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The American Healthcare Conundrum

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Re: The American Healthcare Conundrum

#421

Post by CWuestefeld »

gamblor956 wrote: post #237
Retric wrote: post #78

Earlier quoted context omitted.

> nearly half of medical spending > something like 2 FTEs focusing just on the reimbursements from Medicare and Medicaid 2FTE’s vs what? The question isn’t is this free, the question is how large is the total staff including price negotiations, doctors, and IT time spent handling billing issues, and is Medicare more or less than 50% of the total. I am ware of one hospital and 2 medical clinics where the difference is…

2 FTEs vs a department. Most hospitals have entire departments to handle insurer coding and some even have departments just to handle insurer disputes.

to handle insurer coding

Coding is a different layer. Everything needs coding, whether for gov't or commercial payers. So the folks doing this coding can't be separated out for commercial. In fact, it's kind of the opposite:

CPT codes (for procedures) - these are defined by AMA, but mandated by CMS (i.e., Medicare/caid). Because the gov't mandated them, the commercial payers adopted them too.

HCPCS codes (equipment and supplies) - defined by CMS.

ICD-10-PCS codes (hospital inpatient stuff) - defined by CMS.

Re: The American Healthcare Conundrum

#422

Post by Taikonerd »

mekdoonggi wrote: post #374
onlyrealcuzzo wrote: post #366

Earlier quoted context omitted.

Health care is so broken that I think it will unbreak itself. You can eliminate most of the problem by mandating true cost billing by hospitals (get rid of their insurance mandated 500%+ markups to make it look like your insurance does anything at all besides make your care as costly as possible). As you said, it's oftentimes cheaper to buy drugs without insurance. The average person would quickly find out that insur…

You are extremely close to arriving at the solution, which is medicare for all. Cover everyone, then almost noone uses the insurance except when they need it, which is when they get old. If the US had the equivalence of Canadian health insurance, the spending reduction would be so big, that as a working person, your health insurance bill would go to zero, out of pocket costs to zero, and everyone would have health in…

> You are extremely close to arriving at the solution, which is medicare for all. Cover everyone, then almost noone uses the insurance except when they need it

Most Medicare recipients do get supplementary private insurance though? It's called "Medigap."

Medicare pays for 80% of patients' costs, but even the remaining 20% is a lot. (You get a $100,000 procedure -- you're on the hook for $20,000.) That's why people get Medigap coverage.

Re: The American Healthcare Conundrum

#423

Post by Taikonerd »

I think the root problem is fee-for-service.

Doctors and other providers bill for each individual thing they do. But that means that their incentive is to do as much as possible, so they can quickly rack up billable codes.

It's like if developers billed their employer per line of code they wrote: the incentive is for churn, when it should be for slowing down and thinking about quality.

Re: The American Healthcare Conundrum

#424

Post by glitchc »

kdheiwns wrote: post #294
glitchc wrote: post #259

Earlier quoted context omitted.

Try seeing a doctor in Japan as a foreigner. Just a simple consult costs $300 USD or so, and it goes up from there. It's actually a rather expensive system.

This is absolutely not true. I pay the equivalent of about $40 for X-rays and blood tests. A simple consultation is about $15, if that. I recently got diagnosed with asthma, and the whole set of tests plus a month of medicine came out to about 6000 yen, which I suppose is $40. The only reason you would pay that much is if you're visiting a private no-insurance clinic and not using insurance. And private clinics prett…

The whole debate is about what insurance companies are paying for those services, right? It's when one walks in without insurance that you see the true cost of the service.

> The only reason you would pay that much is if you're visiting a private no-insurance clinic and not using insurance

What alternatives does a tourist have? If Japan truly had cheaper procedures, it would see a huge uptick in medical tourism. There's no doubt that Japan has state-of-the-art facilities and treatment options, comparable to the US. It's no surprise that costs are comparable too.

Re: The American Healthcare Conundrum

#425

Post by hermanzegerman »

WarmWash wrote: post #399
hermanzegerman wrote: post #277

Earlier quoted context omitted.

What an arrogant comment. Nursing is one of the most physically and mentally demanding jobs I know of, at least in Germany. And I bet 80% of the Techbros here wouldn't last a month in it, given how many lost their minds over a simple RTO-Mandate. Maybe watch the movie "Late Shift" to get an idea of how a Workday is https://m.youtube.com/watch?v=C7o-omvW_DI I doubt that "directionless" people would put up with those w…

Perhaps unlike Germany, in the US, people in those positions will not be able to come close to earning what they earn if they leave. Probably only half at best. A medical cert doesn't translate to much else besides the cert. So like you mentioned, it's very difficult and grueling work, and people (in the US at least) get trapped because of the money. Passionless souls doing something they hate because they'll lose th…

I doubt that they hate what they do, it's just the shitty working conditions that render you unempathic and cynical.

Most of them care very much about what they do, and give everything they can for the patients. Otherwise they would have quit a long time ago. (I've had to do a 3-month nursing internship as part of my medical studies, it's mandatory in Germany)

Better staffing makes a day and night difference. I've experienced it first-hand as a doctor. The more overworked you are, the more cynical and unempathic you get.

After a weekend or some time off, it's already much better

In other countries with better staffing (Switzerland or Austria), it's a also very noticeable how much better the mood and morale is of the staff.

