OT: Healthcare

[mstateglfr]

A coworker recently had to have a surgery. Was told that it would cost in the neighborhood of $15-17k. He asked what it would cost to pay out of pocket and not through insurance and they told him around $3k.

A surgery could be done for $3k out of pocket that would be billed at $15-17k?

- What procedure?
- When I hear these stories, I wonder why/how nobody is getting in trouble for insurance fraud. I understand the bill to insurance is inflated so it can then be negotiated down, and that alone should questionably be fraud. But claiming something costs $17,000 that they only charge $3,000 for sure seems like an easy case of billing fraud. They are billing insurance over 5x more than they actually charge a customer.

 

[MagnoliaHunter]

Our company is self-insured and it is great. My son flipped our SxS and crushed his arm. He was in the hospital for about 30 days, including many surgeries. When we left the hospital, the bill was over $750K. In total he has had 19 surgeries with the bill getting close to $1.2M and we have never had to pay more than $3000 in any year. His arm is pretty functional now, he can shoot a hunting bow, granted it is not back to 65 lbs like before.

 

[Dawgbite]

We are fortunate in that my wife’s retirement includes full employee healthcare for life but even then the out of pocket is expensive. We have found, especially on prescription medications that it’s much cheaper to pay cash for drugs rather than letting the pharmacy file them on our insurance. We pay for routine doctor visits with cash also as it’s more often than not cheaper than the insurance copay. The medical system gouges insurance companies to make up for the dead beats My wife takes an unique drug, there is no generic form, our copay filing it on insurance is $338 for a 90 day supply. We have the Dr write a paper prescription and have shopped it around to several different pharmacies. We get the same 90 day supply for less than $100.

 

[Dawgbite]

A surgery could be done for $3k out of pocket that would be billed at $15-17k?

- What procedure?
- When I hear these stories, I wonder why/how nobody is getting in trouble for insurance fraud. I understand the bill to insurance is inflated so it can then be negotiated down, and that alone should questionably be fraud. But claiming something costs $17,000 that they only charge $3,000 for sure seems like an easy case of billing fraud. They are billing insurance over 5x more than they actually charge a customer.

This is exactly how the system works. A good friend of mine’s wife works in billing at the local hospital ER. If you don’t have insurance then your bill is only 20% of what is billed to the insurance companies for the same care.

 

[ckDOG]

I had a long couple of paragraphs written up but I'll just contribute this one very cynical thought.

Healthcare is very expensive and a lot of people get rich off consumers having little financial choice. Someone "not your doctor" is going to decide what you need and don't need and that's going to be true whether it's in a private insurance world or public single payer.

So...bend over and cough.

 

[Beretta.sixpack]

Single payer would be better than this hodgepodge we have now. It's a mess.

I have no experience in the single payer system. I will make a few observations over the last 10 or so years though:

1. When the ACA was passed by congress, I asked my PC doc (who is still my PC today) what it meant long term? He answer was that it was it was designed to create a single payer plan in the long term. When asked how long that would take? He said 10-15 years. We are closing in on that time frame.

2. My in laws live half the year in Canmore, Alberta. They tell me that all of their neighbors come to the US for all their major healthcare. They are all retired, and have the money, so it makes sense.

3. I worked a medical sales job for the same company for 17 years. In that time I worked in the VA systems at Jackson, Memphis, Shreveport, Little Rock, and Montgomery. I hope and pray that a single payer system is run better than the VA system. I won't get into the govt waste in those clinics, different topic for different day. But folks die waiting on their appts in the VA. I have an uncle who complains about this all the time.

I wish there was an answer. I work for a global healthcare company right now, and we get to choose our carrier, but they are all the same really, and keep on going up year over year.

 

[8dog]

I wonder how many people stay at jobs that hold them back, only for the healthcare?

I wonder how much that holds back entrepreneurship, growth, and freedom?

Or have to keep working until they are 65. All that seems like a bad thing.

 

[dorndawg]

Or have to keep working until they are 85. All that seems like a bad thing.

