Selling across state lines isn't illegal, immoral or anything else....

It's simply incompatible with creating physician networks/ACOs to control costs.

A physician network or 'Accountable Care Organization' by definition is a closed system. That's how you get 'buy in' at the lower reimbursement to save money. They get a guaranteed $10,000 as opposed to anything between 0 and $20,000. You can buy a Texas policy in Maryland, but you won't find many 'in network' physicians on it in Maryland. Even if you could, the 'adjustment' for physicians in Texas is entirely different from Maryland... which is a large part of why they are priced differently. Surely you don't think the pay scale in San Francisco or NYC is the same as in rural Montana or Texas?

until you understand this very key component of the ACA, you have zero chance of solving the problem.


Bison, you want to get rid of the 'preferred network', but the only way to do that is to go back to 'fee for service'... which is more expensive.

(03-15-2017 12:13 PM)bullet Wrote:  

(03-15-2017 12:04 PM)Bull_Is_Back Wrote:  Tom,

I suspect that if companies would be allowed to cross state lines you would find provider networks far more organized. It would create incentive for doctors in a network to be out there and available.

It would be easy enough to do. It would save on costs from having separate entities in each state and dealing with each state's regulations.

Now there is an argument that having these truly national networks might reduce competition in the long run.

Guys...guys...guys. The Health Insurance lobby is huge. If they wanted this ability, meaning it would be in their best interest, wouldn't they already have it? I mean other than what they already have available through the ACA.

Again, we have a few states that already tried it.

(03-15-2017 12:53 PM)Hambone10 Wrote:  Selling across state lines isn't illegal, immoral or anything else....

It's simply incompatible with creating physician networks/ACOs to control costs.

A physician network or 'Accountable Care Organization' by definition is a closed system. That's how you get 'buy in' at the lower reimbursement to save money. They get a guaranteed $10,000 as opposed to anything between 0 and $20,000. You can buy a Texas policy in Maryland, but you won't find many 'in network' physicians on it in Maryland. Even if you could, the 'adjustment' for physicians in Texas is entirely different from Maryland... which is a large part of why they are priced differently. Surely you don't think the pay scale in San Francisco or NYC is the same as in rural Montana or Texas?

until you understand this very key component of the ACA, you have zero chance of solving the problem.


Bison, you want to get rid of the 'preferred network', but the only way to do that is to go back to 'fee for service'... which is more expensive.

So before the ACA, this wasn't part of the issue?

(03-15-2017 09:26 AM)MplsBison Wrote:  

(03-15-2017 09:23 AM)Hood-rich Wrote:  More consolidation, less choices for individuals as companies pull out.

Easy answer to that:

1) open up state borders

2) abolish the practice of "networks" .... an insurance pays a maximum of X for a given procedure, regardless where in the country that procedure is performed. Done.

It well not work. Doctors, hospitals, clinics and pharmacies in the state of Arkansas refuse to take several insurance companies because of their track record of not paying. Blue Cross Blue Shields is the only one that would be accepted. This began way before Obama became President.

(03-15-2017 01:24 PM)DavidSt Wrote:  

(03-15-2017 09:26 AM)MplsBison Wrote:  

(03-15-2017 09:23 AM)Hood-rich Wrote:  More consolidation, less choices for individuals as companies pull out.

Easy answer to that:

1) open up state borders

2) abolish the practice of "networks" .... an insurance pays a maximum of X for a given procedure, regardless where in the country that procedure is performed. Done.

It well not work. Doctors, hospitals, clinics and pharmacies in the state of Arkansas refuse to take several insurance companies because of their track record of not paying. Blue Cross Blue Shields is the only one that would be accepted. This began way before Obama became President.

Bite your tongue! Everything was perfect before the reign of Obama.

(03-15-2017 12:53 PM)Hambone10 Wrote:  That's how you get 'buy in' at the lower reimbursement to save money.

(03-15-2017 12:53 PM)Hambone10 Wrote:  but the only way to do that is to go back to 'fee for service'... which is more expensive.

And here you see a preview of the semantics shell game that the healthcare insurance industry will use to fight the framework that attacks the root problem. Granted, it may take a long time for people to figure it out and come around that that solution ... but we'll get there eventually.

The only way to kill the root of the problem is with a solution that addresses the root: the artificial costs of health care services.


Why is it a shell game? Because, the "savings" he's referring to stem from those artificial prices, in the first place.


