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New health insurance “transparency data” looks suspiciously wrong

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Re: New health insurance “transparency data” looks suspiciously wrong

#81

Post by Alupis »

inetknght wrote: post #71
BoorishBears wrote: post #65

Earlier quoted context omitted.

Not a solution for everyone... but I have to ask, since you have the time to go to the EU for routine medical work, why not move to somewhere in the US that has doctors? Also looking at a primary care wait time is fine, but what is broken in most single player systems is specialists and "non-emergency surgery"... which is often stuff that significantly affects your quality of life. https://worldpopulationreview.com/c…

> why not move to somewhere in the US that has doctors? Do you have a suggestion where in the US that is? The US has many doctors but essentially all of them are gated behind insurances and especially hospitals.

What are you imagining it should be?

You can see your doctor pretty much freely within the US for nearly any reason. This idea you cannot see your doctor in the US, or that you receive treatment from nurses or administrators is simply not true.

> insurances and especially hospitals

You may be confused, because some doctors operate private practices, while others choose to work for large hospital organizations. Private practices may be more akin to what some people's idea of a doctor should be. Most insurance plans offer a selection of hospitals and doctor networks, allowing you to chose the style and type that works best for you.

In all cases, you can see your doctor if needed, with very little lead time if any.

Re: New health insurance “transparency data” looks suspiciously wrong

#82

Post by ethbr0 »

medellin wrote: post #78
ethbr0 wrote: post #77

Earlier quoted context omitted.

> but it's definitely eye opening just how malicious they made it As someone familiar with insurer, provider, and facility IT systems, I'd offer an alternate explanation -- the data is bad because healthcare IT is understaffed (and often incompetent). These are businesses that have squeezed most costs out, and IT is definitely a cost. Imagine banking... if there were much less competitive pressure and an inability to…

If this is the best they can do maybe capital markets don’t work best for insurance companies and they should be taken over. Dealing with them right now feels like dealing with the government might as well just have the government run it

Not going to argue. In their defense, I'd say insurers are more innovative (especially on the operations side and post-ACA) than the federal government.

IMHO, best of both worlds would be the federal government taking over and centralizing the most core services (rates, interchange, data systems, etc) and allowing private insurance companies to build offerings on top of that (customer service, servicing, product mix, etc).

Re: New health insurance “transparency data” looks suspiciously wrong

#83

Post by walnutclosefarm »

ethbr0 wrote: post #77
candiddevmike wrote: post #3

Everyone assumed there would be malicious compliance here but it's definitely eye opening just how malicious they made it. Speaks volumes for the perceived risk releasing this data, IMO. Still waiting to hear about someone using this data to negotiate down a hospital bill, seems like it's just insurance companies that can weaponize this data for better rates.

> but it's definitely eye opening just how malicious they made it As someone familiar with insurer, provider, and facility IT systems, I'd offer an alternate explanation -- the data is bad because healthcare IT is understaffed (and often incompetent). These are businesses that have squeezed most costs out, and IT is definitely a cost. Imagine banking... if there were much less competitive pressure and an inability to…

I'm pretty sure the truth is a mix of malicious compliance and inability, but I'd weight it heavily in favor of malicious compliance, especially for the insurance data. Insurers know their costs, and when and why they pay specific charges.

(My qualifications to make this statement: 15 years in healthcare IT, including UHG/Optum, and 8 years as CTO of a large clinical organization that included primary through tertiary care, research, and an insurance operation.)

Re: New health insurance “transparency data” looks suspiciously wrong

#84

Post by ChrisMarshallNY »

lazide wrote: post #80
maxwell wrote: post #31

Earlier quoted context omitted.

And why federal governments make the best health insurance carriers. Brokers, medical billing staff, and other middlemen serve no purpose other than increasing cost (in order for an inefficient, openly colluding private cabal to invest premiums, deny claims, and collect profit) because everybody needs access to medical treatment.

