US Supreme Court Ruling on Health Care Law

[diableri]

Originally Posted by Storythree

I am a doctor and this post bothers me. Makes me feel like eventually I'm just going to be another government resource to be rationed and given out at the discretion of a bureaucracy.

If someone wants to see a doctor (demand) and I am willing to see them (Supply) then why can't we set a price (money: mutual benefit) for the service?

I hate to write this but... isn't that already happening? That's what the docs I work with every day are asserting; loudly. It's also what I observe from my perspective one step removed from them.

They are cardiologists, cardiac surgeons, radiologists, vascular interventionists, vascular surgeons, intensivists and emergency medicine physicians along with our various different regional hospital directors who are within a few years of clinical practices throughout our system. I don't know what discipline you practice in and as you know, things are different among the service lines so your experience could be quite different.

I can only think of one of them that thinks this approach is a good for patients and applied health care. That's one of the directors (Medical Staff Office). We have had quite a few speakers come through from places like the Advisory Board that really extol the virtues of the changes but there's always subtext in these topics like, "The best choices are no longer the best choices, but the best choices available". Yikes.

We get weekly webinars from Medtronic, Boston Sci etc about how to figure out who can get an ICD vs who has to wear a vest and everyone still makes mistakes figuring that out. The sickening part is that we don't actually know if we're going to be reimbursed for the devices and procedures until AFTER it's billed because medicare can only give us, "Guidance" and not rulings on individual cases. That's a $50k+ case that is life and death to the patient. Then, if we go ahead and do them and submit for reimbursement and CMS sicks the Dept of Justice on us (just like my previously mentioned Cleveland Clinic example who was used as a MODEL for THEIR SYSTEM). At the end of that, what is a hospital (or any provider) going to do? Go after a fixed income medicare patient that cannot possibly pay that back? Of course not, it's written off as a loss.

That type of system has completely commoditized both the service and the supplies from my understanding of the concepts.

[Storythree]

Originally Posted by RainforestMoon

The best doctor I have seen in my life was up in NYC. He didn't take insurance. He set his own prices. He didn't rush me through a fifteen minute visit, and he managed to figure out what eleven doctors before him couldn't.

As a doctor, If you don't mind my asking, what do you think about the ACA? Should congress work to continue to improve it? Or should they do what the GOP is saying they will do, completely repeal and replace it with...what?

I've heard many stories similar to yours and it does not surprise me at all.

I am just out of residency and have been very preoccupied with studying so I have not given much thought to the ACA, to be honest. - definitely not to legitimately respond to your questions above. Though I can say that when I read now about the ACA provisions all I see is the creation of many new governmental agencies and gigantic bureacracies. Even one that will conduct and oversee research as to how effective the ACA is! I cannot imagine how self-serving systems like these can avoid corruption (A governmental agency has to decide on how effective the system is that is funding their own institution).

My own personal belief is that as a civilized society there should be a net of basic health services that cover basic human needs (emergencies, OB/GYN, pediatrics, basic primary care) - in other words some sort of "social" system that is better than the current ER-based system we have now.
That said, this must be the basic minimum and not interfere with free-market medicine. The second the state takes hold of the field of medicine you can expect it to be rationed and stifled. The drive for new and cheaper technology and medicine (and better doctors!) will only come from competition.

[RainforestMoon]

Originally Posted by Storythree

I've heard many stories similar to yours and it does not surprise me at all.

I am just out of residency and have been very preoccupied with studying so I have not given much thought to the ACA, to be honest. - definitely not to legitimately respond to your questions above. Though I can say that when I read now about the ACA provisions all I see is the creation of many new governmental agencies and gigantic bureacracies. Even one that will conduct and oversee research as to how effective the ACA is! I cannot imagine how self-serving systems like these can avoid corruption (A governmental agency has to decide on how effective the system is that is funding their own institution).

My own personal belief is that as a civilized society there should be a net of basic health services that cover basic human needs (emergencies, OB/GYN, pediatrics, basic primary care) - in other words some sort of "social" system that is better than the current ER-based system we have now.
That said, this must be the basic minimum and not interfere with free-market medicine. The second the state takes hold of the field of medicine you can expect it to be rationed and stifled. The drive for new and cheaper technology and medicine (and better doctors!) will only come from competition.

