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The Bomb Buried In Obamacare Explodes Today-Hallelujah!
"provision of the law, called the medical loss ratio, that requires health insurance companies to spend 80% of the consumers’ premium dollars they collect—85% for large group insurers—on actual medical care rather than overhead, marketing expenses and profit. Failure on the part of insurers to meet this requirement will result in the insurers having to send their customers a rebate check representing the amount in which they underspend on actual medical care."
http://www.forbes.com/sites/rickungar/2011/12/02/the-bomb-buried-in-obamacare-explodes-today-halleluja/
I LOVE THIS!
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ZombieHorde
(29,047 posts)
russspeakeasy
(6,539 posts)
gateley
(62,683 posts)The Doctor.
(17,266 posts)
WonderGrunion
(2,995 posts)Without the ability to grow profits and the requirement to provide for pre-existing conditions, investors will abandon insurance companies like they were plague stricken.
Bye Bye Anthem!
Blacksheep214
(877 posts)Him and his repeal Obamacare is the worst in propaganda!
Motown_Johnny
(22,308 posts)without 60 Senators and a majority in The House plus the President all agreeing to repeal it.
Not gonna happen. Besides, it would be political suicide.
Sometimes I call that number just to tie up the line and leave a nasty message when they ask me to record my name.
leeroysphitz
(10,462 posts)
LiberalFighter
(53,544 posts)and which health insurance provide financial assistance with his scam
ask him if it is true that Eli Lilly backs him or name another name
MilesColtrane
(18,678 posts)as a "bomb".
Thrown, no doubt, by that terrorist, Marxist Muslim in the White House.
livetohike
(24,159 posts)Glad to see my health care premiums go to a good use 
.
mistertrickster
(7,062 posts)
leveymg
(36,418 posts)For instance, it's 93-7 for BC/BS in Kansas. http://www.khi.org/news/2011/mar/04/most-insurers-meet-medical-loss-ratio-requirement/
On the Road
(20,783 posts)where are the higher costs in the US compared to other countries? Are they medical salaries, drugs, more health problems, or Americans' greater use of medical facilities?
leveymg
(36,418 posts)The cost of coverage is so high because MD and upper management compensation are extremely inflated, as are the costs of pharmaceuticals, medical equipment and facilities acquisitions, insurance, and other overhead.
On the Road
(20,783 posts)The others -- pharmaceuticals, medical equipment, and facilities are expenses common to the US and single-payer states. Am still not getting where the big difference between the US system and single-payer countries.
leveymg
(36,418 posts)Doctors and medical industry executives are paid far higher in the US than practically anywhere else in the world. Also, we have a huge for-profit medical sector that practically doesn't exist in most other countries, which further drives up prevailing wages. HMOs and other "non-profits" have to compete with for-profit institutions for staff, which keeps wages high. "Non-profit" is really a misnomer, as these providers are essentially privately-held corporations that set their own compensation levels at whatever level they want to, and further divide earnings among shareholders.
tblue
(16,350 posts)We better get a damn rebate
Man, I hope there is real oversight on this one.
Throckmorton
(3,579 posts)and my youngest, our third child, is covered by the state of Connecticut, as he is a former foster child that my wife and I adopted.
tblue
(16,350 posts)It stinks to high hell that you should have to pay anything out of pocket for it. You wouldn't in Canada or France, but then you probably know that.
I wish you and your family a wonderful new year! 
MedicalAdmin
(4,143 posts)Insurance companies are allowed to charge any expenses they use to deny claims as a medical care expense.
Look to them divert an increased amount of administrative cost into expanding their departments of "no."
An increasing part of your premium will go toward the funding of the very people who will gleefully deny your claim in order to qualify for their bonus.
Bob Wallace
(549 posts)My understanding has been that claim verification is an administrative expense....
MedicalAdmin
(4,143 posts)Claim research? Less so.
Companies are ready retaining more investigators, hiring more IMEs and medical personnel to find ways to either deny currently or retrograde.
I'll look for link when I am back in my office next week although this info comes from an aquantence who is pretty high up in a regional insurance admin office who is ambililent about her job. I'll see if I can find a link but this is what one of the big players is telling their HR and audit managers inservice.
So, regular paperwork will be administrative but all investigative and medical review will not.
Bob Wallace
(549 posts)If an insurance company denies a legitimate claim then they cut their profits.
Every dollar less they pay out in services cuts their administrative/profit portion by twenty cents.
I can see more investigations if there is some sort of a penalty for inappropriate payouts that they are trying to avoid.
MedicalAdmin
(4,143 posts)They shift the expense from paying for care to paying for staff to investigate claims.
And even if you were right, would you spend 20 to make 80? Seems like a bargain to me.
Bob Wallace
(549 posts)You're saying that the XYZ insurance company is going to prioritize claim denial over providing services?
All of that money is part of the 80%, not the 20% out of which its profits will derive. They can't cut services and increase the size of their 20%.