Don’t bet on it. There is enough (potential) money and incentive here that almost any system will be perverted eventually. NHS is not known for speedy treatment, for instance. It’s about ongoing oversight and a willingness and ability to cut through bullshit to fix things. That’s in short supply here and everywhere else. The stories (first hand from relatives who use it) of blatant profiteering and abuse of the syste…

> NHS is not known for speedy treatment, for instance.

From what I understand (I am not a UK citizen, but me mum's mum spoke Scouse. My mother, on the other hand, spoke The Queen's English), everyone loves to hate on the NHS, but no politician in their right mind will touch it. It's a "third rail."

Re: New health insurance “transparency data” looks suspiciously wrong

#85

Post by aintgonnatakeit »

yunohn wrote: post #15
aintgonnatakeit wrote: post #10

There are two problems here: 1) Hanlon’s razor 2) The author doesn’t understand health insurance data. I’m not trying to excuse the other bad behavior, but within the data itself, he’s experiencing a combination of health insurers’ incompetence, the kludged up data models they’ve had to build to represent the output of the multiple generations of claims processing systems and other administrative processes, and the g…

But the given examples are basic procedures like “wrist x-ray” or “endoscopy”. Surely they have simpler rate calculations than the potential special cases you mention?

Let’s do wrist x-ray and keep it simple. I’m sure I’ll mess up the formatting here.

When you get an x-ray, you would expect to see 3 claims (again, simplifying).

—— One is the x-ray tech taking the picture. That gets a professional claim with a CPT code and is straightforward.

—- One is the interpretation by a radiologist of the imaging. That is a professional claim with a CPT and a modifier.

—- The last depends on the place of service. If it’s in a hospital, or at an outpatient facility, or at an ASC, then you get a facility claim to go with it.

Next, under what circumstances did the x-ray occur? Was it during an inpatient stay? If so, the payor might pay based on a DRG, which is basically a bundle of all the services that occur during the stay. How do you decide how much of the cost to allocate to the various parts of the x-ray? There are more variations on this.

Next, how are the providers contracted? Are they participating providers? Par vs non-par have different payment rates.

Next, was the service in-network or out-of-network, defined by the patient’s insurance benefits?

Does the patient’s PCP participate in a capitated arrangement (fixed fee to the PCP’s office per month)? If so, what is the allocated cost for the service based on the submitted encounter?

What about fees for network rental? Sorry, this one is esoteric, but it’s another factor.

And so forth and so on. It’s a mess.

Re: New health insurance “transparency data” looks suspiciously wrong

#86

Post by lazide »

ChrisMarshallNY wrote: post #84
lazide wrote: post #80

Earlier quoted context omitted.

Don’t bet on it. There is enough (potential) money and incentive here that almost any system will be perverted eventually. NHS is not known for speedy treatment, for instance. It’s about ongoing oversight and a willingness and ability to cut through bullshit to fix things. That’s in short supply here and everywhere else. The stories (first hand from relatives who use it) of blatant profiteering and abuse of the syste…

> NHS is not known for speedy treatment, for instance. From what I understand (I am not a UK citizen, but me mum's mum spoke Scouse. My mother, on the other hand, spoke The Queen's English), everyone loves to hate on the NHS, but no politician in their right mind will touch it. It's a "third rail."

Well, it’s the same here for the existing healthcare system in the US. Even basic reforms (obamacare) get met with insane opposition.

Re: New health insurance “transparency data” looks suspiciously wrong

#87

Post by ChrisMarshallNY »

lazide wrote: post #86
ChrisMarshallNY wrote: post #84

Earlier quoted context omitted.

> NHS is not known for speedy treatment, for instance. From what I understand (I am not a UK citizen, but me mum's mum spoke Scouse. My mother, on the other hand, spoke The Queen's English), everyone loves to hate on the NHS, but no politician in their right mind will touch it. It's a "third rail."

Well, it’s the same here for the existing healthcare system in the US. Even basic reforms (obamacare) get met with insane opposition.

The difference is who the opposition is from.

In the UK, it's from the voters.

In the US, it's from the Healthcare Industry.

