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Author Topic: That healthcare thing ... again...  (Read 5512 times)

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Offline Torch

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Re: That healthcare thing ... again...
« Reply #50 on: October 15, 2011, 12:52:57 PM »
This isn't the case where I'm at. At least not at the moment. We have a raging OB service going! lol We have two large groups and like four smaller ones and then our residents clinic as well and everyone is doing just fine.

And I'm guessing you live in a well-populated area of the country, like the Northeast. Those are the only areas of the country which could support a practice such as you describe. As for the rest of the country, there is an appalling lack of obstetrical providers in rural areas, i.e. less than 3 OB/GYNs per 100,000 residents of counties which are designated as 'rural' in the US.


Quote
Talking to one of the old GYN's I used to work with (he had his own practice, not part of a hospital and no partners so everything fell on him) and he told me that to get all the bills paid for the year, staff, equipment, malpractice insurance etc. he had to clear a million dollars...before he started actually getting to pay himself. Nearly 1/3 - 1/2 of that was malpractice insurance ALONE. The man had reached the point in his career where he did strictly elective procedures, NO OB, no high risk surgeries, no oncology etc. and still nearly a 1/4 of his yearly income went to malpractice insurance. It is insane what they will let people sue a doctor for.

Well, this only proves my point. It is so hideously expensive to set up an OB/GYB practice that the only cost-effective way to do it is in an urban area where you are guaranteed plenty of patients. No one practicing obstetrics is going to set up a solo practice in the rural Midwest or South Dakota or some other place with a similar population, it would be financially insolvent from the get-go.

Offline Jude

Re: That healthcare thing ... again...
« Reply #51 on: October 15, 2011, 03:29:00 PM »
True.. but when you have a disease being TREATED with no intent for curing by industry
Could you elaborate on this?  Specifically I'd like to hear what areas of healthcare you believe treat diseases instead of curing them by choice and whether or not you believe this is done for the sake of profit.

Offline Caela

Re: That healthcare thing ... again...
« Reply #52 on: October 15, 2011, 05:40:06 PM »
And I'm guessing you live in a well-populated area of the country, like the Northeast. Those are the only areas of the country which could support a practice such as you describe. As for the rest of the country, there is an appalling lack of obstetrical providers in rural areas, i.e. less than 3 OB/GYNs per 100,000 residents of counties which are designated as 'rural' in the US.


Well, this only proves my point. It is so hideously expensive to set up an OB/GYN practice that the only cost-effective way to do it is in an urban area where you are guaranteed plenty of patients. No one practicing obstetrics is going to set up a solo practice in the rural Midwest or South Dakota or some other place with a similar population, it would be financially insolvent from the get-go.

I live in the Midwest actually but do live in a well populated area that has the population to support our practices and for the largest hospital system in my direct area. Which is why I only said it wasn't true where I was at.  I would be willing to bet that a lot of types of doctors are avoiding rural areas for the same reasons. You can't make enough money to support a solo practice and the only way not to work for a hospital system is to be in a practice, either solo or with partners. In a rural setting you might not have enough of a population to be able support having partners so you avoid them.

This is partly why a lot of GP's also cover some basic OB services in a lot of areas. They should be referring out the high risk patients (VBAC's, pre-eclamptics etc.) but a standard, routine pregnancy and delivery can, often times, be handled by a GP with the appropriate training.

Offline Torch

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Re: That healthcare thing ... again...
« Reply #53 on: October 16, 2011, 09:24:07 AM »
This is partly why a lot of GP's also cover some basic OB services in a lot of areas. They should be referring out the high risk patients (VBAC's, pre-eclamptics etc.) but a standard, routine pregnancy and delivery can, often times, be handled by a GP with the appropriate training.

Ironically, this was the standard of care in the early to mid 20th century, before the population shift to large urban areas began. The "town doctor" handled it all: measles, broken bones and delivering babies. I know my grandmother was born at home with the help of a local doctor, as well as all of her siblings.

