Rant (healthcare costs)

Discussion in 'The Tiki Bar' started by boatman37, Jan 13, 2020.

  1. Boat Guy

    Boat Guy Well-Known Member

    Not sure where you got your numbers @Golfman25 but they appear to be close, so thanks for that...

    That's still, by my rough math, about $510/member. Further, since they aren't, IMO, primarily motivated by cost reductions, I think there's a great deal more fat on the table.
  2. FootballFan

    FootballFan Well-Known Member

    Jun 20, 2012
    Marquis 59
    MTU Series 60
    so, all of our posts are discussing what we pay to the insurance company.

    Not at all discussing what the insurance companies pay to healthcare providers.

    I think revolutionary change is changing what the providers are considering a reasonable profit model when they determine costs.

    If we focus on what we pay for insurance, the end result is government will eventual promise that they can do it cheaper.

    Personally I would rather the government to use their regulatory and taxation clout to facilitate a new solution.

    I am not in favor of a single payor solution. Just another discussion about how do we pay for the costs - versus - how do we lower the costs
  3. atrick

    atrick Active Member

    Mar 4, 2017
    1995 searay 290 Sundancer
    1990 21 maxum
    Twin 4.3 mercrusers with alpha one genII drives
    305 chevy with a alpha one drive
    That was the numbers that were on the news tonight that were supposed to be from them as their profit so don't know the exact break down but its still too much profit from us at the little guys expence. The doctors and hospitals charge high prices but the insurers only pay them 30 cents on the dollar so they have to charge high fees to make a profit. Check your statements from your insurer next time you have something done and see what the doctors and hospitals really get in the end!
  4. yobub

    yobub Active Member PLATINUM Sponsor

    Jul 29, 2016
    1998 400 Sundancer
    Cat 3116's
    FWIW, I’ve earned my living for the past 20 years fixing inefficient processes like the ones that @Steve S and @Frtbroker are frustrated with. I’ve worked with both payers (insurance companies) and providers (physicians / hospitals) and over the years I’ve redesigned almost every operational process for one company or another. My business isn’t exclusively focused on health, and I have clients in other industries, but over the years health clients have represented probably 60-70% of my work. Given the fundamental dysfunction in the industry, I suspect I will have gainful employment for longer than I would like.

    I generally stay out of these discussions because the discussions turn political, and I’m not interested in arguing. That said, here are some observations from being inside many of these organizations as an outsider:

    Like almost every other company, insurance companies and providers are both in it to make money. Period. That doesn’t mean they are bad people or act from bad motivations, but that is what they are all in business to do. Insurance companies and providers both ultimately want you to get healthy (for different reasons), but at the end of the day, the doctors are going to charge for what they do, and insurance companies have to make money to stay in business.

    A health insurance company may stop offering a plan because it isn’t profitable for them or because a company no longer qualifies for the plan because they don’t have enough employees or not enough employees participate in the plan, but they can’t force the company to take another plan. They are selling a product, and you can buy it or not. They also can’t force your company to self-insure. Your employer can get proposals from various insurance companies, and then select the carrier and the plan that best fits the company’s needs. Your employer decides whether they want to take the loss risk themselves, or leave the loss risk to the insurer. It is competition for a service, and it is cost/risk decision for the employer. Not every state or region in a state has a wide variety of insurance companies, but many do. If you don’t have good competition in your state or region, and many areas don’t, then maybe that isn’t a great place to do business.

    There is a lot of frustration with health insurance claims being denied, and feeling like the insurer is acting maliciously, but honestly, behind the scenes, none of the people I’ve worked with are like that, from front line staff to the most senior executives. None. The policies state what is covered and what isn’t like any other type of insurance. If a service isn't covered under a plan, somewhere along the line your employer agreed to that. If a service is covered under the plan, they will pay for medically necessary services, typically based on guidelines created by 3rd party organizations are widely used in the industry. Some procedures need to be evaluated for medical necessity before they are performed. Doctors and patients have an appeal process that starts with the guidelines but then flows through physicians and ultimately physician peer review to evaluate medical necessity. If a service isn’t covered, it doesn’t matter whether it is medically necessary.

    I don’t believe the systems are designed to be confusing or burdensome. They just have ended up that way. Companies pay me a lot of money to make them less complex and less burdensome. I’m sorry that I haven’t gotten to all of them yet, but feel free to send them my way.

    In my opinion, one of the biggest issues is the consumer/patient. In general, no one actually wants to buy health care services, and in general we buy the services without ever asking how much they cost. What else do you buy in your life without asking how much it costs??? And then people are frustrated, after the fact, when it costs too much. Ask in advance. Shop around. Understand your coverage. Don’t just blindly go for every test your doctor might order – understand the trade-offs before you go for that $2500 MRI the doctor ordered “just to make sure”. That’s not a message that anyone wants to hear, but ultimately you pay for the service one way or another. Act like a consumer.

