As Obamacare goes into effect, new criticisms leveled

[WhoWee]

Its not about comparing to the government. If we look at the main topic we are discussing (health care), the government is obviously more efficient because it does not have to evaluate risk (a large part of insurance). http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf.

(my bold)
The Government uses the Medicare Advantage plan to offset some of their risk. They have evaluated risk. The Federal Government has expanded Medicaid recently - this forces a share of the cost onto the states - are the states evaluating that risk?

Original Medicare is paid through Payroll deductions for Part A and a premium payment for Part B. The Part B premium was increased from $96.50 to $110.50 in 2010 - because the risk was evaluated - wasn't it?

There are at least a dozen possible healthcare outcomes when a person reaches age 65.
1.) Original Medicare only
2.) Original Medicare plus Part D
3.) Either 1 or 2 above plus a Medigap Supplement
4.) Original Medicare plus Medicaid (multiple levels)
5.) Original Medicare plus Part D with LIS (multiple levels)
6.) Part C Medicare Advantage (MA)
7.) Part C Medicare Advantage with Prescription (MAPD)
8.) no Medicare coverage (Group/Private or nothing at all)
9.) no Medicare coverage - Medicaid only
10.) VA only
11.) VA in combination with something from above
12.) TRICARE (multiple)

There are other cost sharing and specialized (ESRD) plans (for instance).

Other than people with Group/Private insurance, the only insurance scenario that eliminates risk to the Federal Government is the Medicare Advantage program. The Government pays a fixed amount to a 3rd party insurance carrier that pays instead of Medicare. Every other scenario puts the Government at risk. The Government does not have unlimited resources (believe it or not). I've posted several links previously that estimate long term deficits from Social Security, Medicare, and Medicaid spending approaching $86 Trillion. The Federal deficit is currently $14 Trillion - up almost $5 Trillion in the past 5 years - there are limits to the risk Government can cover. Government does have to evaluate risk.

I've posted multiple times in the various healthcare debate threads on this topic. This is a condensed version of my OPINION. The Government needs to fund facilities (including large ticket equipment), including local clinics - perhaps convert some of the Post Offices that are closing. Provide tax incentives to doctors to volunteer in the clinics. The goals would be to address routine and preventative issues and to eliminate non-emergency Medicaid visits to emergency rooms. Next, the Government can create high risk insurance pools to cover catastrophic claims/pre-existing above a certain limit - $5 million (IMO). This will give the insurance industry a $5 million maximum risk to address. The next level of concern is leveling the playing field for carriers. We need to standardize insurance regulations (to some of the higher standards) across the 50 states, D.C., Guam, Puerto Rico, etc. to allow more companies to participate and reduce the administrative (nightmare and) cost. There are other concerns including an evaluation of the cost of litigation (including Doctors ordering unnecessary tests to protect themselves). Medicare already sets the reimbursement rates - need evaluation. The Government also needs to address the costs of bringing a drug to market. Insurance is the "demon", not the problem. Again - IMO.

 

[mheslep]

We both agree asymmetry of information is a difficulty for a market.

Yes agreed, a difficulty. It doesn't make markets untenable, at least not in many cases.

Its not about comparing to the government. If we look at the main topic we are discussing (health care), the government is obviously more efficient because it does not have to evaluate risk (a large part of insurance). http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf.

Where in that 167 page document is the government shown to be obviously more efficient?

Its about the efficiency of the specific market- over time do crooked dealers go out of business and honest dealers prosper? In an efficient market, this is what happens. In a market-for-lemons situation, the crooked dealers will thrive and drive out the honest dealers. You are making a positive claim- the market has solved the asymmetrical information problem inherent in car repair.

Let's not turn this around. I entered the discussion to suggest there were obvious exceptions to your positive claims:

Market based healthcare solutions are based on a myth- there is no market for healthcare. The demand for life-saving care is completely inelastic. Information is completely asymmetric between doctor and patient, and in an emergency, patients can't chose which state, hospital, provider, etc, they end up with.

Without state support (medicare), the insurance model would be completely broken. Over a long enough time scale, everyone becomes incredibly risky. Hence, Daniels' arguments are broken. More privatization = more inefficiency in this case.

I take exception with every sentence of the above.

 

[ParticleGrl]

Where in that 167 page document is the government shown to be obviously more efficient?

Medicare loses about 4% in overhead, to insurance's 11%. Further, look at:

http://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf

Medicare's cost per beneficiary has been rising about 9% per year since 1970. Private insurers have seen premium rise 10% per year. Also, these rapid growths underscore that we don't simply have out of control medicare growth. We have out of control health care expense.

I take exception with every sentence of the above.

