This sort of thing gets to two critical problems of the American system:
1. It is largely designed to make money, not actually help patients. So every step in the healthcare chain that can extract a bit of value will do so, largely to boost profits.
2. Insane complexity with limited transparency. How much will something cost? Hard to tell. Will it be covered? Who knows?
On the opacity, I have one informative anecdote. I had a single blood test done awhile back and no one knew if insurance would cover it, or which of the dozen or so billing codes it involved (taking the sample, delivering the sample, testing the sample, etc.) might be covered. It was an expensive test so I spent days bouncing between the doctor's billing team and the insurance company until the settled answer was: No one knows, do the test and insurance will decide. So I did it and insurance denied covering the doctor-recommended test. The salaries involved for all the billing people (and my time) would have covered the cost of the test. </rant>
I’ve found, as a fairly recent phenomenon, it’s often higher than the insurance price. The pessimist in me thinks that insurance companies have worked to close that loophole. They need to maintain the illusion of their utility, after all.
"What is the cash price?" magically puts you back in the land of Classical Capitalism, where the service provider wants to keep you as a customer and knows their internal costs and you as a consumer of the service can evaluate their reputation for quality and cost vs other providers.
It's adding 3rd parties like "insurance" (which only works as insurance in very limited catastrophic circumstances) and government plans that create the nightmare of the Mystery Price Only Knowable After Service Has Been Rendered.
not magic words. sometimes cash price is non-insurance price and is 3x the insurance price. since insurance and providers have a negotiated rates. so paying cash means paying 3-5x
>Here are the magic words in US Health Care: "What is the cash price?"
I'm not so sure about that. Especially in a hospital setting.
Many years ago, I was admitted to the hospital for several days as it was suspected (wrongly, but that's another issue with the perverse incentives in US "healthcare") that I had MRSA and the doctor wanted me on IV antibiotics while testing proceeded.
I spent three days in the hospital, getting discharged when the tests came back negative for MRSA.
Shortly thereafter, I received a detailed "explanation of benefits" (EOB) from my insurer, which put the cost of my hospital stay at ~USD$12,000 which included stays in two hospital rooms simultaneously as well as a pap smear (despite the fact that I do not have a cervix). When I complained about this, the insurer tried to make it seem unimportant, but I pressed the issue as both the hospital and the insurer seemed to be involved in some sort of fraud WRT billing.
I was told I shouldn't care because I wasn't actually paying, but I persisted as I was concerned that there was something hinky going on. That culminated in a conference call with my insurance company, the hospital's accounts receivable group and me.
The two other parties talked in insurance billing jargon for a while, but when pressed, they stated that the charges on the "explanation of benefits" was a fiction and that the insurance company and hospital group's contract set a USD$1,500/day flat rate for patients admitted to the hospital's facilities -- roughly 1/3 of the "costs" cited in the EOB.
The made up stuff (which they didn't even try to hide that it was made up) was there as "protection" for the hospital group as the "cash price" of such services, even though I couldn't have received such services (two rooms at the same time? A pap smear[0] despite the fact that I don't have a female reproductive system, nor do/did I present as anything other than a cis male?).
I imagine that there may be some cases where a "cash price" actually does reflect costs and might even be less than insurance costs (although that seems unlikely given my experience), but insurers and healthcare providers do and have for decades gamed the "cash price" to justify the insane overcharging of healthcare services. YMMV.
In Australia I just take my blood test form to any pathology place and they do it for free (for me) and bill the government a set price from the medicare benefits schedule.
Hmm sure, but there must similarly be things that are denied right?
I lived in both systems. In a single payer system, the state essentially decide what is allowed and what is not. And with the state as a single payer, they also go back and forth on price with the hospitals.
It still is a better system overall but there is no places where you can just spend as much as you want on healthcare without some type of centralized supervision.
I've had numerous encounters where doctors (and dentists) attempt to charge me for services they've already been reimbursed for from the insurance company.
It's only after hours of scouring my EOBs and being on the phone with my insurance that I then come back to the practice's office with evidence in hand, and they dismiss the charges.
I'm pretty sure this is just a racket because they expect most people not to put up a fight and just pay, or get sent to collections hell.