    To that end, I wouldn’t have any problem with what @Boat Guy proposed. The advocacy and simplified billing would be beneficial. I don’t quite understand whether you are proposing premiums or just sharing all of the loss equally across all members, so maybe you could clarify that. The idea of reducing premiums by 50% is optimistic, because insurers’ loss ratios are more like 83%, so you have about 17% of admin costs and profit combined to work with. There is a little bit of fudge in that number, but not a lot.

    I’ve believed for a long time the point that @alnav and @Golfman25 made. In my opinion it doesn’t make any sense for the consumer to have health insurance controlled through the employer. It makes sense for the insurance companies, because they can risk rate a large, identifiable pool of members, and they only have to sell once instead of 5000 times and bill once instead of 5000 times (which creates efficiencies), but it creates a situation where people can’t really shop a competitive market, and they stay in a job they don’t like just so they don’t lose insurance.

    Just my 2 cents.
  5. M Prod

    M Prod Well-Known Member

    Oct 6, 2017
    North Vancouver, BC
    2005 Sundancer 340
    Zodiac Cadet 300 w/Yamaha 20hp
    Kohler 5KW Genny
    Raymarine Electronics
    8.1 Horizons /V Drives
    While technically correct, those numbers are for suckers. Anyone paying 53% on $220k needs to rethink their life choices and get a good accountant. There are so many loopholes anyone can take advantage of.
  6. Boat Guy

    Boat Guy Well-Known Member

    Well, I like you already...haha

    Ok, the truth is I was hoping to bait someone into the discussion that is in the industry or affiliated. My background is entrepreneurial and tech, so while I'm researching rough figures, I in no way stand by them...For example, my 50% is arguably optimistic. But, The problem with using the figures of today is there is so much waste and inefficiencies. (To your point of being gainfully employed). So my numbers are taking into consideration the reductions in these areas after implementation.

    Yes, I would say that the members would either make up the loss or the co-op would fail. I'm in support of a model that keeps the co-op out of the red. While we can clearly create scenarios where this is possible, I would simply address it like a special assessment similar to an HOA. While I can see these issues arising in the early years of implementation, I think you could get to a point where you have a good handle on the estimates.

    Further, my "non-profit co-op" model is only step one....But I think it's fundamental to a disruption. After this implementation and scale, you can add the other parts to be discussed at a later date. But, I will say, I do see where the "co-op" can provide limited healthcare services for members. Since I already think the word "insurer" is improper in my model, I would call the "co-op" a "wellness co-op". They would take the role of insurer, advocate, billing admin, and primary care....Yes, I think it would be possible to scale this system similar to the concierge doctor practice...Possibly have tiers...But if you combine primary and advocate under the same roof, they can make sure the specialists and hospitals are getting things right...

    Do you know that I read the #3 reason people die in the US is medical mistakes... This system would fix that.

    Truth is, I share this with you guys knowing full well it will never go anywhere. It's so hard to get people to see clearly. And, even those that do will be attacked from every angle. Lobbyist, attorneys, politicians, etc. like legacy systems and they don't care about what's best for the country....After all, they are only doing their job. They're not bad people....

    BTW- I think your words are worth at least a nickle, you are modest...
    Last edited: Jan 16, 2020
  7. Steve S

    Steve S Well-Known Member GOLD Sponsor

    Jun 5, 2007
    Northern IL.
    2000 400 Sedan Bridge with twin CAT 3116's

    2000 340 Sundancer - SOLD!
    210 Monaco 1987 - SOLD!
    Twin Caterpillar 3116's 350 HP straight drives
    Boat Guy. I have heard of Co-op’s already in existence to pray for medical costs versus insurance. I will have to see if I can find the details out again.
  8. ENstig8or

    ENstig8or Active Member GOLD Sponsor

    Jun 4, 2013
    New Jersey
    2003 Sea Ray 450 Express Bridge.....

    2016 Sea Ray 21 SPX BR
    Cummins 480CE (450)
    Mercruiser 4.3L (21 SPX)
    I understand and agree with most of what you said with the exception of this quoted paragraph. The problem I have with this statement is not what you pointed out here, because I agree. It is that a huge percentage of citizens in our country cannot do what you suggest here. They have enough trouble deciphering the differences between things like when to use the words to, two, or too, or when to have their car breaks replaced or when to take their lunch brake. They think MRI is my rectum itches! All kidding aside, most do not understand what they read in their policies if they were to take the time to do so. They don't understand medical terminology and rely on their insurance brokers to take care of what they should carry and their doctor to order what they need. If you were to go on the Healthcare Marketplace website, and in your business you probably have, you would witness a sea of confusion. You have some silver plans that are better than the more expensive gold plans. You also find plans that play with the deductibles to make them seem comparable with a more expensively priced plan. You literally have to study those plans for hours before you can make an educated choice. Bottom line is, in my humble opinion, the average Joe in the US is not equipped to understand his or her health options so they are ripe to purchase less than the optimal option for them at a price that is more than they should pay.
  9. yobub

    yobub Active Member PLATINUM Sponsor

    Jul 29, 2016
    1998 400 Sundancer
    Cat 3116's
    Agreed. I was describing the lack of understanding as a key issue in the overall system, and I agree with everything that you said. My comments about being a good consumer were directed towards this audience, which I think has a greater capacity to understand these things.
  10. bobeast

    bobeast Dance the Tide SILVER Sponsor

    Oct 22, 2017
    Isleton, CA
    2002 310DA
    350 MPI w/V-drives
    The quickest way to improve any government service is to mandate that lawmakers use that service to the exclusion of all others.
    ENstig8or likes this.
  11. Golfman25

