in the exchanges (and I expect that to be more and more people as time goes on), or people who don't make enough to pay for that "extra tier" coverage, are not going to have access to those resources, and will find fewer choices and longer waits for care, and will find doctors spending less time with them, as insurers limit their options to doctors who will accept lower reimbursements, and therefore must crowd in more patients in a day so as to cover expenses and still make money..  The "best" hospitals, doctors, and care facilities, the notion of calling and getting an appointment fairly quickly, the notion of a doctor spending 30 or 45 minutes with you, will be largely for those who pay for that "extra tier" coverage.

        And I'm not sure how well that will be received  here, frankly.

        •  Hahahahahaha (2+ / 0-)
          Recommended by:
          Roadbed Guy, Tonedevil
          the notion of a doctor spending 30 or 45 minutes with you
          I've got pretty darn good employer provided insurance. I can't recall if I've ever - EVER - had 30 - 45 mins with a doc. They've been crowding in more patients a day for years.

          “Texas is a so-called red state, but you’ve got 10 million Democrats here in Texas. And …, there are a whole lot of people here in Texas who need us, and who need us to fight for them.” President Obama

          by Catte Nappe on Sun Nov 24, 2013 at 04:41:47 PM PST

          [ Parent ]

          •  My doctor does. Both (1+ / 0-)
            Recommended by:
            Catte Nappe

            my internist and my Ob-Gyn -- generally, it's half an hour or more at my annual checkup.  That counts the exam, and questions (my internist discusses lifestyle, diet, risks, etc.).  

            I actually checked at may last annual checkup with the internist because someone asked me.  that one was 40 minutes.  

            •  I'm lucky to have the same experience... (2+ / 0-)
              Recommended by:
              coffeetalk, Tonedevil

              My primary care physician never rushes my visits. She will take time every visit to review all my health history and talk about what is happening with my family, etc. I once commented on the time she seems to be able to take and she commented that as long as the Medicare and Medicaid load on the practice is low, she can take as much time as necessary. If she and her partner were to accept Medicare patients, then they would need to resort to shotgun doctoring to stay in business. Right now, they do no Medicaid and only accept Medicare patients who have "graduated" from being regular billing patients.

          •  But I frankly think that the limits on (0+ / 0-)

            hospitals and such facilities will be the biggest problem.  How upset will people be who are diagnosed with serious cancer, and then find out that M.D. Anderson is "not in network"?  

            I have a friend just diagnosed here in New Orleans with serious lung cancer (very sad -- never a smoker, in her late 50's).  She immediately chose to go to M.D. Anderson rather than stay at the hospital in New Orleans.  I suspect those kinds of options will be less and less available, unless you can avoid extra for the higher tier insurance.  

            •  What ought to be our basic level of care? (0+ / 0-)

              Should we insure that everyone who gets cancer goes to the most expensive prestigious hospitals to be treated? I don't see how that is possible.

              •  That's probably realistic. But my point is (0+ / 0-)

                that people with "average" employer provided heath insurance are used to that -- like the friend I mentioned. She and her husband have good jobs, but are certainly not what I would consider "rich."

                I think a lot of people are going to be unhappy when they discover that their former expectations no longer realistic.

                I think you are right -- it probably is necessary.  But it' will come as an unpleasant surprise to people who were promised that the ACA could cover a lot of additional people without any downside to those who had insurance that they liked.  The Administration did not manage expectations well at all, and I think they are feeling the results of that, and may feel them over the next year as well.  

                •  I think you are right (0+ / 0-)

                  I've heard acquaintances in California lamenting that the most expensive hospitals are no longer in their network. They maintain that they ought to be able to see any doctor, go to any hospital, and their insurance should pay. They are furious that they have to pay more for insurance, and it doesn't cover any hospital they want to go to.

          •  My son's doctor always spends that much time (1+ / 0-)
            Recommended by:
            Catte Nappe

            during every visit.  Hence one of the reasons I have chosen him to be my son's doctor.