The amount of work you need to do as a patient in our health system is so dumb.
> No one knows, do the test and insurance will decide
Oh, someone knew but the doctors office wanted to do the expensive thing and get paid (either by you or the insurance)
Not saying the blood test was unnecessary but we have no idea what communication happened between the doctor and insurance company. Did they possibly recommend a less expensive test and the doctor decided that'd make him less money so he went forward anyway?
Health insurance companies have told me, on the phone, that they will not tell me the codes the doctor needs to charge for preventative visits in order to for my visit to be covered as preventative care (meaning I don’t have to pay anything).
However, I could tell the insurance customer service person a code, then they could tell me if it was classified as a covered preventative service.
So I, the insurance company’s customer,
Googled medical procedure codes and found some on random PDFs, and checked which ones were covered, and then I asked the doctor to provide me the services for that code.
That is American healthcare.
On the flip side, I also had a doctor’s office try to bill my insurance $25 for towels used to wipe the ultrasound jelly off my wife’s belly. My insurance didn’t pay, so the doctor’s office sent me the bill for what insurance didn’t cover, so I called the doctor’s office and asked why I am being charged $25 for the few pieces of paper towel (not even linen towel), and the receptionist said they would waive the charge.
So, moral of the story is bring your own paper towel roll when you expect to get messy at the doctor’s office.
No, I assure you, it is very common for doctors' offices not to know whether a particular procedure will be covered.
This is not just because of the capriciousness of insurance adjusters, but because they have to deal with all the 273 different variations of insurance plans that people who come through their offices might have.
In general, a doctor's primary goal will be to get you good care.
An insurance company's only goal nowadays is to make as much money as possible for as little effort as possible.
It was not designed to make money. It was designed to cost less, in the same way the USSR was designed to make workers rich - it simply failed spectacularly.
Neoliberals dislike both regulation and public ownership, but made a Faustian bargain where they replaced public ownership with more regulation, thinking that regulation was the lessor of the two evils. In reality, it's not - like in the USSR where they had corporatised but heavily regulated "companies". A heavily regulated company doesn't make money by offering better value to customers, it makes money by finding loopholes in regulations, and regulators will always lose the cat and mouse game of closing these loopholes.
Neoliberals end up creating a system that's actually a lot like the USSR (if the famous "Well intentioned Commissaire" essay is representative of the USSR) - heavy regulations, with corporate entities outsmarting the regulators to enrich their owners (or managers) while minimising the value they create. Neoliberals deny the need for pubic management, but are forced to badly reinvent it (via heavy regulation). Communists deny the need for incentives, and are forced to badly reinvent it (once again via regulation), ending up not a million miles away from where neoliberals end up - with endless regulation and lost efficiency.
It's worth noting that the US spends far more tax dollars (per capita) than Australia on health (Australia has a hybrid public / private model). Medicare, Medicaid and the VA costs about as much as Canada's expensive public system (per capita) since the US is so insanely inefficient.
I'm sorry, but this is bullshit. The American system is nothing like the Soviet one. I've seen both first hand. Both are kinda crappy but in very different ways. If I had to choose one though it'd be Soviet for sure because it's still guaranteed healthcare no matter what your financial situation is.
The biggest problem with the American system is that it's just illegal for me to sell you good, simple insurance.
Let's say I draft an insurance contract that says for any treatment if >5 of 10 randomly selected doctors agree that the procedure was warranted, then I have to pay out the cost of the procedure, no questions asked. This contract is less hassle, clear, and doesn't require arguing with an insurance company since it specifies how disputes are resolved.
But I'm not going to give it to you for free. I need to know the expected payout in order to come up with a price and sell it to you. You know, like how all other insurance works. There is a price that is positive EV for me, but better aligns with your risk tolerance, and is therefore positive utility for you as well. In America, pricing it is illegal. I cannot, by my own methods, determine a fair price and sell it to you.
That's why we can't have nice things, because it's illegal for two people to agree on a price and terms and create a good deal for themselves.
There's plenty of upcoding going on with doctors as well though.
I go to a particular doctor and I'll see a bunch of random things on the bill that don't seem to have anything to do with my visit. Like a thousand dollars worth.