Offline Vekseid

Re: That healthcare thing ... again...
« Reply #54 on: October 16, 2011, 05:40:37 PM »
Callie, the video is interesting. My biggest issue with what he said was when he mentioned trying to change the way we pay docs/hospitals to being from fee for services, to fee for healthy outcomes. I promise you if they do that you will get a lot of docs and hospital that will simply STOP performing many of their services! You can't always fix someone that's sick and get a healthy outcome.

The ACA's plan is to move to bundled payments - which is similar, but payment is given for a treatment, rather than necessarily providing a cure. This should, in theory, help squeeze out the excess testing which is one of the root causes of health care costs skyrocketing in general - a quarter of your hospital bill goes to compensating for medicare underpayment. End of life care is the worst offender, of course this got the 'death panels' bullshit spewed everywhere.

Offline alxnjsh

Re: That healthcare thing ... again...
« Reply #55 on: October 16, 2011, 07:48:16 PM »
The ACA's plan is to move to bundled payments - which is similar, but payment is given for a treatment, rather than necessarily providing a cure. This should, in theory, help squeeze out the excess testing which is one of the root causes of health care costs skyrocketing in general - a quarter of your hospital bill goes to compensating for medicare underpayment. End of life care is the worst offender, of course this got the 'death panels' bullshit spewed everywhere.

I would suggest that excess testing is one cause and not necessarily a significant cause of the skyrocketing health care costs. I would say ineffective and unproven testing is probably more accurate a descriptor. It's not like people are getting 100 tests, they are just getting tests that now cost 100% more and aren't necessarily more accurate that predecessors. Unfortunately much of private health care costs are unknown, we just can't reach into company portfolios and get the true cost of health care. We do have some data from states like mine where health insurance and hospitals are legally required to be not-for-profit.

I would point you to the Kaiser Family Foundation and their citations of the main causes of the rise in health care costs:

1.Technology and prescription drugs
2. Chronic disease management
3. Aging of the population
4. Administrative costs

http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx

Offline TriesteTopic starter

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Re: That healthcare thing ... again...
« Reply #56 on: October 16, 2011, 08:40:08 PM »
I don't recall where I read it - and someone can feel free to debunk me, here, as I would love for this not to be true - that insurance companies are actually not allowed to ask for itemized billing from hospitals. If they start questioning charges, their contracted discounts (or group costs, or wholesaler's discount, or whatever) will be revoked by the hospital.

I think I read it when I was trying to get a breakdown of the bill from a trip to the ER, and was unable to do so.

I'm not a huge fan of the insurance companies. I think that they're on very shaky ground as far as making a profit off of sick people. However, I also don't blame them entirely for the rising costs in healthcare. I feel that the medical providers and their support staff, along with Big Pharma, are all part and parcel of the rising costs. So if the above is true, it's one more example of lack of accountability.

Offline Caela

Re: That healthcare thing ... again...
« Reply #57 on: October 16, 2011, 10:02:55 PM »
I don't recall where I read it - and someone can feel free to debunk me, here, as I would love for this not to be true - that insurance companies are actually not allowed to ask for itemized billing from hospitals. If they start questioning charges, their contracted discounts (or group costs, or wholesaler's discount, or whatever) will be revoked by the hospital.

I think I read it when I was trying to get a breakdown of the bill from a trip to the ER, and was unable to do so.

I'm not a huge fan of the insurance companies. I think that they're on very shaky ground as far as making a profit off of sick people. However, I also don't blame them entirely for the rising costs in healthcare. I feel that the medical providers and their support staff, along with Big Pharma, are all part and parcel of the rising costs. So if the above is true, it's one more example of lack of accountability.

I don't know if they can or not but I do know that sometimes they pay for things they shouldn't have to which certainly doesn't help with the costs they pass along to us.

Ex. A friend of my mother's had a baby girl. When she got her bill from the hospital she realized that it included a charge for a circumcision. Calling her insurance company to tell them not to pay the charge, she was informed that it would be paid even though it hadn't been performed because it actually cost less just to pay it then to spend the man hours doing the paperwork to fight the charge.

