[ksilty]

Originally Posted by spacenurse

Inquiry Set on Health Care Billing

It is a common medical puzzler.
The benefits statement arrives from the insurance company, saying that although the doctor has charged, say, $200 for that recent office visit, only $80 is covered — and the consumer is obliged to pick up the balance.

http://www.nytimes.com/2008/02/14/bu...=1&oref=slogin

No one pays this balance. All payers pay on a discounted rate, contracted with the provider. The doc only gets $80 for this visit. They are simply billing for $200 to let us know what they think their skill is worth.

[dria]

Re-read the article ksilty.....
You are correct that that is the case when a consumer uses a contracted or in-network provider. However, when a consumer uses an out of network provider, the insurer pays only a percentage of the reasonable and customary rate based on that policy's SPD. The remaining balance is the consumer's responsibility.
The thrust of the NYAG's lawsuit is that Ingenix intentionally low-balled the R&C, resulting in a higher out of pocket cost for consumers.
I question where Mr. Cuomo got his numbers, and whether his re-election is coming (but then I always ask that question when a politician starts calling press conferences to announce he's doing his job.) Working in the insurance industry, I can honestly say I've never seen R&C that low for an office visit...the same question that UHG raised. Interesting that the AG's office declined to specify where they obtained their numbers....so much for the "transparency" that they are looking for....

[bobweiss]

I think that the current health care system almost mirrors the "average" behavior of it's citizenry when it comes to personal healthcare. That is to say, in a word, it's "dysfunctional". There is something called "responsibility" for the consequences and lack thereof of one's behavior that MUST be taken into account if the health care delivery system is to be reformed.

We are inundated with assorted information, all well-intended, via all manner of media outlets on how we may act more responsibly as individuals to insure a better quality of health. Most of the population ignores such and goes about consuming high sugar food and drink, high sodium food products and much other that is marketed, because it's out there and they lack self-discipline. The individual has a responsibiity for one of the two factors that effect his/her health. One, which is a genetic predisposition one cannot effect by behavioral modification, but the other...enviromental influence can be addressed.

This country is in the throes of a diabetes typeII epidemic. Health care folks know the devastation that diabetes can wrack upon an individual's health, so why is it that such a large percentage of morbidly obese people can be observed working wihin the nation's hospital systems? It's symptomatic of the greater overall problem and NO health system can be designed that can long endure and compensate for the accumulation of personal neglect and abuse running rampant in this society.

In short, we must not put the cart out ahead of the horse. There are very real philosphical considerations that must be recognized as being significant drains upon ANY and ALL health systems. I'm not a 'big government' advocate at all. Politicians have no genuine concern when they voice opinion on health care and are, as may be now daily observed, pandering to segments of the population as they go about whoring for the vote among the intellectually challenged. In short, in the main, they are pathologically disingenuous.

The problem here that I've commented upon needs ideas to address it. I'd much rather see serious constructive commentary on how to 'responsibly' deal with the matter of creating an environment that insists upon, not entreats, those of bad behavioral attitude to change or else be left 'out in the cold' so-to-speak. I believe government's responsibility is to be the ombudsman for the public whilst carefully treading that gray line, which when crossed makes them a burdensome, irrelevant, regulatory bureaucracy. We live in times when a spoiled public, for political reasons, has come to expect that the vague Goliath of an entity we call the "federal government" is the provider of all things from cradle to grave. Not yet friends, but the attitude towards rampant socialism is upon us. Government is nothing and it creates nothing...it produces nothing. It's assets and liabilities are the peoples' assets and liabilities. There is no free ride!

Allow me to lay the first BET (BehaviorEncouragementTherapy) protocol on the line:
1. Impose, not a tax, but a 25% surcharge at the retail level to the price of a specific approved lists of food and drink products. That money would be collected and deposited in a specific health cost allotment account at the state level to defer the state cost of state-run universal health care. And while were about it...all federal cigarette taxation will CEASE and go to the appropriate states who collect same to go into the same allotment account. The reason for state-run is that a federal plan cannot properly address the varied conditions at many different state levels. States can be more responsive and responsible in maintaining such and MORE EASILY held to account. This knee-jerk attitude of going to the federal government for everything is a destructive process from every view. The federal government should be responsible for setting and applying the basic minimal standards for states to comply with and then step out of the picture. Plans should state that the health delivery system costs, paid for by individual and corporate taxation (as Medicare is phased out as a federal responsibility and changed to a state responsibility), will cover 75% of the "reasonable and customary" charges for procedures. Insurance companies can be revamping their coverages to highlight Major Medical insurance plans to address the bulk of that 25% with varying deductibles for pricing considerations. Just a few thoughts off the top of the old bean......., so
LET'S HAVE AT IT!!