But then insurance rejects them, but I still don't have to pay a cent -- the doctor never actually charges me.
It seems quite clear they're just trying to throw things at the wall and see what sticks.
Are clinicians any more competent than in other countries with similar levels of training? In Europe, UK, or here in Australia for example, the quality of public care seems to be competitive with the US, and the quality of private care here seems often even better.
I've heard this "US healthcare is expensive but at least it's good" thing a few times, but never with any particular evidence, and from the few numbers I remember seeing, healthcare outcomes are generally no better.
This doesn't surprise me: The "fee for service" system encourages doctors to perform as many services as they can so they can bill for more. I've certainly had my fair share of tests and procedures where I wonder if the provider was just trying to find something to bill for.
I'm also not surprised that some providers will try to figure out which codes they can use to get the most revenue. ("Hey, if I do procedure A instead of B, I get paid more, so why would I do B?")
That being said, I also wouldn't be surprised if many of these turn into lawsuits, or ultimately push to revise the whole "fee for service" system.
"Figure out which codes they can use to get the most revenue" is a billion dollar industry with many players, subspecialties and surprisingly few lawsuits.
A lack of lawsuits can just be an off the record agreement that no one benefits from the entire mess being dragged in front of the courts with public record laws, because that is how you give future Luigis ideas.
The more shady the industry, the more everyone involved is shying awaa from sunlight.
The counter to this is that now when you go to urgent care, they're only allowed to do one thing and send you to the ER for any other concurrent problems where you pay 10x more because it's an "emergency"
I've seen a lot of upcoding on my bills and it really aggravates me. It's fraud and the doctors should be happy that the insurance company is just reducing their payments instead of dropping them or trying to get them prosecuted. When someone loads their grocery bag full of cosmetics and razor blades, they get on the news and YouTube, but when a doctor systematically bills for services he didn't perform to the tune of millions of dollars, almost nothing happens.
They're talking about shoplifting. Specifically hiding high dollar items in with their groceries, a practice akin to just adding a little bit extra to a medical bill for services not performed.
I’ve lived under several different healthcare systems around the world as an adult. Coming from my time America, nothing felt more like freedom to me than walking out of a hospital in London, with a new child, and having had no interaction with a billing desk.
On the other hand, aren’t comments like yours about the aesthetic experience of billing exactly the problem? It’s not like you didn’t pay for healthcare in Europe, you just had good vibes about the particular way that you paid. Employer sponsored health insurance plans are popular and also give good vibes.
> Employer sponsored health insurance plans are popular and also give good vibes.
This sounds so crazy to me that I feel like something got miscommunicated.
Who has good vibes about their health insurance? In America?
It's not the "aesthetic experience". It's about paying fairly and progressively in a predictable way via taxation, vs. completely unpredictable billing in the US. Is it in network? Is it pre-authorized? Did your doctor code it correctly? Is it below your deductible? Is there a copayment? What mystery charges will there be? What will insurance refuse to cover, wrongly? How many rounds of appeals will you have to go, over how many months? Not so good vibes.
I've heard enough "can't afford the risk of changing jobs" and "current work sucks, but I have to have insurance for my current issues". Honestly it doesn't feel like good vibes, especially with the recent issues on the job market.
Who have you talked to that enjoyed dealing with their insurance provider? Every single provider I’ve had had nightmarishly complicated customer support who couldn’t be trusted to give you accurate information.
I never had good vibes with an employer sponsored plan. I had the same employer for eleven years in TX. Every year the insurer changed. Every year there was the paper work and trying to decipher what was included and what the copay might be. There also weren’t good vibes from the providers and the way they’re forced to operate.
Yes I agree, I pay for healthcare as part of my taxes, essentially the same amount as the guy sitting next to me. To be honest it doesn’t feel any different to paying taxes in the US.
If anyone wondering why it is call 'downcoding', it's because there's WHO ICD coding standard or international classification of diseases now at version 11 or ICD-11 [1]. It's mainly used for classification of disease mortality not morbidity, not until the latest version iteration of ICD-11 in which it now caters for both [2].