Something you shouldn't have to fight! She had a girl, the baby wasn't circumcised, take the damned charge off. This should be a ten minute phone call, not a 10 page, lord knows how many hour, investigative process.

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Re: That healthcare thing ... again...
« Reply #58 on: October 16, 2011, 10:08:34 PM »
I'd tell them that circumcision for a female is illegal, and if they paid that fee, they'd be complicit.  But I'm evil that way.  ;D

Offline TriesteTopic starter

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Re: That healthcare thing ... again...
« Reply #59 on: October 16, 2011, 10:38:57 PM »
Errr, looking again at my post, I appear to have misspoken. It's not that they can't ask for an itemized bill, but that they can't question the items behind that bill. For instance, if a nurse gives a child patient a teddy bear and the hospital charges for a $300 "comfort device", the insurance company isn't allowed to call up and say, "Really? A $300 teddy bear?"

I'll have to google it or something when I'm not about to head to bed.

Offline Caela

Re: That healthcare thing ... again...
« Reply #60 on: October 17, 2011, 06:20:42 AM »
Errr, looking again at my post, I appear to have misspoken. It's not that they can't ask for an itemized bill, but that they can't question the items behind that bill. For instance, if a nurse gives a child patient a teddy bear and the hospital charges for a $300 "comfort device", the insurance company isn't allowed to call up and say, "Really? A $300 teddy bear?"

I'll have to google it or something when I'm not about to head to bed.

Oh yeah, the price for anything in a hospital, or being sold to a hospital is RIDICULOUS. I looked at one of our instrument catalogs once and the prices were utterly unrealistic! Looking at the ortho tools, the cost of a wrench (a damned wrench that you could buy at Home Depot for like10 bucks!) was over 300$ and some were closer to 500$.

For something I could buy at the hardware store. Part of the problem with the cost of healthcare isn't just the insurance companies, the doctor and the hospitals, it's the suppliers who rip those people off as well. They see the word "hospital" or "dr. office" and think the pockets are so deep that they can charge anything they want and the cost will never come back on them...except it comes back on all of us.

That teddy bear you mentioned Trieste, unless it was donated, the company that sold it to the hospital could easily have charged (for something you wouldn't pay more than 20$ in the store for) the hospital over 150$ for the thing. The whole pricing scheme surrounding anything you end up with at a hospital is blow way out of proportion.

Offline alxnjsh

Re: That healthcare thing ... again...
« Reply #61 on: October 17, 2011, 08:18:00 AM »
Errr, looking again at my post, I appear to have misspoken. It's not that they can't ask for an itemized bill, but that they can't question the items behind that bill. For instance, if a nurse gives a child patient a teddy bear and the hospital charges for a $300 "comfort device", the insurance company isn't allowed to call up and say, "Really? A $300 teddy bear?"

I'll have to google it or something when I'm not about to head to bed.

They can cap the amount of reimbursement regardless for medically necessary items/procedures. Health insurance providers offer a schedule of reimbursements and then it is up to the health care provider to determine if they want to accept that health insurance based on what they will get reimbursed. Often these are negotiated through contracts - buy in bulk is the idea. If a hospital takes a health insurance plan they assume that if they give a slight discount more of those health insurance customers will go to that hospital. The state may also allow a certain amount to be overcharged which goes back to the client for out of pocket.

If the health insurance plan says that they will reimburse for teddy bears at $150 when it is deemed medically necessary and the hospital charges $300 the health insurance plan is only going to pay $150. The other $150 goes to the patient or is written off by the hospital.

Take Medicare for example. Providers can charge 120% of the cost of a service. Medicare paying 80% of the cost and the rest being sent to the client.

Jane goes to get a procedure done. Medicare assigns a price to that procedure of $100.
The doctor can charge Jane $120.
Medicare only pays $80.
Jane is responsible for $40.

