Health Care Reform in the US

[dcmdale]

Generally, insurance accounting (at least on the non-governmental side) is very tightly regulated. Insurers generally file their audited financial statements with the Insurance Departments of their states, and those states do regular financial examinations.

Yes. I didn't mean to imply that the accounting standards on either side weren't rigorous. Just different.

Here, for example is the list of financial examinations (not just health insureres) from the Pennsylvania Department of Insurance (IIRC, they generally do them every 5 years).

Here is Independence Blue Cross's report--it's a very large health insurer doing business primarily in the southeast part of Pa (including Philly).

The numbers are interesting--about $360 million in premiums, $321 million in payouts (including reinsurance payouts); but a net underwriting loss of $11 million caused, primarily by "claims adjustment expenses" of $11 million and "general administrative expenses" of ~ $39 million.

Personally, those two--$50 million--are what I've always understood overhead to be.

They also posted an investment income of about $39 million.

Part of the reason private insurance companies have high investment income is that they are required to have very significant assets available should there be catastrophic losses.

I don't know how medicare and other government programs are regulated, as to reserves, though I suspect that being backed up by the Government, they don't have the same requirements, and thus have a much smaller surplus, and so not a whole lot of investment income--but that's just a guess.

Thanks for the links. I think it is going to take me longer than the 10 minutes I have right now to digest them.

[PeterGustafsson]

Hi!


A few weeks ago, my wife and our youngest son were in the People´s Republic of China, her native country. I and the the older one stayed at home. A few days after arriving there, she phoned me and said that he was had just arrived at the hospital, and that he might be up for surgery right off the bat. He had had a stomachache just recently, and it had not gone away. My wife took him to the hospital, and that was where she was phoning from, while the doctor was investigating him. She said that she would phone back once she knew more.
You can imagine how I felt.

A few hours later, in the middle of the night Swedish time, she phoned back and said that he was undergoing appendectomy. She would phone again when the operation was over. She did so, and everything had gone well. Our son had had the good fortune of being examined by a specialist in gastrointestinal surgery as the first gate keeper to health care, and he had decided to do our kid immediately, using a laparascopic procedure. Due to his prompt work, the appendix was taken out when it was inflamed, but had not yet burst. That made the healing that much better. Now he is perfect health, and the incisions can barely be seen.

PR China has a pay-as-you-go health care system, so my wife had to pay for the operation, wages, supplies, 3 days aftercare, a checkup, and some minor doodads out of pocket, which set her back approximately 760$. However, our travel insurance covered it all, with no more hassle than sending in copies of the hospital documents. (Swedish insurance companies do not try the deny-as-long-as-possible tactic, unless in really unusual cases.)

I would like to compare this experience to the one when our older son got appendicitis here in Sweden. He had classical appendicitis symptoms, but was sent home several times in one day until we were finally persistent/obnoxious enough so that another doctor - a surgeon - examined him by simply cutting him up and looking at the appendix. By then, it had burst, and it took approximately 3 months until all aftereffects had disappeared. We sent in a formal complaint to the State medical complaint board. The doctor was not formally reprimanded, but the hospital decided upon a policy that cases of possible pediatric appendicitis must be examined by a senior doctor before sending home, the junior doctors could not take that decision themselves. 3 burst appendixes had happened in 2 weeks time, luckily none fatal.

Some time afterwards, I visited the ER where the send-back doctor had been working, and asked the nurse what doctor X (name available upon email request) was doing nowadays. She was very uncomfortable with the question, and tried to dodge it, but I was persistently inquisitive and it soon came out of her that he was not working there anymore. She claimed to have no knowledge about his present work place.

Our younger son´s appendicits problem had come quickly, so my parents-inlaws had not known about it before the operation was underway, but they obviously came to the waking up room as soon as possible. There, the assembled health care professionals got a surprise - the grandfather of this half-foreign kid was a Chinese health care professional, who previously had been head of the major hospital in that big city, and a man who many a local doctor had interacted with as subordinate. I imagine that there were some major sighs of relief in the tea room when they realized that they had done everything right, since he still knows several movers and shakers in the city health bureaucracy.

Before my father-in-law went into hospital bureaucracy, he was a doctor himself. In that capacity, he came into a situation where he saw that a cholera epidemic was imminent unless he took immediate action, and he did so. This angered some other bureaucrat - that other guy thout that it should have been his call to make, and that my FIL should have filed applications in triplicate and just let the epidemic start while those whose real jurisdiction it was took action. However, a higher-up in the town caught wind of the whole situation, and told the turf-protector to back off. Instead, my FIL was offered the recognition of being invited to become a full member of the Communist Party. That is an honor in PRC, one can not just become a member by applying and paying dues. My FIL is darn proud of his party membership, and has the party membership book on display, with citation, in the bookshelf.

