(08-03-2019 04:03 PM)Hambone10 Wrote:  

(08-02-2019 04:24 PM)RiceLad15 Wrote:  Are there not cases where a doctor prescribes a specific treatment and someone's insurance doesn't cover that treatment?

In a similar vein, there are in/out of network mixups that can create a headache, and it would be nice to find a way to deal with these more effectively. I know that there are situations where people either misunderstand themselves, or are misinformed about who is in/out of network, leading to massive bills that they have to either fight or negotiate down.

OO answered this correctly... the insurance company decided (and you contracted with them) that such things wouldn't be covered ahead of time. If you know you need that, then buy a different policy. If you don't know you need it and ultimately find out you do, how is that any different than a drug company coming up with a new drug that costs $1mm per dose, but cures cancer... and you didn't pay a premium based on some percentage of people needing $1mm... how are they supposed to pay for it?

Insurance is math, not magic. If the standard of care for varicose veins in the legs is to inject saline and close them off, relying on ancillary circulation to manage... and your doctor decides to go outside that standard of care and individually repair all of them... it is likely that they won't be covered, because that is not the currently accepted standard of care.

As to in/out of network, that's not the insurers fault. They have a very clear list and you can always call them to verify. If you don't, or your doctor doesn't, how is that THEIR fault?

Doctors offices generally require that you pre-register to make sure of this.
Urgent care or Emergency rooms have systems that do this as well, though they aren't foolproof. I deal with this every day

This isn't in any way the same thing though as insurance denying a claim which was the topic. This is insurance doing exactly what they said they would do. I agree that this can be confusing... so choose an HMO instead where you get no coverage at all out of network... you can only go to a network provider...

I don't really see how that is actually better for you in terms of care, but it certainly solves the issue you have.

The reason for in and out of network providers is that network providers have signed contracts with the insurers to accept a) a fixed amount of money (a stipend) for your care, whether or not you use it and usually also b) pre-set amounts for specific services. Out of network providers haven't been paid the stipend, nor have they agreed to the pre-set amount. Maybe they're the best in the world at what they do and rightfully charge a premium for their services, or have an exceptionally convenient location or hours that costs them more than average, maybe they use more or better staff or offer extra amenities while the insurer pays for an 'average' provider at an 'average' location with 'average' staff and amenities? Or maybe they're just in one area and your policy expects you to be in another.

Insurance is both complex and simple. It's complex in that there are thousands of possibilities for any population, but simple in that all it does is take a list of illnesses and injuries... and the standard of care for each... and the probability that a population will need those services. They calculate the cost to deliver that care and administer the policies, plus a reasonable profit, and then they divide that total by the population size, which determines everyone's premium. It's math.

They do not (generally) accept the risk of new or experimental or 'outside the standard of care' treatments... and if they did, they would charge a higher premium for assuming that risk. Similarly, some don't let you go out of network at all (so they are cheaper)... some let you go out, but pay less when you do... because they've already paid someone to provide at least some of your care, and you decided to use someone else... and SOME (very few these days, almost none) are fee for service... where they pay no stipends... and just 'pay as you go' for your services. These policies are extremely expensive and very rare these days as a result.

The real topic here is medicare for all... and Medicare has networks, and also 80/20 copays etc etc... and they don't cover everything either.

Almost as easy as thinking of a restaurant with specials.

In the single payer, someone else pays your admission, and the restaurant serves you what the payor ordered for you. Period.

With current policy structures, think of it as paying a price for a 'one from column A, one from column B, one from column C', or a prix fixe with options for salad, entree, and side. Different prix fixe gets you different levels of entrees.

But the contract you make is for the 'at this price, I get X'.

The issues that lad speaks of are when a diner wants the lobster, when his prix fixe that he has paid for calls for sirloin steak as the entree.

But it isnt the restaurant deigning that 'you cant have lobster and denying you lobster', nor is it the payor -- the simple issue is that *you* didnt pay (whomever) for the lobster dinner column.

Massively unfair to conflate the two as he tries to do. But easy to do when the goal is to make the insurance companies the bad guys de jour who are simply out to 'deny coverage'. But, that is the story that the anti-insurance and the single payer folks will lean on for all it is worth.

It is easy to make a bad guy when Little Johnny doesnt get a specific treatment..... but then again perhaps Delaney hit it on the head when he stated: " I’m starting to think this is not about healthcare. This is an anti-private sector strategy."