Hypothetical example:

- procedure A actually costs hospital X $1000 to provide.
- but the small board of doctors who set the price of every procedure in the country has decided that procedure shall charge a retail price of $2500 multiplied by a factor to take local cost of living into account. Hospital X in fact charges $3000 retail, for the procedure.
- however, if you have insurance from HealthCo, which has a preferred network agreement with hospital X, they'll give a break and only charge $1800

SEE! A savings!


But the actual root solution is:
1) to completely open the market nationally, and make all healthcare providers charge retail pricing to all patients for all procedures, regardless what health insurance (or lack thereof) they have, and especially regardless for that plan's willingness to pay "full" price

2) play big time hardball --- really grind them down --- on the prices of all procedures.


Meaning, you force hospital X to lower its retail price down to $1500 for all patients, regardless which insurance company they have or which state the company is located in.

(03-15-2017 12:53 PM)Hambone10 Wrote:  Surely you don't think the pay scale in San Francisco or NYC is the same as in rural Montana or Texas?

But is it honest to pretend that a national healthcare insurance company wouldn't be able to take that into account??

No, that is absurd to suggest.


The national plan would simply pay up to X for a given procedure, taking local cost of living into account to adjust the amount that will be paid to that local healthcare provider.

Geez...

Some of you (not necessarily those I'm quoting) need to put down the coffee cup.

(03-15-2017 12:57 PM)Redwingtom Wrote:  

(03-15-2017 12:53 PM)Hambone10 Wrote:  Selling across state lines isn't illegal, immoral or anything else....

It's simply incompatible with creating physician networks/ACOs to control costs.

A physician network or 'Accountable Care Organization' by definition is a closed system. That's how you get 'buy in' at the lower reimbursement to save money. They get a guaranteed $10,000 as opposed to anything between 0 and $20,000. You can buy a Texas policy in Maryland, but you won't find many 'in network' physicians on it in Maryland. Even if you could, the 'adjustment' for physicians in Texas is entirely different from Maryland... which is a large part of why they are priced differently. Surely you don't think the pay scale in San Francisco or NYC is the same as in rural Montana or Texas?

until you understand this very key component of the ACA, you have zero chance of solving the problem.


Bison, you want to get rid of the 'preferred network', but the only way to do that is to go back to 'fee for service'... which is more expensive.

So before the ACA, this wasn't part of the issue?

Where did I say that? All I said was that the ACA 'doubled down' on it making it the cornerstone of 'cost savings'. It's a circuitous argument. The reason it wasn't done isn't that you can't price it... it's that the largest cohorts of these policies shop by price... and such flexibility us counter to that. Have you seen these 'AllState' commercials where they talk about getting 75% of the value of your new car back being 'the wrong policy'? That's because you bought on price, not coverage. Same here.

(03-15-2017 01:27 PM)Redwingtom Wrote:  

(03-15-2017 01:24 PM)DavidSt Wrote:  

(03-15-2017 09:26 AM)MplsBison Wrote:  

(03-15-2017 09:23 AM)Hood-rich Wrote:  More consolidation, less choices for individuals as companies pull out.

Easy answer to that:

1) open up state borders

2) abolish the practice of "networks" .... an insurance pays a maximum of X for a given procedure, regardless where in the country that procedure is performed. Done.

It well not work. Doctors, hospitals, clinics and pharmacies in the state of Arkansas refuse to take several insurance companies because of their track record of not paying. Blue Cross Blue Shields is the only one that would be accepted. This began way before Obama became President.

Bite your tongue! Everything was perfect before the reign of Obama.

wow... so many things that sound right but aren't.

the primary driver of the acceptance of insurance/networks is the 'negotiated price'. If BCBS pays $100 and Aetna pays $90 and Medi-Cal pays $60... lots of places/providers (especially the better ones) won't take Medi-Cal or perhaps Aetna. The secondary driver is 'medical necessity'. If you're in for COPD and the Dr orders an X-Ray of your spine without documenting the medical necessity, the insurer isn't paying for the x-ray. You can be as mad as you want at the insurer, but it's actually the doctors fault. YOU think 'the doctor is just being careful and looking out for you', but that isn't always the case. SURE, there are exceptions, but by and large the problems lie with the physicians and poor coding... often because they're seeing 50 patients in a day due to physician shortages rather than 30 and they just don't have time.

As for not making regional adjustments, what world do you guys live in? Why would a doctor work in NY and pay NY prices to live there if they couldn't charge NY prices?

(03-15-2017 01:54 PM)MplsBison Wrote:  And here you see a preview of the semantics shell game that the healthcare insurance industry will use to fight the framework that attacks the root problem. Granted, it may take a long time for people to figure it out and come around that that solution ... but we'll get there eventually.

The only way to kill the root of the problem is with a solution that addresses the root: the artificial costs of health care services.


