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The Company Behind Many Surprise Emergency Room Bills

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361–370 of 481 posts

Re: The Company Behind Many Surprise Emergency Room Bills

#361
post #70

Earlier quoted context omitted.

I had this same thing happen. My daughter was admitted via ER and it turned into a 6 day stay. At the end we received a bill for 40k for being out of network. Luckily I have friends in the industry and it turns out if they fail to inform you within 48 hours that you're not in network you don't have to pay the out of network cost. We ended up paying just our deductible after a letter was drafted. Do not take what the…

Can someone knowledgeable on the subject comment on whether the "Obamacare movement" has been up front in acknowledging this aspect of the problem with health care in the US? My perception is that the problem is typically framed as a lack of insurance problem for financially challenged people, but the "abuse" on the billing side to me seems like at least as big of a problem. And if this is being conveniently ignored,…

> it feeds my conspiracy thinking that the Democrats are actually largely indistinguishable from Republicans

Have you been watching anything that's been happening with the healthcare debate over the past, oh, 25 years? The Democrats have been trying with varying degrees of success to inch this country in the direction of a more sensible healthcare system and the Republicans have pitched a generation-long hissy fit about it.

Re: The Company Behind Many Surprise Emergency Room Bills

#362

Earlier quoted context omitted.

Many attorneys will provide a free or very low cost initial consultation; you may have an unrealistic picture of what the actual cost of legal services for this particular scenario would be, and may benefit from actually finding out before assuming they are too expensive.

Attorneys have a reputation of charging $600 a visit, much like the hospital bills one is trying to escape.

Some attorneys will actually answer the phone and have a small conversation. Maybe it's rare or different for healthcare issues, but I've made that phone call before. I politely asked a few questions and that was it.

Re: The Company Behind Many Surprise Emergency Room Bills

#363
post #4

Over here (in Europe) we get the impression that US has such a crazy healthcare system. Why aren't people marching in the streets? Is it not as crazy as it sounds for most users? If you're taken to ER how are you supposed to know if the doctors are all part of "your network" (whatever that even means)?

Propaganda. Pure and simple. People have been lied to about how healthcare should and could work for so long that they hold political beliefs that are completely at odds with their best interests.

We have the resources to fix many of these problems. But we won't. The powers that be would prefer lower taxes.

Re: The Company Behind Many Surprise Emergency Room Bills

#364

So, basically, if you visit any emergency room then your handing them a blank Check and they can write whatever number on there they want. That's egregious beyond belief. I'm never one to call for legislation and price controls, but in the face of such adversity, I think it may be our last hope. I think they should either provide a quote before they offer the services or there should be a law limiting the amount that…

If we had an ounce of common sense in this country we would've moved to single payer decades ago.

Re: The Company Behind Many Surprise Emergency Room Bills

#365

Earlier quoted context omitted.

The bill goes to the government, who gets its funding from the people. This in no way stops any systemic over-billing that may be occuring.

Well, in my country, the government would laugh, and then only pay a standard amount.

I thought that was what medic(aid/are) in the US already pretty much did.

Re: The Company Behind Many Surprise Emergency Room Bills

#366

Earlier quoted context omitted.

Can someone knowledgeable on the subject comment on whether the "Obamacare movement" has been up front in acknowledging this aspect of the problem with health care in the US? My perception is that the problem is typically framed as a lack of insurance problem for financially challenged people, but the "abuse" on the billing side to me seems like at least as big of a problem. And if this is being conveniently ignored,…

> it feeds my conspiracy thinking that the Democrats are actually largely indistinguishable from Republicans Have you been watching anything that's been happening with the healthcare debate over the past, oh, 25 years? The Democrats have been trying with varying degrees of success to inch this country in the direction of a more sensible healthcare system and the Republicans have pitched a generation-long hissy fit ab…

Take your politics elsewhere.

Re: The Company Behind Many Surprise Emergency Room Bills

#367
post #317

Earlier quoted context omitted.

You can measure whatever you like, but my costs have gone up nearly threefold and my plan is worse now than it used to be. I'm not interested in solving world peace here. I just want to understand why insuring a relatively healthy family of three under a very high deductible plan costs $1700/mo, and why is it now illegal to not go along with this ridiculous rip off.

Your plan was already going up before the ACA was proposed, even if you were in medium or large group markets. (My firm offered health insurance to employees in California, New York, and Illinois from ~2006-2012.) Family health insurance on the group market was something like 1100-1200 pre-ACA. If you're paying for your own insurance, you're in the individual market, which is significantly more expensive, and what yo…

Yep, prices were rising before ACA and continued to rise thereafter. I'm not sure on the rate of increase, but the absolute levels are getting to the impossible.