Nurses in Germany could never afford a Mercedes or an upscale home, but they would also probably make less, switching jobs. It's not that they don't love their job, they just can't take it anymore. You also rarely see old nurses for that reason.

Re: The American Healthcare Conundrum

#426

Post by biophysboy »

youknownothing wrote: post #368
Turskarama wrote: post #353

Earlier quoted context omitted.

> In many ways the quality of care in the US is far better than what folks get elsewhere, which in part is probably why there isn’t a total patient rebellion How sure of this are we really? Other countries mostly have problems with emergency departments being full, but that's less because those emergency departments are worse and more because in the US people aren't going, they just stay home and hope they don't die.

As a person who has lived in Spain, UK, and now California, I can attest to one thing: the quality of care in California (I can't speak for the whole country) is vastly superior to what I received in both Spain and UK. Sate-sponsored universal healthcare is amazing, I love the concept, but it also means that they have to run it like a very stingy HMO. They have a rulebook and they go by it, if your case is even the s…

There are other public healthcare models besides Beveridge though. Some countries do the payment & financing via gov, but the actual service is a mix of public/private. Not a perfect solution, but in my opinion better than what we have now. Maybe more achievable than Beveridge too.

Re: The American Healthcare Conundrum

#427

Post by Taikonerd »

bcooke wrote: post #220

This project reminds me of a book I highly recommend called An American Sickness. It sheds a lot of light on the same sorts of issues. One underlying, perverse incentive behind many of the problems is that insurers are regulated based on percentages of spending rather than total costs. The US passed laws meant to limit marketing and overhead that tied insurers economics to the size of the overall medical bill... whic…

> The US passed laws meant to limit marketing and overhead that tied insurers economics to the size of the overall medical bill... which means as healthcare spending rises, the dollars they’re allowed to retain can rise too, which basically means they're incentivized to drive costs up rather than down.

Yes, this is an important piece of the puzzle. The "medical loss ratio" for large insurers (the kind we all know and love) is set to 85%. So they can keep up to 15% of their revenue as profit.

As you said, if total spending goes up, they get 15% of a larger number.

Re: The American Healthcare Conundrum

#428

Post by graemep »

pjc50 wrote: post #341
legitster wrote: post #91

Earlier quoted context omitted.

The US also has GDP per capita of $90k and Japan has a GDP per capita of ~ $35k. Put another way, in both countries a hip replacement surgery is almost exactly 1/8 of someone's per capita GDP.

This is called "purchasing power parity". There's an official index for it, as well as ad hoc measures like the Economist Big Mac Index. To some extent it's circular: the US has a higher number of GDP because it spends more on healthcare. The broken leg version of the broken window fallacy.

This is an excellent point. Another comment pointed out that the gap in median salary is not as great as the gap in per capita GDP. Depending on the causes this and lower prices may mean Japanese are better off then Americans - e.g. if there is greater self-supply within households that would not be captured by GDP.

Re: The American Healthcare Conundrum

#429

Post by conductr »

wonnage wrote: post #255
conductr wrote: post #232

Earlier quoted context omitted.

Social reasons it would never work. I hate to mention anything race related online but simple truth is America has complicated history and African Americans are 30% more likely to be obese than White Americans and also earn approximately 60% of income that whites earn. A fat tax, especially one that properly allocated the cost burden to the individual, would erode race relations.

fwiw the “tax” in Japan is not paid by the individual, and generally taxing the behavior via e.g sugar taxes rather than the outcome has worked better without much public outcry after the fact

Not sure that would play the same in US though.

Black population in the US is still concentrated in neighborhoods formed by overt racism and segregation and same neighborhoods tend to be food desert where no healthy or even fresh options exists. Even if we taxed just the bad food, the lack of options and mobility that higher income might provide, basically means it’s something that would be seen as targeted. Not to mention, people will draw the most racist perception no matter how carefully you crafted the tax because race relations are always unfortunately weak and these correlations are being forced/drawn.

Re: The American Healthcare Conundrum

#430

Post by mekdoonggi »

Taikonerd wrote: post #422
mekdoonggi wrote: post #374

Earlier quoted context omitted.

You are extremely close to arriving at the solution, which is medicare for all. Cover everyone, then almost noone uses the insurance except when they need it, which is when they get old. If the US had the equivalence of Canadian health insurance, the spending reduction would be so big, that as a working person, your health insurance bill would go to zero, out of pocket costs to zero, and everyone would have health in…

> You are extremely close to arriving at the solution, which is medicare for all. Cover everyone, then almost noone uses the insurance except when they need it Most Medicare recipients do get supplementary private insurance though? It's called "Medigap." Medicare pays for 80% of patients' costs, but even the remaining 20% is a lot. (You get a $100,000 procedure -- you're on the hook for $20,000.) That's why people ge…

By "the insurance" I was referring to Medicare. I'm a working, healthy person and rarely use healthcare outside of preventative care. You could raise my Medicare taxes by hundreds monthly and still be less than what I pay for private insurance.

In a Medicare-for-all scenario, the individual price of a given procedure doesn't need to be so high, because the reimbursement is guaranteed. Right now, the "list" price of the procedure has to be high to subsidize the uninsured and Medicaid who lose money.

I'm sure there are single payer health insurance countries in which people still purchase insurance, which should inspire debate about the universal insurance cost-sharing.

Regardless, the only viable solution in the US is a single payer insurance model.

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