Medical Insurance Question

[Superman]

My efforts to PARF-up the other thread failed. I must be slipping. At any rate, I have a question for the PP Braintrust.

Let's say somebody goes to the ER with a complaint and they find there is artery congestion. Patient needs a stint or something. Patient is not old enough for Medicare or whatever and has no insurance. What happens? Or perhaps the problem is a tumor or whatever. A procedure is necessary. Is the patient out of luck, or does the patient get some modicum of medical care to take care of the problem? I'm not talking about heart/lung transplants here. I'm not talking about extraordinary care. I'm talking about a procedure that should cost $500 or $5000, not a million dollars. Is the patient SOL?

Oh, and BTW, I wasn't really trying on the other thread. I still got it.

[wdfifteen]

The patient will get medical care and be billed for it. If he can never pay - bankruptcy or just refuses to pay, other patients who pay cash or have insurance pay for it through higher billing.

[Noah930]

I would imagine it would depend on the acuity of the cardiac problem. If the patient is critically-ill, then all of that would happen during that one visit to the ER (which would wind up as an admission to the hospital, with attendant cardiac cath/angioplasty/bypass). If the patient has no insurance (often listed as "self-pay" in the computer billing info), the providers can bill the patient full well knowing it'll be likely they won't get paid. Hospital/doc just eats it.

If an uninsured patient goes to the ER with a problem, but they're stable enough for discharge from the ER/hospital, then they're a little bit SOL financially. They can try to negotiate with the hospital/doctors for pricing. Some hospitals will have some sort of free-care/indigent care programs in place, so you can get care at that hospital and not have to pay (or pay some significantly reduced amount). Or, they can try to get care from a public hospital. Granted I've lived almost all my life in metropolitan areas (so I don't know how it is if you live in BFE), but there's always a public hospital to provide free care for the non-insured. Often it'll be tied into a teaching/university type scenario, so there will be medical students and residents, but they will all be overseen by attending staff. Arguably, that care may be better than what you get at community hospitals.

[id10t]

With a family of 5 and a taxable income of just over $50k I qualified for "no out of pocket" care with Shands/UF. But they aren't satisfied with just my tax returns - they want access to my bank account and all sorts of other stuff. More info than getting a mortgage, etc. So I just pay the bill.

[LWJ]

My buddy had a heart attack and got a stint. No insurance. This was about two years ago. The hospital ate the cost and billed him a tiny amount.

I have heard this practice may be history with the ACA now.

[Superman]

Originally Posted by wdfifteen

The patient will get medical care and be billed for it. If he can never pay - bankruptcy or just refuses to pay, other patients who pay cash or have insurance pay for it through higher billing.

I see that the threads so far, suggest that we already have socialized medicine of sorts. We all pay for it. "Single payer" for the debts that insurance companies and Medicare won't pay for. So it seems not to be a question of whether we pay for it but rather, how. Medical insurance companies and Medicare dictate certain prices. Or at least, bargain for them with some economic clout. In an ocean of costs that are inflated to cover the 'free' medical care that nobody pays for. Ultimately, we pay for that. Do I have that right?

[gchappel]

At least in my area, if a patient needs care- they get it.
I see patients every day that are treated- yet have no funds.
I have the most experience in oncology patients.
If you have cancer, yet have no insurance you will still get the care you need.
Long term chemo therapy, radiation treatments, surgery, radiology staging are all done. Yes you will get care.
The hospitals as well as the oncologists private practices will "eat" the costs. So yes, it actually costs the physicians a large amount of money to treat these patients.
At the same time, they are looking for ways to get at least partial coverage for these patients. The hospitals have teams that help them apply for Medicaid, and other funding. The funds have to come from somewhere, so yes some of the funds also come from profits from other patients.
The same thing with other acute conditions. Come in with appendicitis and no insurance- you get the same surgeon and care as everybody else.
Now elective cosmetic procedures- no.
Life threatening conditions- they get care.
Gary

[Superman]

Okay. It sounds like medical service organizations (hospitals, clinics, etc.) tweak their billing and pricing system to address these costs. Similarly, medical insurance companies make pricing and coverage decisions that suit their bottom lines. Without a say in how this system is structured, our role (the public) is to....pay for it all. It sounds like we have a unique system here. A different kind of socialized medicine system, said to be the most expensive of all developed countries. Hmmmm....