(08-03-2019 12:56 PM)ausowl Wrote:  

(08-02-2019 01:27 PM)RiceLad15 Wrote:  

(08-02-2019 01:18 PM)Owl 69/70/75 Wrote:  

(08-02-2019 01:02 PM)RiceLad15 Wrote:  

(08-02-2019 12:50 PM)Owl 69/70/75 Wrote:  That's why I've backed Bismarck, which is basically free market (or a lot more free than ours is now) universal health care. Government pays for a basic plan of your choosing (essentially something like single-payer or a bad HMO) either directly (France) or indirectly through a tax credit (Heritage). You are then free to supplement your coverage, and employers can offer upgrades as an employment incentive. Or you can purchase an alternative plan, using the government contribution (where the government pays directly) like a voucher. Alternatives can include high deductible plans coupled with health savings accounts, which is probably the most economically sensible approach.
Heritage proposed a Bismarck-type approach 25 years ago. I don't know why republicans didn't pass it when they controlled both houses. Bill Clinton would have signed it just so e could have his name on health care reform, and we would have avoided the whole Obamacare debacle.

What's the mechanism that keeps the supplemental private options? I'd imagine in a single payer program you would have the same options available if companies wanted to offer those options.

The mechanism that keeps the supplemental private options is demand in the marketplace.

No, you would not have the same options available in single-payer because you don't have companies to offer them. Single-payer means one payer. That's why it's called single-payer.

See bold above.

That's what led to my question. I was wondering how something like single payer differed from single payer and allowed for the private options. Would a Bismark-payer (let's just call it that to not be confusing) offer plans that would offer lower levels of coverage from a single payer program? That would drive the demand for supplemental insurance.

Lad, Owl#s has posted a volume of good information on this subject over the years. You might also review the following NY Times op-ed: A Better Path: Germany

Thanks for passing along the NYTimes column. I know Owl#s has advocated for this plan for a while, and assumed he had probably posted some explainers over the years, but admittedly, I didn’t want to trudge through the search function to find them.

Reading the op-Ed, I’m still not sure I understand the intricacies of the German system, and how it differs from the ACA. I also can’t see that model getting passed, given the author’s statement that it would require heavy regulation of the insurance market, which the current iteration of the Republican Party would never allow.

I’ll need to do a little bit of trudging on my own.

(08-03-2019 05:14 PM)RiceLad15 Wrote:  

(08-03-2019 12:56 PM)ausowl Wrote:  

(08-02-2019 01:27 PM)RiceLad15 Wrote:  

(08-02-2019 01:18 PM)Owl 69/70/75 Wrote:  

(08-02-2019 01:02 PM)RiceLad15 Wrote:  What's the mechanism that keeps the supplemental private options? I'd imagine in a single payer program you would have the same options available if companies wanted to offer those options.

The mechanism that keeps the supplemental private options is demand in the marketplace.

No, you would not have the same options available in single-payer because you don't have companies to offer them. Single-payer means one payer. That's why it's called single-payer.

See bold above.

That's what led to my question. I was wondering how something like single payer differed from single payer and allowed for the private options. Would a Bismark-payer (let's just call it that to not be confusing) offer plans that would offer lower levels of coverage from a single payer program? That would drive the demand for supplemental insurance.

Lad, Owl#s has posted a volume of good information on this subject over the years. You might also review the following NY Times op-ed: A Better Path: Germany

Thanks for passing along the NYTimes column. I know Owl#s has advocated for this plan for a while, and assumed he had probably posted some explainers over the years, but admittedly, I didn’t want to trudge through the search function to find them.

Reading the op-Ed, I’m still not sure I understand the intricacies of the German system, and how it differs from the ACA. I also can’t see that model getting passed, given the author’s statement that it would require heavy regulation of the insurance market, which the current iteration of the Republican Party would never allow.

I’ll need to do a little bit of trudging on my own.

One of the major differences is that in addition to an opt-out, the private system can offer a huge smorgasborg of offerings; contrasting with the class-based ban on cadillac-health plans available under ACA and the huge restrictions (i.e. three flavors) on what private offerings can actually be put forward.

The ACA is egalitarian/class based in that the Democrats instituted a 'thou cannot offer a really good, really expensive policy' because..... Well, probably because the Democrats dont want those evil corporations to have a lot of deductions.

