The Goat Pen

I'm on the verge of going full Bundy. I had to drop my health insurance last year because what we had at work was shit and I could get insurance for my wife through the marketplace that was better and cheaper. She was previously uninsured and so I just switched. Because I could get it through work, I wasn't eligible for subsidies. Otherwise, we both could have gotten insured for less than $200/month.

About this time last year, I started getting $600 power bills (don't ask, we have the worst rates in the state) and had to drop her insurance. I didn't actually drop it so much as not pay the monthly premium. Since my statement plainly said, by the second missed payment, that her policy would be canceled if payment wasn't sent immediately, I assumed that was the case. However, they kept sending me statements as the amount owed grew and grew.

So when I did my taxes on TaxAct.com, I learned that, unlike the previous 2 years, I was being assessed a penalty for being uninsured. Previously, I was excused (filing jointly) from penalty because I didn't earn enough. OK, fine, I'll get back $400 less this year. So, after not receiving a refund nearly 3 weeks after I e-field, I started to wonder when it would come but since I haven't paid property taxes yet and have a shitload of other things that are waiting on my refund, I'm getting antsy. I've already been hit with a wage garnishment for property taxes.

Today, I received a letter from the IRS saying that I needed to submit a form 8296 or whatever because I am liable for the subsidies that were paid by the gov't for my wife's health insurance that was canceled. I can't call the IRS or the TaxAct folks until Monday, so it's either going to be worked out (yet I still won't get my refund for another 2 months) or, worse case, I'll end up not getting a refund because it will all go to paying back the subsidies.

And that's when I go Bundy. This whole healthcare thing has been a clusterfuck and now I could be penalized to the point where my home could be threatened and I still won't have health insurance and damn sure won't be able to afford it this year.

Somebody's going to end up getting shot or blown up over this shit.

Well it just make sense to fine people who can't afford insurance.

Hope and change!! 8 more years!!

yes, the healthcare thing has been a huge clusterfuck

but you don't want singlepayer health care. What you don't hear about Canada and the UK is the 3 month wait for non-emergency surgery or the 6 month wait for screenings. Imagine having a mole on your back that you don't know is cancerous or not and you can't see the doctor for 6 months.

The bottom line with insurance is you can't let the government start paying or subsidizing while leaving the ceiling open. Pharmacies, Hospitals and other Health Care providers are prime to make a mint in an environment where everyone pays and they set the prices (even with insurance companies negotiating). But the flipside is the moment you put a ceiling on rates or how much can be earned, you kill off the quality or quantity of health care available to the consumer.

I think the only way to control this is to incentivise the policy holders to save money and to force competition among providers.

A local company here called Pro Scan offers MRIs for $300-$500. A MRI at a hospital will cost you 3X - 5X that. But what is my incentive to choose the cheaper MRI if I am insured. Especially if I am in the mindset that I will hit my deductible.

What I think they should do is certify health insurance companies AND health care providers, streamline the insurance submittal and payment process so that providers don't have to spend so much on administration and then mandate that all health care providers must accept certified insurance. Now you have the option to go to any health care provider without worrying about whether they take your insurance or not - and you know that you aren't going to some fly by night mexican health clinic because they have been certified.

The next step is all health care providers must publish flat rates on all standard procedures performed. In January I got a colonoscopy and received a bill for $2200. OK, that seemed to be about the general rate, then 2 months later the fucking doctor bills me for $444 for his services. Now I'm pissed because I just paid a huge chunk of money and now I have to pay him again?

So publishing the flat rate total cost for the procedure will help me make more cost effective decisions. So why should I do it? Because there should be some kickback to me from the insurance company for saving them money. Now I have the motivation to save money. Emergency room or Urgent Care, Family Practitioner or Local Mini Clinic. Proscan Imaging or Hospital Outpatient MRI.

The government (not the insurance company) or better yet a consumer watchdog agency can publish a flat rate average for what they expect a procedure to cost and people will use it as a guideline. If a consumer continually gets procedures done above the national average, then an insurance company can penalize them with a rate increase.