[gchappel]

We do similar funding throughout our soceity.
Police show up at any accident- whether or not those involved have insurance. I pay extra for insurance, as others may not have any.
Firemen respond to any fire- even if those involved do not live locally, and have no insurance to pay for the costs.
Many that have never paid our taxes drive on our roads, and use our infrastructure.
Those that do pay for it, pay more than they would if everyone paid.
It is not just medicine.
Gary

[asphaltgambler]

I know this very well as my wife was in the billing / coding aspect of the industry on behalf of the medical providers. She now is on the people side as a surgical assistant, much more rewarding.

Ethically, they / them should treat the patient and resolve the issue, hopefully. That patient is classified as 'Self-pay'. Some providers or the facility will require some up-front payment in cash or check prior to any surgical procedure. Then a monthly repayment plan that both parties agree to and sign off on.

On medical billing, know that 'Self-pay" billing rates are the highest. Think in terms of paying full retail + 20% or more for a service or product. Or like a buy-here-pay here used car dealership in terms of the $$ structure on the 'deal'. In this example you're going to pay $6K for a $3500. car.

Most Physicians and facilities understand that fully collecting on self-pay cases is a long and tedious process and that some - they will never collect and use that to offset tax liabilities. That portion is sold off for pennies on the $ to collection agencies.

[Noah930]

Originally Posted by LWJ

I have heard this practice may be history with the ACA now.

No, same rules. ACA made no change to that. There may be fewer uninsured out there, but if you are uninsured and cannot pay, the provider often still winds up eating it.

Originally Posted by Superman

... It sounds like we have a unique system here. A different kind of socialized medicine system, said to be the most expensive of all developed countries. Hmmmm....

I think a major part of why we have the most expensive system of all hasn't even been touched upon by the discussion so far. It's the public's expectations and demands on the medical system, as if it's a consumer product/service. People want/expect/demand everything, regardless of cost. I think that's a major problem of why medical care is so expensive in America.

Originally Posted by asphaltgambler

Most Physicians and facilities understand that fully collecting on self-pay cases is a long and tedious process and that some - they will never collect and use that to offset tax liabilities. That portion is sold off for pennies on the $ to collection agencies.

As a provider, you cannot write off what you didn't get paid (but performed). You (financially) just lose. There's no tax write-off allowed. A provider may euphemistically say, "I'm going to have to write it off." But that just means the provider stops trying to collect from someone with limited financial means (no blood from the proverbial stone). You can't actually tell the IRS that because you didn't get pain for seeing/treating one patient, in return you aren't to be taxed on the money you made for providing the same service to a paying customer. This isn't capital gains and stocks, for example.

[t-tom]

This is what I did. I went to the Doctors office for some intestinal bleeding. They wanted to do a colonoscopy and an EGD. I called the billing department got all the cost up front and talked to them about a payment plan. The total was just over 15 grand (for less than an hour). After the procedure was done the billing department told me to fill out some paper work and the hospital wrote off all but 3500.00 of it. Now keep in mind I went to a very good catholic hospital, and I'm sure they just chalked it up to charity work.

[onewhippedpuppy]

I have a number of family members in health care, including two that are ER trauma nurses. If you need care, you get care, regardless of ability to pay. Sadly they have an abundance of stories about people who don't actually need the care, just the drugs, and they know exactly what to say in order to get what they want. The cost gets eaten by the hospital, which ultimately means their rates are adjusted such that we all foot the bill. If hospitals and doctors were truly providing "free" health care, they would eventually go out of business. It may be free to the individual who is receiving the care, but ultimately SOMEBODY pays for it.