And that is how Doctor Hong became Comrade Hong.

I fully expect that Chase, Bayou Bum, and a few other assorted figures will berate him for his party membership. To anyone so inclined: I challenge you to show that you have done as much for your fellow men as stopping a cholera epidemic before it even got started.


Have a nice time!

Peter Gustafsson

[Bayou Bum]

Hi!

A few weeks ago, my wife and our youngest son were in the People´s Republic of China, her native country. I and the the older one stayed at home. A few days after arriving there, she phoned me and said that he was had just arrived at the hospital, and that he might be up for surgery right off the bat. He had had a stomachache just recently, and it had not gone away. My wife took him to the hospital, and that was where she was phoning from, while the doctor was investigating him. She said that she would phone back once she knew more.
You can imagine how I felt.

A few hours later, in the middle of the night Swedish time, she phoned back and said that he was undergoing appendectomy. She would phone again when the operation was over. She did so, and everything had gone well. Our son had had the good fortune of being examined by a specialist in gastrointestinal surgery as the first gate keeper to health care, and he had decided to do our kid immediately, using a laparascopic procedure. Due to his prompt work, the appendix was taken out when it was inflamed, but had not yet burst. That made the healing that much better. Now he is perfect health, and the incisions can barely be seen.

PR China has a pay-as-you-go health care system, so my wife had to pay for the operation, wages, supplies, 3 days aftercare, a checkup, and some minor doodads out of pocket, which set her back approximately 760$. However, our travel insurance covered it all, with no more hassle than sending in copies of the hospital documents. (Swedish insurance companies do not try the deny-as-long-as-possible tactic, unless in really unusual cases.)

I would like to compare this experience to the one when our older son got appendicitis here in Sweden. He had classical appendicitis symptoms, but was sent home several times in one day until we were finally persistent/obnoxious enough so that another doctor - a surgeon - examined him by simply cutting him up and looking at the appendix. By then, it had burst, and it took approximately 3 months until all aftereffects had disappeared. We sent in a formal complaint to the State medical complaint board. The doctor was not formally reprimanded, but the hospital decided upon a policy that cases of possible pediatric appendicitis must be examined by a senior doctor before sending home, the junior doctors could not take that decision themselves. 3 burst appendixes had happened in 2 weeks time, luckily none fatal.

Some time afterwards, I visited the ER where the send-back doctor had been working, and asked the nurse what doctor X (name available upon email request) was doing nowadays. She was very uncomfortable with the question, and tried to dodge it, but I was persistently inquisitive and it soon came out of her that he was not working there anymore. She claimed to have no knowledge about his present work place.

Our younger son´s appendicits problem had come quickly, so my parents-inlaws had not known about it before the operation was underway, but they obviously came to the waking up room as soon as possible. There, the assembled health care professionals got a surprise - the grandfather of this half-foreign kid was a Chinese health care professional, who previously had been head of the major hospital in that big city, and a man who many a local doctor had interacted with as subordinate. I imagine that there were some major sighs of relief in the tea room when they realized that they had done everything right, since he still knows several movers and shakers in the city health bureaucracy.

Before my father-in-law went into hospital bureaucracy, he was a doctor himself. In that capacity, he came into a situation where he saw that a cholera epidemic was imminent unless he took immediate action, and he did so. This angered some other bureaucrat - that other guy thout that it should have been his call to make, and that my FIL should have filed applications in triplicate and just let the epidemic start while those whose real jurisdiction it was took action. However, a higher-up in the town caught wind of the whole situation, and told the turf-protector to back off. Instead, my FIL was offered the recognition of being invited to become a full member of the Communist Party. That is an honor in PRC, one can not just become a member by applying and paying dues. My FIL is darn proud of his party membership, and has the party membership book on display, with citation, in the bookshelf.

And that is how Doctor Hong became Comrade Hong.

I fully expect that Chase, Bayou Bum, and a few other assorted figures will berate him for his party membership. To anyone so inclined: I challenge you to show that you have done as much for your fellow men as stopping a cholera epidemic before it even got started.

Have a nice time!

Peter Gustafsson

I don't have any problem with his party membership. I respect that he is proud of his affiliation, not like those in the US that secretly push socialist ideas because they are ashamed.

I think your comparison is a good one between pay as you go in PR China and government paid health care in Sweden. Obviously, the pay as you go system is much better. I couldn't have said it better.

My regards to Comrade Hong.

[Inquartata]

providers have to expend more time and money forcing the HMOs to pay up. The expression I've heard is that "you have to hire a barracuda" to keep after the HMOs or they'll stonewall on payments indefinitely. In short - it seems that Medicare is no more expensive, and apparently less expensive and arduous to deal with.