You're right but I fixed it for you.

 

[mstateglfr]

This is exactly how the system works. A good friend of mine’s wife works in billing at the local hospital ER. If you don’t have insurance then your bill is only 20% of what is billed to the insurance companies for the same care.

Yep, and that seems like insurance fraud.
Claiming a procedure costs more than five times what it cost seems like insurance fraud.

That would be fraud in a whole lot of other instances.

 

[John Deaux VII]

I don't know how much this actually impacts the cost of insurance, but it has always seemed to me that it would work better if we utilized health insurance the way we do any other insurance. We pay routine upkeep and maintenence out of pocket for a homes and cars, but use insurance for something catastrophic like a wreck or storm damage. Why not use health insurance the same way?

 

[johnson86-1]

A surgery could be done for $3k out of pocket that would be billed at $15-17k?

- What procedure?
- When I hear these stories, I wonder why/how nobody is getting in trouble for insurance fraud. I understand the bill to insurance is inflated so it can then be negotiated down, and that alone should questionably be fraud. But claiming something costs $17,000 that they only charge $3,000 for sure seems like an easy case of billing fraud. They are billing insurance over 5x more than they actually charge a customer.

It's not fraud because the insurance companies are in on it. Everybody wants the appearance that they are getting a deal. Everybody's "pricing' affects everybody elses. We had a hospital "bill" of north of $70k, and it was adjusted down to under a couple of thousand. We paid the entire amount. The insurance paid nothing (our deductible was $2,500 I think).

But it seems to be hit or miss whether at the end of the day insurance gets you a price that is lower than the cash price or not. It seems sometimes it's more, and sometimes less, I presume based on the negotiating power of the insurance company? Or maybe it's procedure by procedure and there is no real rhyme or reason to it on the individual level but overall it results in a mix providers and insurance companies can live with.

 

[ZombieKissinger]

Yep, and that seems like insurance fraud.
Claiming a procedure costs more than five times what it cost seems like insurance fraud.

That would be fraud in a whole lot of other instances.

Usually there’s a contractual requirement related to a self-pay charges to covered members that doesn’t allow the clinic to charge under. Generally, clinics are going to charge the charge master rate to self pay as well, so it’s usually a higher self pay charge than an insured charge. You can see this as insurance adjustment on most medical bills. It’s possible the person got quoted a sliding scale payment plan rate or something.

 

[ckDOG]

I don't know how much this actually impacts the cost of insurance, but it has always seemed to me that it would work better if we utilized health insurance the way we do any other insurance. We pay routine upkeep and maintenence out of pocket for a homes and cars, but use insurance for something catastrophic like a wreck or storm damage. Why not use health insurance the same way?

That's how we manage our situation. High deductible, low premium. Take advantage of HSA incentives. It's not a bad setup but we've also been fortunate enough to avoid needing pricey medial care (knocks on wood). But I also realize a lot of people don't have access to those and their personal health situations are expensive every year with certain recurring treatments and medicines. Those situations become some bizzare mix of what we think of as traditional insurance and "prepaid medicine" using the agreements insurers have set up with providers in your location.

 

[00Dawg]

Our company is self-insured and it is great. My son flipped our SxS and crushed his arm. He was in the hospital for about 30 days, including many surgeries. When we left the hospital, the bill was over $750K. In total he has had 19 surgeries with the bill getting close to $1.2M and we have never had to pay more than $3000 in any year. His arm is pretty functional now, he can shoot a hunting bow, granted it is not back to 65 lbs like before.

Do you know what management company they use? My employer has gotten so many complaints, they're likely going to change out for the third time in as many years.

 

[FormerBully]

Honestly, when that time comes for me, I want them to pull the plug so the damn Drs and hospitals don't wipe me out financially and I can leave something to my heirs.

My uncle had Pancreatic cancer that had spread. The doctors told him they could do this and that. He said, I have lived a long life. Just make me comfortable. He died two years later and had almost zero medical debt. I have a lot of respect for that man making that call. He lived a good 75 year life.

