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Insurers rely on doctors whose judgments have been criticized by courts

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Re: Insurers rely on doctors whose judgments have been criticized by courts

#241

Post by nradov »

s1artibartfast wrote: post #234
nradov wrote: post #204

Earlier quoted context omitted.

How exactly would doctors fund their own residency programs? They already graduate from medical school $500k in debt. There's no more room to squeeze them further. And teaching hospitals have no real incentive to fund more residency program slots. Their customers aren't willing to pay more for it. In game theory terms this is essentially a free rider problem: many entities in the healthcare system would benefit from…

It is a billing problem. Simple as that. Residents provide a vast amount of care, both under the supervision of an attending physician, that currently goes uncharged. Federal residency payments to hospitals forbids charging for it, and insurance refuses to pay for it. It is enough to cover the salary and cost of the residents. You are right that the current state is a free-rider problem. Free rider problems have tons…

That's not accurate and the problem is hardly simple. Medicare already reimburses teaching hospitals at higher rates.

https://www.cms.gov/medicare/payment/prospective-payment-sys...

What solution are you suggesting here exactly? Who should pay for graduate medical education, and how will we incentivize or force them to do it?

Re: Insurers rely on doctors whose judgments have been criticized by courts

#242

Post by Aloisius »

azalemeth wrote: post #15

I'm not American and grew up (and work) in Western Europe. Everyone is born, and, at some point, will get sick and die. Why does each of these cost tens or hundreds of thousands of dollars? I've heard American doctors at conferences describing their system as "the worst imaginable". Every American I know hates their system. It costs a lot more, has worse outcomes and shovels money and privilege towards the rich. Why…

> I've heard American doctors

Physicians are largely why the US doesn't have single payer.

They've been funding a massive influence campaign against government health insurance and most cost containment efforts for nearly a century under the guise of "protecting patients" (in reality protecting their pocketbooks).

https://citationsneeded.medium.com/episode-134-the-80-year-p...

Re: Insurers rely on doctors whose judgments have been criticized by courts

#243

Post by nradov »

gmerc wrote: post #154
GiorgioG wrote: post #37

Earlier quoted context omitted.

As an American born to European immigrant parents I can assure you that the grass is not always greener on the other side. All systems have problems. I say this as the parent of a child with a chronic illness (t1d) who is extremely frustrated with our health(insurance)care system.

Classic diversion. Healthcare is better in Europe. That's the topic.

Europe is a big place. Which part of Europe are you referring to? There's a huge variance in cost and quality of care between, let's say, Copenhagen and Chișinău.

And even if we look only at the wealthier EU member states, "better" depends on which metric you look at. They're generally more cost effective. But the US is better for 5-year survival rates on most types of cancer.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#244

Post by throw10920 »

ceejayoz wrote: post #98
throw10920 wrote: post #44

Earlier quoted context omitted.

This is one of the drivers of cost disease[1] in healthcare, which is a huge problem that won't completely go away even if insurance is radically reworked. [1] https://slatestarcodex.com/2017/02/09/considerations-on-cost... ?

> This is one of the drivers of cost disease... The ACA (with this new 80/20 provision) passed in 2010. Costs have been on a steady upward march (yes, adjusted for inflation) since the 1970s. https://www.healthsystemtracker.org/chart-collection/u-s-spe... The "Average annual growth rate of GDP per capita and total national health spending per capita, 1970-2023" chart even shows the 2020s as the first decade with lowe…

That's a good point - I didn't know that the ACA was that recent. Haven't health insurers still had been regulated to cap how much they can make off payouts for longer than that, though?

Re: Insurers rely on doctors whose judgments have been criticized by courts

#245

Post by s1artibartfast »

nradov wrote: post #241
s1artibartfast wrote: post #234

Earlier quoted context omitted.

It is a billing problem. Simple as that. Residents provide a vast amount of care, both under the supervision of an attending physician, that currently goes uncharged. Federal residency payments to hospitals forbids charging for it, and insurance refuses to pay for it. It is enough to cover the salary and cost of the residents. You are right that the current state is a free-rider problem. Free rider problems have tons…

That's not accurate and the problem is hardly simple. Medicare already reimburses teaching hospitals at higher rates. https://www.cms.gov/medicare/payment/prospective-payment-sys... What solution are you suggesting here exactly? Who should pay for graduate medical education, and how will we incentivize or force them to do it?

I wasn't suggesting a solution. I was highlighting one of the current problems with residency funding. Hospitals need to be able to make money of residents, not lose money on residents.

If I were to suggest a solution, the first step would be allow all hospitals to bill for work done by residents. IF they can make money on residents the entire problem goes away.

If a resident fixes your broken arm with the same quality as regular doctor, I think the hospital should be charging the payer the same.

From the papers I have seen, unbilled procedures by residents is more than enough to cover their salary.

IF it doesnt get there, we could talk about contractual solutions, but the first step should always be figuring out the true value of their work.

PS, I don't pretend to understand the intricacies of the law you linked, but it does not seem to address the issue on first read. It seems that Medicare will pay an arbitrary premium set by Congress on healthcare services not performed by residents to compensate for the fact that neither Medicare nor private insurance pays for the healthcare services that are provided by residents.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#246

Post by liontwist »

ClumsyPilot wrote: post #230
liontwist wrote: post #169

Earlier quoted context omitted.

