No. of Recommendations: 8
Starting Monday night, CBS is airing a 3-part series on so-called "surprise medical bills" and price gouging.

Medical Price Roulette: CBS News investigates the lack of transparency in America's health care system
https://www.cbsnews.com/news/medical-price-roulette-cbs-news...

</snip>


intercst
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Meanwhile, the TV adverts from the dark money group saying all the hospitals would close if they aren't allowed to gouge patients by laying "out of network" traps, have stopped running here.

Steve
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Meanwhile, the TV adverts from the dark money group saying all the hospitals would close if they aren't allowed to gouge patients by laying "out of network" traps, have stopped running here.

Steve


Canuck election has a lot of healthcare issues surfacing as well. Ontario's still fairly new Cons government has been cutting services in specific areas that the majority don't rely on. Autistic kids, mental health and overdose prevention sites to name a few. They have also cut staffing levels in the industry. They don't call it "Cuts" but rather "restructuring".

https://www.ontariohealthcoalition.ca/index.php/category/key...

Some provinces have a shortage of Primary Care (Family Practice) doctors which of course just dumps the load on overworked ERs. Some of this is actual shortage but a lot of docs have gone into the much lighter work load "Walk-In" business.

While the cities are fairly well served smaller towns with declining populations often have to drive to the city or hope they don't get sick on weekends.

Much more but wife has a dental appointment and I'm the driver.


Tim
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Ontario's still fairly new Cons government has been cutting services in specific areas that the majority don't rely on.

That's the strategy that has been used so effectively in the exceptional nation for the last 40 years: use dogwhistle rhetoric to isolate and demonize a minority, to justify withdrawal of government programs they benefit from.

Face it. The USisiation of Canada is inevitable, as Canada has too much natural resource wealth to escape forever.

Steve
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The USisiation of Canada is inevitable, as Canada has too much natural resource wealth to escape forever.

Steve


Hmmmm since you mention it, just watched a guy on CBC explain how our National PharmaCare will work assuming the Liberals win the election. Basically it will work just like doctors and hospitals do as in 'Free' at point of service. Only drugs with scientific merit will be covered and there will be a national list rather than allowing differences between provinces.

In theory the provinces each run their Healthcare system but of course the Feds chip in a significant amount of the cost which gives them some say in standards expected.

https://www.cbc.ca/news/politics/liberal-health-care-pharmac...

Leader Justin Trudeau commits to $6B over 4 years as 'down payment' to improve system

Kathleen Harris · CBC News · Posted: Sep 23, 2019 9:08 AM ET | Last Updated: 3 hours ago

...

Promising to take the "critical next steps" toward a national pharmacare program, party background materials released to journalists say the Liberals are seeking a mandate to design and implement such a program and would negotiate with the provinces and territories to improve health care outcomes.

Holding a campaign event in Hamilton, Ont., Liberal Leader Justin Trudeau said Liberals "believe in" universal pharmacare as laid out by the advisory council report commissioned by his government. But he said it's not a decision for the federal government alone; it requires partnerships and negotiations across provinces and territories.



https://www.cbc.ca/news/politics/pharmacare-hoskins-recommen...

Politics

Advisory council calls for $15B universal, single-payer pharmacare plan

...

Dr. Eric Hoskins says national program would save $5B annually on drug costs
Kathleen Harris · CBC News · Posted: Jun 12, 2019 9:19 AM ET

An advisory council appointed by the Liberal government is recommending the establishment of a universal, single-payer public pharmacare system.

The council's 171-page report, released Wednesday, calls for the creation of a new drug agency that would draft a national list of prescription medicines that would be covered by the taxpayer, beginning with an initial list of common and essential drugs, by Jan. 1, 2022.

The council recommends that initial list be expanded to a comprehensive plan by Jan. 2, 2027. When fully implemented, the total cost would be $15 billion a year.



Perhaps the Canadianization of USia is inevitable? Nah, wouldn't work, would take decades just to get through the Metric system. }};-D

Tim
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tim443 writes,

Hmmmm since you mention it, just watched a guy on CBC explain how our National PharmaCare will work assuming the Liberals win the election. Basically it will work just like doctors and hospitals do as in 'Free' at point of service. Only drugs with scientific merit will be covered and there will be a national list rather than allowing differences between provinces.

</snip>


That's astonishing. Designing a system based on arithmetic and science for the benefit of the governed.