The lack of market is made up of each of the supporting points:

On price elasticity see the famous RAND health insurance experiment. It is the largest study I know of, and concludes a price elasticity of about -0.2. Its not quite 0, but its pretty close : http://www.rand.org/health/projects/hie.html

On asymmetry of information, we seem to agree- correct me if I'm wrong?

Also, do we need to argue about whether patients in an emergency have choice?

The question then, is can a market operate efficiently in these situations.

 

[talk2glenn]

Medicare loses about 4% in overhead, to insurance's 11%.

This is complete nonsense. Forget for a moment that relative administrative overhead costs tell us nothing of practical value about efficiency of healthcare delivery; let's pretend for a moment that having an advantage in administrative services is necessary or sufficient to lend a given firm a comparative advantage.

What exactly are we talking about when we say Medicare spends (the money is spent, by the way, not "lost")? This means that 4% of the premiums collected by Medicare are spent on administration, with the remaining 96% spent elsewhere - specifically, mostly on covering medical bills. It is also true, then, that private insurance likewise spends its remaining 89% elsewhere - specifically, mostly on covering medical bills.

Does this corollary (Medicare spends 96% of its revenues paying medical bills, and private insurance spends only 89%) prove that private insurance has an efficiency advantage in paying medical bills relative to Medicare? I gather you'd reject that claim. And you'd be right to do so on the basis of this statistical sleight of hand - in fact, I've proven no such thing.

Medicare, by design, covers the elderly, and they are a much riskier portion of the population. Even if Medicare and private insurance companies spent an identical real dollar amount per patient on administrative costs, the relatively higher medical expenditures in Medicare would make administrative costs a smaller percentage of overall costs. When we actually look at the per patient administrative costs for Medicare versus private insurance, we find that they are not equal. In fact, Medicare spends far more per patient than the private sector, despite the fact that private firms must pay taxes, fees, marketing and regulatory costs that Medicare simply does not have.

On price elasticity see the famous RAND health insurance experiment. It is the largest study I know of, and concludes a price elasticity of about -0.2. Its not quite 0, but its pretty close : http://www.rand.org/health/projects/hie.html

A PPD of -0.2 is not at all close to the perfectly inelastic case of 0, which does not exist in real markets. In fact, there are an infinite number of real values between 0 and 0.2 on the number line.

In real terms, this figure tells us that the price elasticity of demand for healthcare is relative inelastic, but still elastic - a 1% rise in prices, ceters perebus, results in 0.2% less consumption. This is more than sufficient to create viable markets. For comparison, the market for eggs is relatively more inelastic than the market for healthcare, by a factor of 2. Consumers are twice as responsive to changes in the cost of healthcare than to changes in the cost of eggs!

This is a far cry from your original claims - that dieing people will spend anything on life saving treatments, and that therefore healthcare is not a marketable good. Shall we nationalize the egg market next?

On asymmetry of information, we seem to agree- correct me if I'm wrong?

I don't! I haven't seen any argument that the market for healthcare is more prone to moral hazard or adverse selection than any other technical or specialized marketplace. The existence of asymmetries in healthcare makes the sector neither special nor unworkable. Consumers and suppliers deal with information scarcity constantly; this fact alone is not sufficient to establish market failure. Rational market participants are understood to invest the resources necessary to inform their decisions before they make them. Where they cannot, they price in risk premiums. If they cannot, the transactions don't occur.

This is confirmed by most studies which attempt to measure the adverse impact of information asymmetries on real world markets; in practice it's virtually impossible to find and measure statistically. Do so on a systematic basis, and you'd probably win a Nobel prize. Good luck, though; I think you'll find market mechanisms are remarkably self-preserving.

Also, do we need to argue about whether patients in an emergency have choice?

Of course patients in emergency have choice. That patient may prefer immediacy of care, all things being equal, but this is not determinant. If the nearest hospital is closed, the consumer certainly won't choose it on the basis of distance. Likewise if the nearest hospital only accepts Visa and he carries Mastercard, or if it only treats cancer patients and he is having a heart attack. These points might seem absurd, but they serve to make the point. Indeed, critical patients are routinely routed to medical centers other than the closest for myriad reasons.

You seem to imagine that the healthcare market is some extreme, fantastic place full of zeros and infinites. In the real world, you simply don't find that, and if your theory suggests you ought to, there's probably something wrong with the theory.

 

[ParticleGrl]

This is complete nonsense. Forget for a moment that relative administrative overhead costs tell us nothing of practical value about efficiency of healthcare delivery;

How do you define efficiency of healthcare delivery? I would argue that in the context we are discussing, the administrative costs are a good measure.

What exactly are we talking about when we say Medicare spends (the money is spent, by the way, not "lost")? This means that 4% of the premiums collected by Medicare are spent on administration, with the remaining 96% spent elsewhere - specifically, mostly on covering medical bills. It is also true, then, that private insurance likewise spends its remaining 89% elsewhere - specifically, mostly on covering medical bills.