Why is it a shell game? Because, the "savings" he's referring to stem from those artificial prices, in the first place.

But you have no idea why. I do.

Quote:Hypothetical example:

- procedure A actually costs hospital X $1000 to provide.
- but the small board of doctors who set the price of every procedure in the country has decided that procedure shall charge a retail price of $2500 multiplied by a factor to take local cost of living into account. Hospital X in fact charges $3000 retail, for the procedure.
- however, if you have insurance from HealthCo, which has a preferred network agreement with hospital X, they'll give a break and only charge $1800

SEE! A savings!

This hypothetical is so absurd and under-informed that i don't know where to start to correct it. The 'small board of doctors' you're talking about is CMS/Medicare.

Quote:But the actual root solution is:
1) to completely open the market nationally, and make all healthcare providers charge retail pricing to all patients for all procedures, regardless what health insurance (or lack thereof) they have, and especially regardless for that plan's willingness to pay "full" price

Wow... you so completely don't understand healthcare economics.

Quote:2) play big time hardball --- really grind them down --- on the prices of all procedures.

Pfft. You don't think CMS does this? You're insane. What they do is simply decide what they will pay and force us to live with it. Sometimes it's fair, sometimes it's not.

More significantly, 'procedures' isn't what costs so much money in healthcare. You act like we're fixing a Buick. What do we do with the 'lemons'? Send them back to the factory or the junk yard?

Quote:Meaning, you force hospital X to lower its retail price down to $1500 for all patients, regardless which insurance company they have or which state the company is located in.

(03-15-2017 12:53 PM)Hambone10 Wrote:  Surely you don't think the pay scale in San Francisco or NYC is the same as in rural Montana or Texas?

But is it honest to pretend that a national healthcare insurance company wouldn't be able to take that into account??

No, that is absurd to suggest.


The national plan would simply pay up to X for a given procedure, taking local cost of living into account to adjust the amount that will be paid to that local healthcare provider.

[/quote]

Okay... let's ignore that 'office space' ALONE in Manhattan is a large multiple of what it is in Bugtussle, Ok....

Once again, you're describing a Fee For Service model.

What part of 'that's not what we have anymore' do you not understand?

You simply don't understand healthcare economics... and I don't have the patience to explain it to someone who obviously thinks they know something about it already.

Let's start with this. If every hospital charges the same amount for every procedure... that implies that the volume of every hospital for those procedures is approximately equal... it also implies that the 'ability to pay' for all of the people in those various areas is approximately equal....

Otherwise, the ACCESS to such services won't be remotely close to equal... and insurers (even 'national companies') will simply decline to cover services in places where they can't recoup their costs. This is precisely the ignorance that Democrats engaged in that lead to all of these companies withdrawing from ACA policies.


If you want FFS or at least a PPO for all, that's fine. Prepare to DOUBLE what healthcare costs.


Hint.... two people come in with almost identical symptoms. One has a strong immune system, makes healthy life choices and has substantial resources and a quality home life. The other has none of those. The 'procedures' are the same... but the former costs me $1500 to treat and is home in 48 hours. The latter is here for a week or more and costs $15,000. I get paid $1,800 either way. and if the one without help at home doesn't take his meds as prescribed and comes back in 30 days... I don't get paid one additional dime to treat him.

Do YOU want to try and run that business model?

That business model is basically an HMO. And health plans already adjust cost by region using their reasonable and customary payment. It's based on specific geographic region

(03-15-2017 02:41 PM)Hambone10 Wrote:  Geez...

Some of you (not necessarily those I'm quoting) need to put down the coffee cup.

(03-15-2017 12:57 PM)Redwingtom Wrote:  

(03-15-2017 12:53 PM)Hambone10 Wrote:  Selling across state lines isn't illegal, immoral or anything else....

It's simply incompatible with creating physician networks/ACOs to control costs.

A physician network or 'Accountable Care Organization' by definition is a closed system. That's how you get 'buy in' at the lower reimbursement to save money. They get a guaranteed $10,000 as opposed to anything between 0 and $20,000. You can buy a Texas policy in Maryland, but you won't find many 'in network' physicians on it in Maryland. Even if you could, the 'adjustment' for physicians in Texas is entirely different from Maryland... which is a large part of why they are priced differently. Surely you don't think the pay scale in San Francisco or NYC is the same as in rural Montana or Texas?

until you understand this very key component of the ACA, you have zero chance of solving the problem.


Bison, you want to get rid of the 'preferred network', but the only way to do that is to go back to 'fee for service'... which is more expensive.