And yet, I see lots of television ads for lawyers offering to "help you get what you deserve" from Social Security and Medicare/Medicaid, but none specializing in doing that with HMOs...

[jessicasimpson]

And yet, I see lots of television ads for lawyers offering to "help you get what you deserve" from Social Security and Medicare/Medicaid, but none specializing in doing that with HMOs...

Well, I have never seen a TV add for a lawyer specializing in contracts, or corporate law, or real estate law.

[Inquartata]

What's your point?

[erik_blank]

And yet, I see lots of television ads for lawyers offering to "help you get what you deserve" from Social Security and Medicare/Medicaid, but none specializing in doing that with HMOs...

Perhaps that's because the HMO's can afford better lawyers?

[I_luv_saber]

And yet, I see lots of television ads for lawyers offering to "help you get what you deserve" from Social Security and Medicare/Medicaid, but none specializing in doing that with HMOs...

Oh, please tell me you are joking!

Seems like every other lawyer commercial is about "us fighting the insurance companies for you!". The other half being about fighting to lower debt to the IRS...

[lindajdunn]

Oh, please tell me you are joking!

Seems like every other lawyer commercial is about "us fighting the insurance companies for you!". The other half being about fighting to lower debt to the IRS...

Much depends upon the state where you live since insurance companies and regulations vary by state. For that matter, how companies handle claims vary by states (based partially on what they can get away with doing in different states).

[jeff]

And yet, I see lots of television ads for lawyers offering to "help you get what you deserve" from Social Security and Medicare/Medicaid, but none specializing in doing that with HMOs...

Besides ILS' point, the big difference is that I was talking about a completely different situation - these are two completely different things.

The TV lawyer ads are for payouts for denied care (either treatment wasn't provided, or the providers are billing the patient). The target audience is patients.

What I was pointing out was part of a discussing with dcmdale about provider costs. The context is that providers have to hire staff (the barracudas) to pursue insurers to pay for services they've typically already rendered. They're trying to get paid, and the HMO is stalling (very frequent tactic) or saying "we'll pay you if you accept 35% of the billed amount (ditto), or deny that the procedure or service was already authorized (also very common procedure).

So, we're talking about completely different scenarios: different populations of potential plaintiffs, and different amounts of money: the unpaid fee to a surgeon, radiologist, or anesthesiologist may be from hundreds of dollars to a few thousand bucks, not the tens of thousands of dollars (or more) for the aggregate costs of a denied claim. There are a lot more potentially screwed patients than potentially screwed providers, so it makes sense to advertise for that business in public channels, not so for suits filed by a doctor or lab. A practitioner's loss for a denial is not generally going to be enough to make it cost-effective to retain counsel, either.

[Inquartata]

Seems like every other lawyer commercial is about "us fighting the insurance companies for you!". The other half being about fighting to lower debt to the IRS...

Those are talking about auto insurance companies, for the most part. At least where I live.

Go to an online yellow pages for your area. See how many law firms specializing in general health insurance law you can find. Then see how many you can find specializing in Medicare/Medicaid/Social Security law...

In the one I checked, the latter actually had a separate section! The former all seemed to be sidelines of personal injury law firms...

What I was pointing out was part of a discussing with dcmdale about provider costs.

OK.

However, I still think it's indicative of the relative number and size of denials, when there are law firms specializing in the one and not the other. So it makes a point in the general discussion, if not in your narrower one...

[erik_blank]

However, I still think it's indicative of the relative number and size of denials, when there are law firms specializing in the one and not the other. So it makes a point in the general discussion, if not in your narrower one...

On the other hand, it may also simply indicate that the government has a much lower standard, is much easier to bend, and pays it's lawyers much les than the insurance companies pay their lawyers...
After all, how mch time would you spend if you knew that the opposition would actually BE an opposition instead of the lap dog the government lawyers seem to be...

[jeff]

Or it might simply be that since there's no legal obligation for an HMO to have any business relationship with a potential customer, there's no basis for a legal specialty based on "rights" that simply don't exist, at least, not at all until the customer has signed with the HMO - and then its straight up contract law. By contrast, Medicare, Medicaid, and general system of entitlements represent legal rights that can be asserted with the help of a lawyer. Two very different situations, and has nothing to do with who may or may not deny more frequently.

Also, and again emphasizing that a consumer has no rights at all until after he has contracted with an HMO, I wonder how many HMO agreements stipulate that conflicts be resolved by mandatory binding arbitration. Kaiser does. Pacificare does. So that also eliminates the legal subspecialty since there's no opportunity to sue - and hence no ads. This contrasts with the entitlement programs.

So, presence of ads for this type of lawyer doesn't really provide evidence one way or the other for the rate of denials.

[I_luv_saber]

Those are talking about auto insurance companies, for the most part. At least where I live.