For the case of medicare, the remaining money is spent mostly on medical bills, obviously. For private insurance, the rest of the money won't be spent on medical bills, some of it is profit. It is obviously unfair to count profit as inefficiency.

Medicare, by design, covers the elderly, and they are a much riskier portion of the population. Even if Medicare and private insurance companies spent an identical real dollar amount per patient on administrative costs, the relatively higher medical expenditures in Medicare would make administrative costs a smaller percentage of overall costs. When we actually look at the per patient administrative costs for Medicare versus private insurance, we find that they are not equal. In fact, Medicare spends far more per patient than the private sector, despite the fact that private firms must pay taxes, fees, marketing and regulatory costs that Medicare simply does not have.

Per patient administrative costs is obviously not a good metric. If I insure a pool of 22 year olds who makes no claims in an average year, my administrative cost can approach 0. The per CLAIM administrative cost would be a better number, but we can't get it from the CBO data above.

BUT, what we can do is directly compare medicare advantage plans (through private companies) to the similar pool of medicare. Now we have the same demographics, I hope you would agree? What do we find- between 3 and 4% administrative costs for medicare, and about 11% for the private medicare advantage plans. Comparing these similar demographics, we find private companies spend more in administration per patient of the same demographic.

A PPD of -0.2 is not at all close to the perfectly inelastic case of 0, which does not exist in real markets. In fact, there are an infinite number of real values between 0 and 0.2 on the number line.

Of course the perfectly inelastic case doesn't exist. Generally, anything between 0 and -1 is considered inelastic. I would say -0.2 is extremely inelastic.

Consumers are twice as responsive to changes in the cost of healthcare than to changes in the cost of eggs!

Yes, eggs are famously inelastic. Largely because they are among the cheapest proteins, so there are no close substitutes, to follow the econ 101 logic (although I don't know an actual study of their inelasticity, could you provide one?) . Of course, if the price of eggs jumped above the price of chicken or beef, elasticity would set in. With health care, what do you think can explain the inelasticity? Is there a price where health care becomes more elastic? Given that it is obviously a necessity, with no substitutes, might the relative elasticity be due to people who are priced out of the market all together?

This is a far cry from your original claims - that dieing people will spend anything on life saving treatments, and that therefore healthcare is not a marketable good. Shall we nationalize the egg market next?

First, the PPD I quoted is across all health care, not simply life saving care. I still contend that the demand for life saving care is very nearly perfectly inelastic. For life saving care, if you arrive at the hospital the hospital is obligated, both morally and legally, to treat you, regardless of price.

Rational market participants are understood to invest the resources necessary to inform their decisions before they make them. Where they cannot, they price in risk premiums. If they cannot, the transactions don't occur.

Yes, all rational participants in the health care market invest the resources to get the MD required to understand the best course of action, and successfully negotiate with their provider and insurance company.

Of course patients in emergency have choice. That patient may prefer immediacy of care, all things being equal, but this is not determinant. If the nearest hospital is closed, the consumer certainly won't choose it on the basis of distance. Likewise if the nearest hospital only accepts Visa and he carries Mastercard, or if it only treats cancer patients and he is having a heart attack. These points might seem absurd, but they serve to make the point. Indeed, critical patients are routinely routed to medical centers other than the closest for myriad reasons.

Right, but the routing is done by the ambulance, not the patient, on the basis of medical reasoning, not patient choice. If you call 911, you are going to where the ambulance takes you, whether or not they are in your provider network, or take whatever payment you have on you, etc. The choice is whether or not to call 911.

 

[nismaratwork]

I would add... by definition some emergencies don't leave you in a position to make choices, or make them known. The economics... I am steering clear of, but the point about emergent care is also accurate. You can refuse treatment doctor to patient, but your going to have a hell of a lot of explaining to do if ALL of your doctors do it. There might be whispers of it being "policy", and that would be *sounds of axe falling*.

 

[WhoWee]

Medicare loses about 4% in overhead, to insurance's 11%. Further, look at:

http://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf

Medicare's cost per beneficiary has been rising about 9% per year since 1970. Private insurers have seen premium rise 10% per year. Also, these rapid growths underscore that we don't simply have out of control medicare growth. We have out of control health care expense.

It's not clear how much of "insurance's" overhead is due to Medicare/CMS and state regulations compliance - any idea?

Just in the context of Medicare (not group or individual or group Medicare or Medigap), in order for a company to offer a Medicare Advantage (usually 1 basic MA plan per state), a Part D prescription plan (most file 2 or 3 -plans per state), a Medicare Advantage plan with prescription coverage (typically HMO's, PPO's, PFFS's, and possible SNP's - typically 3 to 4 per state) - the insurance company must file a specific plan for each county in the state - some vary by zip code. As an example, Ohio has 88 counties. This process has to be repeated for each and every state in which the company intends to offer plans. The CMS must approve the plans each year - plans are then subject to state oversight. The insurance companies must also re-train and certify their entire sales force in every state - every year - for each product line. Again, this must be done in every state.