At the end of the year the insurance company can give me a balance sheet that shows the average cost of these services I had and what my actual cost was - and then send me a check for 30% - 50% of the delta. That could mean a family of 4 getting a check back for $500 to $3K if they are diligent about it - BUT it also gives you the option to go to the health care you want. You want your doctor but he's more expensive? Fine, no profit sharing for you at the end of the year, you'd rather go to the Jewish Hospital than Good Samaritan, go for it. As a side benefit of that, the consumer will be more engaged on what is being spent on them so there is this whole new level of watchdog protection because no one is going to want to be overcharged. They have skin in the game. $12 for a tylenol? fuck that, I'll bring my own.

The governments role shouldn't be to subsidize - but to regulate and create competition - then the consumer wins in the end.

But as long as the government is saying you have to have insurance, and we're going to cut a check to anyone that can't afford it - there is zero incentive to decrease cost and compete on behalf of consumers in the marketplace.

That's the same with housing and education - both areas the government has completely fucked up.

The problem is our society can stomach the idea of have and have nots, so the government gets involved in an effort to give everyone their shot to be a have and stop being a have not. And thats when it gets shitty for everyone - especially the middle class who have to make choices and compromise constantly in order to stay a "have" and not become a have not.

Hospitals have higher costs, insurance, maintenance staff, and accreditation - to name a few things - than a free-standing clinic like ProScan. That's why HealthSouth's one day surgery centers became so big. There is also less accountability in places like that. Staff certifications up-to-date? Qualified, licensed staff? Who knows...

To be competitive, hospitals would have to do the same. Decertify JCAHO and let hospoutals operate in the same manner as these free-standing profit clinics? Okay. But right now, CMS mandates it with hospitals.

Other notes...I'm not for the government mandating that doctors take a particular kind of insurance. Also, having people get a bounty because they found a low-rent place that offers a procedure as a loss leader is a horrible idea. As opposed to that, just have government set prices. We essentially do now, anyway.

AlabamAlum wrote:Hospitals have higher costs, insurance, maintenance staff, and accreditation - to name a few things - than a free-standing clinic like ProScan. That's why HealthSouth's one day surgery centers became so big. There is also less accountability in places like that. Staff certifications up-to-date? Qualified, licensed staff? Who knows...

To be competitive, hospitals would have to do the same. Decertify JCAHO and let hospoutals operate in the same manner as these free-standing profit clinics? Okay. But right now, CMS mandates it with hospitals.

Other notes...I'm not for the government mandating that doctors take a particular kind of insurance. Also, having people get a bounty because they found a low-rent place that offers a procedure as a loss leader is a horrible idea. As opposed to that, just have government set prices. We essentially do now, anyway.

sound like a great plan to make sure hospitals stay profitable

but screws the consumer. Do you go to a car dealership for an oil change or do you go to the $19.95 place? What was the price of oil changes at the auto dealership before the $19.95 place opened up? Give the consumer the choice. Hospitals shouldn't be in the business of providing low risk procedures if someone else can do it cheaply (again, as long as they are certified) and hospitals should stick to the big ticket items that cannot be provided for and should be heavily regulated. That's basic marketplace 101.

I can understand a doctor not wanting to take insurance if their negotiated rates are horrible or if they are a nightmare to deal with administratively - but that why a doctor/provider would only be required to accept certified insurance providers - who have been vetted on those things - thus freeing red tape and a host of other issues associated with that industry.

the concern I would have in my scenario would be asking - do you want health care to be run like the airline industry? and the answer I'd give is the airline industry sucks and is frustrating because there is too little government regulation. Its too marketplace driven because consumers only care about what is cheap in that industry. Health Care is too important to be completely free enterprise but competition and incentive has to drive it.

There also has to be transparency and some standardization on pricing for the consumer to make better decisions. There has to be an understanding that the competency for a procedure and your care at clinic X is at or above standards.