The message seems to be 'dont you dare spend on really good medical coverage companies, even though we are mandating that you provide it when you have more than 40 employees.'

Where the ACA stomps the fk out of the offerings made available, Bismark allows that private offerings market to flourish.

(08-03-2019 05:40 PM)tanqtonic Wrote:  Where the ACA stomps the fk out of the offerings made available, Bismark allows that private offerings market to flourish.

That's the big difference. Obamacare seeks to regulate everyone into compliance. Bismarck lets the market compete and consumers choose.

Of course, transparency is a huge part of Bismarck. That's the one thing that has been legislated/regulated out of our health care system over the past 70 years or so.

(08-03-2019 06:20 PM)Owl 69/70/75 Wrote:  

(08-03-2019 05:40 PM)tanqtonic Wrote:  Where the ACA stomps the fk out of the offerings made available, Bismark allows that private offerings market to flourish.

That's the big difference. Obamacare seeks to regulate everyone into compliance. Bismarck lets the market compete and consumers choose.

Of course, transparency is a huge part of Bismarck. That's the one thing that has been legislated/regulated out of our health care system over the past 70 years or so.

Doesn’t Bismarck result in a heavily regulate the industry? Everything I’ve read so far says that government regulates the insurers and does things like mandates that insurers don’t make a profit.

(08-03-2019 07:25 PM)RiceLad15 Wrote:  

(08-03-2019 06:20 PM)Owl 69/70/75 Wrote:  

(08-03-2019 05:40 PM)tanqtonic Wrote:  Where the ACA stomps the fk out of the offerings made available, Bismark allows that private offerings market to flourish.

That's the big difference. Obamacare seeks to regulate everyone into compliance. Bismarck lets the market compete and consumers choose.
Of course, transparency is a huge part of Bismarck. That's the one thing that has been legislated/regulated out of our health care system over the past 70 years or so.

Doesn’t Bismarck result in a heavily regulate the industry? Everything I’ve read so far says that government regulates the insurers and does things like mandates that insurers don’t make a profit.

Varies from country to country. The Dutch (probably best system) are essentially all for-profit. The Germans are all nominally non-profit, but they get there by operating at a profit and then bonusing out all the profits to the management team.

Typically, I think the "free" side is fairly heavily regulated, but the "pay" side is much less tightly regulated.

(08-03-2019 07:25 PM)RiceLad15 Wrote:  Doesn’t Bismarck result in a heavily regulate the industry? Everything I’ve read so far says that government regulates the insurers and does things like mandates that insurers don’t make a profit.

This is also a bit of a play on words....

Insurance is not a one year thing, but something that follows you your whole life. There will be years where you pay a lot in and take nothing out, and years you pay the same amount in and get a multiple of what you paid in that year out.

How can you mandate that insurers never make a profit unless you also indemnify them from losses?

(08-04-2019 08:24 PM)Hambone10 Wrote:  

(08-03-2019 07:25 PM)RiceLad15 Wrote:  Doesn’t Bismarck result in a heavily regulate the industry? Everything I’ve read so far says that government regulates the insurers and does things like mandates that insurers don’t make a profit.

This is also a bit of a play on words....

Insurance is not a one year thing, but something that follows you your whole life. There will be years where you pay a lot in and take nothing out, and years you pay the same amount in and get a multiple of what you paid in that year out.

How can you mandate that insurers never make a profit unless you also indemnify them from losses?

Idk - I just read a number of articles/pieces on the German Bismarck model that said government controls prices and regulates the industry in a way that they don’t make a profit.

(08-04-2019 10:40 PM)RiceLad15 Wrote:  

(08-04-2019 08:24 PM)Hambone10 Wrote:  

(08-03-2019 07:25 PM)RiceLad15 Wrote:  Doesn’t Bismarck result in a heavily regulate the industry? Everything I’ve read so far says that government regulates the insurers and does things like mandates that insurers don’t make a profit.

This is also a bit of a play on words....

Insurance is not a one year thing, but something that follows you your whole life. There will be years where you pay a lot in and take nothing out, and years you pay the same amount in and get a multiple of what you paid in that year out.

How can you mandate that insurers never make a profit unless you also indemnify them from losses?