Next are the marketing restrictions - must be approved by CMS and each state. There are also records management and disclosure requirements. In order to talk to a Medicare beneficiary, an insurance agent needs to file a "scope of appointment" form. Basically, it's a document that states the beneficiary requested the meeting and has agreed to discuss specific plans - nothing else can be discussed. This document must be kept on file for 10 years. Next are telephonic records management - calls are recorded and kept on file for 10 years. The greatest challenge to complete documents in a timely manner - some 24 hour and 48 hour restrictions. There are MANY other regulations - many subject to FBI inspection under HIPPA and MIPPA. (Almost forgot the annual agency meetings with HIPPA/MIPPA attorneys - more certifications.)

 

[nismaratwork]

WhoWee... have you considered making something for the PF library, or a sticky based on this? You have a hell of a lot of facts on hand, and when we've taken all ideology out of the mix as you seem to naturally do with your business... it's very sound. I can't help but think you could write a guide to some of these entities that would inform future discussion.

 

[WhoWee]

WhoWee... have you considered making something for the PF library, or a sticky based on this? You have a hell of a lot of facts on hand, and when we've taken all ideology out of the mix as you seem to naturally do with your business... it's very sound. I can't help but think you could write a guide to some of these entities that would inform future discussion.

There is a lot of information to consider - a quick CMS link - a few downloads:

https://www.cms.gov/ManagedCareMarketing/03_FinalPartCMarketingGuidelines.asp

"Downloads
2012 Revised Draft Medicare Marketing Guidelines Memo, 1/06/2011 [pdf, 62Kb]

2012 Draft Medicare Marketing Guidelines [zip, 1Mb]

2011 Medicare Marketing Guidelines Memo, 6/04/2010 [pdf, 223 Kb]

2011 Medicare Marketing Guidelines [pdf, 1.5Mb]

Allowable Use of Medicare Beneficiary Information Obtained from CMS & Prohibition on Using Federal Funds for Non-Plan Related Activities [zip, 73Kb]

Clarification of MMG and Appeals Related Error in Annual Notice of Change/Evidence of Coverage Templates [pdf, 76Kb]

Clarification of Medicare Marketing Guidelines Requirements and Outbound Enrollment Verification Policy [pdf, 81kb] "

 

[WhoWee]

Sorry - here's a working link:

https://www.cms.gov/ManagedCareMarketing/Downloads/2011_MMG_060410.pdf

Skim from page 145 to 165 - just for fun.

 

[ParticleGrl]

It's not clear how much of "insurance's" overhead is due to Medicare/CMS and state regulations compliance - any idea?

I have no idea how you could begin to pull it from the data in the report. I know the administrative cost data does not include the marketing costs, etc, but it certainly includes the cost of complying with regulations.

On the flip side, the cost of overseeing the regulations shows up in the medicare administrative costs.

Either way, since its once yearly, and more or less cost-fixed, I'd be willing to bet its a very small percentage of administrative costs on both sides.

 

[nismaratwork]

There is a lot of information to consider - a quick CMS link - a few downloads:

https://www.cms.gov/ManagedCareMarketing/03_FinalPartCMarketingGuidelines.asp

"Downloads
2012 Revised Draft Medicare Marketing Guidelines Memo, 1/06/2011 [pdf, 62Kb]

2012 Draft Medicare Marketing Guidelines [zip, 1Mb]

2011 Medicare Marketing Guidelines Memo, 6/04/2010 [pdf, 223 Kb]

2011 Medicare Marketing Guidelines [pdf, 1.5Mb]

Allowable Use of Medicare Beneficiary Information Obtained from CMS & Prohibition on Using Federal Funds for Non-Plan Related Activities [zip, 73Kb]

Clarification of MMG and Appeals Related Error in Annual Notice of Change/Evidence of Coverage Templates [pdf, 76Kb]

Clarification of Medicare Marketing Guidelines Requirements and Outbound Enrollment Verification Policy [pdf, 81kb] "

Thank you very much! To say that I have reading to do would be a grotesque understatement, but you've given links to someone who will read this. I still think you could put something together that would be a valuable guide, but this is certainly a fantastic place to start.

 

[mheslep]

On asymmetry of information, we seem to agree- correct me if I'm wrong?

If you standby your original claim on the subject no we do not agree. I granted asymmetric info exists, it creates challenges, and went on to provide some examples of how people routinely work around them. You stated information for patient-doctor is "completely" asymmetric , which I read as saying no work arounds are possible, especially if one goes on to conclude there "there is no market for healthcare." because of asymmetric information.