It will be interesting to compare the patient cost of the Canadian system with the "job creator" model used in the US, 5 or 10 years down the road.

intercst
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It will be interesting to compare the patient cost of the Canadian system with the "job creator" model used in the US, 5 or 10 years down the road.

intercst



How about January of this year? We have had Pharmacare for seniors and those on social assistance for decades in many (all?) of our provinces for decades, we know how it works. Now we just have to expand it nationally.

Tim

https://www.jhsph.edu/news/news-releases/2019/us-health-care...

January 7, 2019

U.S. Health Care Spending Highest Among Developed Countries
AMERICANS ON AVERAGE CONTINUE TO SPEND MUCH MORE FOR HEALTH CARE—WHILE GETTING LESS CARE—THAN PEOPLE IN OTHER DEVELOPED COUNTRIES

...

The paper finds that the U.S. remains an outlier in terms of per capita health care spending, which was $9,892 in 2016. That amount was about 25 percent higher than second-place Switzerland’s $7,919. It was also 108 percent higher than Canada’s $4,753, and 145 percent higher than the Organization for Economic Cooperation and Development (OECD) median of $4,033. And it was more than double the $4,559 the U.S. spent per capita on health care in 2000—the year whose data the researchers analyzed for a 2003 study.

The researchers, along with the late Princeton health care economist Uwe Reinhardt, who died in 2017, came to the same conclusion in their well-known 2003 study, “It's the prices, stupid: ...
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That's astonishing. Designing a system based on arithmetic and science for the benefit of the governed.

Worst of all, it's socialistic

This piece ran on CBS "news" this evening. The guy had a herniated disc in his back, which, beside being very painful, the Doctors said threatened to permanently paralyze him and he needed immediate surgery.

He has medical insurance, from United Health, the largest for-profit health insurer in the US. UH decreed the surgery was neither an emergency, nor medically necessary, and refused to pay. The guy was stuck with $650,000 in bills.

After Frank Esposito started having back pain, an MRI revealed a bulge in his spine and he was told he needed surgery. The surgery was a success, but then the bills started coming in: over $650,000 in all.

https://www.cbsnews.com/video/how-am-i-gonna-pay-this-man-le...

Of course, so many providers are finding it so profitable to be "out of network" we may see a day when USians pay thousands of dollars a year for insurance that is worthless, because every provider is "out of network".

But that wouldn't be socialistic, so, apparently, that makes it OK.

Steve....got his flu shot today, courtesy of "big gummit" Medicare.
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Hmmm would have been free for a Canadian as long as he didn't insist on a private room, telephone and TV ... ambulance ride to the hospital could hit you for C$146.55 though free if you have supplemental insurance. Which I do and is why it was really stupid of me to drive myself to ER when I had the gangrenous gall bladder? }};-@

My wife's Brest Cancer operation cost us I think ~ $80 for parking if you include the 16 radiation treatments (the parking was half price due to multiple visits) ... oh and some OTC pain killers we picked up on the way home.

https://novascotia.ca/dhw/ehs/ambulance-fees.asp



https://www.cbsnews.com/news/back-surgery-saved-him-from-par...

By ANNA WERNER / WERNERA@CBSNEWS.COM CBS NEWS September 23, 2019, 6:31 AM

Back surgery saved him from paralysis. Then the bills arrived: over $650,000



But of course according to some people of a particular political persuasion we have death panels? }};-D


Tim <will the fun never stop>
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Back surgery saved him from paralysis. Then the bills arrived: over $650,000

Seems the obvious thing to do, in this case where the insurance company says the treatment was not necessary and it was not an emergency, and the Dr says it was necessary and an emergency, would be to let the providers and the insurance company litigate it. If it turns out that the Dr was wildly overtreating the patient, because it's profitable to do so, the bills are voided. If the Dr was right, the insurance company pays the bills at it's negotiated rate.

But no. Can't "burden" the job creator class like that. Much easier, and more profitable, for the insurance company to refuse to pay and the providers bill the patient at full price, rather than the discounted rate the insurance company would have paid.

Steve
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Seems the obvious thing to do, in this case where the insurance company says the treatment was not necessary and it was not an emergency, and the Dr says it was necessary and an emergency, would be to let the providers and the insurance company litigate it.

The Job Creators feel that a mid-level bureaucrat with no medical training and without examining the patient should be able to override your doctor's medical opinion.