The health insurance companies don't compete though. They collude.

[diableri]

Originally Posted by RainforestMoon

The health insurance companies don't compete though. They collude.

Perhaps a decade ago yes, that was their MO. However these days, they simply rewrite their coverage and reimbursements schedules to mimic those of medicare/medicaid on the next contract cycle. If they collude with anyone today, it's the Feds; as completely evidenced by the fact that they are going to make billions over the next decade via the ACA.

EDIT: My only hope is that HHS abolishes private coverage and all those companies get ramrodded for this short sighted shit within a couple decades. Not that I like that solution, but it would be a bit of sweet justice for those still trying to make money at that time. It won't take back all the damage done before that then though.

[barefoot]

If companies are going to be forced to offer their employee's health care can they charge fat/unhealthy people more? Why can car insurance companies charge more for high risk drivers? Why can life insurance companies charge more for smokers? If the govt is going to shove health care down our throats we should be allowed to charge certain groups more and certain groups less.

[diableri]

Originally Posted by barefoot

If companies are going to be forced to offer their employee's health care can they charge fat/unhealthy people more? Why can car insurance companies charge more for high risk drivers? Why can life insurance companies charge more for smokers? If the govt is going to shove health care down our throats we should be allowed to charge certain groups more and certain groups less.

That's already the case. See smokers, patients with cancer HX or transplants etc. Have no fear, I'm sure we'll be doing far more behavioral modification. Harrison Bergerons will have their day.

[RainforestMoon]

Originally Posted by diableri

Perhaps a decade ago yes, that was their MO. However these days, they simply rewrite their coverage and reimbursements schedules to mimic those of medicare/medicaid on the next contract cycle. If they collude with anyone today, it's the Feds; as completely evidenced by the fact that they are going to make billions over the next decade via the ACA.

I disagree. The large healthcare bureaucracies operate as mini-monopolies that together form one giant cartel, fixing prices. The mergers and acquisitions have swallowed up the small and medium companies, and now the insurance market nationwide is dominated by what, 7 big companies? Aetna, United Health Group, Cigna, Wellpoint, Coventry, Health Net, Humana...

There aren’t enough market forces to make healthcare affordable. Capitalism works, where's there's competition Most of America’s insured receive health insurance through employers, who essentially choose the plan providers based on the dictates of the cartels. The insurance provider chooses the customer instead of the customer choosing who to give their business to; businesses get rejected, or slapped with prohibitively high fees if there are too many medical claims. That's back-asswards for a capitalist economy. Competition is supposed to provide cheaper choices. But cartels don’t compete. They collude. And they have congress protecting their ability to do so. The McCarran-Ferguson Act of 1945 essentially protects health-care organizations from antitrust prosecution.

[RainforestMoon]

Even doctors and other providers, like labs are slaves to the industry. If they don’t participate in the insurance cartels’ programs, the majority of patients evaporate.

[diableri]

Originally Posted by RainforestMoon

I disagree. The large healthcare bureaucracies operate as mini-monopolies that together form one giant cartel, fixing prices. The mergers and acquisitions have swallowed up the small and medium companies, and now the insurance market nationwide is dominated by what, 7 big companies? Aetna, United Health Group, Cigna, Wellpoint, Coventry, Health Net, Humana...

There aren’t enough market forces to make healthcare affordable. Capitalism works, where's there's competition Most of America’s insured receive health insurance through employers, who essentially choose the plan providers based on the dictates of the cartels. The insurance provider chooses the customer instead of the customer choosing who to give their business to; businesses get rejected, or slapped with prohibitively high fees if there are too many medical claims. That's back-asswards for a capitalist economy. Competition is supposed to provide cheaper choices. But cartels don’t compete. They collude. And they have congress protecting their ability to do so. The McCarran-Ferguson Act of 1945 essentially protects health-care organizations from antitrust prosecution.

If what you assert is true, why wouldn't these companies that control prices pay less than medicare? Wouldn't it be to their benefit if they could set the price?

[hmich176]

Originally Posted by RainforestMoon

The McCarran-Ferguson Act of 1945 essentially protects health-care organizations from antitrust prosecution.

Yeah, they need to lose their anti-trust exemption.

