The Future of US Healthcare

[monir]

Originally Posted by Vexx

Yours seems pretty high a deductible for a silver plan but maybe your monthly is really low? We're just at the age where the more expensive gold plan made better sense. In about 10-15 years we'll be hitting Medicare (unless everything changes, of course).

It's indeed high. I'm in Maryland, with Aetna. The reason for my high deductible are two reason: the company that I'm with is ACA exempt for one year thanks to Obama, and as a result they are keeping the deductible to the same as before. Not only that, my monthly isn't all that low even though the company pays for about 75% of the total. I shouldn't see a drop in the monthly for at least one more year. Kaiser sounds appealing. I should look into it.

[Vexx]

Originally Posted by monir

It's indeed high. I'm in Maryland, with Aetna. The reason for my high deductible are two reason: the company that I'm with is ACA exempt for one year thanks to Obama, and as a result they are keeping the deductible to the same as before. Not only that, my monthly isn't all that low even though the company pays for about 75% of the total. I shouldn't see a drop in the monthly for at least one more year. Kaiser sounds appealing. I should look into it.

KP had a bad start in history but they've evolved to an HMO that understands that good aggressive preventative care saves money over the long run. The West Coast version is great (though I can't speak for other regions). The costs to me are much more predictable and they're like a Dr. McCoy poking me to come in for no-cost-to-me scans, evaluations, diet suggestions, references to specialists, etc. They're the only company I've ever encountered that actually left me feeling like they wanted me to stay well (instead of just shut up and pay them the premiums).

It's *almost* like the subscription model used in other advanced countries.

[darkchibi07]

Originally Posted by Netto Azure

Most of the coverage is standardized now at least. And it does depend whether he gets it through his employer or not. If he bought insurance through the previous individual market, he probably would have been underinsured as it does not cover most of the cost and at the same time saddles him with a huge deductible subject to lifetime caps in coverage. As for the cost, there's a scaled subsidy with various tiers of coverage. If premiums cost the full price of $750 (Which is quite high since in Cali full premiums in the exchange range around $500) then I'd presume that he's making more than $75,000 a year?

Nah, it's around $34,000 a year.

[Netto Azure]

That is indeed quite troubling. I'd personally try and contact the state exchange agency and inquire as to why. $34,000 a year income is quite on the lower 1/3 of the subsidy scale (Considering the cutoff is 400% above the Poverty line) and should have allotted a much higher subsidy and lower premium for him.

[darkchibi07]

I should add that there are potential tax credits he could gain that could reduce the premiums to about $60-$100+ per month, but I guess he's taking account the worst case scenario. Still trying to find a way to get him to stop watching Fox News.

[Netto Azure]

Oh! So he did not take into account the subsidies/tax credits. Then of course the prices will be inflated to about the $500 range. It's the same everywhere.

[darkchibi07]

Originally Posted by Netto Azure

Oh! So he did not take into account the subsidies/tax credits. Then of course the prices will be inflated to about the $500 range. It's the same everywhere.

Though is it normal for those premiums to increase "unexpectedly"? He looked up those same plans that were in the $60-$100+ range and all of them got increased by $80 the next day he looked them up.

[Ithekro]

They seem to be in the $250/month range here. Or maybe that's just Kaiser.

[darkchibi07]

Originally Posted by Ithekro

They seem to be in the $250/month range here. Or maybe that's just Kaiser.

That's not exactly affordable, isn't it?

[Ithekro]

California is being sort of dickish about who they make things affordable too. I have a job and not very many expenses, so I don't qualify for Medi-Cal. Doesn't matter if it is not much over minimum wage or that it might be temporary. Just that "I can afford an HMO with my income and expenses". In just about every other state I would be covered under some sort of State plan through by work. But not California.

[darkchibi07]

I wonder if Florida is the same; I still don't get the $80+ increase.

[Ledgem]

Originally Posted by Vexx

In about 10-15 years we'll be hitting Medicare (unless everything changes, of course).

It sounds like Medicare is trailing some changes to how it pays healthcare providers. What Medicare does (and pays) seems to set the trend for the rest of the insurance companies.

Physicians are paid for what they do under the current system in America. This is also why procedure-based specialties tend to bring in much more money than others. There are some insurance companies that pay physicians a set amount per patient per year (capitation), which creates a greater incentive for the physician to ensure the health of the patient; the less they see the patient, the more money they get per unit time (and the more patients they can take on). The only hard payment numbers from an insurance company offering capitation that I've personally come across were pretty horrid, however, and I get the impression that most physicians would rather accept patients under our current system. At the very least, we know what to expect with it.

The new Medicare model that is currently being trailed at some institutions grants a payment for an overall procedure or hospital stay, and that's it. For example, suppose a patient has a surgical operation, stays in the hospital for a few days, goes home, and then has to return to the hospital with some post-surgical complication. Under the current system, the insurance company would pay for the operation and ensuing hospitalization, and then again for the subsequent hospitalization. Under the new system, the amount of money paid initially would have to cover both hospitalizations. This makes it in the financial interests of the institution (or healthcare providers, for those in private practice) to ensure that the patient is fully taken care of and won't need to return for anything related to that initial issue.

The new system, if implemented, puts a bit more of a squeeze on healthcare providers. It's not a bad idea, though. It forces greater efficiency, which is something we could do with more of in medicine.

[Vexx]

I keep hoping the subscription model sweeps in soon (with a bonus for keeping patients healthy). The "for fee" system is corrosive.

[Ledgem]

Originally Posted by Vexx

I keep hoping the subscription model sweeps in soon (with a bonus for keeping patients healthy). The "for fee" system is corrosive.