 

[FormerBully]

Yep, and that seems like insurance fraud.
Claiming a procedure costs more than five times what it cost seems like insurance fraud.

That would be fraud in a whole lot of other instances.

True story, when I was I the hospital last year I got a break down of my bill. They charged me $18 per Tylenol dose I got. That is insane to me.

 

[Lucifer Morningstar]

I have a few points I would like to make about this, and let me start out by saying my knowledge of this pretty much comes from personal experience. In 1985, my dad was diagnosed with stage 4 Lymphoma. He decided to fight it, and literally took part in every trial and experiment imaginable. He was part of the early interferon trials, for example. He had two bone marrow transplants along with countless other things, and ended up living until 2005. His battle with it also inspired my sister, a Chem E graduate from MSU, to go into medicine. She ended up attending the Mayo Clinic and becoming a hematologist/ oncologist who is now running her own clinic out of St. Vincent's, Birmingham. Now my dad was a college professor and had to build a rental property business to be able to afford to pay the medical bills. We honestly do not know what his entire course of treatment would add up to in dollar figures, but it would have been staggering. Thank god he did have some insurance and was willing to create other income streams to account for the rest.



Through the experiences with dad, and now my sister, I have seen the healthcare industry from the perspective of a patient trying to stay alive, and now a doctor. When my dad was getting treatment, I will always remember that we stayed in the Rotary House Hotel close to the M.D. Anderson Cancer Center in Houston. That was a place for the patients and families that were dealing with the ravages of cancer. I can remember every summer it seemed like we had to go stay in Houston for a few months, and I made friends with the other kids of patients. Over the years, I began to notice that there were kids that I never saw again. The easy answer would be the patient they were with died, right? When I talked to my dad, I was told most of them did not die. They simply ran out of coverage. That is when I was introduced to the idea that medicine is a for-profit industry. Now, over the years of being by my dad's side at every doctor's appointment, all I heard were the doctors talking about the best results for the patient.



You should have seen my dad when my sister graduated from the Mayo Clinic. To me and my brother, it was pretty clear which child my folks loved most on that day. She started out wanting to be a doctor that was different from the other oncologists because she had seen how my dad was treated over the years of his treatment along with all the people close to him. She even said she wanted to be different in terms of supporting the families and patients. That sentiment lasted until she took over her own clinic and got her first real big check. Now she lives in a 12,500 square foot house in Mountain Brook with literally 3 different Porsches in the driveway and my Bil's Ford Black Widow diesel. She became about money so fast. It was amazing to me given the experiences our family had gone through. I love my sister, but it has been hard to see her become all about money and not about the patient.



Now comes the points I wanted to make, and I have no grand answer as to how to reform the system. I do know that when you put money over patients' lives and run the system for profit, you end up with what we have now. As a little kid I was told by countless doctors that the goal is patient care in terms of my dad. Once I got older, I got to see what it really is about, and most things are about it, money. As long as we have pharmaceutical companies, doctors, and all the people associated with the healthcare care industry chasing the bag and not the best results for patients, we will continue to have what we have in terms of the healthcare system. And let me say I am all for capitalism, but not at the expense of patient lives. I am all for doctors making as much money as they can, but not when the patients suffer because of it.

 

[greenbean.sixpack]

End-of-life care is a major issue. I get that people want Granny to make it 5 more months, but she has been around 98 years. It is time to go.

This is a huge issue and will only continue to grow. Personally, i have no desire to go into a nursing home. Same for expensive care when i’m nearing the end. I’d rather tie up lose ends, say goodbyes and take a big handful of pills and drift into sleep.

 

[StarkVegas Steve]

This is exactly how the system works. A good friend of mine’s wife works in billing at the local hospital ER. If you don’t have insurance then your bill is only 20% of what is billed to the insurance companies for the same care.

I work in insurance and can personally vouch this is true. If you just call the dr and start negotiating the bill it goes down drastically. We've settled 20K-30K hospital bills for well under 5K hundreds of times.