> who starves and dies. It’s not a binary decision. Healthcare is a gradient of treatment options and outcomes. The concept you are missing is called economizing which includes substituting services, adjusting time preferences, sharing, expanding network of providers, etc. > post-2008 fail-capitalism You mean the one where government agencies were taking the risk of bad mortgages from sellers? We don’t have anything…

Well we did have TrueCapitalism in the FreeBanking era where all banks could issue their own currency and they would go bust every Tuesday. https://en.wikipedia.org/wiki/Free_banking

From your own article:

> Although the period from 1837 to 1864 in the US is often referred to as the Free Banking Era, the term is a misnomer in terms of the definition of "free banking" above. Free Banking in the United States before the Civil War refers to various state banking systems based on what were called "free banking" laws at the time. These laws made it necessary for new entrants to secure charters, each of which was subject to a vote by the state legislature with obvious opportunities for corruption. These general banking laws also restricted banks' activities in important ways.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#247

Post by nradov »

s1artibartfast wrote: post #245
nradov wrote: post #241

Earlier quoted context omitted.

That's not accurate and the problem is hardly simple. Medicare already reimburses teaching hospitals at higher rates. https://www.cms.gov/medicare/payment/prospective-payment-sys... What solution are you suggesting here exactly? Who should pay for graduate medical education, and how will we incentivize or force them to do it?

I wasn't suggesting a solution. I was highlighting one of the current problems with residency funding. Hospitals need to be able to make money of residents, not lose money on residents. If I were to suggest a solution, the first step would be allow all hospitals to bill for work done by residents. IF they can make money on residents the entire problem goes away. If a resident fixes your broken arm with the same quali…

You have misunderstood the problem and misinterpreted the papers you read. Hospitals bill for everything they do (although some bills are written off as bad debt or charity care). They don't fix broken arms for free. The bill might have an attending physician's name on it rather than the resident who actually performed the procedure but it still gets billed.

The problem is that employing a resident incurs a lot of overhead. Some of this is paying attendings for training and supervision. There's also a lot of other general overhead expense associated with having another clinician on staff. None of that overhead is directly billable to customers as a separate line item. So, who should pay?

Re: Insurers rely on doctors whose judgments have been criticized by courts

#248

Post by SilasX »

kfarr wrote: post #117
afthonos wrote: post #21

Earlier quoted context omitted.

Everyone hates “the system”, including the people in it. But every party of the system is perfectly fair and reasonable for the people benefitting from it, even if they hate every other part. So every part of the system will have people fighting for it—and if you try to change the whole system, the entire system will fight you. It’s an equilibrium, even if it’s obviously far from optimal.

There's an old essay "Meditations on Moloch" which is an exploration of themes around why humans create systems with destructive outcomes even when no individual wants them: https://slatestarcodex.com/2014/07/30/meditations-on-moloch/

I still expect people to raise awareness if and when they're caught in a perverse incentive/Moloch situation so as to give the public greater insight into how it can be fixed.

Health insurers ... don't seem to do that.

Earlier comment: https://news.ycombinator.com/item?id=42435020

Re: Insurers rely on doctors whose judgments have been criticized by courts

#249

Post by inferiorhuman »

derektank wrote: post #105
inferiorhuman wrote: post #51

Earlier quoted context omitted.

The conversion factors for private insurance are 2–3x those of Medicare. There's plenty of room to lower costs. Either private insurance companies aren't interested in lowering costs or their claims process is so arduous that providers demand higher rates to deal with the high rate of denials and ever changing minutiae. Providers are not the problem here.

Pharmaceutical companies and hospitals both have much higher profit margins than insurance companies and represent a much larger share of the total cost of healthcare than insurance companies so while I don't think they're the entire problem, they are at least part of it. You and another commenter make a good point regarding inefficiencies in claims processing but I'd be curious to know how substantial that is relati…

  much higher profit margins
That is an entirely worthless metric. Pharma and for-profit hospitals benefit from the insurance companies' perverse incentives to keep costs high. Higher cost for care means that the insurance companies can jack up the premiums to maintain their legally allowable margin. A 20% slice of a bigger pie is a larger amount than a 20% slice of a smaller pie after all.

Even better, insurance companies can wag their fingers at the doctors and all of Ayn's acolytes will chime in about how for-profit care is here to save humanity from the evils of doctors. All the while the for-profit insurance companies are laughing to the bank because they're disincentivized from negotiating more reasonable prices. There's a reason Medicare pays conversion factors that are about a third to a half of what for-profit insurance companies are willing to pay.

Even better, insurance companies have a captive audience. While the federal mandate to redirect your money to for-profit insurance was struck down, five states (and DC) have their own individual mandates.

Re: Insurers rely on doctors whose judgments have been criticized by courts

#250

Post by s1artibartfast »

nradov wrote: post #247
s1artibartfast wrote: post #245

Earlier quoted context omitted.

I wasn't suggesting a solution. I was highlighting one of the current problems with residency funding. Hospitals need to be able to make money of residents, not lose money on residents. If I were to suggest a solution, the first step would be allow all hospitals to bill for work done by residents. IF they can make money on residents the entire problem goes away. If a resident fixes your broken arm with the same quali…

You have misunderstood the problem and misinterpreted the papers you read. Hospitals bill for everything they do (although some bills are written off as bad debt or charity care). They don't fix broken arms for free. The bill might have an attending physician's name on it rather than the resident who actually performed the procedure but it still gets billed. The problem is that employing a resident incurs a lot of ov…

What I said especially holds true if you are billing in the name of the attending. If you have residents doing real work and the attending checks it out, that shows up as $0 on the books for the resident, and potentially millions of billable services for the attending. When the hospital says, "we lose money on residents", of course they do! They way they bill ensures exactly that.

That's why I say that step 1 is determine and bill the actual value of resident work. Lots of papers claim teaching hospitals actually make money on residents before medical education payments (and that doesnt even include the unbilled work I mentioned earlier [1])

If after a true accounting of the value, it still comes up negative due to overhead, then bill the customer! they are the ones that should be paying overhead anyways. There are 101 ways to recoup overhead, especially capital investment.

https://pubmed.ncbi.nlm.nih.gov/21217491/

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