Regardless of the cause, it's extremely frustrating to be hit with such a large monthly bill for rather poor coverage. I'm not quite as bad off as 0xbear, but we're at $1550/mo for a family of three for much crappier coverage than we had a few years back.

Here in Phoenix we've seen double digit increases every year for years, and are down to a single provider on the individual market.

Paying $18k/yr before you even use a plan is insane. Use it at all and you're looking at $20 or 25k total, with coverage limits not really kicking in to stop the bleeding until you've shelled out 30k or so.

Somebody making $80k/yr just hits the subsidy payout and is spending 20-40% of income on health care. Unsustainable.

Argue the whys all you want, these sky high rates have to change.

Re: The Company Behind Many Surprise Emergency Room Bills

#368
post #300

Earlier quoted context omitted.

As far as I can tell by looking at my premiums, it actually significantly sped up the growth of costs. I don't know how anyone could argue otherwise with a straight face.

There are a couple of forces at work: 1. Medical folks charge more over time, for...reasons. 2. Previously insurance could be sold tailored to the customer's ability to pay; but that insurance didn't actually cover many useful things and had a low cap (hence was almost worthless). ACA disallowed that and made insurance industry offer policies that cover the stuff a regular person needs covered. So you could have the…

I made significant use of my healthcare pre-ACA ($30k-$50k charges before insurance). All of it was in-network, covered, and a small annual premium.

The very year ACA took effect my health plan was canceled, my doctor went off-network, my new plan had 3x the annual premium and has grown 30% year over year, as have deductibles, and I fight tooth and nail every single charge to make sure it is in network and covered.

Yes, one anecdote is not data. But there is no more validity to the politician's lie that I can "keep my health plan, keep my doctor, and health care costs will go down."

Re: The Company Behind Many Surprise Emergency Room Bills

#369

Earlier quoted context omitted.

This sounds like fraud to me. Fight it legally! A co-worker told me that this happened to her, and that made me not take the in-network only plan, but I got the PPO instead. I still think it's illegal or morally not right what they are doing, so we should all fight this practice!!!

Sadly this is how hospital stays are conventionally billed. The cost of being admitted covers only the bed and routine nursing, literally everything else is billed separately. As unfair as it is, the best patients can do is vehemently question the necessity of any interaction with a physician, or else get billed for it. And good luck with that if your case is complicated and you're getting referrals to a wide range o…

And honestly, when you're admitted to the hospital unexpectedly, you're probably not in the frame of mind to be questioning everyone who comes by. I know when I was in for a few days, I only recognized the name of one of the hospitalist doctors that later billed me. And the bills can come months later!

Re: The Company Behind Many Surprise Emergency Room Bills

#370

I am having problems with my insurer at this very moment. I went to an in-network hospital for an ER visit, which turned into an 8-day stay (yes, it was serious). Evidently, none of the doctors at the hospital are in-network, however, (claims from various technicians are still "in processing", so I don't know how they will turn out) despite the fact that the hospital itself is definitely in-network. I had no choice a…

When I had back surgery, there were all these therapists coming in the moment I got out of surgery trying to get their 1 minute in. It was throughly ridiculous. One of them was attempting to do physical therapy and pulled on my leg a little and put me into so much pain I went into shock. She probably got her $600 bucks. I am with Kaiser now and it is the most BS free medical experience I have ever had. To fix healthc…

I work in investment banking and cover hospital facilities (i.e. the "hospital chains"). You are right that the Kaiser model, or what the industry calls fully integrated systems, can often produce more efficient healthcare. For people that aren't as familiar with the healthcare system, I thought it might be helpful to provide a brief overview of why that is the case.

Since the ACA, there has been an emphasis on shifting from a fee-for-service model (FFS) to a value-based care model (VBC). Under a FFS model, doctors and hospitals are paid for each service they provide and make their profit from the margins built into the prices they charge for their services. In an ideal VBC world, doctors and hospitals are paid a certain amount for each patient they cover, and don't make additional revenue when they provide services to patients.

You can immediately see the incentives in each model. In a FFS world, doctors and hospitals are incentivized to give you the most care possible at the highest possible prices. For example, you could see how a doctor could be motivated to give a patient an unnecessary MRI. In a VBC world, the best-case scenario for the doctor is that he never sees you, and that you never enter the hospital. Each time you receive care, he spends time and money providing that care, but doesn't get paid any additional money for it. In other words, his margins decrease when he provides care (or, as those in the industry think about it, his medical loss ratio increases). When you become sick, the doctor would prefer that you seek care in a setting that is as low-cost as possible - via telemedicine, an urgent care center, or his office. That way, he keeps more of the monthly premium.