[wdfifteen]

Originally Posted by Superman

I see that the threads so far, suggest that we already have socialized medicine of sorts. We all pay for it. "Single payer" for the debts that insurance companies and Medicare won't pay for. So it seems not to be a question of whether we pay for it but rather, how. Medical insurance companies and Medicare dictate certain prices. Or at least, bargain for them with some economic clout. In an ocean of costs that are inflated to cover the 'free' medical care that nobody pays for. Ultimately, we pay for that. Do I have that right?

Pretty much. The ACA was an attempt to fix that, but shortly after it passed it was handed off to people who just wanted to destroy it, so none of it's shortcomings were ever attended to.

[speeder]

Originally Posted by asphaltgambler

Most Physicians and facilities understand that fully collecting on self-pay cases is a long and tedious process and that some - they will never collect and use that to offset tax liabilities. That portion is sold off for pennies on the $ to collection agencies.

Just curious, (for the MDs or others in the know); can providers generate huge medical bills for patients they know will never pay, (indigent), and then write that amount off their income taxes as a "loss"? Sounds like a vital part of their business plan if so.

[wdfifteen]

Originally Posted by Noah930

I think a major part of why we have the most expensive system of all hasn't even been touched upon by the discussion so far. It's the public's expectations and demands on the medical system, as if it's a consumer product/service. People want/expect/demand everything, regardless of cost. I think that's a major problem of why medical care is so expensive in America

Can you expand on that?

[Nickshu]

Originally Posted by Noah930

No, same rules. ACA made no change to that.




I think a major part of why we have the most expensive system of all hasn't even been touched upon by the discussion so far. It's the public's expectations and demands on the medical system, as if it's a consumer product/service. People want/expect/demand everything, regardless of cost. I think that's a major problem of why medical care is so expensive in America.




As a provider, you cannot write off what you didn't get paid (but performed). You (financially) just lose. There's no tax write-off allowed.

Exactly the problem. Everyone wants top notch care but no one wants to pay for it. In my practice I see many people who say they can't afford care then drive out of the parking lot in a $100k vehicle.

Sent from my SM-G930V using Tapatalk

[MRM]

Originally Posted by Superman

I see that the threads so far, suggest that we already have socialized medicine of sorts. We all pay for it. "Single payer" for the debts that insurance companies and Medicare won't pay for. So it seems not to be a question of whether we pay for it but rather, how. Medical insurance companies and Medicare dictate certain prices. Or at least, bargain for them with some economic clout. In an ocean of costs that are inflated to cover the 'free' medical care that nobody pays for. Ultimately, we pay for that. Do I have that right?

In my opinion you have it precisely correct. All the care that is given to patients is paid for. Either the patient (or his insurer) pays directly, or the provider pays for it. of course if the provider pays for it, the cost gets passed along to all patients or insurers who do pay fee for services.

This seems to me to be both the problem and solution to our health care system. Those with enough money to pay for insurance coverage or to pay out of pocket already cover the expenses of those who can't pay. This system is hugely inefficient. Therefore the solution seems obvious to me. We should create a system that efficiently pays for all medical expenses in a reasonable and predictable manner with accountability to the provider and patient and cut out the middle man. If that's what single payer looks like, there are ways to implement it in a market-based solution. Single payer doesn't have to mean socialized medicine.

The quid pro quo, though, needs to be that those who are currently subsidizing health care for those who don't pay should not be called to pay more with my hypothetical new system. We're already paying for the care that's being given. Our bills shouldn't go up when we create an efficient system to pay for everyone's bills. The medical expense should remain constant and the reimbursement expense should go down. There should be an equal offset for people who currently pay into the system.

[MRM]

Originally Posted by wdfifteen

Can you expand on that?