I'll get back to the rest of your reply time permitting.

 

[mheslep]

Medicare loses about 4% in overhead, to insurance's 11%. Further, look at:

http://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf

Some more research on the subject will show you otherwise. That CMS overheard figure was the first go-to figure cited during the US healthcare legislation debate and it was shown to be at least superficial, and possibly misleading:

1. The CMS table gives 6.6% as the overhead figure in 2009, though I'd also read 3-4% elsewhere. Where did you get 4%?

2. Medicare doesn't include the huge fraud costs in that figure, some $60 billion last year according to AG Holder and the WSJ. To prevent that, Medicare would have have to staff a lot more qualified medical personnel - just like the private insurers do.

Advocates of government-run health insurance like to point to Medicare's low administrative costs (which, as I noted yesterday, is a controversial claim). But even if that factual claim were true, the argument would hardly be dispositive as to the greater efficiency of a publicly run system. As I put it in my recent Times article, "True, Medicare’s administrative costs are low, but it is easy to keep those costs contained when a system merely writes checks without expending the resources to control wasteful medical spending."
...
By taking the fraud and abuse problem seriously this administration might be able to save 10% or even 20% from Medicare and Medicaid budgets. But to do that, one would have to spend 1% or maybe 2% (as opposed to the prevailing 0.1%) in order to check that the other 98% or 99% of the funds were well spent. But please realize what a massive departure that would be from the status quo. This would mean increasing the budgets for control operations by a factor of 10 or 20. Not by 10% or 20%, but by a factor of 10 or 20.

http://gregmankiw.blogspot.com/2009/07/costs-versus-efficiency.html
http://online.wsj.com/article/SB124649425934283347.html
http://www.usdoj.gov/opa/pr/2009/May/09-ag-491.html

3.Medicare serves a market, the elderly, that has a high medical cost per patient, and since overhead scales on a per-patient basis, overhead is lower for the elderly:

Medicare beneficiaries are by definition elderly, disabled, or patients with end-stage renal disease. Private insurance beneficiaries may include a small percentage of people in those categories, but they consist primarily of people are who under age 65 and not disabled. Naturally, Medicare beneficiaries need, on average, more health care services than those who are privately insured. Yet the bulk of administrative costs are incurred on a fixed program-level or a per-beneficiary basis. Expressing administrative costs as a percentage of total costs makes Medicare's administrative costs appear lower not because Medicare is necessarily more efficient but merely because its administrative costs are spread over a larger base of actual health care costs.

http://www.heritage.org/Research/Reports/2009/06/Medicare-Administrative-Costs-Are-Higher-Not-Lower-Than-for-Private-Insurance This last one is not about overhead, but still goes to an evaluation of efficiency:
4. Medicare costs shifts onto the private system, paying only 85-95% of the going health care rate.
https://www.physicsforums.com/showpost.php?p=2344564&postcount=799

 

[ParticleGrl]

1. The CMS table gives 6.6% as the overhead figure in 2009, though I'd also read 3-4% elsewhere. Where did you get 4%?

I got it from the CBO report linked above.

2. Medicare doesn't include the huge fraud costs in that figure, some $60 billion last year according to AG Holder and the WSJ. To prevent that, Medicare would have have to staff a lot more qualified medical personnel - just like the private insurers do.

To my knowledge, this keeps getting revised down, so its not quite 60 billion. Further, that fraud number includes privately administered plans like medicare advantage. Look at http://paymentaccuracy.gov/high-priority-programs

Consider that medicare advantage has an improper payment rate of about 14%, compared to traditional fee-for-service improper rates of about 10.5%. The privately administered plans are seeing more fraud, not less, despite higher overhead cost.

3.Medicare serves a market, the elderly, that has a high medical cost per patient, and since overhead scales on a per-patient basis, overhead is lower for the elderly:

I dealt with this above, by using the CBO numbers to compare Medicare Advantage (which are private) plans to traditional Medicare. The numbers are still the same.

Also, overhead doesn't scale on a per patient basis, as I discussed above. If you only insure a pool of 22 year olds who never file any claims, you can push your overhead costs down to 0. It scales on a per claim basis.

especially if one goes on to conclude there "there is no market for healthcare." because of asymmetric information.

I concluded that all of the points together- extreme inelasticity, lack of consumer choice, large asymmetry of information, add up to create a market that doesn't operate efficiently, and shouldn't be expected to.

 

[WhoWee]

Further, consider that medicare advantage has an improper payment rate of about 14%, compared to traditional fee-for-service improper rates of about 10.5%. The privately administered plans are seeing more fraud, not less, despite higher overhead cost.

Let's take a look at how that 14% breaks down - specifically, what benefits are most likely to have a problem? Is any of it allocated to prescriptions? The "traditional fee-for-service" plan is Original Medicare - no prescription coverage included.