For some reason, this seems to be an acceptable condition for many people.
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No. of Recommendations: 6
This piece ran on CBS "news" this evening. The guy had a herniated disc in his back, which, beside being very painful, the Doctors said threatened to permanently paralyze him and he needed immediate surgery.

He has medical insurance, from United Health, the largest for-profit health insurer in the US. UH decreed the surgery was neither an emergency, nor medically necessary, and refused to pay. The guy was stuck with $650,000 in bills.


The ye old use of fear to drive the patient toward unnecessary surgery. There is no evidence based science about herniated discs.
https://www.nytimes.com/2006/12/30/business/30spine.html
Spinal-fusion surgery is one of the most lucrative areas of medicine. An estimated half-million Americans had the operation this year, generating billions of dollars for hospitals and doctors.

But there have been serious questions about how much the surgery actually helps patients with back pain and whether surgeons’ generous fees might motivate them to overuse the procedure.

https://www.bjmp.org/content/back-pain-how-avoid-surgery
Treatment of low back pain remains a dilemma. In the USA more than 300 thousand back surgeries are performed each year. For about 10% to 39% patients, pain may continue or even get worse after back surgeries1.
With the MRI evidence of a disc herniation and nerve root compression, patients are more easily convinced surgery is their best and only option. However, the reliability of MRI as the evidence for surgical decision has been questioned. An early study found that in a group of asymptomatic volunteers at age of 60 years or older, about 57% had abnormal MRI findings including disc herniation and spinal stenosis4. Follow up studies have yielded similar results. Now it is widely accepted that degenerative disc disease, such as disc herniation is a common finding in asymptomatic adults. Even though at the age of 60 years or older, 57% or more may have abnormal MRI findings in the lumbar spine, however, only less than 20% of this group of people have chronic low back pain. A recent study also suggested a lack of correlation between imaging findings of spine degenerative change and back pain5. Simply, degenerative change in the lumbar spine, such as a herniated disc, is not necessary painful.
A herniated disc is not a sole indication for back surgery and up to 70% to 95% of patients may be pain free after 12 months without major intervention7
https://www.americanbackcenters.com/does-anyone-need-spine-s...
Depending on where you live in the country, you can run a 10-fold greater risk of being offered and accepting surgery for a regional back disorder than if you live in any other country. It’s open season on the American spine.

Nearly all this surgery is for low back pain. Spine surgeons have long felt beleaguered by critics such as me. After all, there have been a number of studies, mainly from Europe, that fail to generate an iota of evidence for any benefit from any form of spine surgery for regional low back pain. For workers’ compensation claimants, surgery is likely to leave you worse off.

If you are offered any form of surgery for regional low back pain, please ask for the evidence. Before you agree to the surgery, ask whether you are likely to do as well without it. To my way of thinking, if elective surgery for regional back pain were a pharmaceutical it wouldn’t be licensed.


https://www.rebuildyourback.com/herniated-disc/pain.php
a study published in the New England Journal of Medicine involving the use of Magnetic Resonance Imaging (MRI) to diagnose back pain. In this study researchers (who were intrigued by the findings of several other studies concerning herniated discs) selected 98 subjects who did not have back pain or any other back related symptoms and sent them to be evaluated by MRI scans. What makes this interesting is that the evaluators were not told that these people did not have back problems.

The results were pretty astounding and sent a shock wave through the medical community at that time. What they found was that 64 percent of the test subjects came back with MRIs that showed disc problems that normally would have marked them as prime candidates for surgery except, of course, for one little problem and that was that they did not have back problems at all!

Remember medicine is a business. Carpe diem!
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The ye old use of fear to drive the patient toward unnecessary surgery. There is no evidence based science about herniated discs.

Which is why I suggested the providers and the insurance company litigate the issue of the necessity for the surgery. But it is more profitable to just drop the bill on the patient. The insurance company avoids paying a claim, and the providers can charge full boat for everything, rather than accept the discounted rate the insurance company would have paid. Everyone wins, except the poor sod who had no idea if the Dr was feeding him a line, or not, but is stuck with the bills.

Steve
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The ye old use of fear to drive the patient toward unnecessary surgery. There is no evidence based science about herniated discs.

Which is why I suggested the providers and the insurance company litigate the issue of the necessity for the surgery. But it is more profitable to just drop the bill on the patient. The insurance company avoids paying a claim, and the providers can charge full boat for everything, rather than accept the discounted rate the insurance company would have paid. Everyone wins, except the poor sod who had no idea if the Dr was feeding him a line, or not, but is stuck with the bills.