Re: New health insurance “transparency data” looks suspiciously wrong

#88

Post by jcrawfordor »

Alupis wrote: post #81
inetknght wrote: post #71

Earlier quoted context omitted.

> why not move to somewhere in the US that has doctors? Do you have a suggestion where in the US that is? The US has many doctors but essentially all of them are gated behind insurances and especially hospitals.

What are you imagining it should be? You can see your doctor pretty much freely within the US for nearly any reason. This idea you cannot see your doctor in the US, or that you receive treatment from nurses or administrators is simply not true. > insurances and especially hospitals You may be confused, because some doctors operate private practices, while others choose to work for large hospital organizations. Privat…

There are large parts of the US where private practices are very rare and the major care provider organizations have multi-month waits for both primary care and specialists. As I understand the overall trend is towards longer wait times but it is significantly worse in some cities than in others. Where I am, for example, it is around six months to get an appointment with some fairly common specialists... and that's a mid-size city with a university hospital and everything. My former primary care doctor only had availability about three months out, but I am fortunate enough to have found a small private practice that has far fewer patients per provider... at the cost that I pay a large annual practice fee to be a patient.

I think this is pretty uneven across the country but it is definitely far from guaranteed that you can see a doctor on demand with a short lead time. I have heard of similar problems pretty much throughout the central region of the country. In an attempt to alleviate the situation a number of states have programs where they pay subsidies to providers in areas with longer wait times, but this turns into a complex billing system and states often can't afford enough to really make a big difference.

In some ways the private insurers are doing some good here, as several offer "patient concierges" that will do things like try to find a provider for you that's accepting new patients. But in a recent experience that involves calling every two weeks and being told they still can't find any availability, for a couple of months.

Re: New health insurance “transparency data” looks suspiciously wrong

#89

Post by TedDoesntTalk »

lostlogin wrote: post #61
xupybd wrote: post #45

Earlier quoted context omitted.

I live with free healthcare. The last three trips to the emergency department have been over eight hour waits. My father's cancer treatment was not covered so the last year of his life cost him everything. On the other side my child's healthcare is amazing and all free. We get instant access to great services.

I have both, and the wait at the paid clinic is long, as is the wait at the free clinic. It’s not whether the cost is socialised or not that decides how long the wait will be. It also doesn’t help that the private system is incentivised to undermine the ‘free’ system at every turn.

> It’s not whether the cost is socialised or not that decides how long the wait will be

If care is free, aren’t you more likely to go than if you had to pay even a minimal cost?

Re: New health insurance “transparency data” looks suspiciously wrong

#90

Post by genocidicbunny »

Alupis wrote: post #81
inetknght wrote: post #71

Earlier quoted context omitted.

> why not move to somewhere in the US that has doctors? Do you have a suggestion where in the US that is? The US has many doctors but essentially all of them are gated behind insurances and especially hospitals.

What are you imagining it should be? You can see your doctor pretty much freely within the US for nearly any reason. This idea you cannot see your doctor in the US, or that you receive treatment from nurses or administrators is simply not true. > insurances and especially hospitals You may be confused, because some doctors operate private practices, while others choose to work for large hospital organizations. Privat…

> You can see your doctor pretty much freely within the US for nearly any reason.

Sorry, as someone who knows multiple people in various parts of the US healthcare system, this is pretty laughable. At the very least, we have different definitions of 'freely'.

Most of the urgent care clinics near me, for example, no longer accept patients without appointments. ER wait time is several hours, and you will owe hundreds if not thousands of dollars after unless you have _very_ good insurance.

> This idea you cannot see your doctor in the US, or that you receive treatment from nurses or administrators is simply not true.

Not from administrators, but nurses yes. Many clinics will only have a RN on duty large parts of the time. There are also systems where you can set up telehealth appointments, but a lot of the time they will be with a nurse and not a doctor.

> In all cases, you can see your doctor if needed, with very little lead time if any.

My parents have been trying to address some conditions they've developed, in one case, pretty serious. There's a several month lead time on their appointments to deal with this.

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