 

[ParticleGrl]

Let's take a look at how that 14% breaks down - specifically, what benefits are most likely to have a problem? Is any of it allocated to prescriptions? The "traditional fee-for-service" plan is Original Medicare - no prescription coverage included.

Fraudulent and improper payments are extremely had to estimate. It is my (admittedly limited) understanding that accurate numbers for improper prescription payouts haven't been compiled, which is also why medicare D improper payment numbers don't exist.

If someone else has these numbers, chime in.

 

[nismaratwork]

I'm just accepting that here, I can only read and learn... I'm so far out of my depth I can't see daylight.

 

[WhoWee]

Fraudulent and improper payments are extremely had to estimate. It is my (admittedly limited) understanding that accurate numbers for improper prescription payouts haven't been compiled, which is also why medicare D improper payment numbers don't exist.

If someone else has these numbers, chime in.

Are you suggesting these are estimates - rather than hard data? (my bold)

"Consider that medicare advantage has an improper payment rate of about 14%, compared to traditional fee-for-service improper rates of about 10.5%. The privately administered plans are seeing more fraud, not less, despite higher overhead cost. "

Also, please note the private plans operate under significant regulatory and compliance cost as noted in earlier posts.

Does anyone know what CMS means when they categorize something "an improper payment"? (Hint - look up medical billing/coding) Also look up the MIPPA/HIPPA and ARRA funding references posted earlier.

 

[WhoWee]

BTW - please also note MEDICARE ADVANTAGE plans pay INSTEAD of Medicare - excessive cost in a MAPD does not increase the cost to Medicare. Again, Medicare pays a FIXED amount to the private carriers each month for the MAPD's.

 

[nismaratwork]

BTW - please also note MEDICARE ADVANTAGE plans pay INSTEAD of Medicare - excessive cost in a MAPD does not increase the cost to Medicare. Again, Medicare pays a FIXED amount to the private carriers each month for the MAPD's.

OK... how the hell are elderly and sick people supposed to figure out ANY of this? I'm catching up, but I'm healthy and interested and I still find it painful to read through. When you add these twists and turns, why the hell is Medic.* considered a liberal "gift" to anyone?! Bankrupting ourselves while turning healthcare into something we need CPAa to slog through ist nicht KOSHER!

 

[ParticleGrl]

Are you suggesting these are estimates - rather than hard data? (my bold)

Please review the link above, for full information on methodology. The way to estimate fraud and improper payment rates is by careful auditing of a representative pool of beneficiaries, and extrapolation of those results to the whole.

Does anyone know what CMS means when they categorize something "an improper payment"?

It includes legitimate accounting mistakes and fraud, again see the link above. Its also worth noting that dropping the improper payment numbers to 0 won't recover the full amount. i.e. if a doctor erroneously receives $2000 instead of $1000, its an improper payment of $2000. However, only $1000 is recoverable.

please also note MEDICARE ADVANTAGE plans pay INSTEAD of Medicare - excessive cost in a MAPD does not increase the cost to Medicare.

The fixed payment from medicare for advantage plans is risk adjusted. Private companies get more money from medicare for sicker people- more cost on the private side will eventually lead to more cost on the public side.

 

[WhoWee]

I'm going to throw some gasoline on this fire:

https://www.humana-medicare.com/Plans/compare/details.aspx

"Physician and Hospital Costs:

Explains details for Physician and Hospital Costs Primary Care Physician: Specialist: Hospitalization:


$0.00 Copay per visit $0.00 Copay per visit $0.00 per admission

Amounts apply after any applicable deductible.


