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From the Harvard Business Review:
https://hbr.org/cover-story/2019/03/how-employers-are-fixing...

Much is at stake: Various actors in the health care ecosystem, some large insurers and providers among them, benefit from an arrangement that layers on administrative costs and rewards volume, not value. Yet business as usual is unsustainable for those absorbing the costs and experiencing the uneven quality of care. Pioneering employers and providers are in a position to upend the status quo and change expectations about what affordable, quality care can and should be. What follows is an account of our experience with one important effort, among several being tried, to find a better way.

Walmart and other innovative companies, including Lowe’s, McKesson, GE, and Boeing, are disrupting how employers pay for care by taking insurers out of the equation and contracting directly with leading health systems.

</snip>


Eliminate the 20% insurer's skim, reduce costs. It's just arithmetic.

intercst
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Eliminate the 20% insurer's skim, reduce costs. It's just arithmetic.

intercst


Yes but the workers are still chained to the machine. It's inching towards the old "Company Store" model. Altho I guess the current system is pretty much that only with the middle-person.
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Eliminate the 20% insurer's skim, reduce costs. It's just arithmetic.

intercst
--------------------------
Yes but the workers are still chained to the machine. It's inching towards the old "Company Store" model. Altho I guess the current system is pretty much that only with the middle-person.


=========================
Exactly. Which is why the obvious solution is a single-payer or Medicare For All solution. Guaranteed portability, the same plan no matter where you work. It's what every other civilized country does. Why can't more Americans realize that?

Bill
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AS long as I can remember, major companies like GE 'self insured' and only hired others to manage all the paperwork.

Same deal at MCI/WCOM......while I was there......


t.
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Which is why the obvious solution is a single-payer or Medicare For All solution


I suppose so... if you lack imagination.

Heaven forbid we should imagine a world of direct pay subscription primary care with a small monthly fee for unlimited visits, no copay at time of visit and consumables/testing/services at wholesale. And major medical paid costs negotiated on your behalf by your primary care doc as part of that service.

But the actually requires no imagination. It's being done.

https://www.youtube.com/watch?v=bGZaRnC1wNg
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And major medical paid costs negotiated on your behalf by your primary care doc as part of that service.

I’d rather my doc just spend his time doctoring, not negotiating.
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telegraph analyzes,

AS long as I can remember, major companies like GE 'self insured' and only hired others to manage all the paperwork.

</snip>


In recent years, large employers have also relied on insurers to manage the network of providers (e.g, doctors, hospitals, labs ,x-rays, etc. as well as drug costs.) Employers have found that they can't a trust a for-profit insurer to get the best deal from a provider if the insurer can cut a side deal to line his own pocket (e.g., the insurer's "claw back" on drug costs when the drug is cheaper than your co-pay.)

I take three cheap generic drugs. If I pay cash at Costco or Walmart, a year's supply for the three costs less than $300. If I use my insurance, they charge me $800 for the same meds.

Cutting a dishonest insurer and fraudulent Pharmacy Benefit Manager out of the equation is going to save Big Business billions.

intercst
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NozRydr writes,

Heaven forbid we should imagine a world of direct pay subscription primary care with a small monthly fee for unlimited visits, no copay at time of visit and consumables/testing/services at wholesale. And major medical paid costs negotiated on your behalf by your primary care doc as part of that service.

</snip>


You realize that's a complete croc, right? Your primary care physician has no market power to demand a price concession from a large hospital corporation. You need a large employer or a large Gov't plan free to negotiate prices to do that.

intercst
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And major medical paid costs negotiated on your behalf by your primary care doc as part of that service.

I’d rather my doc just spend his time doctoring, not negotiating.



I know it's a bit of a listen but that Doc discussing his business and that aspect of it -- it all makes sense. They act as your healthcare advocate when going outside their office/practice capabilities. As a subscriber they watch over all your medical care stem to stern (or that which you choose to involve them in).

Pick the quality service and most of that negotiation has already been done and is part of established pricing agreements they have got on behalf of all their patients. And of course much of that is done by an office staff member -- not the docs.
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I know it's a bit of a listen but that Doc discussing his business and that aspect of it -- it all makes sense. They act as your healthcare advocate when going outside their office/practice capabilities. As a subscriber they watch over all your medical care stem to stern (or that which you choose to involve them in).

