A lot of people don’t think that way. They believe that unlimited healthcare is a birthright. People will spend millions of dollars on their homes and untold thousands of dollars on their fancy cars, consumer electronics, and even cosmetic surgery. But these same people will grumble when they have to pay a $10,000 deductible for their life-saving coronary artery bypass surgery or a $50 co-pay to see their humble primary care physician for a regular check-up.
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Bingo! Although I hasten to add that with the ever expanding insurance minimums (which you need to reach before getting significant coverage) many people are paying out of pocket for things that are described above. When my kiddo broke his wrist it cost us $3k because insurance didn’t cover much - we hadn’t reached our “co-insurance” minimum or our family deductible. I’m not sure who has the kind of insurance that is covering much of what is described above but it isn’t us or our friends. Typically, folks are saddled with high co-insurance and deductible amounts so that relatively little beyond the basics (annual physicals and screenings) are 100% covered. It is especially bad if, like us, you don’t have a lot of health issues so that you are almost never meeting your deductible.
I had arthroscopic meniscus surgery about 24 years ago.
I had injured my knee wrestling at a Spring party in college. I walked with a limp – it was pretty sore – all summer, thinking I had simply sprained the knee.
It was such a pain, and wasn’t improving, so i went to the doc. Turns out I had a torn meniscus. They did the surgery – three small holes at separate corners of the knee. They removed about half of the meniscus. One week on crutches… then a week of walking… and i was more or less back to 100% after 2-3 weeks. It was wonderful – I was able to play beach volleyball and tennis without limited mobility and pain.
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But did you and/or your employer save much more than the $3k over the years with a higher deductible compared to a lower deductible plan?
The main problem generally is that many people won’t save up to cover $3k of medical bill risk, even if they were getting an extra $3k over the year in their paychecks to take the higher deductible plan.
High or low deductible insurance, I would rather have fewer health issues than more health issues.
None of the plans offered by our employer were low deductible - there were “lower” but none that I’d categorize as “low”. We picked the middle. I don’t think we’ve ever met the deductible in the past 10 years. Of course, I’m glad we haven’t experienced any big health issues and glad that we are in the position to afford all this but I’m acutely aware that many people are not. Some folks choose the high deductible plan because that is all they can afford and they pray they don’t have to go to the doctor for anything beyond the basics since it isn’t going to be covered.
The model that many people suggest is the managed care system that Kaiser use: doctors are paid a salary not per procedure. The result (according to our neighbor who has worked there) is that Kaiser mostly get average doctors (rather than the most talented and ambitious ones who would earn more by the procedure elsewhere) and do a good job with common primary care stuff and routine operations but have to send out complex cases to higher level hospitals. She considers that they are much more likely to miss obscure conditions or rare side effects than doctors at a place like Stanford.
I was in the Kaiser system for many years, including for cancer treatment, and I think you are probably right. But doing primary preventative care well, and doing things for which there is an established “standard of care” is totally worthwhile in this time when it can be so hard to find a primary care doc who takes your insurance. I got the same care as all the folks I met online who were all over the country in all kinds of systems, with fewer extras (like heated robes and individual infusion rooms). I also found that the Kaiser system, like most systems, was responsive to individual advocacy which I knew would be harder for folks with fewer resources than I had. I said many times that if single-payer looked like Kaiser I would back it 100%. But that was southern California 10 years ago.
Our medical system is falling apart. And so is Canada’s and so is the UK’s. The pandemic really did escalate what had been a gradual decline. We just pay a lot more for a system that doesn’t treat everyone.
Edited to add: Kaiser may not have superstar doctors, but they also can have very good doctors who would like a better work-life balance.
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Considering how elite one has to be to get into US medical school, or a US residency from a foreign medical school, is an “average” doctor anything to be worried about?
Indeed, one disadvantage of physicians who earn by the procedure is an incentive to run up the costs by recommending more expensive choices even if the incremental benefit over a less expensive choice is minimal or even negative.
Problem with Stanford is that it is expensive and in-network for very few insurance plans, so it is financially inaccessible for many.