But even if we did all this - that doesn't solve the problem of a 3 month supply of cancer medicine costing $9500. The challenge there is make sure big pharma makes an investment in R&D, but keeps prices affordable. Clearly that model isn't working.

Hospitals and Nursing Homes are the fucking devil. They suck your life savings dry.

Those places can exist, eCat, but giving a bounty? Nope. It's not apples to apples.

You work in IT. How about if a consumer finds a company that does IT work cheaper than yours? Does your company have to pay the difference? Should it? Hospitals are mandated to follow procedures and do things that free-standing places aren't. Quality and equipment differences are real. This isn't like buying a widget.

It's just a bad idea. And it will never happen. Thank god. Single payer would be a much better system than this.

AlabamAlum wrote:Those places can exist, eCat, but giving a bounty? Nope. It's not apples to apples.

You work in IT. How about if a consumer finds a company that does IT work cheaper than yours? Does your company have to pay the difference? Should it? Hospitals are mandated to follow procedures and do things that free-standing places aren't. Quality and equipment differences are real. This isn't like buying a widget.

It's just a bad idea. And it will never happen. Thank god. Single payer would be a much better system than this.

I'm not getting the does my company have to pay the difference part?

Insurance would add your insurance costs over the course of the year and if you came in lower than expected because you shopped around, you'd get a kickback from the insurance company.

Again, if hospitals are mandated to do things free standing are not, then that needs to be addressed, not just assumed that the consumer has to take responsibility for covering the cost of it. Its nothing like buying a widget but since there is no transparency, the consumer is left in the dark on whether they are getting value on the procedure or getting ripped off.

What you're telling me is that I shouldn't have a choice between IT groups to who covers my payroll because one IT group has to buy a big mainframe and its not fair the other can do it with a laptop.

And in my solution at least, I give the consumer the choice to go to either one depending on what their comfort level is.

Doctor's and hospital worker's salaries should be capped at $50K a year...

eCat, c'mon. You can't be serious. People would be going for discount tests that they didn't need (or avoiding care altogether) to get the bounty. Places would pop up with a 1954 Soviet CT scanner and offer tests for $99 and people would go just to get the bounty - whether they needed the test or not and the scheme would cripple all insurance companies and Obamacare to boot. Taxpayers would foot the bill. Now, some use a lot, some use a little, we pay a price point in the middle because of that. If all use a lot, Jesus...

You want to help medical costs, remove some of the red tape, and cap end of life care. Also, convince Americans that they don't need concierge service, marble fountains, and a medical center every 3 miles.


Agreed, hedge. Personally the whole licensure and accreditation thing needs to just be suggestion, not a mandate. Billy at the Auto Lube took a biology course once.

AlabamAlum wrote:eCat, c'mon. You can't be serious. People would be going for discount tests that they didn't need (or avoiding care altogether) to get the bounty. Places would pop up with a 1954 Soviet CT scanner and offer tests for $99 and people would go just to get the bounty - whether they needed the test or not and the scheme would cripple all insurance companies and Obamacare to boot. Taxpayers would foot the bill. Now, some use a lot, some use a little, we pay a price point in the middle because of that. If all use a lot, Jesus...

You want to help medical costs, remove some of the red tape, and cap end of life care. Also, convince Americans that they don't need concierge service, marble fountains, and a medical center every 3 miles.


Agreed, hedge. Personally the whole licensure and accreditation thing needs to just be suggestion, not a mandate. Billy at the Auto Lube took a biology course once.

why in the hell would you get get a test you didn't need if the whole incentive is to save money? and people are avoiding care now altogether because they can't afford medical care as it is. I don't think you understand what I'm talking about

Here's what I'm saying: Your guy that gets the $3000 windfall at the end of the year ... Who gets 50% of what he "saved" - that would be manipulated to hell and back with ultra low cost shams. And it would cripple insurance/obamacare.