Pick the quality service and most of that negotiation has already been done and is part of established pricing agreements they have got on behalf of all their patients. And of course much of that is done by an office staff member -- not the docs.


This completely ignores economies of scale. Unless the doctor is part of a huge network, he’s got absolutely no pull to negotiate for anything other than the most common treatments. It may actually work OK if your doc sends you to a lab for some tests, or maybe to the local MRI office, or even a surgeon to do a routine appendectomy.

But what happens if you’re like my friend who has cancer and she’s exhausted all of her treatment options locally? She treated in North Carolina at Duke for a while, and now she’s treating at MD Anderson in Texas. How does a local GP in TN negotiate with those providers?

Or what happens when the patient has a car accident in a different state? How does the local doc deal with that? Even if he’s part of a large network in, say, Massachusetts, it’s not going to help if the patient is in Oregon and needs surgery.
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If you like the personal care you get at thr Post Office or the VA hospital, you will love Medicare for all.
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If you like the personal care you get at thr Post Office or the VA hospital, you will love Medicare for all.

I'm not a veteran, so I've never personally been treated at the VA. I have talked to many people who were quite happy with their treatment at VA facilities. Also talked to many who weren't.

I have been to the Post Office pretty regularly. I usually get fine service there. And when I watch their interaction with other customers while waiting in line, I usually see exceptional amounts of patience demonstrated.

But why would I compare those to Medicare? If you want to guess how Medicare for all would work, take a look at how Medicare currently works. Once again, I do not have personal experience with Medicare (too young yet), but I do talk to a lot of people who ARE on Medicare. In general, most people I talk to are reasonably happy.

--Peter
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If you like the personal care you get at thr Post Office or the VA hospital, you will love Medicare for all.
=============================
I'm on Medicare Advantage (Part C) now. It's great. Still using the same doctors as before I retired; except my wife had to find a new hand specialist.

Bill
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....except my wife had to find a new hand specialist.

Bill


And so, my friends, the Communists have won. In our once free country, no one, but no one had to find a new hand specialist.
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And so, my friends, the Communists have won. In our once free country, no one, but no one had to find a new hand specialist.

</snip>


I understand that they're going to investigate Trump's "hand specialist" down in Florida.

Call For Investigation Into Pro-Trump Former Owner Of Massage Parlors
https://www.npr.org/2019/03/18/704557685/democrats-call-for-...

</snip>


intercst
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I understand that they're going to investigate Trump's "hand specialist" down in Florida.


I’m pretty sure it wasn’t hands that were her specialty....
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And so, my friends, the Communists have won. In our once free country, no one, but no one had to find a new hand specialist.

In actuality, the only reason that the OP's wife had to find a new hand specialist was if she wanted it to be covered by Medicare. She was certainly still free to stay with her hand specialist, but she would have had to pay for those services herself, and would not have had any insurance coverage.

This is no different that someone on a PPO plan, for instance, who pays a different amount if they go out of network. Or someone on an HMO plan who pays the whole thing if they choose to go to a doctor not in the HMO network.
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I'm on Medicare Advantage (Part C) now. It's great. Still using the same doctors as before I retired; except my wife had to find a new hand specialist.

In beginning to look at choices for Medicare, it wouldn't surprise me that people choose advantage plans because they look cheap which may be true if you don't travel at all. They seem very limiting.
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And so, my friends, the Communists have won. In our once free country, no one, but no one had to find a new hand specialist.

Sure they did. Most people were/are at the mercy of what insurance their employer chooses for them. If the employer changes insurance--which is often at least partially based on factors such as cost and not quality of care and convenience to the employees--the employees may find themselves needing to find new doctors, unless they can afford to pay full price out of pocket. I've been working for the same company for 27 years and we have changed insurance carriers at least 5 times. Every time it has resulted in painful changes for some employees, like changes in doctors (particularly mental health) or prescription coverage.
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Where this guy works 1500 lives may give him some negotiating power and the model is good for what it does.

OTOH I worked in the medical field for centuries and 99% of the MDs I knew would rather walk on hot coals than negotiate $$$ with insurance companies and other providers.

Also, these patients must apparently all still have insurance. Catastrophic might be enough. If not the 5 patients in the practice with needs for cardiac surgery or needs for chemo therapy would probably sink the practice, or bankrupt those patients.

I wish I'd been in the audience at the Q & A. I would have had a ton of questions.
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Edith of course you're right in some part of the spectrum of care. But for the lion's share of what most of us need from doc's it looks like a win IMHO.