For most people in the area, the main choices are Kaiser and Sutter.
I wouldn’t go so far as to say the medical system is falling apart. I think the medical system is more than capable of adapting to suit the needs of the population. The problem is that healthcare utilization continues to increase and the responsible parties cannot reach a consensus on how to effectively limit costs and who is responsible for shouldering the burden. As one would expect, the delivery of services in many areas have been constrained.
If you have the money, you don’t have to wait for anything. It’s called concierge medicine.
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I get it. It’s because of the lack of transparency in actual medical pricing though. Most offices and hospitals can’t even quote their own book rates. The general populace hasn’t a clue at how things are priced in healthcare. They won’t care until there is openness in pricing. That won’t happen though unless it’s forced. The system can only survive on this opacity.
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You don’t believe pricing is part of the problem? Should a heart transplant cost $1,600,000 when it’s $60,000 in India? Is charging over $2,000,000 for a course of Zolgensma okay?
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It’s been mentioned that med students want to be specialists rather than work in primary care, due to higher pay and more challenging jobs. Challenging may be true, but I wanted to point out that the while compensation is higher for procedural specialties, it may be lower for thinking specialties.
In the thinking specialties, doctors are managing multiple problems, dealing with mental health, helping those with chronic diseases, solving medical mysteries, etc. These jobs can be very complex, but the docs don’t do expensive procedures. Thus, some of them make (on average) less than primary care, even though they usually have more training.
The specialties below all make less than internal medicine (primary care for adults):
Psychiatry
Neurology
Allergy/Immunology
Preventive Medicine
Rheumatology
Endocrinology
Infectious disease
It shows what our system values (procedures), and since we pay specialties like Interventional Cardiology and Orthopedic surgery the most, they have the strongest professional organizations and lobbyists. Of course, they do a lot of good, but so do the docs in specialties above (some of which have severe shortages).
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Money can solve almost any problem. Not all people have enough. Even if they work hard and do jobs you value.
And I’m glad to know there are places where the healthcare system isn’t falling apart. But real-life people tell me about being caught in pre-authorization hell with their insurance companies, waiting 12 hours in an ER waiting room with one bathroom with vomiting and diarrhea, being unable to find a new patient primary care appointment in less than 6 months, and being unable to find a mental health provider taking new patients at all. Nurses who are striking not for more money but for safer patient/staff ratios. Living in states that didn’t expand Medicaid and being caught in the gap between Medicaid and the ACA policies. How it all looks depends on where you are standing.
Edited to add: Cancer patients who spend hours monthly fighting with insurance companies to cover the chemotherapy that was covered last month and is needed this month and next month too.
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As a patient myself, I also share your frustration. But I am only sharing my opinion. There is no single villain responsible for this situation. All parties have a responsibility to contain costs, whether it is to limit reimbursement as well as potentially limit care. There are no easy answers. Otherwise, we would have addressed it nearly 40 years ago when it was first recognized.
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Unfortunately, for probably most Americans, $60,000 is out of reach like $1,600,000. Even $6,000 or $600 may be out of reach of many, given the state of personal finance in the US.
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I agree with almost everything you say here. But I do think that I would nominate insurance companies as the primary villain. I was told by a representative of a major company that the reason that my claim wasn’t handled properly was “the software doesn’t handle those well”. They were violating the “Surprise Billing Act” that had been passed 9 months earlier. They’d been operating on the “we won’t have to pay if no one notices” principle ILLEGALLY for 9 months! And were not apologetic in the least. I’m not saying that government control would necessarily be better. I’m just saying it’s bad right now.
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I don’t have any fondness for insurance companies either. But I am trying to be fair to all parties.