Keep in mind it isn't just health insurance that I have a problem with. For example, I believe dcmdale's post (post #371) regarding bad faith agreements was a disability insurance company. This is a problem industry wide.

However, from what I've seen, there are those lawyer ads as well - but also a plethora of ads vowing to fight health insurance companies (or even more often, disability insurance companies) who are refusing to pay out.

Go to an online yellow pages for your area. See how many law firms specializing in general health insurance law you can find. Then see how many you can find specializing in Medicare/Medicaid/Social Security law...

A quick Google search for Health Insurance Lawyers returned 31,400,000 hits, whereas a search for Medicare Lawyers returned 2,340,000, Social Security Lawyers returned 14,400,000, and Medicaid Lawyers returned 1,450,000. All that together equals 31,400,000 vs. 18,190,000. This proves nothing of course, just making the points that 1) There's probably no way to tell which there is more of and 2) It really doesn't matter regarding the subject at hand.

[Capt. Slo-mo]

This proves nothing of course...

It proves you can Google with the best of them!

[lindajdunn]

http://www.washingtonpost.com/wp-dyn...902451_pf.html

On the issue that has been perhaps the most pronounced flash point in the national debate, 57 percent of all Americans now favor a public insurance option, while 40 percent oppose it.

If a public plan were run by the states and available only to those who lack affordable private options, support for it jumps to 76 percent. Under those circumstances, even a majority of Republicans, 56 percent, would be in favor of it, about double their level of support without such a limitation.

I note that the poll shows we're still divided over the bill making its way through Congress but I think part of the problem there is that we don't trust the Congresscritters to get it right.

[Epee_Pox]

Most health insurance is an absolute waste of money, and I do not want it to be mandatory.

Where I live, in New York, a modest health insurance plan for a family of 4 costs more than $2,000 per month.

In return, you get to pay a modest copay on those few occasions each year when you might go to the doctor. And a less modest copay on those once-or-never-in-a-lifetime occasions when you might have a serious medical emergency requiring hospitalization.

On the other hand, paying out of pocket for a doctor visit to a good Park Avenue doctor runs about $150.

So if everyone gets a checkup every year, and maybe has one other doctor visit for whatever reason, the out-of-pocket cost would be about $1,200 for the entire family, for the entire year.

That's about half of what most insurance policies charge per month.


There are reasons it's so expensive -- healthy folks who never go to the doctor are lumped together with sick folks and hypochondriacs who go all the time -- insurance companies have to give you a policy even if you've already gotten an expensive-to-treat condition -- all kinds of stupid stuff like acupuncture and holistic crap has to be covered. So premiums do not reflect YOUR risk, they represent the risk of the expensive health-care users.

Health insurance would make sense if it only covered emergency needs -- you take care of the inexpensive doctor visits, but the insurance is there in case someone breaks a leg or gets in a car accident or gets cancer. But that's not how it works here. It's all or nothing.

Health insurance would make sense if your premiums reflected your own risk of ever needing to use it. Healthy people who exercise and don't smoke and only go to the doctor for their annual checkup should not have to pay as much as constant smokers or emergency room frequent fliers. But that's not how it works here.

So the rational choice is to decline health insurance, save the couple grand every month, and put a little aside for the off chance that you might need it some day.

[Hauptman]

Sure it seems unfair to pay for insurance while you're healthy, but the idea is that it will be there when you get sick. And while healthy living will decrease your chances of getting many illnesses it will not guarantee anything. Live long enough, which your healthy living adds to, and you will eventually get sick.

And when the time comes that you do get ill, unless you are a multi-millionaire, I guarantee that you will not have enough money to cover every contingency.

[jessicasimpson]

I am wondering why when I was coaching full time I was lighter, in better shape, alot healthier in general. Health Insurance was $1200 per month. Now I am teaching lecture classes full time, have gained weight, smoke more, and in alot worse shape, my insurance is $400 a month. this makes no sense whatsoever.

Edit: I know the reason for the drop in price is that I am on the schools plan, but it still makes no sense

[Inquartata]

On the issue that has been perhaps the most pronounced flash point in the national debate, 57 percent of all Americans now favor a public insurance option, while 40 percent oppose it.

If a public plan were run by the states and available only to those who lack affordable private options, support for it jumps to 76 percent. Under those circumstances, even a majority of Republicans, 56 percent, would be in favor of it, about double their level of support without such a limitation.

And this is a reason why it should be adopted, no doubt.

But when public opinion is AGAINST a policy, then we hear "Well, we elected representatives to use their best judgements and do what they think is best for us".

As long as it's a policy we like. If it's not, we reverse the logic...

we don't trust the Congresscritters to get it right.

I will go farther than that and say that I DO trust them to get it wrong. It's what they do best.