Even in that part of the spectrum of care outside the realm of negotiation there is significant value in having a knowledgeable shopper with deep medical knowledge coordinating the care on your behalf.


Where this guy works 1500 lives may give him some negotiating power and the model is good for what it does.

Jakalant,
Yes, apparently. And this seems to be a growing trend with other doc's in other parts of the country following suit.

Further, a doc, or group of docs, in the know can be the difference between you having confidence in quality of care to safe money and travel to a cash only surgical center or go south of the border or abroad as a medical "tourist". And the savings can be tremendous. I was south of the border yesterday saving a couple thousand dollars on some major dental work for my son. And got better care than from the Dentist and oral surgeon we decided to fire up after foul ups here in SoCal.

https://surgerycenterok.com/

And there's still high deductible insurance or medical costsharing programs (Medishare et al) to subscribe to for covering the major medical you don't get under this sort of system.
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And so, my friends, the Communists have won. In our once free country, no one, but no one had to find a new hand specialist.
---------------------
Sure they did. Most people were/are at the mercy of what insurance their employer chooses for them. If the employer changes insurance--which is often at least partially based on factors such as cost and not quality of care and convenience to the employees--the employees may find themselves needing to find new doctors, unless they can afford to pay full price out of pocket. I've been working for the same company for 27 years and we have changed insurance carriers at least 5 times. Every time it has resulted in painful changes for some employees, like changes in doctors (particularly mental health) or prescription coverage.


In case anyone was wondering, the above, was my point.

Why is it "the free market" and "personal choice of the doctor or the insurance company" when the private sector causes these perturbations but communism and the government stealing your freedom when it happens from a government program that actually helps more than it hurts? This stuff happens all the time and always has.
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Edith of course you're right in some part of the spectrum of care. But for the lion's share of what most of us need from doc's it looks like a win IMHO.


Hm. Maybe. I work in insurance and I know for a fact that everyone absolutely hates insurance until they need it, and then they’re usually really happy they have it.

To me, the whole point of health insurance is to insure for those big scary things, which as I get older, I see happening more and more often to friends and family. Friend’s bone cancer, several friends’ breast cancer, dad’s kidney cancer, friend’s kidney cancer, mom’s Parkinson’s, mom’s weird blood disease with complications last year, etc etc etc.

It’s not the routine stuff that a local doc might be my advocate on that really concerns me—it’s the other big scary stuff that he can’t.


Even in that part of the spectrum of care outside the realm of negotiation there is significant value in having a knowledgeable shopper with deep medical knowledge coordinating the care on your behalf.


But you said yourself that it’s not REALLY the doctor doing this, but his staff. Given my experience with office staff dealing with insurance stuff, let’s just say I’m not confident.
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....except my wife had to find a new hand specialist.

Bill
--------------------
And so, my friends, the Communists have won. In our once free country, no one, but no one had to find a new hand specialist.

====================
Au contraire. This is no different that any other PPO plan you can be stuck with at work. In fact we are on Medicare Advantage (Part C), which is an alternative to a Medicare supplement plan. We selected a plan from Aetna. It is a PPO arrangement, and our doctors were almost all in it. We also started using a different pharmacy, because while our previous pharmacy was in-network, it was not a "preferred" pharmacy, so the co-pays would have been higher. Our plan includes Part D, so our usual monthly drugs (Lipitor and Lisinipril-generic) are free.

I'd say "the Communists" at Aetna Insurance are doing pretty well.

Bill
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re: It’s not the routine stuff that a local doc might be my advocate on that really concerns me—it’s the other big scary stuff that he can’t.



For that there are options other than traditional insurance. e.g. Medical cost sharing plans. Some of those have been around pretty long time now and seem to be of good repute.


re: But you said yourself that it’s not REALLY the doctor doing this,

Actually what I said was not nearly so narrow as that. "And of course much of that is done by an office staff member -- not the docs."
You attempt and fail to make much less of the significance of having a dedicated medical office shopping and advocating for you.


I'll go back to the point I posted to contest and to show the failure of imagination that leads people to think the only way out is the Post Office and DMV, err.... Single payer healthcare.