Steve


I'm sure you remember the huge heart by pass fraud case in Redding California & Tenant Healthcare.
https://www.nytimes.com/2003/08/07/business/tenet-healthcare...
https://www.sfgate.com/health/article/Hospital-settles-with-...

There was a similar fraud involving heart pacemakers in my hometown.
https://www.abqjournal.com/458952/las-cruces-jury-hands-down...

A lot of retired folk in Las Cruces. A target rich environment for sleazy doctors.
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I'm sure you remember the huge heart by pass fraud case in Redding California & Tenant Healthcare.

Oh, yes. I was long Tenant. Management insisted it was "rogue underlings" in that one hospital. Turned out cheating Medicare was the core of Tenant's business model as, as soon as management said they had not cheated Medicare and they wouldn't do it anymore, earnings collapsed.

So, that is why I said litigate between the Doc and insurance company. The patient is least able to ascertain if the Doc is lying, or the insurance company is lying.

There was a huge medical fraud case in metro Detroit a few years ago. By patient's testimony, the guy was running a virtual torture chamber for his personal profit.

Farid Fata

... the admitted mastermind of one of the largest health care frauds in American history. He was the owner of Michigan Hematology-Oncology (MHO), one of the largest cancer practices in Michigan. He was arrested in 2013 on charges of prescribing chemotherapy to patients who were either perfectly healthy or whose condition did not warrant chemotherapy, then submitting $34 million in fraudulent charges to Medicare and private health insurance companies over a period of at least six years. He pleaded guilty in 2014 to charges of health care fraud, conspiring to pay and receive kickbacks, and money laundering. On July 10, 2015, he was sentenced to 45 years in federal prison.


https://en.wikipedia.org/wiki/Farid_Fata

Imagine being subjected to an aggressive course of chemo, when you don't have cancer at all, all for this guy's personal profit.

Then there was "The Scooter Store". Remember their TV ads promising a "free" granny scooter to people on Medicare? They had crooked Doctors lined up that would prescribe a scooter for anyone, whether they really needed it or not, with the company and the Dr making a profit on the deal.

The SCOOTER Store shutting down after federal scrutiny, CBS probe

https://www.cbsnews.com/news/the-scooter-store-shutting-down...

A touch of irony in the CBS news item: That city later sued The SCOOTER Store to get back more than $2.6 million in job-creation incentives awarded to the company.

As soon as The Scooter Store was shut down, another outfit sprang up promising free knee and back braces to people on Medicare. Same scam. They were shut down a year or two ago.

The insurance companies could serve as a restraint on knife-happy Doctors, but they haven't showered themselves with goodwill either as they look for *any* excuse to deny a claim, rather than looking more closely at whether the Doc is on the up and up.

Steve
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The Job Creators feel that a mid-level bureaucrat with no medical training and without examining the patient should be able to override your doctor's medical opinion.

For some reason, this seems to be an acceptable condition for many people.



Our doctors decide what is necessary but of course they get paid the going rate for the job. Generally the family doctor refers the patient to the specialist if it is beyond her field but of course an ER visit bypasses the family doc. If it is a valid emergency things get done really quickly (gangrenous gall bladder), if not then you go on the list (double hernia repair).

I was able to move several weeks up the list for the hernia repair by offering to get a drive to a less busy hospital 45 minutes away where my specialist also had operating privileges.

Tim
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<<The Job Creators feel that a mid-level bureaucrat with no medical training and without examining the patient should be able to override your doctor's medical opinion.

For some reason, this seems to be an acceptable condition for many people>>


Of course insurance companies do no such thing. Based on the evidence they merely decide if they are obligated to pay for proposed procedures in advance.

In Washington State, if an insurance company denies coverage for a procedure but the patient subsequently wins a lawsuit over the issue, the patient gets to collect three times the amount at issue.

But you aeem to be suggesting that it's reasonable for doctors to be able to spend the money of the insurance company without review. That's certainly not reasonable.



Seattle Pioneer
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SP analyzed,

Of course insurance companies do no such thing. Based on the evidence they merely decide if they are obligated to pay for proposed procedures in advance.

</snip>


You need to go back and review the original story. Patient goes to the ER in severe pain. MRI was done and surgeon was called. Patient was told if he didn't have immediate surgery he could be paralyzed if disk ruptured.