So before the ACA, this wasn't part of the issue?

Where did I say that? All I said was that the ACA 'doubled down' on it making it the cornerstone of 'cost savings'. It's a circuitous argument. The reason it wasn't done isn't that you can't price it... it's that the largest cohorts of these policies shop by price... and such flexibility us counter to that. Have you seen these 'AllState' commercials where they talk about getting 75% of the value of your new car back being 'the wrong policy'? That's because you bought on price, not coverage. Same here.

I didn't say you did...that's why I was asking for confirmation. Your words sort of left that impression to me. If I misconstrued, I'm sorry.

(03-15-2017 02:59 PM)Hambone10 Wrote:  

(03-15-2017 01:54 PM)MplsBison Wrote:  But the actual root solution is:
1) to completely open the market nationally, and make all healthcare providers charge retail pricing to all patients for all procedures, regardless what health insurance (or lack thereof) they have, and especially regardless for that plan's willingness to pay "full" price

Wow... you so completely don't understand healthcare economics period.

FIFY
I'm convinced that this is the case OR this person is a troll.

Sent from my SM-J700T using CSNbbs mobile app

(03-15-2017 04:56 PM)bullet Wrote:  That business model is basically an HMO. And health plans already adjust cost by region using their reasonable and customary payment. It's based on specific geographic region

See below so yes... My debate was with someone suggesting that we shouldn't adjust who doesn't understand the HMO model (where 'procedures' don't have much to do with reimbursement).

In an HMO model, you literally CAN'T price services. Xhronic COPD with acute exacerbation isn't only a different level from AOC combined CHF (and the various severity and chronicity in there), but it's a different level if you have both of them

(03-15-2017 12:57 PM)Redwingtom Wrote:  I didn't say you did...that's why I was asking for confirmation. Your words sort of left that impression to me. If I misconstrued, I'm sorry.

My apology for misreading your comment.

It was less of a problem before only because of the number of people on HMOs now vs then. I don't have the numbers but 'before' we had 40% PPO, 30% HMO and 30% uninsured/State insured... Now we have more like 70% HMO and 30% PPO... again... numbers for effect/relative value... not 100% accuracy.

(03-15-2017 01:54 PM)MplsBison Wrote:  The only way to kill the root of the problem is with a solution that addresses the root: the artificial costs of health care services.

You have yet to demonstrate they are artificial. Period.

Quote:Hypothetical example:

- procedure A actually costs hospital X $1000 to provide.
- but the small board of doctors who set the price of every procedure in the country has decided that procedure shall charge a retail price of $2500 multiplied by a factor to take local cost of living into account. Hospital X in fact charges $3000 retail, for the procedure.
- however, if you have insurance from HealthCo, which has a preferred network agreement with hospital X, they'll give a break and only charge $1800

Do you have a real example of this? And BTW, you left out the part where you add in the overhead of keeping up with all the government regulations.

Oh and I love "the small board of doctors who set the price of every procedure in the country" Do they meet next door to the illuminati? You do realize the price for procedures does vary by market, right?

http://www.npr.org/sections/health-shots...other-town

Quote:Need knee replacement surgery? It may be worthwhile to head for Tucson.

That's because the average price for a knee replacement in the Arizona city is $21,976, about $38,000 less than it would in Sacramento, Calif. That's according to a report issued Wednesday by the Health Care Cost Institute.

Quote:2) play big time hardball --- really grind them down --- on the prices of all procedures.

And you'll get what you pay for...

Quote:Meaning, you force hospital X to lower its retail price down to $1500 for all patients, regardless which insurance company they have or which state the company is located in.

So doctors and nurses in NYC should charge the same as in bumbleburg mississippi?

Quote:The national plan would simply pay up to X for a given procedure, taking local cost of living into account to adjust the amount that will be paid to that local healthcare provider.

If you've ever worked for the government you're aware their "price adjustments" is foolishness. Typically a city like NYC is adjusted up about 5-8% depending on the agency. And as anyone who's lived in NYC or Boston will tell you, 8% does not begin to cover the differences.

https://www.wsj.com/articles/cbos-prophe...?mod=e2two

White smoke coming from the CBO de-mystified.

WSJ article points out that nobody who understands takes these as gospel. Its merely one data point. The Democrats spent months gaming the system to get better numbers out of them on Obamacare. Another estimate out of the University of Minnesota of a plan similar to the Republican plan showed a big gain in private insurance, but the Medicaid reduction would result in a net loss of coverage of 4 million, far different than the 24 million CBO shows.