Due the usefulness of the diseases classification coding based on ICD, it's also being used in many part of the world especially in US for healthcare insurance claim purposes.
[1] International Classification of Diseases 11th Revision:
The global standard for diagnostic health information:
No, that's completely wrong. Downcoding has nothing to do with ICD versions. This article is talking about changes to the billed HCPCS (including CPT) codes to ones with lower rates. Most US healthcare claims do include at least one ICD-10-CM code to indicate the diagnosis but this is just supporting information. Payers don't change diagnosis codes. ICD-11 isn't used on US claims at all, although it might be adopted in a few years.
My pediatrician always charges us for an office visit + preventative care when we go in for a preventative care visit. It's obviously to get more $$ from insurance. I feel like this goes both ways...
Yeah enough gets talked about insurers acting in bad faith, but let’s not forget hospitals also acting in bad faith for their end. Some personal examples:
1. Sitting in a Urgent care. They get you in the exam room. You sit there for 15 mins, doctor comes and sees you for 5 mins (mostly rushes the exam), do a blood draw, ask me to sit around while they run the test, doctor leaves, as soon as 45 mins are over the nurse comes over to let me know it’s taking longer to run the test so I can go home and they’ll call when the results are out. A month later charge thousands of dollars to insurance for a 45 min Urgent Care visit that doesn’t cover the lab work.
2. Go to PCP with cold symptoms that haven’t cleared in 10 days. I insist it’s a sinus infection, they send me back with no antibiotics and ask to schedule and online appointment in 2 days. I insist I come in in person, but they schedule an online appointment anyway. Nothing gets better and I see the doctor online after 2 days, they say I’ll have to come in so that they can evaluate me in person and prescribe antibiotics. I go in person, get antibiotics and get cured. Insurance gets charged for 3 separate hour long visits ($750 each and none of them lasted more than 10 mins).
Or it was viral after all and you cleared it on your own.
Doctors who specialize in this have a hard time accurately distinguishing bacterial infections from viral. There’s no reason to trust your own opinion on the matter. It’s too easy to fool yourself.
If doctors prescribed antibiotics to every person who came in insisting they have a bacterial infection, we’d all be in for a bad time.
An obligation to pay is always good for the billing side. Think about the sociopathic prices of US pharmaceuticals.
Afaik any other country with mandatory health care also puts a ceiling on prices. In germany, there is a price catalog for any service, with only few exceptions, and doctors/hospitals cannot legally charge anything else for these covered services. Now guess what the US does not have, even thought obama had foreign consultants explicitly advising for it.
Health ensureance companies are certainly not the most altruistic but any profit oriented company trying to cut cost where ever possible is hardly a supprise.
> In germany, there is a price catalog for any service, with only few exceptions, and doctors/hospitals cannot legally charge anything else for these covered services. Now guess what the US does not have
Well, we sort of do: we have Medicare's reimbursement rates, which are indeed a price catalog for every service... but only if you're covered by Medicare, of course.
I've heard that price negotiations between private payers and providers are often done with reference to the Medicare rate: "I'll pay you 20% over Medicare for this."
I wonder what would happen if we moved the "medically necessary" requirement burden of proof from the doctor/patient to the insurer. So the insurer would be required to pay out a claim regardless of whether the insurer thought it was medically necessary, but their recourse could be to try to claw it back post-payment.
They'd most likely go bankrupt. There is already an incentive for them to spend on medical care due to the Medical Loss Ratio (MLR) which caps their profits on collected premiums.
If you're saying they need to be forced to pay whatever invoice comes to them and start legal battles for each suspect case then yeah... that doesn't seem feasible.
What would happen is that costs to self-funded employers would increase so much that many of them would simply stop offering health insurance benefits and choose to pay the tax penalty instead. The only way the current system sort of works is with health plans maintaining strict utilization management.
(In general society would be better off if access to healthcare wasn't tied to employment but that's a separate issue.)