Idk - I just read a number of articles/pieces on the German Bismarck model that said government controls prices and regulates the industry in a way that they don’t make a profit.

Then why would they engage in the business?


Serious question. Why would you invest in that company?

(08-05-2019 10:53 AM)Hambone10 Wrote:  

(08-04-2019 10:40 PM)RiceLad15 Wrote:  

(08-04-2019 08:24 PM)Hambone10 Wrote:  

(08-03-2019 07:25 PM)RiceLad15 Wrote:  Doesn’t Bismarck result in a heavily regulate the industry? Everything I’ve read so far says that government regulates the insurers and does things like mandates that insurers don’t make a profit.

This is also a bit of a play on words....

Insurance is not a one year thing, but something that follows you your whole life. There will be years where you pay a lot in and take nothing out, and years you pay the same amount in and get a multiple of what you paid in that year out.

How can you mandate that insurers never make a profit unless you also indemnify them from losses?

Idk - I just read a number of articles/pieces on the German Bismarck model that said government controls prices and regulates the industry in a way that they don’t make a profit.

Then why would they engage in the business?


Serious question. Why would you invest in that company?

Let's make sure we're on the same page.

You do know that the US has countless not-for-profit and non-profit businesses in operation, right?

A bit more digging:

Quote:Health insurance is mandatory for all citizens and permanent residents of Germany. It is provided by two systems, namely: 1) competing, not-for-profit, nongovernmental health insurance funds (“sickness funds”—there were 118 as of January 20161) in the statutory health insurance (SHI) system; and 2) substitutive private health insurance (PHI)...

There were 42 substitutive PHI companies in April 2016 (of which 24 were for-profit) covering the two groups exempt from SHI (civil servants, whose health care costs are partly refunded by their employer, and the self-employed)7 and those who have chosen to opt out of SHI. All of the PHI-insured pay a risk-related premium, with separate premiums for dependents; risk is assessed only upon entry, and contracts are based on lifetime underwriting. Government regulates PHI to ensure that the insured do not face large premium increases as they age and are not overburdened by premiums if their income decreases.

So there is the primary provider which is composed of not-for-profit healthfunds and then a secondary provider that is heavily regulated, but not regulated into not-for-profit status. However, a large minority are not-for-profit.

edit: https://international.commonwealthfund.o...s/germany/

(08-05-2019 11:26 AM)RiceLad15 Wrote:  Government regulates PHI to ensure that the insured do not face large premium increases as they age and are not overburdened by premiums if their income decreases.

So there is the primary provider which is composed of not-for-profit healthfunds and then a secondary provider that is heavily regulated, but not regulated into not-for-profit status. However, a large minority are not-for-profit.

I guess it depends on the definition of "heavily".

(08-05-2019 11:38 AM)OptimisticOwl Wrote:  

(08-05-2019 11:26 AM)RiceLad15 Wrote:  Government regulates PHI to ensure that the insured do not face large premium increases as they age and are not overburdened by premiums if their income decreases.

So there is the primary provider which is composed of not-for-profit healthfunds and then a secondary provider that is heavily regulated, but not regulated into not-for-profit status. However, a large minority are not-for-profit.

I guess it depends on the definition of "heavily".

Per the quote I provided:

Quote:Government regulates PHI to ensure that the insured do not face large premium increases as they age and are not overburdened by premiums if their income decreases.

Don't have time to dig much deeper than this extra info:

Quote:Insurers in the PHI system can set premiums based on a patient’s risk-profile at the time of application, but cannot increase them during the lifetime of the patient. They also cannot cancel contracts, and cannot refuse to cover patients with pre-existing conditions.

https://www.fraserinstitute.org/blogs/ho...ealth-care

(08-05-2019 11:26 AM)RiceLad15 Wrote:  A bit more digging:

Quote:Health insurance is mandatory for all citizens and permanent residents of Germany. It is provided by two systems, namely: 1) competing, not-for-profit, nongovernmental health insurance funds (“sickness funds”—there were 118 as of January 20161) in the statutory health insurance (SHI) system; and 2) substitutive private health insurance (PHI)...
There were 42 substitutive PHI companies in April 2016 (of which 24 were for-profit) covering the two groups exempt from SHI (civil servants, whose health care costs are partly refunded by their employer, and the self-employed) and those who have chosen to opt out of SHI. All of the PHI-insured pay a risk-related premium, with separate premiums for dependents; risk is assessed only upon entry, and contracts are based on lifetime underwriting. Government regulates PHI to ensure that the insured do not face large premium increases as they age and are not overburdened by premiums if their income decreases.