 

[Villagedawg]

I brought up England because my friend was a missionary there and broke his leg. He was treated the same day and never saw a bill. Also, he had a church member who was diagnosed with cancer. She never saw a bill and was treated well. She actually beat it by the grace of God. How is this worse than what we have here?

It isn't worse. Our system is the worst in the developed world.

 

[Trazom]

I work in insurance and can personally vouch this is true. If you just call the dr and start negotiating the bill it goes down drastically. We've settled 20K-30K hospital bills for well under 5K hundreds of times.

Some car body shops do the same thing. It’s just maximizing what the payer (individual or insurance) can/will pay.

 

[StarkVegas Steve]

Some car body shops do the same thing. It’s just maximizing what the payer (individual or insurance) can/will pay.

Most body shops do it. It's no different than the attorney who gets a client and sends them to 12 chiro appts to jack up their 33.3%.

 

[FormerBully]

It isn't worse. Our system is the worst in the developed world.

We also spend the most. People who claim ours is better than Canada's or Europe's have not been there to see it. The only thing we have better is wait time, but what I have seen with my son and wife. We are about to pass them on that.

 

[MagnoliaHunter]

Do you know what management company they use? My employer has gotten so many complaints, they're likely going to change out for the third time in as many years.

I think it is self managed too. Not really sure.

 

[DoggieDaddy13]

I’d rather tie up lose ends, say goodbyes and take a big handful of pills and drift into sleep.

If I can still walk - or operate a motorized wheelchair - I'm traveling to Ciudad Juarez, loading up mi armas and introducing myself to the guys in the cartel.

If you don't go out like Butch and Sundance, have you really even lived?

Goodbyes are for pu$$ie$!

 

[MagnoliaHunter]

A guy I work with, his dad had a major heart attack. He was in cardiac ICU for a while and a regular room after that. When they went to check out, Their bill was way over a million dollars. His mom told them that they didn't have insurance, but they could pay $50-$100 a month. The hospital told them that they would just eat the bill.

 

[HailStout]

I am all for doctors making as much money as they can, but not when the patients suffer because of it.

doctors aren’t the problem. Insurance companies, hospital corporations, lawyers, and the government love to paint us as the problem though.

 

[Maroon Eagle]

This is a huge issue and will only continue to grow. Personally, i have no desire to go into a nursing home. Same for expensive care when i’m nearing the end. I’d rather tie up lose ends, say goodbyes and take a big handful of pills and drift into sleep.

You may not have the desire but what if you lose cognitive functions other than possessing the desire to live on your own because you think you’re independent— and you’re not?

If prostate cancer doesn’t get me in twenty years, dementia will ten years afterwards….

I’ve already said I’m alone… I’ll take a retirement community and assisted living sooner rather than be a hazard to humanity….

 

[skipperDawg]

Everyone dies. Somewhere along the way we have forgotten that.

Willie Nelson (saw him play close to 3 hours Saturday night in Orange Beach) and Keith Richards says hold my beer

 

[HailStout]

Willie Nelson (saw him play close to 3 hours Saturday night in Orange Beach) and Keith Richards says hold my beer

I would argue that Keith Richards has been a zombie for at least 20 years and therefor does not count

 

[FormerBully]

You may not have the desire but what if you lose cognitive functions other than possessing the desire to live on your own because you think you’re independent— and you’re not?

If prostate cancer doesn’t get me in twenty years, dementia will ten years afterwards….

I’ve already said I’m alone… I’ll take a retirement community and assisted living sooner rather than be a hazard to humanity….

My friend's grandfather was a big anti-retirement community person, but one of his buddies decided to go. After his buddy shared the fun he was having, my friend's grandpa changed his tune quickly and joined the fun by moving in. Apparently, my buddy's grandpa turned into a big hoe at the community. True story, his mom found a bottle of the blue pills in his sock drawer. Talk about one last laugh/shock to leave your kid. haha

 

[patdog]

I would argue that Keith Richards has been a zombie for at least 20 years and therefor does not count

That's my theory too.

