Capping lifetime limits is a drop in the bucket. It accounts for about 1% of the total premium. Excluding pre-ex will definitely bring down rates but not solve the social problem. Also, Medicare's allowable fee is not Usual & Customary, nor is 20% higher than Medicare Allowable.
The Dismantling of ObamaCare - Ongoing Updates.
- Thread starter AllenChicago
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Capping lifetime limits is a drop in the bucket. It accounts for about 1% of the total premium. Excluding pre-ex will definitely bring down rates but not solve the social problem. Also, Medicare's allowable fee is not Usual & Customary, nor is 20% higher than Medicare Allowable.
What is a Marxist clown like you doing living in Tennessee anyway? You should be living in the Soviet Socialist Republic I do
Wow, you went too far! I have such background. You guys totally don't understand Marxism, Soviets, and current reality, and past reality. Step down and see: we are all same - working for our families. Pardon me, but too much propaganda is going on here. Better leave this place. You'll do not miss me and it will be mutual.
Before networks, you could see any provider, and your insurance's reimbursement was based on Usual and Customary (U&C), or Usual, Customary and Reasonable (UCR), (or less often based on a policy Fee Schedule). Providers most often stayed withing UCR limits, because the free market forced them to do so. There were some that charged more than UCR, but not far from it. The 3000% mark-ups were unheard of back then. Today, with so many people paying the cash rate, the same free market pressures happen.
I am going to use Justin Bilyj's example where he said:
The insurance price may be $275, but the cash price is $75. What is U&C? Probably $75 to $100. How many providers offer a cash price? Answer - almost all of them do now. Many years ago, Pharmacies started the $4 prescription that radicalized the cash-price system. Today, you can look up LabCorp or Sonora Quest, or other labs, and find a cash price for most lab tests. The prices are not bad. One thing similar about all of them is that they will not let you take the cash price and apply it to your insurance deductible.
The point is that networks force healthcare pricing out of the free market system. It takes the decision from the buyer/seller, and puts it in the hands of a large 3rd party. It makes cost shifting and huge markups impossible to detect.
The new "quality initiatives" also take the buyer/seller's role and gives it to a huge 3rd party. Insurers and the government now want to pay more when the provider proves that his/her treatment was successful. That's what the buyer (patient) wants, too, and this should be the patient's decision. I guess they think the average Joe isn't smart enough to make quality-control decisions with healthcare. But they are. They are incentivized to do so when they have transparent facts and skin in the game.
In a free market, where product, cost, quality, and necessity are all decided by the buyer, the seller must adjust to meet the buyer's demands. This is not true when an insurer (or government) decides if it the product or service is quality and if it is necessary.
Taking away networks means every seller must meet every buyer's expectations. They must clearly state the price ahead of time. The buyer will want to know about quality, and if the treatment brings results. They will want to know if there are alternative treatments. The buyer will talk to other interested buyers about his/her results. Yes, reviews. These are all good things, and they control costs and increase quality. Type A independent practitioner types of physicians would love to get back to this free-market approach, too. Free from the paperwork and rules, they could rock in a free-market approach.
Transition may be tough, but it would bring a big turnaround to the entire system if buyers paid the actual cost (not a $10 copay), paid a premium for catastrophic coverage, and were free to choose any provider, while weighing quality & necessity against cost. Premiums would dive. In the $275 vs $75 example, all providers would be forced to offer the service for $75 or lose the patient, unless they had a quality factor that made it worth more than $75. The difference between $75 and $275 is 366%. If you take that one example and multiply it across the broad spectrum, you realize that insurance costs are 366% higher than free market pricing.
Yes, we all realize there will be a transition as that $75 rate rises because fewer people are paying the $275 rate, however, if it even rises to $137.50, that means it is half of the insurance rate of $275.
So, in my opinion, banning networks would be a very wise move to push this system back to reality. It wouldn't mean pre-ex isn't covered, or your kid to age 26, or anything like that. It just means let the market decide what the market wants to pay. That, along with forced transparency would be enormous moves back to free-market. I mean forced transparency of prices, not price-fixing. Make 'em tell you what a hip replacement costs before you have it done. And let the patient compare that against the provider down the street's price.
Mangled care changed the landscape for health care and health insurance pricing. There was a great deal of resistance at first, by providers and patients, but the die was cast.
Before mangled care the story line was "Every woman over 50 had a hysterectomy whether they needed it or not". Not surprisingly, after mangled care the number of hysterectomy's dropped dramatically.
Along with steerage and network pricing mangled care introduced pre-certification, utilization review, continued stay review, gatekeepers and more.
Before mangled care insureds didn't need permission from the carrier before seeking care, referrals to specialists were not required, providers were free to charge whatever they wish and, patients were still surprised at their share of the fees because there were no real caps.
Early rate making for mangled care plans generated discounts upwards of 15 - 20% vs a straight indemnity plan. As mangled care became the norm and straight indemnity vanished (except for carriers like Mega) the discounts vanished.
Health care costs had "normalized" in a manner of speaking because of mangled care.