[diableri]

Originally Posted by RainforestMoon

Even doctors and other providers, like labs are slaves to the industry. If they don’t participate in the insurance cartels’ programs, the majority of patients evaporate.

What happens if they don't participate in medicare?

[barefoot]

Originally Posted by diableri

That's already the case. See smokers, patients with cancer HX or transplants etc. Have no fear, I'm sure we'll be doing far more behavioral modification. Harrison Bergerons will have their day.

The employer themselves can't charge more, only the insurance company correct?

[RainforestMoon]

Originally Posted by diableri

If what you assert is true, why wouldn't these companies that control prices pay less than medicare? Wouldn't it be to their benefit if they could set the price?

Sorry, I'm not following.

[diableri]

Originally Posted by RainforestMoon

Sorry, I'm not following.

Perhaps I am not understanding you. Aren't you trying to say that insurance companies are controlling the prices of healthcare to their benefit?

If so, I would wonder why they are not reimbursing providers at far lower rates than Medicare instead of rates in lockstep with Medicare. If I could control prices, I certainly would not pay the prevailing rates.

My assertion is that the insurance companies are not in control of prices at all and that CMS and HHS are in fact in control of prices not only for their patients (which is fact and not up for debate) but also for most private schedules by proxy.

My evidence of this is that the adjustments to private insurance rates and coverage comes directly after changes to Medicare/medicaid guidelines and mimic those change within their next opportunity to renegotiate those prices.

There are execeptions but they are very low volume respectively such as some cosmetic surgery, some bariatric and rehabs etc.

[diableri]

Originally Posted by barefoot

The employer themselves can't charge more, only the insurance company correct?

I'm unaware of anything preventing that in WA, OR, CA, NV or AZ as those are the only state I work in. There's nothing in the ACA to prevent or encourage it really. If the employer viewed the benefits package as a line time compensation I'm certain they could juggle those budget numbers however they needed to to pay for those premiums. I have to admit that hr law and budgetary regs are outside my experience and expertise.

I can tell you that a very close friend of mine that works for my company had a kidney transplant about 18 months ago and was strongly advised to not let the insurance lapse when she was looking at taking another position with a different hospital(ie stay on minimally and pay to keep the insurance up) She was told at the next re-up, her portion would go up but that there was a limit. That is probably policy though and not law so could change for company to company.

[RainforestMoon]

Originally Posted by diableri

Perhaps I am not understanding you. Aren't you trying to say that insurance companies are controlling the prices of healthcare to their benefit?

If so, I would wonder why they are not reimbursing providers at far lower rates than Medicare instead of rates in lockstep with Medicare. If I could control prices, I certainly would not pay the prevailing rates.

My assertion is that the insurance companies are not in control of prices at all and that CMS and HHS are in fact in control of prices not only for their patients (which is fact and not up for debate) but also for most private schedules by proxy.

My evidence of this is that the adjustments to private insurance rates and coverage comes directly after changes to Medicare/medicaid guidelines and mimic those change within their next opportunity to renegotiate those prices.

There are execeptions but they are very low volume respectively such as some cosmetic surgery, some bariatric and rehabs etc.

I'm thinking this may be leading to a which came first the chicken or the egg argument.

I'm coming from the view from a benefits manager/plan administrator for some very large multi-state corporations. With the record mergers and acquisitions and the concentration over by a handful of insurance companies, and the loss of non-profit providers, shopping around to compare plans looking for value is a waste of time and money.

[RainforestMoon]

Originally Posted by diableri

I'm unaware of anything preventing that in WA, OR, CA, NV or AZ as those are the only state I work in. There's nothing in the ACA to prevent or encourage it really. If the employer viewed the benefits package as a line time compensation I'm certain they could juggle those budget numbers however they needed to to pay for those premiums. I have to admit that hr law and budgetary regs are outside my experience and expertise.

I can tell you that a very close friend of mine that works for my company had a kidney transplant about 18 months ago and was strongly advised to not let the insurance lapse when she was looking at taking another position with a different hospital(ie stay on minimally and pay to keep the insurance up) She was told at the next re-up, her portion would go up but that there was a limit. That is probably policy though and not law so could change for company to company.

Yeah it was likely policy. Some large employers are self-funded, or partially self-funded, so it's possible. It also depends on how large the group is that the employer is in...and the risk.

