Attacks mount on 'preexisting conditions'

HM2VikingRN, RN · Mar 31, 2009

The commonwealth fund has an interesting article about reform of reimbursement systems. Bottom line is that our peers in the OECD deliver better care at lower cost.

Strengthen and reinforce primary care by revising the Medicare fee schedule to enhance payment for primary care services and to ensure annual increases that keep pace with the cost of efficient practice;
Institute new ways of paying for primary care to encourage adoption of the medical home model and promote more accessible, coordinated, patient-centered care, with a focus on health and disease prevention;
Promote more effective, efficient, and integrated health care delivery by
adopting more bundled payment approaches to paying for care over a period of time or for the duration of an illness, with rewards for quality, outcomes, and efficiency; and
Correct price signals in health care markets to better align payments
with value.

S. Guterman, K. Davis, C. Schoen, and K. Stremikis, Reforming Provider Payment: Essential Building Block for Health Reform, The Commonwealth Fund, March 2009 at http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2009/Mar/Reforming-Provider-Payment-Essential-Building-Block-for-Health-Reform.aspx

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Jolie, BSN · Mar 31, 2009

Interesting articles which debunk Medicare's claims of efficiency:

Medicare Efficiency?

August 10th, 2007 by Tom Matlock

Several considerations suggest “Medicare efficiency” is an oxymoron:

1. Overhead of 2% is based on dividing administrative costs by the dollar amount of the claims paid. Medicare recipients’ claims are on average twice as high as for non-medicare claims. The administrative overhead of Medicare per claim is remarkably similar to that of the private sector.

full article: http://arizonahealthfutures.org/?p=69

Medicare’s Hidden Administrative Costs:

A Comparison of Medicare and the Private Sector

(Based in Part on a Technical Paper by Mark Litow of Milliman, Inc.)

By Merrill Matthews, Ph.D.

One of the most common, and least challenged, assertions in the debate over U.S. health

care policy is that Medicare administrative costs are about 2 percent of claims costs,

while private insurance companies’ administrative costs are in the 20 to 25 percent

range.

It is very difficult to do a real apples-to-apples comparison of Medicare’s true costs

with those of the insurance industry. The primary problem is that private sector

insurers must track and divulge their administrative costs, while most of Medicare’s

administrative costs are hidden or completely ignored by the complex and bureaucratic

reporting and tracking systems used by the government.

This study, based in part on a technical paper by Mark Litow of Milliman, Inc., finds

that Medicare’s actual administrative costs are 5.2 percent, when the hidden costs are

included.

In addition, the technical paper shows that average private sector administrative costs,

about 8.9 percent – and 16.7 percent when commission, premium tax, and profit are

included – are significantly lower than the numbers frequently cited. But even though

the private sector’s administrative costs are higher than Medicare’s, that isn’t “wasted

money” that could go to insuring the uninsured. In fact, consumers receive significant

value for those additional dollars.

http://www.cahi.org/cahi_contents/resources/pdf/CAHI_Medicare_Admin_Final_Publication.pdf

allnurses Guide · Mar 31, 2009

originally posted by herring_rn
when we all have the same insurance doctors won't refuse patients based on their plan.

they won't be able to. the government will mandate participation, regardless of inadequate reimbursement. that will force enrepreneurs into other professions. the number and quality of providers will go down. if you think the wait time for a specialist is bad now, just wait until there are no specialists left willing to practice medicine.

and along with many thousands of nurses i will work to ensure reimbursement to providers is fair.

that sounds good, and is an admirable goal, but look how far we, as nurses, have to go with critical issues such as staffing and mandatory ot. the truth is that we don't have the ability to significantly impact these issues now, and our ability to do so will decrease even further when the government has a monopoly on payment. just like trying to negotiate the price of a postage stamp.

and primary providers will not have to employ the numbers of people to just do billing for the multitude of plans. those smart people who do billing can then do something useful.

sounds good, in theory. but i think we all have at least anecdotal experience with trying to get care approved and paid for medicare or medicaid patients. i have seen absolutely no evidence that those programs require fewer personnel for providers, as our doctor's offices and hospitals employ staff members whose sole responsibility it is to pre-approve services, file claims, etc. then they wait for months to get paid for services rendered. only the government can get away with that.

we will never improve if we don't try.

in my state direct care rns achieved safe staffing by acuity with the ratio as the maximum number of patients a nurse may be assigned in acute care, a whistle blower law with fines as a deterent to retaliation, and through contracts no mandatory overtime.

http://www.cdph.ca.gov/services/dpopp/regs/documents/r-37-01_regulation_text.pdf

of course some hospitals try to flaunt the law. they are committing a crime.

i think we the people have a better opportunity to prevent denials of needed care with our system than with the current profit driven sick care non system we have now.

i think one system would be simplet so would require fewer staff for billing.

my dermatologist only bills medicare. she is quite busy but needs only one employee, an rn who does billing, assists with office surgeries, and takes payment for non medicare procedures.

i then do the paperwork and send it to my insurance company. i'm reimbursed for all except the deductable.

ps: i think i get a bargain when i can send cards, letters, and documents for 42 cents. and it is convenient too.

Jolie, BSN · Mar 31, 2009

Herring,

We obviously come from different philosophies and experiences.

Have I ever had to appeal an insurance decision? You betcha. Have I ever been unable to resolve a private insurance issue to my satisfaction? Nope.

I can't say the same with Medicare, which I have dealt with for relatives.