 

[L4Dawg]

Yep, and that seems like insurance fraud.
Claiming a procedure costs more than five times what it cost seems like insurance fraud.

That would be fraud in a whole lot of other instances.

It's not fraud. That's how healthcare billing works. I'd be willing to bet the insurance company didn't pay anywhere near the full billing price either.

 

[Lucifer Morningstar]

NM.

 

[johnson86-1]

View attachment 1295067

doctors aren’t the problem. Insurance companies, hospital corporations, lawyers, and the government love to paint us as the problem though.

Doctors are the same problem as nurses, hosptial administrators, techs, etc. They all make more than their counterparts in other countries because almost everyone in the US makes more than counterparts in other countries. We have nicer hospitals and way more single occupancy rooms. We don't use monopsony power to purchase drugs, so we let other countries free ride off of us for prescription drugs. Our doctors are more highly trained, which even if we didn't generally make more across the board in the US, would presumably require that they get paid more to get qualified people to sign up for that much extra school/training. We over treat, over test, and over diagnose compared to other countries. Yes, some of that is because we're litigious, but a lot is because we are richer, and therefore our view of the cost benefit analysis appropriately changes.

There are lots of things we do that result in our costs exceeding those in other countries. There is no silver bullet and there is a lot of path dependency that means we can't just "do like so and so" to bring costs down, even if "so and so" was simialrlyl situated, which they almost never are.

ETA: And insurance problems are the problem to the same extent the AMA is. They are responding to incentives, some of which are out of their control, some of which are in their control but are natural ones that a functioning market will tamp down (e.g., doctors and insurance companies wanting to make money).

 

[mstateglfr]

It's not fraud. That's how healthcare billing works. I'd be willing to bet the insurance company didn't pay anywhere near the full billing price either.

I understand it isn't fraud and 'it's just how the system works'.

I am saying that if the provider is paid by insurance more than what they billed a direct pay patient, I think the system is fraudulant.

In other situations, billing insurance 5x more than what a customer is charged would be fraud.
...but magically it isn't here.

 

[doobeeadawg]

I don't know how much this actually impacts the cost of insurance, but it has always seemed to me that it would work better if we utilized health insurance the way we do any other insurance. We pay routine upkeep and maintenence out of pocket for a homes and cars, but use insurance for something catastrophic like a wreck or storm damage. Why not use health insurance the same way?

Used to be an exactly that that way years ago.

 

[holdout]

But we have nice ballrooms

 

[Cjreb]

I’ll try here some we still have by far the best care in the world. Fee for service is the best way to have the best care. Insurance is billed that high because all of us on health insurance are subsidizing everyone else’s care with our premiums Including medicare and the exchange subsidies. Private insurance runs about a 1.5% fraud rate while medicare is in the 25-30% range and has no mechanism to catch the fraud until it is so large the FBI gets involved.
Obamacare has severely hurt or level of care by funneling most of the doctors into employees for hospitals, 85% were self employed before now only 15%. This ruins the patient doctor relationship and gets us more to a single payer system. Insurance cant be blamed for rate increases anymore they have the 85/15 rule with Obamacare,(85 cents on every dollar goes to direct medical cost or has to be refunded, 15% pays for employees, buildings, sales,etc.) No way our government could run a system that lean and still stamp out the fraud.
You can still get an MRI or CT scan in Mississippi within a week to see what is going on try getting one in less than 6 months in Canada or the UK. Orthos in Canada hit their max allotted income by June and come to the states rather than do free surgeries the rest of the year, this is why an ACL surgery wait time is 9 months. Not sure what the answer is but would much rather see a safety net hybrid basic care for all with a private system for the overage for those willing to pay For their healthcare. You can‘t give out gender affirming care and expect pricing to remain level.

 

[BossDawg78]

But we have nice ballrooms

Lock it

It was a good conversation that was going, too. I was actually learning a few things.