[RainforestMoon]

Originally Posted by diableri

Perhaps I am not understanding you. Aren't you trying to say that insurance companies are controlling the prices of healthcare to their benefit?

If so, I would wonder why they are not reimbursing providers at far lower rates than Medicare instead of rates in lockstep with Medicare. If I could control prices, I certainly would not pay the prevailing rates.

My assertion is that the insurance companies are not in control of prices at all and that CMS and HHS are in fact in control of prices not only for their patients (which is fact and not up for debate) but also for most private schedules by proxy.

My evidence of this is that the adjustments to private insurance rates and coverage comes directly after changes to Medicare/medicaid guidelines and mimic those change within their next opportunity to renegotiate those prices.

There are execeptions but they are very low volume respectively such as some cosmetic surgery, some bariatric and rehabs etc.

Not prices of healthcare. Prices of employer plans.

[chevman]

Originally Posted by RainforestMoon

I'm thinking this may be leading to a which came first the chicken or the egg argument.

I'm coming from the view from a benefits manager/plan administrator for some very large multi-state corporations. With the record mergers and acquisitions and the concentration over by a handful of insurance companies, and the loss of non-profit providers, shopping around to compare plans looking for value is a waste of time and money.

If it's a large multi-state corporation why are they not self-insuring?

[RainforestMoon]

Originally Posted by chevman

If it's a large multi-state corporation why are they not self-insuring?

Both companies went through major expansion, one financed new buildings and operations with short-term borrowing, making cash flow extra tight, the second one acquired existing operations, and as you would expect, employee benefit plans and compensation arrangements have important implications for both buyers and sellers in mergers and acquisitions. Just when you get all the transition done for the existing acquisitions, the plan year ends, and more acquisitions begin. Different states have differing regulations...it's not as easy as it sounds to just self-fund a multi-state company.

[chevman]

Originally Posted by RainforestMoon

it's not as easy as it sounds to just self-fund a multi-state company.

No doubt - was just curious about your company's situation - thanks for the explanation.

[RainforestMoon]

I can's speak for all business owners, but IMO if you asked them privately, the majority would say they believe the employer based model for insuring the majority of Americans is outdated and inefficient. There was a time it was an effective competitive recruitment and retention tool as part of an overall compensation plan that provided significant tax savings. With high unemployment and rising insurance costs, it's not a cost effective incentive. It's become a pain to administer and opens employers to all sorts of discrimination lawsuits. I think they're all secretly hoping it becomes an obsolete so they can focus on the core business and design compensation around performance. With the growing elderly population and increasing numbers of Medicare recipients, combined with the fact that the growing areas of the economy, like the service sector that seldom provides benefits, or employers replacing full-time, insured employees with part-time, hourly employees the majority if Americans are no longer covered through employer based insurance. That phenomena was occurring independent of the passage of the ACA. The exchanges can be customized by the states for the states. The five year rollout provides time to ramp up efforts to deal with the Primary Care Physician shortage (which was also growing independent of the passage of the ACA) through the the Primary Care Residency Expansion program. So IMO, business is supportive of the ACA.

[diableri]

Originally Posted by RainforestMoon

I can's speak for all business owners, but IMO if you asked them privately, the majority would say they believe the employer based model for insuring the majority of Americans is outdated and inefficient. There was a time it was an effective competitive recruitment and retention tool as part of an overall compensation plan that provided significant tax savings. With high unemployment and rising insurance costs, it's not a cost effective incentive. It's become a pain to administer and opens employers to all sorts of discrimination lawsuits. I think they're all secretly hoping it becomes an obsolete so they can focus on the core business and design compensation around performance. With the growing elderly population and increasing numbers of Medicare recipients, combined with the fact that the growing areas of the economy, like the service sector that seldom provides benefits, or employers replacing full-time, insured employees with part-time, hourly employees the majority if Americans are no longer covered through employer based insurance. That phenomena was occurring independent of the passage of the ACA. The exchanges can be customized by the states for the states. The five year rollout provides time to ramp up efforts to deal with the Primary Care Physician shortage (which was also growing independent of the passage of the ACA) through the the Primary Care Residency Expansion program. So IMO, business is supportive of the ACA.