I don't think it will. From a business standpoint it's too unpredictable. Insurance companies have an army of actuaries and a large client base that smooths out the impact of individuals who fall on the outer edges of the bell curve. What does the hospital system have, or worse, the private practitioner?

The other problem with this system is that the ones who actually deliver the service are not the ones who get to choose what's being paid. The insurance company, with their armies of actuaries and accountants, decides how much the physician or health service will be paid for a particular patient. (This is true even under the current system, where physicians and hospitals can charge what ever they want but frequently receive only a fraction of it.) If the patient winds up with a bunch of other health issues for what ever reason then the physician or hospital must expend their time and resources for that patient, but the insurance company does nothing. The ideal behind insurance is that there's a monetary safety net for freak occurrences, yet with capitation the ones who have to absorb more of the risk are the healthcare providers. We can and do put forth an effort at preventive medicine, but that's no guarantee that a patient won't exhibit reckless or self-destructive behavior, and it doesn't ward off harms that may occur by chance. If and when the consequences of those behaviors or chance occur, it would be our time and resources on the line with no further support from the insurance company. Under such a model, the insurance company really isn't doing much and could probably be cut out directly. Their actuary services would be the only potential value that they provide.

One idea I'm increasingly hearing proposed is to change health insurance to be more like car insurance. Think about it: when you take your car in for an oil change or some other maintenance work, does your auto insurance come into play? It does not, and yet a visit to your primary care physician's office gets your insurance company involved. I don't think that anyone has fully worked out how this would impact the system, but the hope is that cutting out the middlemen in more situations would result in lowered costs for everyone. It's an interesting idea, although I'm not fully convinced that it is "the solution" (or even a part of it).

[Netto Azure]

This belief of moving from traditional insurance models to a simple catastrophic insurance model does not address the issue of medical costs outpacing inflation. Unless the country pools its purchasing power to put pressure on medical providers, and producers they'll keep charging as much as they can for these inelastic costs.

[Ledgem]

Originally Posted by Netto Azure

This belief of moving from traditional insurance models to a simple catastrophic insurance model does not address the issue of medical costs outpacing inflation. Unless the country pools its purchasing power to put pressure on medical providers, and producers they'll keep charging as much as they can for these inelastic costs.

Are you sure that the pressure should be placed squarely on medical providers? I'm aware of the stereotype that physicians are all filthy rich, yet aside from a few outliers it doesn't match up with reality. The average physician salary is higher than the average salary in America, but the debt burden is pretty high ($350,000 for the average medical student at the time of graduation according to figures from a year or two ago; you're looking at paying that off over 10-20 years unless you're in an ultra-high salary specialty). Compared with historical trends, physicians' salaries have not been keeping up with inflation.

There are a lot of reasons for the high cost of healthcare. If I had to choose any single variable in America, it would be litigation. Here's why:

1) Malpractice insurance. The burden of this cost alone is creating major issues for obstetricians in private practice and for hospital systems with maternity units.

2) Defensive medicine. There are many cases where a test or study doesn't need to be ordered because it is so unlikely that it will show a result that would alter the management of the patient's condition, but often they are ordered anyway. There are two reasons for this. The first is that having the result decreases your vulnerability in a court case. The second is that, in the event that the unlikely is occurring and you catch it, then you've staved off a potential million-dollar lawsuit.

It doesn't cost the physician anything to order these tests, but a lawsuit can cost quite a bit.

[Netto Azure]

I did not mean to say that the medical providers should squarely shoulder the burden akin to Germany nor Japan, but should be part of a holistic healthcare and insurance industry reform.

Alas the issue of tort reform itself is sadly used as a distracting factor in the debate due to it being a small percentage of overall costs. If done alone, it simply shifts the overall burden of medical liability to the patient, rather than it being shared. Still I do agree that it should be addressed but in the context of overall healthcare reform.

Though it seems with this issue, my ideal solution does comes down to a Medicare for all program. Since this issue of defensive medicine would be addressed if Physicians through the Medical associations would negotiate with the government for liability protections in parallel to overall cost negotiations. Akin to the regular ones done in Canada.

[Ledgem]

Originally Posted by Netto Azure

Alas the issue of tort reform itself is sadly used as a distracting factor in the debate due to it being a small percentage of overall costs. If done alone, it simply shifts the overall burden of medical liability to the patient, rather than it being shared. Still I do agree that it should be addressed but in the context of overall healthcare reform.

That partly depends on the field that you're talking about. Malpractice insurance (and malpractice lawsuits) have created crises in various states for OB/GYN providers. As I mentioned in my other posts, the threat of lawsuits also leads to the practice of defensive medicine, which adds on arguably unnecessary costs.

[Guernsey]

Can anyone tell me about Obamacare, what it entails and what is the deadline?

[Irenicus]

Originally Posted by Guernsey

Can anyone tell me about Obamacare, what it entails and what is the deadline?

What is your State? There are generally State-specific websites either run by the State government, or by local advocacy/nonprofit healthcare-related organizations, where you can find real details a lot more trustworthy than random internet persons' understanding. You can even call them and ask questions. Part of the massive Obamacare implementation efforts has always been about mobilizing these groups to educate the public on the sort of things you're asking.

Also, you might try your luck with healthcare.gov and see if they've finally fixed it or not. I imagine there's a ton of links explaining what's up.

Though the basic of basics: if you have health insurance already through your work, chances are you're fine. Your workplace may be required to upgrade health insurance to match the law's requirements, but that's something that's on them, not you. If you don't, you'll eventually have minor fines included, but when or how is not something I can comfortably answer off the top of my head, not the least because there was a lot of fight to delay the penalty deadlines.