CBO estimated people on OBamacare to be 13 million, 24 million and 26 million in 2015, 2016 and 2017 respectively. Actual numbers were 11 million, 12 million and 10 million. They were 50% off on 2017 as late as March 2016. On the 2003 drug benefit, they overestimated its cost by 40%.

One estimate hopefully they are accurate or underestimating is the fiscal impact. They show the Republican plan saving $337 billion.

CBO scores based on the information given to them. If you intentionally give them false data, like the Dems did, you will get a bad estimate. We aren't going to get accurate reports out of them if fair and honest isn't feed to them.

Any efforts to reduce the price of health care must take into consideration the following equation:

Price = cost + profit

Any effort to force prices down without driving costs down means reduced profits. The health care we have today is provided by those who are willing to provide health care for the profits that are built into the system now. Cut prices without cutting costs and you cut those profits. That will inevitably mean fewer, and/or less qualified, people are willing to provide those services at that reduced profit level. So unless costs can be addressed, the ultimate impact will be reduced quality or accessibility of health care. Health care is not health insurance.

What we need to focus on are ways to drive costs down. These would include things like:
1) Reforming medical malpractice, perhaps along the lines of Sweden's no-fault system
2) Streamlining the FDA's drug approval process
3) Utilizing NPs and PAs for more procedures
4) Reducing the cost and/or increasing the availability of medical school (Bismarck countries do something like paying your way through med school if you agree to work on the "free" side for 10 years or so, similar to what the military does here).

By the way, what happens with insurance carriers getting lower rates is simple economics. If you go in without insurance, they have to price it based on the administrative costs of handling one patient, plus the risk of non-payment. The insurance company promises them 100,000 patients for one administrative cost and guaranteed payment (oversimplification, Hambone, I know, but materially correct). Therefore they can make the same profit at a lower price. Rand's approach of allowing individuals to join groups or co-ops to purchase insurance would have the impact of eliminating that difference.

(03-16-2017 10:42 AM)Owl 69/70/75 Wrote:  Any efforts to reduce the price of health care must take into consideration the following equation:

Price = cost + profit

Any effort to force prices down without driving costs down means reduced profits. The health care we have today is provided by those who are willing to provide health care for the profits that are built into the system now. Cut prices without cutting costs and you cut those profits. That will inevitably mean fewer, and/or less qualified, people are willing to provide those services at that reduced profit level. So unless costs can be addressed, the ultimate impact will be reduced quality or accessibility of health care. Health care is not health insurance.

What we need to focus on are ways to drive costs down. These would include things like:
1) Reforming medical malpractice, perhaps along the lines of Sweden's no-fault system
2) Streamlining the FDA's drug approval process
3) Utilizing NPs and PAs for more procedures
4) Reducing the cost and/or increasing the availability of medical school (Bismarck countries do something like paying your way through med school if you agree to work on the "free" side for 10 years or so, similar to what the military does here).

By the way, what happens with insurance carriers getting lower rates is simple economics. If you go in without insurance, they have to price it based on the administrative costs of handling one patient, plus the risk of non-payment. The insurance company promises them 100,000 patients for one administrative cost and guaranteed payment (oversimplification, Hambone, I know, but materially correct). Therefore they can make the same profit at a lower price. Rand's approach of allowing individuals to join groups or co-ops to purchase insurance would have the impact of eliminating that difference.

That's the problem with Medicare. It is priced so low, many providers won't take new Medicare patients, reducing their access to care.

One part about malpractice reform is that it will also reduce unnecessary CYA tests.

An adjunct to malpractice reform is to make sure bad doctors get removed from the system. The current review boards protect the doctors. There was a long series in the Atlanta Journal Constitution focusing on sexual abuse by doctors. The boards just did nothing. Its similar with bad medical decisions by those doctors. Not that it should be easy to take away a license, but its got to happen more than it does now in most states.

One other non-value added cost is what the insurance companies add by delaying or refusing payments without justification. As an individual, I know how much time is required to collect on claims. Multiple that by thousands of patients and you have what the health care providers face. Lots of employees and sometimes lawyers just to deal with the insurance companies.

(03-16-2017 10:46 AM)bullet Wrote:  An adjunct to malpractice reform is to make sure bad doctors get removed from the system. The current review boards protect the doctors. There was a long series in the Atlanta Journal Constitution focusing on sexual abuse by doctors. The boards just did nothing. Its similar with bad medical decisions by those doctors. Not that it should be easy to take away a license, but its got to happen more than it does now in most states.

One thing I really like about Swedish no-fault malpractice is its emphasis is on getting bad docs out of the system, not providing jackpot judgement awards with 40% going to ambulance chasers.