--------------------------------------------------------------------------------

Outpatient Mental Health Care
General
Information for Outpatient Mental Health CareAuthorization rules may apply.
In-Network
Benefits for Outpatient Mental Health Care$0 copayment for each Medicare-covered individual or group therapy visit.
Outpatient Services/Surgery
General
Information for Outpatient Services/SurgeryAuthorization rules may apply.
In-Network
Benefits for Outpatient Services/Surgery$0 copayment for each Medicare-covered ambulatory surgical center visit.
$0 copayment for each Medicare-covered outpatient hospital facility visit.
Ambulance Services
General
Information for Ambulance ServicesAuthorization rules may apply.
In-Network
Benefits for Ambulance Services$0 copayment for Medicare-covered ambulance benefits.
Emergency Care
General
Information for Emergency Care$35 copayment for Medicare-covered emergency room visits.Worldwide coverage.If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the emergency room visit
Outpatient Rehabilitation Services
General
Information for Outpatient Rehabilitation ServicesAuthorization rules may apply.
In-Network
Benefits for Outpatient Rehabilitation Services$0 copayment for Medicare-covered Occupational Therapy visits.
$0 copayment for Medicare-covered Physical and/or Speech and Langauge Therapy visits.
$0 copayment for Medicare-covered Cardiac Rehab services.
Durable Medical Equipment
General
Information for Durable Medical EquipmentAuthorization rules may apply.
In-Network
Benefits for Durable Medical Equipment$0 copayment for Medicare-covered items.
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies
General
Information for Diabetes Self-Monitoring Training, Nutrition Therapy, and SuppliesAuthorization rules may apply.
In-Network
Benefits for Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies$0 copayment for Diabetes self-monitoring training.
$0 copayment for Nutrition Therapy for Diabetes.
$0 copayment for Diabetes supplies.
Colorectal Screening Exams
In-Network
Benefits for Colorectal Screening Exams$0 copayment for Medicare-covered colorectal screenings.
Immunizations
In-Network
Benefits for Immunizations$0 copayment for Flu and Pneumonia vaccines.
No referral needed for Flu and pneumonia vaccines.
$0 copayment for Hepatitis B vaccine.
Mammograms (Annual Screening)
In-Network
Benefits for Mammograms (Annual Screening)$0 copayment for Medicare-covered screening mammograms.
Inpatient Hospital Care
In-Network
Benefits for Inpatient Hospital CareNo limit to the number of days covered by the plan each benefit period.
$0 copaymentExcept in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.
Skilled Nursing Facility (SNF)
General
Information for Skilled Nursing Facility (SNF)Authorization rules may apply.
In-Network
Benefits for Skilled Nursing Facility (SNF)Plan covers up to 100 days each benefit period
No prior hospital stay is required.
$0 copayment for SNF services
Home Health Care
General
Information for Home Health CareAuthorization rules may apply.
In-Network
Benefits for Home Health Care$0 copayment for each Medicare-covered home health visit.
Chiropractic Services
In-Network
Benefits for Chiropractic Services$0 copayment for each Medicare-covered visit.Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers."




This Medicare Advantage Plan is for Medicare beneficiaries in Puerto Rico.
This is the link to the plans detailed Summary of Benefits - please review.

https://www.humana-medicare.com/BenefitSummary/2011PDFs/H4007012SBOSB11.pdf

 

[nismaratwork]

Chiropractic with HOME HEALTH!

Unless I'm missing details here, that list doesn't seem reasonable for the government to provide, and I do believe in the idea of the dreaded, "public option". I'm not for the public "magic" option though... holy <censored> mother of <worse> <incompressible swearing>.

What genius put that together... oh right... committees. "A cul-de-sac down which ideas are lured and then quietly strangled." (John A. Lincoln)

 

[WhoWee]

Chiropractic with HOME HEALTH!

Unless I'm missing details here, that list doesn't seem reasonable for the government to provide, and I do believe in the idea of the dreaded, "public option". I'm not for the public "magic" option though... holy <censored> mother of <worse> <incompressible swearing>.

What genius put that together... oh right... committees. "A cul-de-sac down which ideas are lured and then quietly strangled." (John A. Lincoln)

The benefits in Puerto Rico are quite generous, the Miami-Dade county plans and some of the Katrina-impacted areas in LA are also quite favorable.

My point is that Medicare pays a fixed premium to this carrier. The costs associated with use of the benefits are paid by the insurance company.

 

[nismaratwork]

The benefits in Puerto Rico are quite generous, the Miami-Dade county plans and some of the Katrina-impacted areas in LA are also quite favorable.

My point is that Medicare pays a fixed premium to this carrier. The costs associated with use of the benefits are paid by the insurance company.

I see another problem there... Miama-Dade is "pill central"... coincidence?

 

[Al68]

...When you add these twists and turns, why the hell is Medic.* considered a liberal "gift" to anyone?! Bankrupting ourselves while turning healthcare into something we need CPAa to slog through ist nicht KOSHER!

I can answer that one. Making politically advantageous "entitlements," as well as the tax code, too complicated to understand allows power hungry politicians to deceive people about them, and any potential changes to them, in order to gain political power. Sounds cynical, I know.

Personally, I think congress should repeal the entire U.S. code, effective after a year, and adopt a policy that no law can pass that can't be read aloud during session. Then they can re-enact whatever portion of the U.S. code they think is important enough, or they can simplify enough, to read aloud, or allow exceptions only with a 3/4 vote in both houses.

And laws that cannot be reasonably understood by those they apply to should be prohibited with no exception. As many times as I've heard "ignorance of the law is no excuse", how is ignorance of the law optional, given the law? The laws are purposely designed to make ignorance of them mandatory, which effectively gives government unlimited power to prosecute people at will, despite the fact that there is no reasonable reason to expect them to know what is or isn't illegal in many cases.