Now I see where a lot of our particular differences come from. I agree that the model you reference has failed and would further add that it was doomed to failure; just as this new one is as is all unsustainable spending models.

I hope that before we get to the stage we're at now with the old system, those in power choose to do more to address the problems than their predecessors and do not just pass the buck onto the future again.

Just as the business side of health care (including insurance and employers) is in favor of the ACA, the clinical delivery side is leery of it for the exact same reason and both are valid. If you're sick or a loved one is, it should be very concerning and if your lively hood relies on this business then I understand the emotional investment.

[RainforestMoon]

Originally Posted by diableri

Now I see where a lot of our particular differences come from. I agree that the model you reference has failed and would further add that it was doomed to failure; just as this new one is as is all unsustainable spending models.

I hope that before we get to the stage we're at now with the old system, those in power choose to do more to address the problems than their predecessors and do not just pass the buck onto the future again.

Just as the business side of health care (including insurance and employers) is in favor of the ACA, the clinical delivery side is leery of it for the exact same reason and both are valid. If you're sick or a loved one is, it should be very concerning and if your lively hood relies on this business then I understand the emotional investment.

I agree the ACA is far from perfect. If it were me, we'd move to Medicare for all and work on improving that model.

If you know how to make that more politically acceptable to the American public, given how the GOP spins the ACA (which was a republican proposal in response to Hilary Clinton's Universal Healthcare) as a "government takeover," an "attack on our liberties" to the point that a few on the fringe are fomenting for armed insurrection, please let those of us who are concerned for those who are one catastrophic diagnosis away from bankruptcy, please share how.

[RainforestMoon]

IMO, this is an excellent, dispassionate analysis.

Giving Health Care a chance to evolve.

http://www.nytimes.com/2012/07/01/bu...ewanted=1&_r=1

[diableri]

Originally Posted by RainforestMoon

I agree the ACA is far from perfect. If it were me, we'd move to Medicare for all and work on improving that model.

If you know how to make that more politically acceptable to the American public, given how the GOP spins the ACA (which was a republican proposal in response to Hilary Clinton's Universal Healthcare) as a "government takeover," an "attack on our liberties" to the point that a few on the fringe are fomenting for armed insurrection, please let those of us who are concerned for those who are one catastrophic diagnosis away from bankruptcy, please share how.

The trick is not sacrificing the care of those that are sick regardless of financial concerns because there are plenty of people that are getting poorer care for the changes happening today and those that will happen in the future. And there are more of them than those one catastrophic dx away from bankruptcy.

[diableri]

Originally Posted by RainforestMoon

IMO, this is an excellent, dispassionate analysis.

Giving Health Care a chance to evolve.

http://www.nytimes.com/2012/07/01/bu...ewanted=1&_r=1

That is pretty good. Thanks for the link. Going to pass that around work to some of the folks that talk to us about all this stuff as a good primer.

[mdmarvich]

Great job by Wallace - very fair - HAMMER'S McConnel!!!

http://www.foxnews.com/on-air/fox-ne...care-no?page=1

This highlights the problem the (R) will have...they have no alternative. I'm shockd McConnel came on this unprepared...maybe he was looking for more softballs from Fox?

[mdmarvich]

Another interesting article...gets into the history of employer sponsored insurance.

Here's an interesting tidbit:

The decline in the number of workers covered by employer plans began long before the recent crisis. According to census data, 65 percent of workers had employer-backed plans in 2000, but only 55 percent were covered by 2010. This decline has been driven in part by rapid increases in health care costs.

So employers have been dropping coverage, and to a pretty large extent (65 down to 55), well before the ACA.

[RainforestMoon]

Originally Posted by mdmarvich

Great job by Wallace - very fair - HAMMER'S McConnel!!!

http://www.foxnews.com/on-air/fox-ne...care-no?page=1

This highlights the problem the (R) will have...they have no alternative. I'm shockd McConnel came on this unprepared...maybe he was looking for more softballs from Fox?

Apparently McConnell's not alone in being unprepared. While congressional republicans want to run on the ACA being a tax increase, this morning, Mitt Romney's senior adviser Eric Fehrnstrom told Chuck Todd on MSNBC's Daily Rundown that he agrees with the WH- the fee is a penalty and not a tax.

http://www.politico.com/politico44/2...ty-127863.html