My point is there are options to traditional insurance 3rd party payer and Gov Single payer emerging. More and more people I know are taking advantage of them. Medical cost sharing in particular is on the rise among my cohort. Led by some who have been relying on it as we all watched on for many years (decades) now. And many of us are now shopping for a direct pay subscription primary care doc local to us.
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My point is there are options to traditional insurance 3rd party payer and Gov Single payer emerging. More and more people I know are taking advantage of them. Medical cost sharing in particular is on the rise among my cohort. Led by some who have been relying on it as we all watched on for many years (decades) now. And many of us are now shopping for a direct pay subscription primary care doc local to us.


Don’t get me wrong. It may work out ok for you, and if so, go with God and all that. It’s certainly nice to have the privilege of doing that, if you 1) can afford it and 2) live in a geographic area where it’s possible and 3) you don’t have known medical issues that would make it a problem.

But again, as someone who works in this general area, I can definitely see the pitfalls for individuals who may have catastrophic medical issues, and I also think it’s maybe not that great for society as a whole to have yet more stratification. More and more docs will go to the elite concierge model, leaving those who can’t afford it to have fewer and fewer options for healthcare.
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"For that there are options other than traditional insurance. e.g. Medical cost sharing plans."

And what is a medical cost sharing plan other than insurance without the hoi-polloi?

Insurance provides a vehicle for cost sharing and funds it with premiums.

I suspect that medical cost sharing plans simply screen out the high-cost patients (based on current health).

What do we do with everyone else? Aha - medicare for all (or better would be the government's own insurance coverage for all).
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Re:Don’t get me wrong. It may work out ok for you, and if so, go with God and all that. It’s certainly nice to have the privilege of doing that, if you 1) can afford it and 2) live in a geographic area where it’s possible and 3) you don’t have known medical issues that would make it a problem.

Thanks for that (reply and tone).

Continuing in the vein of using our imagination beyond single payer for all being the only hope.


Could this be covered by tax credit or voucher for those who couldn't afford it otherwise?

If I recollect, some (many?) pre-existing conditions are ok on (some) medishare type programs.

What about publically funding high risk pool options for the corner cases in the population?


Would all this serve to improve costs, efficiency, access? Would dealing (mostly) in a direct pay, non-3rd party payer generate more favorable market signals for both supplier and customer?

Would this improvfe the climate that is burning out Drs? Would this favorably incentivize and reinvigorate morale of Dr's as discussed in that direct pay model Youtube video?
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And what is a medical cost sharing plan other than insurance without the hoi-polloi?


That's your impression (or prejudice). Is that actually the reality?

I guess it depends on the definition of Hoi-polloi.


Not sure if the folks I know who are rely on medical cost sharing plans would be consider the hoi-polloi in anyone's book in the States. I'm talking about a lot of single income families or couples in my extended circles living on tight budgets, often with broods of young children.

If by hoi-polloi one means anyone with difficult expensive pre-existing conditions, then can't we imagine public funded high risk pools for those corner cases?

If by hol-polloi one means anyone not living on public assistance (another corner case -- though larger perhaps) then I would respectfully submit that a tax credit or voucher system to pay direct to a subscription primary care and a cost sharing network is an option. How is that not going to be lower cost and better quality care than those folks get currently using Urgent Care and Emergency Rooms for all their care?

Again, all the above imagining as an option to single payer as the only solution
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Continuing in the vein of using our imagination beyond single payer for all being the only hope.

As you look towards retirement (since this is the Retirement Investing board), I would hope that you are aware that those eligible for Medicare must use Medicare A & B as their primary insurance, and Medishare only pays based on what Medicare doesn't pay.

If I recollect, some (many?) pre-existing conditions are ok on (some) medishare type programs.

Only with significant limitations. From the Medi-Share website https://www.medishare.com/blog/how-does-medi-share-work-with...

Although Medi-Share was designed primarily for new and unexpected illnesses or injuries, some pre-existing conditions may be eligible for sharing.

Medical bills for treatment of a pre-existing condition (a condition that existed prior to membership) are eligible for sharing as follows:

Up to $100,000 per Member per calendar year IF:
- The condition has gone 36 consecutive months without signs, symptoms, treatment or medication OR
- The Member has shared faithfully for 36 consecutive months (has been a member for 3 years)
Up to $500,000 per Member per calendar year IF:
- The condition has gone 60 consecutive months without signs, symptoms, treatment or medication OR
- The Member has shared faithfully for 60 consecutive months (has been a member for 5 years)


AJ
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Could this be covered by tax credit

Tax credits are useless to people who don't have enough income to pay taxes.