      •  Britain basically has a two-tier system (1+ / 0-)
        Recommended by:
        Catte Nappe

        Which might not be so bad, actually.  Even though Britain is one of the most "socialized" in medicine, there is still a distinction between the NHS, which is available to everyone for free or low cost, and "going private" for the more affluent, who can either purchase supplemental insurance or, if they are well-heeled enough, just pay the freight.  

        That doesn't bother me too much.  As long as everyone gets a reasonable standard of care, there's no reason not to let the more affluent pay for more comfort, quicker service, etc.  It is probably true that, under the ACA, the wealthy will continue to get whatever services they want, because they can pay for them, which the majority will be required to use mainstream providers with negotiated rates.  Still a lot better than no care at all.  

    •  I expect Health Insurers to spend less on control (1+ / 0-)
      Recommended by:
      JesseCW

      of unnecessary care.  If 15% of premiums is for administrative expenses, taxes and profit, it is much easier to increase profits by reducing admin expenses.  As it costs money to monitor unnecessary procedures, this would be a great way to increase profits.  If the result is higher premiums, then there is just more revenue to apply the profit margin on.

      If competing insurers largely act this way, they don't risk fewer customers from price competition.

      The most important way to protect the environment is not to have more than one child.

      by nextstep on Sun Nov 24, 2013 at 04:32:58 PM PST

      [ Parent ]

    •  That's why nations around the world have (1+ / 0-)
      Recommended by:
      JesseCW

      healthcare systems with a quality of care standard that provide the most affordable and highest quality of care for the most people. And having done so leave the US 38th or 42nd in healthcare outcomes for much more money per patient.

      The rich in every country will get better healthcare than the average citizens. So because of this we should do nothing to extend more care to more people?

      If the 2nd tier hospitasl 99% of us will have to be treated in, provide as good of care as a hospital in the Netherlands or France, whats to beef about?

      ACA is the start.

  •  Reading the Kaiser article (4+ / 0-)

    I'm not so sure the problem is entirely a consequence of the ACA. It seems to be a consequence of games insurance companies have always played. The ACA is bringing it into focus. That will be a  good thing in the long run.

    “Texas is a so-called red state, but you’ve got 10 million Democrats here in Texas. And …, there are a whole lot of people here in Texas who need us, and who need us to fight for them.” President Obama

    by Catte Nappe on Sun Nov 24, 2013 at 03:18:31 PM PST

  •  I hate having to defend insurance companies... (4+ / 0-)
    Recommended by:
    Catte Nappe, boudi08, Theston, ban nock

    because they're bloodsucking leeches profiting off human misery. But you know who else are bloodsucking leeches profiting off human misery? Hospitals. We have hospitals charging twice as much as other hospitals in the same damn area, for the same damn routine gall bladder removal or knee replacement.

    Insurance companies are trying to lower premiums. Not because they are good people-- they are not-- but because they want to lure your business away from other equally sleazy insurance companies. And they are doing that, in some cases, by playing hardball with hospitals. They're saying, lower your prices for us or you aren't going to be in our network. And the hospitals are saying no, and the insurance companies are saying, fine, our patients will go elsewhere and not pay your ridiculously inflated prices.

    An individual patient has no leverage against these large greedy hospitals. An insurance company has a lot of leverage. I'm glad they're using it.

    (In another, similar diary, someone else posted a similar comment. I don't remember who you were, but thanks. I agree with you.)

    •  Agreed, insurers are seeking to maximize returns (4+ / 0-)
      Recommended by:
      quill, gooderservice, JesseCW, aliasalias

      That's my point. They're shifting costs onto consumers (see Olenick) and onto doctors (this story).

      And according to the article, the Exchange plans are paying out rates lower than Medicare, which has already cut back on reimbursements. You'd agree there's a point where the cuts go too far, correct?

      Of course, it's hard to tell if we've reached that point because the insurance companies are not being open or up front about this process.

      •  I think we have a looooooong way to go (2+ / 0-)
        Recommended by:
        OrganicChemist, ban nock

        before prices are too low. And doctors in the US are overpaid compared to doctors in every other country. Not so much primary care docs, but specialists are way overpaid. If a surgeon can't buy a second vacation home, I'm not going to shed a tear.