Readit News
On the opacity, I have one informative anecdote. I had a single blood test done awhile back and no one knew if insurance would cover it, or which of the dozen or so billing codes it involved (taking the sample, delivering the sample, testing the sample, etc.) might be covered. It was an expensive test so I spent days bouncing between the doctor's billing team and the insurance company until the settled answer was: No one knows, do the test and insurance will decide. So I did it and insurance denied covering the doctor-recommended test. The salaries involved for all the billing people (and my time) would have covered the cost of the test. </rant>
It's usually less than you think and often worth avoiding the insurance company hassle. Then you can just get reimbursed with your FSA or HSA anyway.
"Guess how much money you're spending in a year on healthcare! But beee caaareful: if you guess too high, YOU LOSE IT"
I still used mine while I still had access to one, but it was grumpy-making and was usually almost more trouble than it was worth.
Me: "Okay, what if we don't go through insurance?"
Pharmtech: "$45 for the prescription."
Me: "That's a bit higher than last time."
Pharmtech: performs some sort of incantation "Okay, $12."
Me: "How did we go from not at any price to $12?"
for those of you keeping score at home, the medicine was generic colchicine which costs $.30/dose (https://pmc.ncbi.nlm.nih.gov/articles/PMC7851728/), and I was getting 12
And if you have an HSA, you have a high deductible plan.
It's adding 3rd parties like "insurance" (which only works as insurance in very limited catastrophic circumstances) and government plans that create the nightmare of the Mystery Price Only Knowable After Service Has Been Rendered.
I'm not so sure about that. Especially in a hospital setting.
Many years ago, I was admitted to the hospital for several days as it was suspected (wrongly, but that's another issue with the perverse incentives in US "healthcare") that I had MRSA and the doctor wanted me on IV antibiotics while testing proceeded.
I spent three days in the hospital, getting discharged when the tests came back negative for MRSA.
Shortly thereafter, I received a detailed "explanation of benefits" (EOB) from my insurer, which put the cost of my hospital stay at ~USD$12,000 which included stays in two hospital rooms simultaneously as well as a pap smear (despite the fact that I do not have a cervix). When I complained about this, the insurer tried to make it seem unimportant, but I pressed the issue as both the hospital and the insurer seemed to be involved in some sort of fraud WRT billing.
I was told I shouldn't care because I wasn't actually paying, but I persisted as I was concerned that there was something hinky going on. That culminated in a conference call with my insurance company, the hospital's accounts receivable group and me.
The two other parties talked in insurance billing jargon for a while, but when pressed, they stated that the charges on the "explanation of benefits" was a fiction and that the insurance company and hospital group's contract set a USD$1,500/day flat rate for patients admitted to the hospital's facilities -- roughly 1/3 of the "costs" cited in the EOB.
The made up stuff (which they didn't even try to hide that it was made up) was there as "protection" for the hospital group as the "cash price" of such services, even though I couldn't have received such services (two rooms at the same time? A pap smear[0] despite the fact that I don't have a female reproductive system, nor do/did I present as anything other than a cis male?).
I imagine that there may be some cases where a "cash price" actually does reflect costs and might even be less than insurance costs (although that seems unlikely given my experience), but insurers and healthcare providers do and have for decades gamed the "cash price" to justify the insane overcharging of healthcare services. YMMV.
[0] https://www.mayoclinic.org/tests-procedures/pap-smear/about/...
Outside of certain procedures which are used to cash payers (dentists, lasik, plastic surgeons, imaging) this is nearly impossible in my experience.
Ummm
I lived in both systems. In a single payer system, the state essentially decide what is allowed and what is not. And with the state as a single payer, they also go back and forth on price with the hospitals.
It still is a better system overall but there is no places where you can just spend as much as you want on healthcare without some type of centralized supervision.
It's only after hours of scouring my EOBs and being on the phone with my insurance that I then come back to the practice's office with evidence in hand, and they dismiss the charges.
I'm pretty sure this is just a racket because they expect most people not to put up a fight and just pay, or get sent to collections hell.
The amount of work you need to do as a patient in our health system is so dumb.
Would any of that work?
Oh, someone knew but the doctors office wanted to do the expensive thing and get paid (either by you or the insurance)
Not saying the blood test was unnecessary but we have no idea what communication happened between the doctor and insurance company. Did they possibly recommend a less expensive test and the doctor decided that'd make him less money so he went forward anyway?