So there is the primary provider which is composed of not-for-profit healthfunds and then a secondary provider that is heavily regulated, but not regulated into not-for-profit status. However, a large minority are not-for-profit.
edit: https://international.commonwealthfund.o...s/germany/

The German system is probably the most heavily regulated of the Bismarck systems, and to some extent is an outlier in that regard. One thing I don't like about it is that you must make a minimum income in order to be able to buy the private insurance. It is not the Bismarck model that I would choose to emulate, although it has some good features.

The non-profit funds are actually run by the Lander (states). They are nominally non-profit, but actually operate as profit-seeking enterprises, and then bonus out all profits to executives at year-end to maintain non-profit status. In order for them to compete, Germany must allow interstate insurance purchases. This is the reason for the exchanges in Germany, to facilitate purchases of out-of-state insurance policies. Thus the German exchanges are like the Heritage exchanges but not like the Obamacare exchanges. Obamacare borrowed a word but not an idea.

I prefer the approach where insurance is mandatory, the basic coverage is subsidized by the government, either directly or through tax credits, and the supplemental/upgraded plans are sold in a competitive free market.

(08-05-2019 11:44 AM)RiceLad15 Wrote:  

(08-05-2019 11:38 AM)OptimisticOwl Wrote:  

(08-05-2019 11:26 AM)RiceLad15 Wrote:  Government regulates PHI to ensure that the insured do not face large premium increases as they age and are not overburdened by premiums if their income decreases.
So there is the primary provider which is composed of not-for-profit healthfunds and then a secondary provider that is heavily regulated, but not regulated into not-for-profit status. However, a large minority are not-for-profit.

I guess it depends on the definition of "heavily".

Per the quote I provided:

Quote:Government regulates PHI to ensure that the insured do not face large premium increases as they age and are not overburdened by premiums if their income decreases.

Don't have time to dig much deeper than this extra info:

Quote:Insurers in the PHI system can set premiums based on a patient’s risk-profile at the time of application, but cannot increase them during the lifetime of the patient. They also cannot cancel contracts, and cannot refuse to cover patients with pre-existing conditions.

https://www.fraserinstitute.org/blogs/ho...ealth-care

Compared to the US system, that is not "heavily regulated." Government does not get into micromanaging care as it does here. At any rate, Germany is almost certainly the most heavily regulated of the Bismarck systems.

(08-05-2019 11:44 AM)Owl 69/70/75 Wrote:  They are nominally non-profit, but actually operate as profit-seeking enterprises, and then bonus out all profits to executives at year-end to maintain non-profit status.

That would encourage profit-making/bonus increasing behavior on the part of the execs.

Quote: risk is assessed only upon entry, and contracts are based on lifetime underwriting.

This puts a premium on getting it right the first time, and I would think it leads to conservative underwriting, since mistakes cannot be compensated later.

(08-05-2019 12:18 PM)OptimisticOwl Wrote:  

(08-05-2019 11:44 AM)Owl 69/70/75 Wrote:  They are nominally non-profit, but actually operate as profit-seeking enterprises, and then bonus out all profits to executives at year-end to maintain non-profit status.

That would encourage profit-making/bonus increasing behavior on the part of the execs.

Exactly.

(08-05-2019 12:18 PM)OptimisticOwl Wrote:  

(08-05-2019 11:44 AM)Owl 69/70/75 Wrote:  They are nominally non-profit, but actually operate as profit-seeking enterprises, and then bonus out all profits to executives at year-end to maintain non-profit status.

That would encourage profit-making/bonus increasing behavior on the part of the execs.

With the government controlling some aspects of how they can generate profit (Germany controls the rate of premium increases per these factoids).

(08-05-2019 11:12 AM)RiceLad15 Wrote:  Let's make sure we're on the same page.

You do know that the US has countless not-for-profit and non-profit businesses in operation, right?

Wow... Really?

I have very intimate knowledge of healthcare finance... and you admitted you don't know... but you 'read' something somewhere... so I asked you a very direct question in order to help you understand what you read... and you come back with this?

being 'not for profit' and 'not making a profit' are not the same thing.