Invisible fraud is not fraud. /s
My wife will qualify for medicare and has set it up to begin next February. She will be adding one additional bit of coverage then (B) and will add the other (D or F?) when she quits working in the summer. We have been inundated with phone calls from who know who for the last couple months with people trying to sell supplements, but she is going with our current insurer.
Don’t get me wrong, I support single-payer. I hate insurers. I work in billing. It is an inmense waste of time.
Perhaps it would help a little re:costs (certainly getting rid of marketing departments at HMOs and a million different bullshit plans would help with saving a bit of time.) It will do nothing by itself to address the overall health costs (ie overuse) in of by itself. However, a single payer would have some price pressure and other ways to perhaps reduce margins for other players (suppliers, drug companies, hospitals, etc).
People smarter and more knowledgeable than me would have to design for that. However, no committee will remove the fact that lobbyists for moneyed interests do and will lobby Congress to cover certain (expensive) procedures. Perhaps they will accept slightly reduced margins.
Perhaps some measure of cost-control will be implemented (which is either setting appropriate medical criteria, or delaying care, or some other way of reducing access and availability of certain procedures). The funny thing is almost NOBODY WANTS THIS TO HAPPEN. Not the doctors, not the hospitals, not the patients. The only people who want this to happen are the damn “libertarian” assholes who merely pretend they want to cut costs when they really just want to gut the overall budget and keep stuff for themselves.
I’ve worked for the AF for the last 20 years. And I’ll tell you flat-out that DoD is by far the single greatest source of fraud, waste and abuse in America by so many goddamn orders of magnitude it’s not even funny.
But none uncovered!
If fraud falls in a forest, but no one hears it, is it still fraud?
See the thing is, the private HMOs are actually pretty efficient. They do very close to what people say they want, they don’t charge by service and they tend to have lower costs. It’s a take care of the patient sort of approach. We also have a mostly HMO system run by the government. And it;s pretty shitty, really awful and usually pops up a scandal every fews years… the VA. They’re also one of the slowest systems to adopt any sort of technological advances forcing other system to send them boxes and boxes of charts, and that’s just for the services their patients are actually allowed to get from other systems… which isn’t a whole lot.
No one has guess at what a government run system might look like run under our government, just go ask a vet or a hundred or wait for the next scandal so we can all see it again.
You mean commercial HMOs where they have the incentive to cut costs by restricting service (hello preexisting conditions!) Because you must know medicare advantage plans eat up a big percentage of money on marketing and administration. IIRC along with ACA reforms the HMOs had to use 80% of costs (Medical cost ratio), actual numbers at the time were around 70%ish for some of the major players (forget which, United, Aetna, BCBS etc). I remember at the time of implementation various plans were cheating by counting things like the nurses that do preauthorization as medical care instead of administration, for example. According to this, the MLR is now 85% as of Jan 2014.
Around my shitty neighborhood I see mostly small regional players. They have lots and lots of influence now. I keep up with news of penalties and fines mostly as personal vindication. They cheat an awful lot in very obvious ways. Doctors too. One of the latest abuses is something to do with a risk-factor, where medicare will pay more money per year if patients have been diagnosed with certain conditions (depression for example, is worth 4k-8k a year ballpark). There’s a whole industry of third-party people that will scour records, they pretty much pull every encounter to find MORE diagnosis. They want the patients to seem sicker than they are.
Which leads me to a second, closely related problem with “competition” - cherry picking of patients. If the sicker patients cost more to treat, they will want healthier population if it’s any sort of capitated/lump sump payment. if it’s a pay-per-service, it’s the opposite, the payers want even more encounters. Wellcare, for example, got caught making up claims that didn’t even happen just so they could charge the government more.
The funny thing is I can see how the risk-factor score is meant to prevent this problem, but you see how that’s gamed too. There’s too much of other people’s money (tax dollars) that industry is too happy to suck on.