It doesn't happen that way everywhere. In Minnesota, providers that accept Medicare must "accept assignment." That means if Medicare assigns $100 to a procedure, the health care provider can only charge $100.
« Last Edit: October 17, 2011, 08:20:01 AM by alxnjsh »

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Re: That healthcare thing ... again...
« Reply #62 on: October 17, 2011, 11:31:07 AM »
Oh yeah, the price for anything in a hospital, or being sold to a hospital is RIDICULOUS. I looked at one of our instrument catalogs once and the prices were utterly unrealistic! Looking at the ortho tools, the cost of a wrench (a damned wrench that you could buy at Home Depot for like10 bucks!) was over 300$ and some were closer to 500$.

I watch Dr. G. as often as I can.  There's one episode where she talks about the tools she uses, and she actually talks about going to the kitchen store for some (ladles) and the hardware store for others (she prefers limb-loppers to rib-cutters because of the leverage).

Offline js207

Re: That healthcare thing ... again...
« Reply #63 on: October 17, 2011, 12:45:11 PM »
I would like to point out its not always the patiants fault I often get treatment orders up front I have no hope to follow up with. Case in point I had a leg infection and was in the hospital almost a week ,yes I paid the bills the charity care law eliminated all hospital charges, but the doctor ordered a $1500 antibiotic (10 pills) and I was clear I did not have that kind of money. I insisted he find something I can afford or I would not sign any release papers and when he did not take that seriously I did just that. A visiting Indian doctor suggested a drug available at Walmart that cost $4 for a ten day course of treatment (40 pills for $6) and it worked fine. My follow up was not an issue. But the prefered drug was for me astronomical in cost.

So what is a patiant to do if you say this to most doctors its like talking to a brick wall that money is an issue in care. I would argue most of the time its this case we are not bad patiants just have to be realistic on what we can and cannot do.

A fine example of a big part of the problem, RubySlippers: the $6 treatment did the job, so why was your doctor trying to spend the extra $1494? How many patients with the "Cadillac" insurance Congress denounced (while quietly retaining for itself) would just have handed over the $1500 from their insurance company's funds without quibbling or even thinking? That's the problem with Trieste's $400 contraceptives becoming "free" ... what will stop her doctor up-selling her to the same pills for $900 from the company with the hotter sales rep, or encourage her to switch to a $100 treatment that does the same job?

I've been away lately (illness in the family), and see a lot more posts on this subject since I started on this reply - all essentially pointing out the problem with the "blank check" mentality. HMOs were supposed to fix this sort of thing - they'd have contracts with the hospitals they use, ensuring they can veto the $300 teddy bears and object to paying $300 for a $10 wrench - but there seem to be obstacles to that now, often from well-meaning people thinking an HMO must be evil if it tries to stop the hospital buying the most expensive tool in the catalog... Why isn't there more anger about that? Maybe someone could do an exposé documentary - instead of posing in Cuba, get the $300 wrench from the medical supply company and the same one for $10 from Home Depot, the teddy bears, etc, and try asking the people involved about the insane prices.

It's a bit like the recent debit card processing fee change - the companies were giving some services away "free", then making up for it with hugely inflated charges for the other services. Half of the $300 teddy bear fee will be going to pay for other things: the loss they have to eat on Medicaid patients, for example, other bad debts... That, getting back on topic, was the one area ObamaCare was actually supposed to address - although it accidentally prohibits the introduction of fraud counter-measures in Medicaid, as well as imposing massive cuts in Medicare.

Offline Pumpkin Seeds

Re: That healthcare thing ... again...
« Reply #64 on: October 17, 2011, 04:27:14 PM »
Keep in mind that many times a doctor has their hands tied over what medications they can prescribe and administer.  Much of their recommendations come from what the hospital is willing to not only pay, but protect them if something goes wrong with the medication.  Physicians are very much bound to the administration as anyone else.  Their license, money and practice depend on staying in the good graces of hospital administration if they work for them or with insurance companies if they are private practice.  Hospitals and insurance companies spend thousands researching the “best practices.”  These practices are the ones that they will cover and protect the doctor against.  Some physicians can go outside the boundaries and do, but they take a risk.