      •  They're like unruly children who are kicking and (1+ / 0-)
        Recommended by:
        ban nock

        screaming because they are not being allowed unlimited indulgence in the toy store.

        They will have to learn to behave, that's all there is to it.

        We're still in the stage in which they're trying to kill the ACA. More correctly, they want to kill the parts they don't like.

        The parents are going to have to remain firm but calm until they settle down. Once they get used to the exchanges, there will be insurers who start to offer better products, and in some states there will be public options or single payer. Then... things will start to change.

        You can't make this stuff up.

        by David54 on Sun Nov 24, 2013 at 04:21:47 PM PST

        [ Parent ]

  •  You want to control costs (2+ / 0-)
    Recommended by:
    Cardinal Fang, ban nock

    You need to control what is paid. And if they are unhappy with reimbursement eaters now imagine how unhappy they would be under single payer.

    If you are against sane gun regulations then by definition you support 30,000 deaths a year by firearms.

    by jsfox on Sun Nov 24, 2013 at 03:46:33 PM PST

  •  Ultimately the doctors and hospitals will win (1+ / 0-)
    Recommended by:
    Catte Nappe

    out over the ins. cos. The doctors and hospitals are necessary for health care, the ins. cos are not.

    You can't make this stuff up.

    by David54 on Sun Nov 24, 2013 at 04:05:24 PM PST

  •  state regulators can make network wide (1+ / 0-)
    Recommended by:
    ban nock

    they do in Maryland!

    fact does not require fiction for balance (proudly a DFH)

    by mollyd on Sun Nov 24, 2013 at 05:02:53 PM PST

  •  Sometime in the second, third, fourth week (0+ / 0-)

    of January, people who did have healthcare insurance but now have it purchased insurance next year on the health exchange will have a rude awakening when they realize that their network can fit into a peanut shell as opposed to the access they had before.  (Yippie, lower premiums but not being able to be treated by the doctors and hospitals you trusted)

    Wait. for. it.  We will be seeing/reading a lot more reporting on this in January.

    On the other hand, those people who didn't have any "insurance" before who will have it in January, that won't be an issue -- a peanut shell network.

  •  That certainly isn't true here in Maryland! (2+ / 0-)
    Recommended by:
    Grabber by the Heel, ban nock

    I checked the other day.  Our primary care doctor is in about half the networks, and every specialist that either my wife or I have seen recently appears to be on all of them.  (And since I've been treated for a retina problem and my wife had a kidney transplant within the past year, we've seen a number of them.)  Perhaps it has something to do with having an insurance commissioner who actually wants the ACA to work, and isn't sabotaging it by approving unduly narrow networks.

    Bin Laden is dead. GM and Chrysler are alive.

    by leevank on Sun Nov 24, 2013 at 07:28:26 PM PST

  •  Very simply, it needs (2+ / 0-)
    Recommended by:
    ban nock, aliasalias

    to be utterly illegal for medical providers to charge different rates depending on who insurers the patient, or to consider the patients lack of insurance.

    Whatever they're willing to accept for a given procedure should have to be made public, just like any auto service provider.  The should be barred from engaging in price discrimination.

    Their opposition to single payer will disappear quickly.

    "I read New republic and Nation/I've learned to take every view.." P. Ochs

    by JesseCW on Mon Nov 25, 2013 at 05:20:47 AM PST

    •  Healthcare providers are concerned that (0+ / 0-)

      under single payer, the government will set their prices and do so unfairly.

      Possible counter maybe to allow healthcare providers to have a union to negotiate with the state on re-embursement rates.

      The most important way to protect the environment is not to have more than one child.

      by nextstep on Mon Nov 25, 2013 at 12:25:39 PM PST

      [ Parent ]

  •  I don't lose sleep over doctors reimbursement rate (0+ / 0-)

    s

    “Conservation… is a positive exercise of skill and insight, not merely a negative exercise of abstinence and caution…” Aldo Leopold

    by ban nock on Mon Nov 25, 2013 at 07:02:46 AM PST

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