--Peter
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ptheland writes,

<<Could this be covered by tax credit >>

Tax credits are useless to people who don't have enough income to pay taxes.


</snip>



Not if you make them "refundable tax credits", as they've done with Obamacare. People who pay little or no taxes get the money anyway as a reduction in their monthly insurance premium.


intercst
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I'm on Medicare Advantage (Part C) now. It's great. Still using the same doctors as before I retired...

The reason Medicare is such a great deal is that us people on Medicare is that we only pay 17% of the total cost of the premium. Taxpayers (that is, people who are NOT on Medicare) pay the other 83%. This only works if there is a pool of people who subsidize the people on Medicare.

Problem with "Medicare For All" is that since everybody is in the pool, there is nobody outside the pool to pay the subsidy.
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Problem with "Medicare For All" is that since everybody is in the pool, there is nobody outside the pool to pay the subsidy.

Yes. Old People will never go for that. They've never met a child or grandchild they'd worry about throwing under the bus.
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As just a framework.....

First things first...separate the insurance from the front-end 'routine' insurance industry cash management, which is what makes health 'insurance' so expensive.

For cash management, credit $XXX/person/month into a locked HSA, whose contents can be used by a card (like a credit card) for qualifying medical expenses. Account balance may be built up to $XXXX level and are otherwise non-transferrable, but once the cap is met, contributions would no longer be made to the HSA until the balance is reduced by qualified expenses. Consumers may then spend this where ever they wish. $$ would come from an employer, SE Medical tax and direct tax deductible contribution by all others, which would be less (likely much less) than the employer/SE and individuals are currently paying the insurer in premiums and cost sharing. This would effectively remove the insurance industry from 'routine' medical services and replace it with market forces. The HC industry would probably love it as they'd no longer have to fight with insurers over claims, thus helping to drive down costs for services.

For true catastrophic insurance, through the NAIC (national non-profit insurance policy analysis provided to state insurance regulators), develop a standard model $5,000 or $10,000 deductible catastrophic policy that is guaranteed renewable and may be offered with lifetime caps. Require policies, like life insurance policies, to carry a one year (or some fixed period) contestability period after which the insurer may not contest a claim. These would closely resemble Medicare Supplemental (Medigap) policies. No deductibles and no copays (i.e. no cash management...just catastrophic coverage). Like Medigap policies, these may offer added bells and whistles, but must provide the basic bare-bone catastrophic coverage. Premiums would be tax deductible on Schedule 1 and they should be relatively inexpensive with medical underwriting.

This leaves pre-existings (high risk). These individuals would need coverage through high-risk pools managed by state governments.

Concurrently, laws governing medical malpractice must be re-written to require binding arbitration and limit to rarity punitive damages.

Just a course outline idea

BruceM
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(repeating same question from another board)

...rewards volume, not value...

And how do you determine value?

Doctor X/hospital Z only has 1% of there patients readmitted/bounce back after discharge, so they must be good. Meanwhile, Doctor A/Hospital C has a 10% bounce back rate, they must be horrible. But the first pair are treating highly motivated competitive athletes while the second pair is treating indigent, schizophrenic, alcoholics. Until you come up with an equitable way to compare apples and oranges, ratings are meaningless.

FWIW, my group has to report on 5 measures for each patient we have contact with to Medicare/Medicaid so the government can keep track if we are doing are job properly. Do these measures have any bearing on patient outcome? No. They are merely numbers that can be easily recorded, downloaded, and parsed to determine if we should be "punished" for reaching a success rate of 98% instead of 99.9%.

JLC
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And so, my friends, the Communists have won. In our once free country, no one, but no one had to find a new hand specialist/b>

In actuality, the only reason that the OP's wife had to find a new hand specialist was if she wanted it to be covered by Medicare.


There's something in the original statement that I believe just cannot be true, and this reply, while disagreeing with it, seems to reinforce that "something".

To wit: surely it does happen that hand specialists die, or retire, or choose to emigrate (or otherwise move far away from where you -- and other doctors who cure you -- reside), or to switch to a different profession or specialization.

In all of which cases, if your health makes you need a hand specialist, it follows that you need to find a new one: the previous one is just not available to you any more, no matter how free you are, and no matter what kind of coverage (or lack thereof) you're ready for.
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