For instance if Ruby’s treatment had not worked and the infection gotten worse, the hospital would have backed away from that doctor.  He did not perform a sanctioned and recommended treatment.  Essentially he did not follow protocol and so is not protected.  His own malpractice insurance might have covered him, but he would see an increase in his payment.

Also, the wrench at Home Depot and the wrench in surgery may look the same but are not.  One is calibrated specifically for the equipment being used.  More importantly the wrench at Home Depot is not sterile.  That wrench used in surgery was made sterile back at the company which made it, sealed in a sterile contained, packaged with sterile equipment so that a sterile field could be made when the package is opened.  Then a doctor or surgical tech trained in how to establish, maintain and handle a sterile field opens that package so that it can be used for all of 10 minutes. 

Offline Jude

Re: That healthcare thing ... again...
« Reply #65 on: October 17, 2011, 04:54:58 PM »
Anecdotes don't particularly help the picture.  Maybe the $6 a pill medicine worked for you, but that doesn't mean that the chances of success of the two medicines were equal.  It is entirely possible that the $6 a pill medicine had a much lower rate of efficacy and that by choosing to purchase it, you made a decision that was economically sound but medically perilous.  It is also possible that in most circumstances prescribing the cheaper drug actually results in a larger expenditure, because when it fails you need another hospital visit.

Remember, medical decisions are not made arbitrarily or solely for profit.  Most doctors spend 4 years getting their premed degree, 2-4 years going to med school, and then 1-2 years interning.  Then many become residents, and the learning never really stops -- especially considering there is new research being done all the time both in the form of new therapies and new ways to give old therapies.

Suggested for review:  http://en.wikipedia.org/wiki/Dunning%E2%80%93Kruger_effect
« Last Edit: October 17, 2011, 04:59:50 PM by Jude »

Offline RubySlippers

Re: That healthcare thing ... again...
« Reply #66 on: October 17, 2011, 05:13:26 PM »
People it was an utter lack of ability to get the $1500 for the medicine and then another $1500 if treatment had to be extended, it might as well have been $15k or $15 million I had access to $400 for any aftercare. If one cannot do the prescribed treatment at all then what was I to do if they gave me the medicine to take home I would have taken it. Fortunately I refused to sign out and told the attending doctor unless I get something I can afford it could be non-cheap just affordable I'm not going to sign out and just leave.

I gave them the Target Pharmacy number and told them to check with them to find something in the $400 price range and feel free to talk to the Free Clinic they have doctores and NP's used to treating the poor. I figure with some work they could find a drug I could afford.

And what was the odds I would sue if they gave me an unaffordable treatment and I didn't sign out openly saying that treatment program was outside my ability to perform - and ended up back in a hospital again. State law requires I have an acceptable aftercare arrangement that goes both ways I have to follow the plan and they have to make sure I can execute the plan.

That is the one weapon the hospital has to have my name on the release to be protected and they cannot force me to sign, unless I do I do not approve of my ability for the aftercare a right I have as a patiant. Is it wrong to insist I can get a treatment I can afford and do in this case not in my view assuming I have no other choice.

And the medicine was $6 for a 40 Pill Precription for a thirteen day extended course of treatment, if that wasn't working the Free Clinic would have given me an in office IV and a more powerful drug to take home it was arranged before I left on the second plan of care. I was monitored every three-four days and given blood tests I did what I was told to do to the letter at the Free Clinic. Oddly we all worked together to come up with this plan it just took some work.

Offline Pumpkin Seeds

Re: That healthcare thing ... again...
« Reply #67 on: October 17, 2011, 05:18:26 PM »
The odds you are going to sue are very good.  Also if you come back into the hospital within a set amount of time for the same problem, the hospital does not get paid for the original care given or additional care.  So if the cheaper antibiotic did not work and you came back to the Free Clinic for care regarding the same treatment, the hospital would not be paid for the treatment given.  The hospital may then have to reimburse the Free Clinic for the treatment they gave to you since they did not resolve the issue originally.  Meaning the hospital lost out on money owed and also would have to pay additional money. 