People tend to think healthcare should be free and they get cranky about paying for it, especially when so many get away with not paying for it.

[Noah930]

I'll probably give you a long an rambling reply, wd15. Here are a couple thoughts regarding that.

We do a lot of not-entirely-necessary stuff in medicine. We live in a society that values studies more than providers' clinical acumen. Sometimes, a provider has to convince a non-believer of a patient/family/insurance company (I know you have lateral epicondylitis/tennis elbow based upon your presentation and exam, but you don't believe me although you'll believe the $1000 MRI). Sometimes it's to cover legal butts (see example in next paragraph). Sometimes it's because we live in a time of protocols, and the protocol calls for a specific study/treatment before we can proceed with the next step in management, even if the provider knows--based upon years of personal experience--that the first step is a waste of effort.

Example of wasted $$$$: My partner's teenage son recently had appendicitis. Classic case. We knew he had appendicitis. My partner and I have both graduated from general surgical residencies. So my partner took his son to the local ER. ER doc agreed he had appendicitis, as did the general surgeon on call. And they still ordered an ultrasound and CT scan to confirm the diagnosis, before taking him to the OR. The mentality is: that's the standard of care, so it's inexcusable not to do it. To get every study available, before taking action, even when you're pretty sure you know what the study is going to tell you. Is this just defensive medicine? Because it's not necessarily what I'd call "good medicine" (or, at least, medical resources properly utilized).

How did we get to that point? Are doctors mandating the standard of care? Are regulatory agencies like medical boards (which is not the same as the doctors)? Is the public expecting and demanding perfection? Are lawsuits (or even the potential for lawsuits) shaping what's considered the standard of care? Is it the chicken, or the egg? We try to eliminate all risk in medicine--which is noble--but not necessarily medically realistic or financially smart. But it definitely costs money, for which we collectively pay.

We have enormous waste in medicine: for the sake of "safety." Because "safety" is paramount. Just like anti-bullying was last year, and race relations is this year. So there are expiration dates on everything--even on stuff that doesn't expire. More and more instruments are "single-use only." For example, for laparoscopic surgery, there's a little device to irrigate and aspirate/suck. It's battery-powered with something like 8 AA batteries. It's a single-use item. So we toss 8 almost brand-new batteries after every laparoscopic case, let alone the little motorized pump that actually does the irrigating/sucking. OR packs (of drapes and non-instrument disposable supplies) are pre-packaged by a vendor. For inventory reasons, there's bound to be stuff in the pack that you don't use for every surgery, because it wouldn't be practical to have separate OR packs for each procedure for each surgeon. But that means lots of unused drapes and gauze and sponges and syringes and towels (cloth towels are single-use only!) get tossed with each surgery.

There's also a significant waste of man-power resources (again, in the name of "safety"). There's always more paperwork, more bureaucracy, more compliance. So we log and document everything, even when the likelihood that it will ever be necessary is exceedingly low. That's a lot of nursing power (because RNs have to log this stuff) wasted for paperwork reasons; nursing is as much logging data, as it is taking care of patients. Our surgery center has a full-time RN whose job is solely paperwork, and a surgery center is going to be run a whole lot leaner than a hospital.

Medical choice. We love choice in customer-driven America. We've got maybe the greatest commitment to customer service in the world. And part of that is having choices. But that costs money, too. So in a country with socialized medicine, the government may have one (or two) medications on formulary for each class of medicine. If you need an ACE-inhibitor for your blood pressure, they've got one (or maybe two) available. That's one way in which socialized medicine cuts costs. The government goes to the pharmaceutical company and says: we'll buy only your ACE-inhibitor (you get exclusive monopoly of our market), but you need to give us a really low price. But that's not something that would fly in America; a person may have an allergy (whether real or perceived) to one med, but can tolerate another in the same class. So they switch to the other med. But that's not something that might be possible in a socialized situation.