 

[nismaratwork]

I can answer that one. Making politically advantageous "entitlements," as well as the tax code, too complicated to understand allows power hungry politicians to deceive people about them, and any potential changes to them, in order to gain political power. Sounds cynical, I know.

No... that sounds just about right based on observation and human nature.

Personally, I think congress should repeal the entire U.S. code, effective after a year, and adopt a policy that no law can pass that can't be read aloud during session. Then they can re-enact whatever portion of the U.S. code they think is important enough, or they can simplify enough, to read aloud, or allow exceptions only with a 3/4 vote in both houses.

And laws that cannot be reasonably understood by those they apply to should be prohibited with no exception. As many times as I've heard "ignorance of the law is no excuse", how is ignorance of the law optional, given the law? The laws are purposely designed to make ignorance of them mandatory, which effectively gives government unlimited power to prosecute people at will, despite the fact that there is no reasonable reason to expect them to know what is or isn't illegal in many cases.

This is where I'm less effective... you seem to be adressing elements of the problem, but how to make it happen?

 

[WhoWee]

The solution to the healthcare issue is simple. Use a proven method to solve the problem - here's one:

http://teacher.pas.rochester.edu/phy_labs/appendixe/appendixe.html

 

[nismaratwork]

The solution to the healthcare issue is simple. Use a proven method to solve the problem - here's one:

http://teacher.pas.rochester.edu/phy_labs/appendixe/appendixe.html

Ah yes... and yet so hard to apply in politics. You try, and suddenly you're a "technocrat", or one of O'Reilly's "pinheads". How can the scientific method be implemented when the culture of at least one party is essentially anti-intellectual when they sell to the south/mid-west?

 

[ParticleGrl]

Unless I'm missing details here, that list doesn't seem reasonable for the government to provide, and I do believe in the idea of the dreaded, "public option".

First, why not? The private company thinks it can turn a profit on the spread between what medicare will pay them and what services the beneficiary will actually use.

Second, and this is important- the same thing that is driving medicare costs up is ALSO driving up private costs. The data shown earlier actually demonstrates that private costs are going up FASTER than medicare costs. Its important to realize that we don't simply have a medicare problem, we have a HEALTH CARE problem.

And, we aren't alone, many countries are feeling the strain of rapidly escalating costs.

The solution to the healthcare issue is simple. Use a proven method to solve the problem - here's one:

http://teacher.pas.rochester.edu/phy_labs/appendixe/appendixe.html

I could not agree more. Luckily this is built right into the new law. The creation of large data sets on which to perform evidence based analyses will allow for the identification of effective treatments. The problem with medicare is the same as the problem with healthcare- the costs are growing too rapidly to be sustainable. Hopefully, scientifically identifying effective treatments will turn this around.

My point is that Medicare pays a fixed premium to this carrier. The costs associated with use of the benefits are paid by the insurance company.

Its worth noting, of course, that the private carrier is turning a profit with this type of plan. I also don't understand what your point is with this plan? Some medicare advantage plans pay out to much? Some private companies create lavish plans in order to extract more medicare dollars? Puerto Rico has a different risk analysis?

 

[Al68]

How can the scientific method be implemented when the culture of at least one party is essentially anti-intellectual when they sell to the south/mid-west?

Just the south/midwest? How about the whole nation? The messages of the Democratic Party are consistently and specifically tailored for constituents who are ignorant about the issues, in every state.

 

[WhoWee]

Its worth noting, of course, that the private carrier is turning a profit with this type of plan. I also don't understand what your point is with this plan? Some medicare advantage plans pay out to much? Some private companies create lavish plans in order to extract more medicare dollars? Puerto Rico has a different risk analysis?

Every Medicare Advantage plan must address the same coverage issues as explained in the Summary of Benefits shown above. The plans must be submitted and approved by the CMS/Medicare. To claim the companies "create lavish plans in order to extract more medicare dollars" - please be more specific. How much more does Medicare pay for this very generous plan in Puerto Rico?

Again, the national average cost to Medicare for a Medicare Advantage (Part C) plan approximates $10,000 per year - this includes the plan shown.

A "lavish" plan that has a $0 deductible and $0 co-pay for a hospital stay and doctor visits is clearly going to cost the insurance carrier more money to service.

 

[ParticleGrl]

To claim the companies "create lavish plans in order to extract more medicare dollars" - please be more specific. How much more does Medicare pay for this very generous plan in Puerto Rico?

No doubt, this plan gets more than the national average, as its riskier to the insurance company. But I didn't actually make the claim, I asked you- what is your point? This plan exists, what conclusions am I supposed to draw from it?

 

[nismaratwork]

Just the south/midwest? How about the whole nation? The messages of the Democratic Party are consistently and specifically tailored for constituents who are ignorant about the issues, in every state.

Yes, but ignorance does have a regional componant.