What is the layman supposed to do with that information? Call around and get 3 quotes from other hospitals and surgeons, and hope the disk doesn't rupture in the interim. And surely you know that few medical providers provide prices up front, and even if they do they don't honor them.

intercst
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"But you aeem to be suggesting that it's reasonable for doctors to be able to spend the money of the insurance company without review. That's certainly not reasonable."

It seems reasonable to me that the insurance company should trust the doctors they have chosen to partner with. Assuming there is some sort of vetting process - but if not, why not?

Obviously, periodic audits should be required - and revoking of the partnership when needed (and recovery litigation as needed).
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It seems reasonable to me that the insurance company should trust the doctors they have chosen to partner with. Assuming there is some sort of vetting process - but if not, why not?

Obviously, periodic audits should be required - and revoking of the partnership when needed (and recovery litigation as needed).


Vested interest?

Audits are actually pretty simple with single payer. If the computer notices a high incidence of billing on certain types of treatment from a family doc they send off letters to the patients involved.

Another issue some years back was doctors who were part of the system offering to jump the line for people willing to pay for the service. Since they were using public facilities and staff they were quickly told they could do one or the other ... not both. Since the vast majority of patients prefer to receive treatment on the public system the private idea died instantly as the docs didn't feel they could make a go of it if they had to pay for facilities and staff ... who would have thunk it?

I actually knew the head nurse at the Dartmouth General who busted their little side gig.

Tim
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It seems reasonable to me that the insurance company should trust the doctors they have chosen to partner with. Assuming there is some sort of vetting process - but if not, why not?

Probably no vetting process for doctors, because both the insurance company and the doctors always have the fallback of handing the bill to the patient.

I really hope the doctors on this board weigh in on this issue: what is a patient to do when the Doc says it's an emergency and the patient needs expensive treatment immediately, and the insurance company says the claim is denied because the case was not an emergency and surgery not necessary? If the patient tries to sue for recovery, the insurance company and the Doc just point fingers at eachother, and they both have more resources to fight the suit than the patient has.

And how much does the "malpractice" debate tie into this? Before Dr Fata went to the slammer on criminal charges, there had been malpractice cases filed against him for unnecessary treatment. Would "tort reform" open the doors to unscrupulous doctors overtreating/inappropriately treating patients on a massive scale, to great profit, because "tort reform" would limit their liability, if they get caught, to a trivial amount?

I can't imagine a system more ripe for abuse than that in the US, where no-one who makes the decisions is accountable for their decisions, except the patient. In the UK, all the providers are employees of the national health system, so the profit motive for malpractice/claim denial does not exist. Of course, what the UK has is "socialism".

Steve
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Audits are actually pretty simple with single payer. If the computer notices a high incidence of billing on certain types of treatment from a family doc they send off letters to the patients involved.

Of course, that is far more complicated when the Doc in question is playing a dozen or more insurance companies at the same time, so his activities are harder to track. But, in the US system, where is the incentive for the insurance companies to do that sort of investigating?

Remember my experience with my "welcome to Medicare" checkup last March? The Doc kept billing with the wrong code, so Medicare would reject it, so he'd send the bill to me. I had to do the legwork to find the correct billing code, as if he had never had a Medicare patient before.

Amount the Doc billed to me on the first go around: $233.

Amount the Doc billed to me on the second go around: $330

Amount Medicare paid: $130.93

And *there* is the incentive for the Doc to play stupid and use the wrong billing code.

Steve
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<<
Of course insurance companies do no such thing. Based on the evidence they merely decide if they are obligated to pay for proposed procedures in advance.

</snip>

You need to go back and review the original story. Patient goes to the ER in severe pain. MRI was done and surgeon was called. Patient was told if he didn't have immediate surgery he could be paralyzed if disk ruptured.>>


Easy decision then, for the patient. Go ahead with the procedure and sort out the payment later.

As you know I'm sure, an insurance company which denies coverage to an insured in Washington State and is then successfully sued to recover is entitled to collect three times the actual damages.

The insurance Commissioner is someone you don't want on your incoming telephone line on such issues either.

I would suppose that would tend to keep insurance companies honest.

Of course, all we hear about are stories where the insured claims to be ripped off by the greedy insurance company. I'll bet insurance companies have similar stories of waste, fraud and abuse that they could tell too.


Seattle Pioneer
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