AlabamAlum wrote:Here's what I'm saying: Your guy that gets the $3000 windfall at the end of the year ... Who gets 50% of what he "saved" - that would be manipulated to hell and back with ultra low cost shams. And it would cripple insurance/obamacare.

if he gets a $3000 windfall at the end of the year its because he spent $10K out of his own pocket on medical expenses and that is opposed to him spending $16K or whatever he could have spent by not shopping around

Okay. So, if he shops around, it's not just the total dollars he saved. In other words if he gets $20000 of tests for a $1000, he doesn't get a % of the $19000 he "saved"? So, he goes to drive through surgery place, spends some money, but a lot less, so he gets cash. Say his charges were $10k, but at a real hospital his charges would be $50K. He has already gotten more services than a year of premiums. The drive-thru place got paid, and the real hospital was uninvolved. So...

How much does he get? Where does this money come from?

As a follow up, I am a health nut and active and don't drink sweet tea and never use my health services except for an annual physical. I should get money too. How much amI getting?

I mean the fat guy who smokes is getting a check because he went to a chain saw repair and open heart surgery place. Where's mine.

AlabamAlum wrote:Okay. So, if he shops around, it's not just the total dollars he saved. In other words if he gets $20000 of tests for a $1000, he doesn't get a % of the $19000 he "saved"? So, he goes to drive through surgery place, spends some money, but a lot less, so he gets cash. Say his charges were $10k, but at a real hospital his charges would be $50K. He has already gotten more services than a year of premiums. The drive-thru place got paid, and the real hospital was uninvolved. So...

How much does he get? Where does this money come from?

from the insurance company not having to pay the difference - most , if not all of these plans are pay a deductible first and then pay a percentage after that - and the insurance company pays the bulk of it after the deductible. So the money would come from the insurance company not having to pay the difference in $40K to the hospital or whatever the percentage is. But I'm not proposing on a per incident. It would be a cumulative number for his entire year.

AlabamAlum wrote:As a follow up, I am a health nut and active and don't drink sweet tea and never use my health services except for an annual physical. I should get money too. How much amI getting?

I mean the fat guy who smokes is getting a check because he went to a chain saw repair and open heart surgery place. Where's mine.

its in your pocket the following year in a premium discount./no cost increase for not having to help pay for the $200K in costs the fat guy accrued because he shopped around.

I came here looking for help on making a bomb, not to start a health care debate. Now let's move this back on topic!

eCat wrote:

AlabamAlum wrote:Okay. So, if he shops around, it's not just the total dollars he saved. In other words if he gets $20000 of tests for a $1000, he doesn't get a % of the $19000 he "saved"? So, he goes to drive through surgery place, spends some money, but a lot less, so he gets cash. Say his charges were $10k, but at a real hospital his charges would be $50K. He has already gotten more services than a year of premiums. The drive-thru place got paid, and the real hospital was uninvolved. So...

How much does he get? Where does this money come from?

from the insurance company not having to pay the difference - most , if not all of these plans are pay a deductible first and then pay a percentage after that - and the insurance company pays the bulk of it after the deductible. So the money would come from the insurance company not having to pay the difference in $40K to the hospital or whatever the percentage is. But I'm not proposing on a per incident. It would be a cumulative number for his entire year.

Insurance companies don't pay much of a difference. You know that, right? Insurances have a calculus for UCR and pay what they want to the medical center anyway (for the most part). There is some fluctuation, but it's not near as big as you think. It's not like a medical center sends a bill for $20000 and BCBS pays that. On average, BCBS pays about $7000 on a $20000 bill.

Basic insurance: Say total premiums are $1000/month. That's $12000 gross. After costs, the insurance company nets $10k a year. Any amount spent on the consumer above that is a loss. Giving the heavy user a kick back because he goes to drive-thrus is not the answer. When the free-standing surgery centers folded, and their botched surgeries had to be redone, who pays for that? Does papa who got angioplasty done with a coupon in a strip mall and now has the big MI because it wasn't done right, does he have to give his bounty back? Encouraging end of lifers and frequent flyers with such schemes would cripple an already overtaxed system.

so my question is - why does the medical center send a bill for $20,000 on a $7000 procedure