That is without you suing them by the way. 

Offline RubySlippers

Re: That healthcare thing ... again...
« Reply #68 on: October 17, 2011, 05:31:33 PM »
I was an indigent care charity patiant they should have figured out cost was going to be an issue and told the medical provider assigned to me and the NP that did routine follow up care on behalf of the doctor that and the hsopital lady handling my case. It again was like talking to a brick wall. And by the way I checked all options getting the drug from Canada or Mexico and still cost prohibitive at $1000 including fast shipping by air.

What more could I do my parents didn't even have that kind of money with my dad having a recent medical issue at the time, my SO could chip in something but not that much that left me no options but refuse to sign the release papers. I was going to they said I was going to leave with the pills then I found out it was a prescription for them and so stood my ground. Again state law is on my side they must give me a reasonable aftercare plan and have my signature on the plan, I argued justifiably if I can't afford the plan its not reasonable to me is it? And I was ready to walk out they called security and a police officer and told them fine he can arrest me then I can get the drug from the Sheriff's Jail Medical Facility and my aftercare there I didn't care at that point. But they cannot legally make me sign off. Did I add without that the county will not help pay for my care or the company that provided the drugs reimburse the hospital so I was costing them thousands of dollars by saying no.

I had no choice.

Offline Caela

Re: That healthcare thing ... again...
« Reply #69 on: October 17, 2011, 07:56:46 PM »
Keep in mind that many times a doctor has their hands tied over what medications they can prescribe and administer.  Much of their recommendations come from what the hospital is willing to not only pay, but protect them if something goes wrong with the medication.  Physicians are very much bound to the administration as anyone else.  Their license, money and practice depend on staying in the good graces of hospital administration if they work for them or with insurance companies if they are private practice.  Hospitals and insurance companies spend thousands researching the “best practices.”  These practices are the ones that they will cover and protect the doctor against.  Some physicians can go outside the boundaries and do, but they take a risk.

For instance if Ruby’s treatment had not worked and the infection gotten worse, the hospital would have backed away from that doctor.  He did not perform a sanctioned and recommended treatment.  Essentially he did not follow protocol and so is not protected.  His own malpractice insurance might have covered him, but he would see an increase in his payment.

Also, the wrench at Home Depot and the wrench in surgery may look the same but are not.  One is calibrated specifically for the equipment being used.  More importantly the wrench at Home Depot is not sterile.  That wrench used in surgery was made sterile back at the company which made it, sealed in a sterile contained, packaged with sterile equipment so that a sterile field could be made when the package is opened.  Then a doctor or surgical tech trained in how to establish, maintain and handle a sterile field opens that package so that it can be used for all of 10 minutes.

I am a surgical tech and most of those wrenches ARE exactly the same as the ones at the hardware store. Now if you are talking about a special wrench/screwdriver/hammer needed for an implant (such as plates for broken bones or joint replacements) then you are right, that is specially made equipment for a specific purpose. Many of the instruments surgeons use are NOT that specialized. Many sets (ortho in particular simply because it has the most easily recognizable basics for people that don't work surgery) have basics that are used in lots of cases that are not that specialized including mallets, pliers, wrenches, scissors etc. These are sets that are used again and again and again, they don't have to packaged in a sterile manner at the plant because they are in containers that can go through the hospital sterilizers on delivery. In fact it's considered not as good practice to consider any instrument sets that haven't gone through your own sterilizers as actually sterile. So purchasers could, easily, go to a hardware store, buy the most upscale versions of the instruments they need replaced, bring them back and wash and put them through the hospitals sterilizers and there'd be no difference at all...except the cost savings.

Obviously you can't do that with everything (you aren't likely to find hemostats and kochers at Home Depot) but the fact is there shouldn't be this kind of cost discrepancy to begin with. These things do NOT cost 200$ to produce and the companies shouldn't be charging hospitals and Dr's offices 500$ for them. A cost that gets passed along to everyone and jacks up the costs for whatever those instruments need to be used on.