Practically, though, in the VBC world, the doctor probably wants to see you once or twice a year, to make sure you are healthy and that you are taking preventative measures to avoid becoming sick and utilizing healthcare. That investment of resources can help reduce your need for healthcare in the future, protecting his profit margin going forward.

So in a perfect VBC world, everyone's incentives line up. You spend as little time in the hospital or at the doctor as possible, and check in every once in a while to make sure you are healthy. Doctors and hospitals make more money when they don't have to treat you, and want to keep you out of the healthcare system.

The problem is, the current system is a mix of FFS and VBC. Most hospitals and doctors aren't compensated on a fully capitated basis (capitation is a concept that, in layman's terms, measures how close the system is to VBC vs FFS - more highly capitated = closer to VBC). Under FFS, doctors don't make much money providing preventative care, so there is no incentive to keep people away from the hospital. Unless you are a member of a system like Kaiser, you are most likely covered by a plan that is partially capitated - your insurer may share profits over a certain % with your doctor as a reward for keeping you healthy, but still pays for services on a FFS basis. Often, this profit sharing does not compare with the potential revenue from providing additional acute care services, so the old FFS incentives are still at play. (Hence the $600 1-minute consultation.)

Now, wouldn't it be great if every health system operated like Kaiser, where all the incentives are aligned and the objective is to keep people out of the healthcare system? Yes, but the answer is not as simple as requiring healthcare systems to provide insurance. In fact, Kaiser is one of the only success stories involving provider-sponsored health plans (Presbyterian in New Mexico is another).

The reason why many of these provider-sponsored health plans fail is twofold:

First, most healthcare in the US (70% I believe - but that is from memory) is provided by regional or community healthcare systems. These systems only serve certain communities (their primary service area, or PSA) and therefore certain populations. These populations are often not of significant enough size to provide adequate risk diversification for healthcare systems that provide insurance plans. One of the key reasons insurance works is risk diversification - but these hospitals can't diversify their coverage beyond their community's population. In fact, one of the most common criticisms of Kaiser from the investor community is that its membership is too concentrated in California - and Kaiser has over 10 million members on the East and West coasts.

Second, these systems often don't have the capability to price their insurance and healthcare services correctly to account for the levels of risk embedded in their insurance plans. Sometimes that is due to lack of actuarial experience, sometimes that is due to lack of risk diversification causing risk to exceed estimates, and sometimes that is due to existing healthcare prices driving up costs to a level beyond where they can reasonably charge premiums. Also, it is hard for these systems to predict who will enroll in their health plan, and what their overall risk level will be after enrollment season. There are companies dedicated to helping systems operate provider-sponsored health plans (e.g. Evolent), but this has proved to be a difficult problem. For examples of premier systems getting this wrong, look up Partners (they own Mass Gen), Catholic Health Initiatives, Northwell, Banner Health.

While this is a hard problem to solve, and I don't have the answer, you are right that the Kaiser model has in many ways proven to be more cost effective than FFS or other capitated models. It might be a good intermediate step for some of the larger systems. But there is still a lot of work to do to fix the system, and even solutions that sound good on paper have unintended consequences (for example, if you move to a single payer system to reduce prices, would lower drug prices disincentivize pharma R&D, hurting development in the US and the rest of the world? Would medical device companies making prosthetics go out of business if prices decreased below their cost levels? etc.).

Hopefully this was helpful to people who aren't as familiar with the way the system works. A less-than-perfect analogy I often use is:

The old FFS model is a "supermarket" model: the supermarket makes money by selling you as many gallons of milk as possible, and pricing the milk at a premium to their cost. The higher they can price the milk, or the more milk they can convince you to buy, the better off they are.

The current model is a "Costco" model: you pay a recurring membership fee to Costco, and can buy their products at a lower price, but (let's assume) you still pay a slight margin on those products to Costco. So, Costco would love to have as many members as possible paying membership fees - and, in fact, could offer its products close to cost if there were enough members who didn't use the store. But, they would still prefer that members use the store as much as possible, and buy as much product as possible at the highest allowable margin for Costco.

The "ideal" VBC model is a "Netflix" model: you pay a recurring membership fee to Netflix, and can stream any of their videos for free. Netflix starts out the month with its $10 of revenue from your membership, and each video you stream causes them to incur streaming costs and royalty payments, reducing their margin on your $10 throughout the month. From a pure profit perspective, Netflix would love to have millions of members who never used the service, allowing Netflix to keep 100% of their membership fees. However, in order to grow and be successful, Netflix needs members to use and love the service, so it "invests" some of its membership fee by streaming videos to users. If users are going to stream, Netflix would prefer that users stream its proprietary content, which is lower-cost for them to provide. (That last part of the analogy is stretching it a bit, but meant to demonstrate that for the health of the system, some utilization is required, and the provider would prefer that utilization to be as low-cost as possible.)

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