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The system is opaque by design. This is my understanding. Different payers pay different rates to health care organizations. The uninsured/indigent pay $0. Medicare/Medicaid pay a substantially discounted rate that is usually below cost. Insurance companies pay a negotiated (sometimes a non-negotiated) rate based on a multiple of the customary medicare/medicaid rate or a % of the submitted charge. That is why they significantly up-charge their fees because they know the vast majority of their patients (including the insurance companies) never come close to paying the full amount. They are essentially trying to make up the difference. For example, for an admission for appendicitis, a hospital may earn 0%, 50%, 75%, 100% of the charged amount. The working poor are the ones who get screwed and end up paying 100% of the charged amount- if they don’t want to get referred to a collection agency.
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I have worked for a company that is essentially an insurance company for Medicaid and Medicare health insurance plans. SO MUCH of how things operate are due to the state and federal Medicare and Medicaid regulations.
Every year, new regulations are announced and all of the health plans have deadlines by which to implement them. A LOT of work happens behind the scenes in order to try to streamline things, make things easier for members/patients, make things easier for healthcare providers, etc.
You’d be surprised the incredible amount of attention that has to be spent on a regular basis on audit readiness, doing mock audits, conducting an actual state or federal audit of a specific health plan, and then working to fix any discrepancies or ‘gaps’ in the company’s internal processes in order to prevent the issue from occurring again.
And if you’ve ever wondered why when you turn 65 and sign up for Medicare, suddenly you’re having to go to the doctor, like, ALL of the time for this, that, and the other thing?
You can thank Uncle Sam for that because all Medicare plans are given CMS STARS ratings. If your health plan gets a low STARS rating so many years in a row, then that health plan gets reimbursed/paid by CMS/Medicare at lower reimbursement rates than other health plans. In turn, this means that the company has less $$ to pay providers. Some of the STARS ratings measure stuff like what % of members w/Type 2 diabetes have their A1C levels checked regularly. Each health plan, for example, has to report on that to Uncle Sam.
health plan contracting departments, in turn, then decide to get creative and add incentives into revised contracts w/providers in order to encourage PCPs to make sure that more of their patients get regular preventative screenings (mammograms, colonoscopies, vaccines for children, etc., etc.). This, in turn, results in updates having to be made to all of the claims processing systems so that when your doctor submits a claim to the insurance company, it will be processed correctly and paid correctly according to: (1) the Medicaid or Medicare or commercial plan’s fee schedule; and (2) the provider’s contract term exceptions & other criteria.
any time one of those things are changed…it has to be tested, too. So the insurance company doesn’t screw up and suddenly start denying something that they shouldn’t.
There’s also state and federally-mandated grievance & appeals processes that each insurance company has to follow. You have to track everything that happens on a grievance or appeal that a patient/member or provider submits to the insurance company. Have to follow the very specific process To. The. Letter and be able to show one’s screen live in audits w/CMS auditors/regulators showing the exact date & time that Mr/Ms. Senior Medical Director added a note to the patient’s prior authorization request, in which Sr Medical Director denied it for XYZ reason.
Meanwhile, EVERY insurance company has their own member online portal. They all have their own online provider portals, too. And they all have electronic means for providers to submit claims to them. This means that the paperwork/electronic paperwork for the providers is also hard to manage.
…meanwhile, you the patient just want your mammogram/colonoscopy/whatever approved so you can make sure that you’re ok/don’t have cancer/aren’t going to need further interventions.
Some providers are better than others at managing/navigating through the insurance company electronic paperwork maze. Some providers also are better than others at submitting claims correctly to insurance companies…you’d be surprised how many times a doctor’s office screws up and that’s how you end up getting a bill for $1000 in lab fees when it should have been $20.
As a patient, I have basically fired my doctors before and taken my healthcare business elsewhere because of the incompetence of the office staff. Or I’ve switched to a different doctor because the doctor was a butthead and wouldn’t listen to me, had 1 foot literally out the door and didn’t care about my question or concern.
It’s complicated.
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I am always amazed when people say the US health care system works. Medical bills are the number 1 cause of bankruptcy ( even tho 60% of bankrupts were insured), 30 million people have no medical insurance whatsoever, and tens of millions more can’t afford their needed medicines. If this is considered " working" I am genuinely baffled by what would be considered a failure in their eyes.
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