However, I could tell the insurance customer service person a code, then they could tell me if it was classified as a covered preventative service.
So I, the insurance company’s customer, Googled medical procedure codes and found some on random PDFs, and checked which ones were covered, and then I asked the doctor to provide me the services for that code.
That is American healthcare.
On the flip side, I also had a doctor’s office try to bill my insurance $25 for towels used to wipe the ultrasound jelly off my wife’s belly. My insurance didn’t pay, so the doctor’s office sent me the bill for what insurance didn’t cover, so I called the doctor’s office and asked why I am being charged $25 for the few pieces of paper towel (not even linen towel), and the receptionist said they would waive the charge.
So, moral of the story is bring your own paper towel roll when you expect to get messy at the doctor’s office.
This is not just because of the capriciousness of insurance adjusters, but because they have to deal with all the 273 different variations of insurance plans that people who come through their offices might have.
In general, a doctor's primary goal will be to get you good care.
An insurance company's only goal nowadays is to make as much money as possible for as little effort as possible.
Flood insurance protects against the rare disaster where there's a flood.
Health insurance protects against the rare disaster where somebody's actually able to get healthcare.
It was not designed to make money. It was designed to cost less, in the same way the USSR was designed to make workers rich - it simply failed spectacularly.
Neoliberals dislike both regulation and public ownership, but made a Faustian bargain where they replaced public ownership with more regulation, thinking that regulation was the lessor of the two evils. In reality, it's not - like in the USSR where they had corporatised but heavily regulated "companies". A heavily regulated company doesn't make money by offering better value to customers, it makes money by finding loopholes in regulations, and regulators will always lose the cat and mouse game of closing these loopholes.
Neoliberals end up creating a system that's actually a lot like the USSR (if the famous "Well intentioned Commissaire" essay is representative of the USSR) - heavy regulations, with corporate entities outsmarting the regulators to enrich their owners (or managers) while minimising the value they create. Neoliberals deny the need for pubic management, but are forced to badly reinvent it (via heavy regulation). Communists deny the need for incentives, and are forced to badly reinvent it (once again via regulation), ending up not a million miles away from where neoliberals end up - with endless regulation and lost efficiency.
It's worth noting that the US spends far more tax dollars (per capita) than Australia on health (Australia has a hybrid public / private model). Medicare, Medicaid and the VA costs about as much as Canada's expensive public system (per capita) since the US is so insanely inefficient.
(edit: The essay I mentioned - https://highered.blogspot.com/2009/01/well-intentioned-commi...)
Let's say I draft an insurance contract that says for any treatment if >5 of 10 randomly selected doctors agree that the procedure was warranted, then I have to pay out the cost of the procedure, no questions asked. This contract is less hassle, clear, and doesn't require arguing with an insurance company since it specifies how disputes are resolved.
But I'm not going to give it to you for free. I need to know the expected payout in order to come up with a price and sell it to you. You know, like how all other insurance works. There is a price that is positive EV for me, but better aligns with your risk tolerance, and is therefore positive utility for you as well. In America, pricing it is illegal. I cannot, by my own methods, determine a fair price and sell it to you.
That's why we can't have nice things, because it's illegal for two people to agree on a price and terms and create a good deal for themselves.
I go to a particular doctor and I'll see a bunch of random things on the bill that don't seem to have anything to do with my visit. Like a thousand dollars worth.
But then insurance rejects them, but I still don't have to pay a cent -- the doctor never actually charges me.
It seems quite clear they're just trying to throw things at the wall and see what sticks.
Everything about American healthcare is bad.
If you see this sort of thing happening in the U.S., the place to complain is your state's insurance board.
Medicine is hard enough without people TRYING to do harm.
And actuarial science is brutal enough WITHOUT glossy justifications for assuming that healthcare providers are bad actors.
Except the part where you are cared for by a competent clinician?
I've heard this "US healthcare is expensive but at least it's good" thing a few times, but never with any particular evidence, and from the few numbers I remember seeing, healthcare outcomes are generally no better.
I'm also not surprised that some providers will try to figure out which codes they can use to get the most revenue. ("Hey, if I do procedure A instead of B, I get paid more, so why would I do B?")