ACA addressed this problem. It wasn’t unique to the type of product. The entire industry wanted to avoid taking on people they knew eere sick. I am not talking about commercial payors like Blue Cross and Blue Shield who throw on advantage plans onto their existing systems. I am referencing actual closed systems, systems like Kaiser.
When I say HMO, I am not talking about closed plans, product types, I am talking about closed health systems.
Never seen Kaiser, that’s a California thing right? It is the only case I’ve heard that has done actual cost reductions by analyzing effectiveness. Seems like good stuff.
California, Colorado, Georgia, Hawaii, Washington DC area, and Portland southern Washington.
They are the largest but far from the only HMO. I’ve been please with them but I’ve never been seriously ill.
It’s almost as if there’s a linear graph where the more insurance providers there are, the less regulation there is, the higher healthcare costs go. Doh.
If you haven’t looked into them, I am suggesting you find some articles on them. They’re very, very large. They achieve a lot of cost savings due to an economies of scale. No. I don’t work for them. It’s not me pitching my stuff. I’ve never worked for them, but they’re big enough to make movement in the industry. So loosely speaking, they’re a closed system, a capitated system. They move their patients within that system. Kaiser is also very big in research. You’ll see reps from Kaiser talking about things like Medicare Part D drugs, weighing opinions on what it might mean if you take away access to all drugs as part of Medicare Part B and limit the options so you can save more. So even if you haven’t run into Kaiser or experienced their network chances are you’ve read data coming from them or seen influences from them.
I am not saying they’re perfect or even close to what people really want when they say I want free healthcare, Medicare for all… especially when the reason a number of patients have Medicare and Medicaid together is literally because Medicare does not cover all costs. It’s all the reason so many supplemental insurances are so popular and why the Advantage plans, basically commercial insurances that take over in place of Medicare by offering things Medicare doesn’t… exist.
Now does Kaiser “beat” everyone in all their markets. No. They tend to be efficient and meet quality of care targets, but others can pass them in some years on either or both but they’re… .big., coordinate well as a system.
In Seattle I used Group Health Cooperative for many years. They’re similar to Kaiser in that they are a coordinated care HMO, so they manage everything in house and have many locations through Puget Sound, but can refer outside for specialists at in network rates and have stuff in place for managing care if you’re out of town.
Kaiser just merged with Group Health last year so now my plan is with them. So far things seem ok. I just like being able to go to one place for everything and not needing to find all my own doctors for each purpose.
I knew in general how it worked there and where they were expense wise, but but all the details you mentioned so thanks for that. They use of private insurance is why I mentioned them, though, because it’s a system that’s closer to ours but more regulated and controlled, yet we can’t afford that either, somehow. It just… I guess that’s propaganda for you?
20-odd years ago, when I worked for a software outfit that did automated medical insurance form processing, the joke was that Kaiser was the best health care you could get from doctors willing to work for $60k/year.
Their reputation has improved considerably since then. I still know people who feel they have gotten poor care from them, but most people I know who use them are pretty pleased.
Ohh advantage plans piss me off. I see patients with Medicare / Medicaid and they keep signing up to different plans (they can change every single month since they have medicaid). This one for example gives them $100 over the counter a year. It’s supposed to be for drugs only but patients tell me it’s so they can buy toilet paper and stuff which I can only assume it’s because the pharmacies cheat. The only reason they were so generous in their giveaways is because they used to get 140% of a standard medicare patient’s budget (I think dropped to 120% in the tail end of Obama admin and they bitched so much saying they wouldn’t be able to afford to provide payment for MC members.)
There’s also transportation services which are the most annoying thing. I have to call a number. Another person picks up in the insurance company. They have to call a dispatcher. The dispatcher has to call the cab. Four people involved for such a simple transaction.
Depending on the Kaiser facilities in your area a serious illness or a requirement for surgery could be a problem. I have heard of people having to travel from here to the SF Bay area for surgeries because of Kaiser. And on a day to day basis I have heard mixed reviews. When I was in business our union carpenters used Kaiser. My daughter is currently Kaiser thru her employer.
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shut the fuck up
what a shame if they were the first against the wall