I find it interesting that your dermatologist accepts payment from private insurers (which she probably needs to keep her doors open) but only bills Medicare. That's because she has to. If she accepts it for payment, the government mandates that she bills for it. The government won't allow her to pass off the function of billing to her Medicare patients as she does with her privately insured patients. I think that's a perfect example of a provider needing private pay and insured patients to make a practice run, because it would be impossible to do so with government insured patients alone. Our current system allows her to run her office that way. A government-controlled system won't.

allnurses Guide · Mar 31, 2009

Herring,
We obviously come from different philosophies and experiences.
Have I ever had to appeal an insurance decision? You betcha. Have I ever been unable to resolve a private insurance issue to my satisfaction? Nope.
I can't say the same with Medicare, which I have dealt with for relatives.
I find it interesting that your dermatologist accepts payment from private insurers (which she probably needs to keep her doors open) but only bills Medicare. That's because she has to. If she accepts it for payment, the government mandates that she bills for it. The government won't allow her to pass off the function of billing to her Medicare patients as she does with her privately insured patients. I think that's a perfect example of a provider needing private pay and insured patients to make a practice run, because it would be impossible to do so with government insured patients alone. Our current system allows her to run her office that way. A government-controlled system won't.

She told me most of her income is now Botox and other cosmetic procedures. She would be fine with private pay patients under a single payer system.

But I'm glad she cares for me because I've known her since she removed my daughters warts 30 years ago.

The fact is that NURSES worked to change the constitution so women were finally granted the right to vote.

NURSES began the systems of public health.

And in the 1990's NURSES achieved legally mandated staffing ratios.

Yes WE can!

Jolie, BSN · Mar 31, 2009

Why in the world should taxpayer funded healthcare pay for purely elective procedures such as cosmetic Botox?

allnurses Guide · Mar 31, 2009

Why in the world should taxpayer funded healthcare pay for purely elective procedures such as cosmetic Botox?

Of course they should not.

My doctor treats my skin cancer and other conditions because she is a compassionate person.

Most of her money is NOT from Medicare or other insurance.

She treats Medicare patients for whatever Medicare pays. They can voluntarily pay the 20% not currently paid. I plan to do so.

HM2VikingRN, RN · Mar 31, 2009

I think I'll stick with single payer as a goal. Fragmentation of payers has led to an explosion of costs AND poor quality. One of the end points of reform is to get patients with chronic illness into medical homes and improve their access to primary care. It is extremely difficult to defend a private insurance scheme for medicare that is 20--25% more costly than traditional FFS.

Honnête et Sérieux · Apr 1, 2009

When we all have the same insurance doctors won't refuse patients based on their plan.
And along with many thousands of nurses I will work to ensure reimbursement to providers is fair.
AND primary providers will not have to employ the numbers of people to just do billing for the multitude of plans.
Those smart people who do billing can then do something useful.

Maybe they can go work for the IRS...another efficiently-run gov't revenue collection agency. :coollook:

The only way for this to work would be to outlaw private payor and private insurance totally, and likely that would be litigated in our Supreme court, and the conclusion would likely be that to restrict our privilege to pursue healthcare outside a single-payor program would be a violation of our Constitutional Rights.

Long Term Care Columnist / Guide · Apr 1, 2009

I don't think many would deny people the right to purchase private health plans, or to pursue care that the average Joe or Jane can't afford. I know I wouldn't---if you can afford it and you want it, you should have it. All that we proponents of UHC want is for every man, woman and child to have basic health services.

And yes---we know that what constitutes "basic" services is VERY debatable. In fact, we all will be debating this for the next umpteen years because no nation can afford to pay for every health service people want. Someone will have to draw up a list of services in order of highest to lowest priority, and then determine which will---and which will not---be paid for by the public.

My own state, Oregon, was a pioneer in this arena years ago; there was a list of over 700 medical services/procedures/surgeries etc. in order of greatest benefit to the most people, and the line was drawn at number 568. In other words, if you wanted a surgery listed at number 569, you were out of luck. Rationing? Yes. But we already ration health care as it is, only we do it in the least ethical and most immoral fashion possible---we ration it by a person's value in the eyes of our society, e.g., their income and social standing.

This is unacceptable, to me and millions of others. Universal health care WILL happen at some point because the current system is unsustainable; it just won't happen until the entire system comes crashing down around us because there is still a large minority of Americans who either fear change too much to risk trying something else, or see nothing wrong with the way things are done now. And they are backed by a very powerful ally in the insurance industry.

Just my fifty cents' worth.......again.:wink2:

flightnurse2b, LPN · Apr 1, 2009

Doesn't seem to match up.
I'm seeing speculation that a UHC system would result in fewer abortions, followed by speculation about why they are more frequent or increasing.
I just don't know where to go with that; it's hard to discuss an issue where someone promotes both sides of the issue.
Nonetheless, I'll continue with a speculation of my own; if people are having trouble paying for prenatal care, then they probably can't afford to raise a baby, either.
http://www.emaxhealth.com/84/17339.html
A pregnancy lasts less then a year, and the link above estimates the cost; this falls in line with most estimates.
The non-medical necessities of raising a child range from a low of $10 or 12k if you don't send them to college (this doesn't include healthcare costs).
If you can't afford even the lowest-cost pregnancy and childbirth without the gov't paying the bill, then I don't know how they can afford to raise the child.
Seems to me that people who can't afford kids shouldn't be having them.
Maybe I'm just crazy logical that way.

i don't honestly want to or care to discuss the issue any further with you.

i don't know if this entire post was directed at me or not, because i have been saying that i was having problems with my insurance and can't afford the private PPO plan i'm on which pays for absolutely squat, but if it was i think it was completely out of line, and it was very hurtful.

seems to me that you need to walk in my shoes before you judge me or any other mother to be who is worried about getting prenatal care. my story is one of SO MANY.

i think it would be best for me to leave this thread and let you continue making speculations..

Honnête et Sérieux · Apr 1, 2009

You were the one who speculated that a UHC system would reduce abortions.

Don't then label me when I share facts.