[elkpark]

Originally Posted by ksilty

No one pays this balance. All payers pay on a discounted rate, contracted with the provider. The doc only gets $80 for this visit. They are simply billing for $200 to let us know what they think their skill is worth.

Ah, but it you have the misfortune, for whatever reason, to be uninsured, you do get billed for the whole $200, and they certainly expect you to pay it (even though they will settle for the seriously discounted rate from the insurance company ...)

[forrester]

There are solutions to each one of these problems, from cost to payment, but not if the politicians won't listen to alternatives.

The industry is too entrenched, too powerful, and has too much money to throw at our political leaders.

On the one hand, they want reform. But only reform that they can control. JACHO standards. "Safe" staffing measures (whatever that means). SEIU agreements they can co-create.

There is an alternative. For anyone interested, I refer you to the PUCHA legislation of 1935. This is the model we should be looking at to guide us in creating a not-for-ptofit health care system.

Other structural changes are needed too in the delivery system. Sorry I don't have my website up so you can look at some of the ideas.

[herring_RN]

This brings up a lot that I need to learn.

First baby step start: http://en.wikipedia.org/wiki/Public_...ny_Act_of_1935

[forrester]

Originally Posted by herring_RN

This brings up a lot that I need to learn.

First baby step start: http://en.wikipedia.org/wiki/Public_...ny_Act_of_1935

Exactly, here was the government going into an industry and mandating a structural format.

The issues were remarkably similar-
Cost
Distribution
Control
Oversight
Mandating services to rural areas
The other major philosophical issue was that the government decided access to, in this case electricity, was a basic right, not just a privilege. It wasn't a complete right, you still had to pay for it, but access to it was not an issue of wealth or privilege.
The compromise was a non-competitive, geographically located, system, which would develop and be responsible for, power distribution. Even if the immediate profit return did not justify the expenditure. Long term benefits would now be factors as well as social justice and equality.


The next step is to look at payment. How do we pay for a system which thinks long term and provides services based on community needs??
Any ideas?

[DarrenWright]

Originally Posted by HM2Viking

What is especially instructive is the discussion about hip replacement surgery. In the US it is $40,000+ while in germany it ranges in cost between 10-20,000.

It's only instructive if you tell the whole story; in the US, the patient reserves the right to sue the surgeon, anesthesiologist, and hospital into oblivion, while Germany first persues criminal charges in medical malpractice and rarely awards punitive awards...certainly not millions of dollars as in the US.

If we implement this kind of practice in the US, Sheriff Joe will have to set up many more acres of tents to house the prison population explosion; more than a few RN's and physicians will be going to jail, and the victims would lose out on big settlements. Healthcare costs will soar even more because healthcare professionals are probably more afraid of jail than a successful tort and will usher in a whole new era of defensive medical practice. The shortage of people entering the healthcare field will exponentially increase, and the vicious cycle will only get more vicious. Besides, the liberal legislature opposes caps on awards.

[bobweiss]

I should note I speak from the perspective of some naivete as an outsider (patient) looking in (upon the system). Regardless of country one thing I always felt would be constructive (if not already in place) is what I describe as an AnonymousPeerReview, which would be step one at the first hint of a formal complaint precursor to litigation by a patient or family member. The "anonymity" would be only that the case would be assigned a number from a registry and the physicians name would never be known to those reviewing. As pertains to the USA, I'd be interested to know if such a formality exists now.

[Kyrshamarks]

Everyone talks about the cost of health and the unfair charging by the hospitals/doctors and the unfair practices of the insurance companies but a large part of the blame does belong on the public. Yes i said the public. Due to the large ampunt of people sueing hosptials and doctors and insurance companies, there are large settlements that have to be paid from somewhere, and that is from the rest of us. Get the lawyers out of health care and get tort reform and you might just see prices being dropped, unessacary testing being stopped and patients being treated for what is wrong and not what wil happen if they don't treat.