That being said, I also wouldn't be surprised if many of these turn into lawsuits, or ultimately push to revise the whole "fee for service" system.
The more shady the industry, the more everyone involved is shying awaa from sunlight.
What does this part mean? I don't follow.
This sounds so crazy to me that I feel like something got miscommunicated.
Who has good vibes about their health insurance? In America?
It's not the "aesthetic experience". It's about paying fairly and progressively in a predictable way via taxation, vs. completely unpredictable billing in the US. Is it in network? Is it pre-authorized? Did your doctor code it correctly? Is it below your deductible? Is there a copayment? What mystery charges will there be? What will insurance refuse to cover, wrongly? How many rounds of appeals will you have to go, over how many months? Not so good vibes.
I've heard enough "can't afford the risk of changing jobs" and "current work sucks, but I have to have insurance for my current issues". Honestly it doesn't feel like good vibes, especially with the recent issues on the job market.
Yes I agree, I pay for healthcare as part of my taxes, essentially the same amount as the guy sitting next to me. To be honest it doesn’t feel any different to paying taxes in the US.
Due the usefulness of the diseases classification coding based on ICD, it's also being used in many part of the world especially in US for healthcare insurance claim purposes.
[1] International Classification of Diseases 11th Revision: The global standard for diagnostic health information:
https://icd.who.int/en/
[2] ICD-11 vs. ICD-10 - a review of updates and novelties introduced in the latest version of the WHO International Classification of Diseases:
https://pubmed.ncbi.nlm.nih.gov/32447353/
I doubt the insurance company would downcode the diagnosis, just the procedure.
1. Sitting in a Urgent care. They get you in the exam room. You sit there for 15 mins, doctor comes and sees you for 5 mins (mostly rushes the exam), do a blood draw, ask me to sit around while they run the test, doctor leaves, as soon as 45 mins are over the nurse comes over to let me know it’s taking longer to run the test so I can go home and they’ll call when the results are out. A month later charge thousands of dollars to insurance for a 45 min Urgent Care visit that doesn’t cover the lab work.
2. Go to PCP with cold symptoms that haven’t cleared in 10 days. I insist it’s a sinus infection, they send me back with no antibiotics and ask to schedule and online appointment in 2 days. I insist I come in in person, but they schedule an online appointment anyway. Nothing gets better and I see the doctor online after 2 days, they say I’ll have to come in so that they can evaluate me in person and prescribe antibiotics. I go in person, get antibiotics and get cured. Insurance gets charged for 3 separate hour long visits ($750 each and none of them lasted more than 10 mins).
Or it was viral after all and you cleared it on your own.
Doctors who specialize in this have a hard time accurately distinguishing bacterial infections from viral. There’s no reason to trust your own opinion on the matter. It’s too easy to fool yourself.
If doctors prescribed antibiotics to every person who came in insisting they have a bacterial infection, we’d all be in for a bad time.
Afaik any other country with mandatory health care also puts a ceiling on prices. In germany, there is a price catalog for any service, with only few exceptions, and doctors/hospitals cannot legally charge anything else for these covered services. Now guess what the US does not have, even thought obama had foreign consultants explicitly advising for it.
Health ensureance companies are certainly not the most altruistic but any profit oriented company trying to cut cost where ever possible is hardly a supprise.
Well, we sort of do: we have Medicare's reimbursement rates, which are indeed a price catalog for every service... but only if you're covered by Medicare, of course.
I've heard that price negotiations between private payers and providers are often done with reference to the Medicare rate: "I'll pay you 20% over Medicare for this."
I wonder what would happen if we moved the "medically necessary" requirement burden of proof from the doctor/patient to the insurer. So the insurer would be required to pay out a claim regardless of whether the insurer thought it was medically necessary, but their recourse could be to try to claw it back post-payment.
If you're saying they need to be forced to pay whatever invoice comes to them and start legal battles for each suspect case then yeah... that doesn't seem feasible.
1. pay out claims slowly
and/or
2. deny or downcode claims outright?
Really? That to me would imply that doctors/patients are submitting a huge amount of incorrect claims.
(In general society would be better off if access to healthcare wasn't tied to employment but that's a separate issue.)