    Golfman25 Well-Known Member

    Sep 12, 2009
    I agree. I have this problem when I select plans for my company. I guess that is the flip side of choice.

    But I think we can simplify it. A lot of it is in the presentation. Start with a basic plan - covers all the important stuff. Then add pricing at certain deductible levels and co-insurance levels. Then you can add a deluxe plan and a Cadillac plan. Make HSA applicable to all plans, so people can save for their deductibles.
  12. Boat Guy

    Boat Guy Well-Known Member

    They do...They are being tested in various states. But, because the states still control the regulations, I think it's an even bigger uphill battle....

    IMO, they need to be national.

    I always support thoughts like this
    I would submit that they shouldn't have to...
  13. yobub

    yobub Active Member PLATINUM Sponsor

    Jul 29, 2016
    1998 400 Sundancer
    Cat 3116's
    That is a provision in the ACA. Congress has to buy their health coverage through the health exchanges rather than the Federal Employee Plan.

    Not sure whether that was repealed when the individual mandate was repealed.
  14. bobeast

    bobeast Dance the Tide SILVER Sponsor

    Oct 22, 2017
    Isleton, CA
    2002 310DA
    350 MPI w/V-drives
    Wondering if the ACA includes the provision; "to the exclusion of all others" I bet not.
  15. yobub

    yobub Active Member PLATINUM Sponsor

    Jul 29, 2016
    1998 400 Sundancer
    Cat 3116's
    That was the intent of the Summary of Benefits and Coverages (SBC) that each plan has to provide. It is a mandatory format that summarizes the basic components of the plan, specifically the deductibles, co-pay by provider/facility, and max out of pocket. It is designed to digest some of the key elements of the plan to make it easier for the consumer to understand. It certainly doesn't cover everything, but it is a good start. I would like to see the format require a link to a website with specific coverages, and also a link to the formulary, which is the list of covered drugs, and the drug tier, which guides how the coverage pays.
    Last edited: Jan 16, 2020
  16. yobub

    yobub Active Member PLATINUM Sponsor

    Jul 29, 2016
    1998 400 Sundancer
    Cat 3116's
    Yeah, I don't think so but I can check. I think I still have the legislation on my laptop. The key point was to shift them off of the FEP and create a vested interest in what they were building for consumers.

    If I have time I'll look it up.

    Edit: @bobeast The ACA doesn't prevent members of congress from getting plans outside of the federal government (like through a spouse or business):

    "...the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are— (I) created under this Act (or an amendment made by this Act); or (II) offered through an Exchange established under this Act (or an amendment made by this Act)..."
    Last edited: Jan 16, 2020
    Steve S likes this.

    BOB TYSON Active Member

    Oct 5, 2017
    sarasota, fl
    2005 460 Sundancer
    Cummins 480 CE
    amen Peds here I'm the wife. all you say is true..Medical costs are multi-pronged and there is not one single answer. Burn out is real for physicians, insurance companies are ridiculous for us too. I am sooo glad I am close to retirement as a physician. It's a mess.
    brewster16 likes this.
  18. bobeast

    bobeast Dance the Tide SILVER Sponsor

    Oct 22, 2017
    Isleton, CA
    2002 310DA
    350 MPI w/V-drives
    Thanks for the follow-up!
  19. alnav

    alnav Active Member

    Sep 16, 2009
    West River, MD
    40 MY
    QSB 425
    There is (or was, not sure if it went away) also an ACA provision for insurance companies to return "excess" profits to the insured. I've been getting relatively large (for the size of my workforce) checks every year from CareFirst (a Blue Crosser) that I use to defray the employee's cost in the current year.
  20. boatman37

    boatman37 Well-Known Member

    Jun 6, 2015
    2006 Crownline 250CR. 5.7 Merc BIII
    Previous: 1986 Sea Ray 250 Sundancer. 260 Merc Alpha 1 Gen 1
    5.7 Merc BIII
    Looked on healthcare.gov last night just for fun. Comparable coverage would be about the same price as my employer is offering. I didn't read through the details but there were 3 I compared and the deductibles were $0, $4000, and $7000. For me and my wife would be $900-1000/month. I didn't qualify for any subsidies...lol. Supposed to have a meeting tomorrow to find out details of the new Cigna plan but haven't heard anything about it yet.

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