The other health care issue: Getting costs down

[HM2VikingRN, RN]

[color=#2d648a]new york:

a few weeks ago a friend of mine received a bill from a hospital in new york where he had had a routine colonoscopy, one of those preventive procedures that people over a certain age are supposed to have every five years or so.

the bill, my friend was surprised to see, was for $8,513.36, not including the doctor's fee, which was a few hundred dollars more - this for a procedure involving no anesthesia and taking less than half an hour from start to finish.

what was most surprising about the bill was not even the total, rather high, amount; it was an indication that medicare - the government insurance program for people 65 and over - had paid the lion's share of the bill, or precisely $8,200.61.

over $8,000 of the taxpayers' money for a routine colonoscopy - a procedure that would normally cost a few hundred dollars, maybe a bit more than a thousand for a high-cost doctor in a high-cost area. what was going on here?

source: http://www.iht.com/articles/2008/02/13/america/letter.php?page=1

[Katie82, RN]

Re: the $8K colonoscopy, while I believe Medicare reduced the patient bill to $300, I doubt if they paid the full amount. I look at claims data all day, and while I can't remember the exact amount, the Medicare reimbursement for a colonoscopy is less than $1,000. This means the patient was charged too much for the copay. THe amount of money on the "This is not a bill" confirmation that a Medicare beneficiary usually reflects the amount of reduction Medicare is responsible for, but they seldom actually pay this amount. I worked with a Public Health Cancer Screening Program and we only paid a little over $600 for a colonoscopy with anesthesia, this was the going Medicare rate at the time. I think it's outrageous for any provider to charge $8K for a procedure that takes 15 min.

[HM2VikingRN, RN]

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.

In the end, the result is higher costs than just about anywhere else. In Germany, for example, the cost of a total hip replacement would be €7,000 to €13,000, or $10,200 to $19,000, depending on the patient's condition and whether there are complications, according to a spokesman at the national health insurer AOK. A private clinic would charge about €20,000.

[Jolie, BSN]

Get third party payors out of routine and preventive healthcare and watch costs plummet.

Make individuals responsible for saving (via Health Savings Accounts and tax credits) for their own routine, predictible and non-catastrophic health care expenses. This will not only lower prices, it will encourage individuals to negotiate with providers in non-emergency situations, and choose the highest-quality care available for the price they are willing to pay. It will also make providers accountable to the patient for price and quality, something that doesn't exist now because of government and insurance interference. And it will make individuals responsible for the costly choices they make (such as using the ER when an office visit would do and refusing to care for chronic conditions.)

Make insurance available for catastrophic costs only (costs over and above thousands of dollars due to necessary and extensive ER visit, hospitalization, surgery, etc.)

[HM2VikingRN, RN]

The Germans seem to do just fine with a mixed public private system where everyone is covered as a matter of right. There is absolutely no reputable academic evidence that a market justice based health care system as described will produce lower cost OR better patient outcomes.

Affordability for care is much different with a family income of 150,000/year than for a family making 42,000/year.

It really is a shared responsibility.

If anything we spend much more because we have a market justice system.

[mscsrjhm]

Wonderful idea, however, we (society) cannot MAKE anyone responsible-if this could be done- we wouldn't have prison overcrowding-there would be no child abuse-imagine no possessions....

Some type of universal care is coming, and the backbone of the world may be the main support-

However, it is my understanding that the majority of government money comes from the extremely wealthy- so most of us cannot say that we are supporting others..??

Anyone who has worked in the LTC field knows that mandatory insurance will not work. Health care plans in LTC do not cover basics, are way too expensive, require large co-pays, and are basically a JOKE. It would be unethical to force these workers to pay for something they cannot use-

wow- this is really going to be a bumpy ride, isn't it?

[pickledpepperRN]

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.

That gap may be too big, according to critics of the health insurance industry, whose ranks were joined Wednesday by the New York State attorney general, Andrew M. Cuomo....

...As part of the investigation, Mr. Cuomo said he intended to sue UnitedHealth Group, the state's largest medical insurer and one of the nation's biggest.

"We believe there was an industrywide scheme perpetuated by some of the nation's largest health insurers to deceive and defraud consumers," Mr. Cuomo said at a news conference on Wednesday. ...

http://www.nytimes.com/2008/02/14/business/14health.html?_r=1&oref=slogin

[pickledpepperRN]

From the current issue of the New England Journal of Medicine

Market-Based Failure — A Second Opinion on U.S. Health Care Costs

http://content.nejm.org/cgi/content/full/358/6/549

[HM2VikingRN, RN]

And this graphic shows it all:

http://content.nejm.org/content/vol358/issue6/images/medium/01f1.gif

[Katie82, RN]

However, it is my understanding that the majority of government money comes from the extremely wealthy- so most of us cannot say that we are supporting others..??

quote]

THere are a lot of folks who will disagree with this statement. My husband and I are in the 35% bracket and I wouldn't call us rich. We are simply educated, hard- working, comfortable (for which I do not apologize) upper-middle income good citizens. We represent a large segment of American society. Can we say that we are supporting others? ABSOLUTELY !!!!!!!!

[Katie82, RN]

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/business/14health.html?_r=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....