[Winona Online Democracy]
I think we've been here before on this forum--this is a systemic problem.
Dr. Davis states (and it is true) that providers do charge the same for all.
It is the differences in what the third parties will pay that creates
inequities in the current system and the big "blues" do have a monopoly,
with other insurers following their lead. If a provider does not wish to
become a provider for medicare, MA, or BCBS, then all patients are 100%
responsible for the fee the provider sets. Many providers choose this
option, but serve only a small segment of the population who are able to
afford to go outside their plan or have money or have a health care savings
plan.
If all providers opt out of the third party sick system, maybe the prices
would be lower, but who would serve the poor and elderly? I know that the
idea of health care savings plans is good alternative to the third party
system, but what will happen our most vulnerable citizens?
Is it the providers that are wrong or is it the system of using third party
payors? MA and Medicare were our solutions to making sure that poor,
disabled, and elderly would be able to receive medical care even though they
may be limited in ability to produce an income (for whatever reasons that
some vulnerable folks are not able). If they do not have employment, then
how do they contribute to a health care savings plan? Does a child with
Muscular Dystrophy who needs ongoing medical care and expensive equipment in
order to live and obtain an education have access to funds for care? How
would a family be able to pay? How do health care savings plans assure that
families aren't wiped out by a catastrophic illness? What would any of us do
if it happened to us? And would the health insurance industry stand by and
allow a revolution of providers who opt out of the system of accepting third
party coverage in the first place?
This is what I think of when I start to see the universal and single payor
system as the model of choice. I think that it would be a huge step backward
to abandon folks for whom fate or circumstance makes it impossible to fund
all of one's health care needs out of pocket.
Kathy Seifert
----- Original Message -----
From: "Paul Double" <[EMAIL PROTECTED]>
To: "Online Democracy" <[email protected]>
Sent: Tuesday, March 07, 2006 9:24 AM
Subject: FW: [Winona] Health Care and Insurance
[Winona Online Democracy]
People can buy a book "Medical Fees in the United States" 2006 by James B.
Davis from Amazon for $129.95 which provides the nationwide charges for
Medicine, surgery, laboratory, radiology and allied health service. Medical
prices are not nuclear science but the discounting practices for non profit
entities leaves much to be desired.
Non profits in the thirties were give exemption from price discrimination
law suits which enable them to get special discounts from vendors and to
price their items differently to insurance companies, government and
individuals. For profit companies "do not" by law have that right. The
Federal Trade Commission has many test cases on their web site showing
actions by them to stop discriminatory pricing. The Robinson-Patman Act,
the Sherman Antitrust Act prohibit for profit entities from this practice.
http://www.ftc.gov/bc/bchealthcare.htm
The Minnesota Attorney General and many other groups are trying to bring the
non profits into the same practice as is required by law of the for profit
providers.
There are even some test cases which are pursuing the fact that special
prices offered the Veterans Administration fall under the rules that require
all "for profit providers" provide by law the same prices to any consumer.
Paul Double
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On
Behalf Of Davis, William MD
Sent: Monday, March 06, 2006 9:41 PM
A few comments from a physician perspective. First, the "overhead" of
commercial insurance varies considerably. The best companies spend 8% on
administration (they pay out 92% of the premiums for health care) and the
worst may have an overhead of 50%. Currently Medicare and Medicaid are
running about 3% overhead.
Second, physician offices and hospitals have a "price list" for every
procedure they perform (office visits, shots, office surgeries, hospital ER
visits, operating room costs, etc.). They are all keyed to the CPT codes
(Common Procedural Terminology), a coding system developed by the AMA to
permit standardization. The CPT code for an "average" office visit is
99213. This makes it possible to compare charges across communities and
states for the same service. There is a detailed description of each code
in a manual that is published annually to allow "coders" to determine which
code to apply to a particular service. When new procedures are developed
(like laparoscopic appendectomy"), a code(s) is created for the procedure so
that insurance companies and the government can be billed.
What happens is that big payers (Medicare, Medicaid, BCBS, etc.) can dictate
to physician offices and hospitals what they will pay. It is similar to
Wal-Mart telling its suppliers what they are going to pay for goods Wal-Mart
will sell. It is a take it or leave it kind of deal. If we don't agree to
the contract that BCBS sends us, we can't see their patients (we are "out of
network"). For example, the charge for a 99213 at our office, based on our
"charge master" (price list) might be $75. We currently experience about
50% "discounts" from the big payers.
All patients get billed the same amount ($75 for a 99213) but what they owe
will depend on the deal with their insurance company. So BCBS may have told
us that they will pay only $40 and we cannot "balance bill" the rest to the
patient. You can see this on your insurance EOB (explanation of benefits)
that comes to you after a visit to the doctor. It gets more complicated if
you have a co-pay. You may have to pay $35 to your doctor and BCBS only
pays $5. The office is forced to "write off" the difference. However, if
you have no insurance, you get the bill for $75 and end up paying the whole
bill. This is not so bad for a $75 office visit but it can be a catastrophe
for a $50,000 coronary artery bypass surgery.
Some hospitals and clinics are discounting bills to patients without
insurance to match the discounts they give to the insurance companies but
most are not doing that. Fortunately, the number of uninsured patients is
still small in Minnesota but it is a growing number as employers stop
offering insurance to their employees.
Sorry for this long note but it may be helpful to see what is going on from
an "insiders" perspective.
William Davis MD
[EMAIL PROTECTED]
[Winona Online Democracy]
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