The 300% to 3000% "retail prices" make good headlines along the lines of "if it bleeds it leads". But retail pricing in health care is an accounting move to offset losses from deadbeats, Medicaid and Medicare.
Some providers, especially hospitals, have write downs for uncompensated care that runs 10 - 20% of billed charges. Non-urgent care providers (doctors, labs, free standing imaging, etc) have their own way of dealing with deadbeats. Unlike hospitals that are subject to EMTALA rules, other providers can refuse or limit the number of patients they take based on the ability to pay.
Those without insurance are expected to pay cash on the spot. No pay, no service.
But that doesn't eliminate the deadbeat crowd. Now it is people with high deductibles that pay only a portion of billed charges. And then there are services not covered by copay, such as lab work. Patients go to the doc, pay their copay and leave. Follow up bills for other services are often ignored because they believe everything was covered by the copay.
I do a fair amount of pro bono work on consumer sites and the two most common complaints are from people billed by hidden providers and those that ignore follow up bills because they thought the copay covered it all.
Very few people bother to read and understand their coverage. That won't change if mangled care is abolished and indemnity plans once again become the norm.
My market has shifted to original Medicare which is essentially the way health insurance was when I started in this business, except with more consumer protections. Life is much easier for my clients and for me once they understand how little hassle they have.
Before mangled care the story line was "Every woman over 50 had a hysterectomy whether they needed it or not". Not surprisingly, after mangled care the number of hysterectomy's dropped dramatically.
Along with steerage and network pricing mangled care introduced pre-certification, utilization review, continued stay review, gatekeepers and more.
Before mangled care insureds didn't need permission from the carrier before seeking care, referrals to specialists were not required, providers were free to charge whatever they wish and, patients were still surprised at their share of the fees because there were no real caps.
Early rate making for mangled care plans generated discounts upwards of 15 - 20% vs a straight indemnity plan. As mangled care became the norm and straight indemnity vanished (except for carriers like Mega) the discounts vanished.
Health care costs had "normalized" in a manner of speaking because of mangled care.
The 300% to 3000% "retail prices" make good headlines along the lines of "if it bleeds it leads". But retail pricing in health care is an accounting move to offset losses from deadbeats, Medicaid and Medicare.
Some providers, especially hospitals, have write downs for uncompensated care that runs 10 - 20% of billed charges. Non-urgent care providers (doctors, labs, free standing imaging, etc) have their own way of dealing with deadbeats. Unlike hospitals that are subject to EMTALA rules, other providers can refuse or limit the number of patients they take based on the ability to pay.
Those without insurance are expected to pay cash on the spot. No pay, no service.
But that doesn't eliminate the deadbeat crowd. Now it is people with high deductibles that pay only a portion of billed charges. And then there are services not covered by copay, such as lab work. Patients go to the doc, pay their copay and leave. Follow up bills for other services are often ignored because they believe everything was covered by the copay.
I do a fair amount of pro bono work on consumer sites and the two most common complaints are from people billed by hidden providers and those that ignore follow up bills because they thought the copay covered it all.
Very few people bother to read and understand their coverage. That won't change if mangled care is abolished and indemnity plans once again become the norm.
My market has shifted to original Medicare which is essentially the way health insurance was when I started in this business, except with more consumer protections. Life is much easier for my clients and for me once they understand how little hassle they have.
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Medicare allowable is their ucr schedule by a different name.
When I started in health insurance it was at a major carrier doing sales and agent trainings. The one thing that people don't really understand is that carriers are insurance companies that portray themselves as healthcare companies.
When i was on the inside the culture was "don't bring the losers to the table." That was a common saying (which never sat right with me) and reflective of the culture there. The point is don't expect insurance companies to help with the social aspect of healthcare unless it helps them profit. They are there to make money and limit claims.
- 15,041
And is the patient made aware that an out of network doc is being brought in? At minimum that would be unethical and could very easily be fraud against the patient depending on the exact laws of the state and how it is done.
Bac,in the late 80s, computers were proliferating but providers hadn't hired people to code and file claims. A friend of mine was learning to code are a freelance business opportunity. Her manual cautioned providers to raise their prices above what they needed or expected because of how UCR was determined. Pricing too low would leave money on the table.
Everyou year rates go up whether we use UCR with providers billing high and taking whatever will stick or negotiated network increases.
Everyou year rates go up whether we use UCR with providers billing high and taking whatever will stick or negotiated network increases.
Over 40 years in the health insurance industry, almost half of that on the carrier side, I never heard them refer to themselves as health care companies. The lame stream media uses that term, as well as the misnomer "healthcare", on a regular basis.
How many companies go looking for ways to lose money? Do you run your business in such a way as to target deadbeats who will cost you more money than you make? Will you accept clients pro bono at the exclusion of one where you expect to make a profit?
BTW, profit is not a 4 letter word, except among the left . . .
- 15,041
How is that different than any other segment of insurance industry? Companies engage in behavior to reduce claims and attract more desirable business.
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