If they deny a lot of claims, then they will piss off a lot of customers who then move to another insurance company. Those disgruntled ex-customers will take a lot of other customers with them through word of mouth and bad-feedback posts on public forums.
They don't have the option to "spend 20 to make 80". They have to spend 80 on customer service in order to gain 20 for admin overhead and profit. Their admin overhead is going to be somewhat fixed. You've got buildings, advertising, clerical, financial staff - all that sort of stuff. They're going to be able to pocket about half of the 20%. The last thing they would want is fewer customers paying in so that the pool of 20% shrinks. They want to grow the number of customers so that fixed costs eat a smaller amount of the 20% leaving company owners more profits.
The danger, as I see it, is that some companies provide more services than needed, allow unreasonable claims, in order to raise the amount they pay out and thus justify a higher premium. A higher premium would mean a larger 20%/"half of 20%".
The stopgap here is competition. On a very public buying pool like the Exchange sets up if XYZ, Inc. runs its premiums up in order to increase the size of their 10% profit then they risk losing customers to other companies with lower priced premiums.
Looks to me that some decent contingency engineering went into the thinking on this piece of legislation.
MedicalAdmin
(4,143 posts)Will be applied and everything will be ok? Is that the theory you are advocating?
And understand clearly what I have not stated clearly enough. While the 80/20'is steadfast, what can be accounted in each category is fungible and that includes any expenses that go toward investigating if your claim should be paid or not if it is done by any medical or investigatory personnel. Expect those departments to be vastly expanded as there is no downside to doing so.
Combine that with the fact that anti trust legislation doesn't apply and you will see massive collusion between companies.
And this "competition" you promote will have the effect of concentrating the industry thus placing all the best crooks in charge.
An ancillary benefit will be increased pressure on medical care providers) to increase efficiency ( read: less time with patients ) at the patient level.
Bob Wallace
(549 posts)It's certainly worked to bring us things like computers and cell phones at very affordable prices. It has brought us good prices for car insurance. I cannot see why market forces cannot be used to reduce health insurance premiums to the lowest reasonable levels.
--
My understanding is that the 80% and 20% categories are separate. Administrative costs and profits come only from the 20% portion. You, I believe, have claimed that claim investigation comes out of the 80%. We await conformation of that. And, as I pointed out, it is not in the best interest of the insurance provider to inappropriately deny claims. Those savings cannot go to corporate profits and will only damage the reputation of the insurance provider.
Just a few days ago insurance companies were informed that they would not be allowed to use any of the 80% money for advertising. They were attempting to call advertising "customer education".
--
Will competition concentrate the industry and place all the best crooks in charge? I hardly see how. If companies are not treating their customers properly then business will flow to those companies with higher customer satisfaction ratings.
--
In our attempt to cut health care costs (not cut health insurance costs) might we force doctors to spend too little time with patients? Perhaps.
If so then quality of health care will likely decrease and overall costs rise. Once that starts to show then the system will need tweaking. Those are the sorts of health care issues we deal with all the time.
Efficiency does not simply mean time with patients. It can mean things such as a standardized claim form for all insurance companies.
Check 'Improving Health Care Quality and Efficiency." - 2011
Check "Reducing Paperwork and Administrative Costs." - 2012
Check "Encouraging Integrated Health Systems." - 2012
http://www.healthcare.gov/law/timeline/full.html
MedicalAdmin
(4,143 posts)"and will only damage the reputation of the insurance provider"
This is what trumps your entire market force and competition argument; the exemption to the anti trust laws. They WILL NOT compete, they will collude matching profitable inefficiencies and premium pricing.
In what will be, in effect, a monopoly, market forces won't count because there won't be any.
I'll see if I can find the link today if I have time.
Bob Wallace
(549 posts)Market forces create monopolies.
That's why we have only one company that makes cars, only one that makes TVs, only one....
MedicalAdmin
(4,143 posts)In terms that you get, these companies are EXEMPT from those laws. They can collude their asses off and they will / are.
Market consolidation is already under way. Don't take my word for it, call your broker and ask.
Selatius
(20,441 posts)I believe it was in the 1930s that an exemption to anti-trust laws was given to the health insurance market. The Democrats and FDR were not able to get health insurance reform due to disagreements within the caucus over how to proceed, so the compromise at the time was that states would step up and regulate their health insurance markets to avoid the prickly problem of federal regulation of state markets. However, many states reneged on the agreements by simply not enforcing anti-trust laws.
The result is this:
http://consumerist.com/2011/10/4-out-of-5-us-metropolitan-areas-lack-competitive-health-insurance-markets.html
Bob Wallace
(549 posts)and you've got a few tens of millions new customers entering the market?
I'm betting that insurance companies are going to want that business. I know that in my area very under-served rural area several insurance companies are now offering policies. Insurance companies that I didn't find when I was searching a couple of years back.
MedicalAdmin
(4,143 posts)It's working for you in your area right now and you have faith that it will work everywhere because, er, market forces...
What's that? Exempt from anti trust legislation? That's not a problem. (points over shoulder) . Squirrel!!!
Bob Wallace
(549 posts)If it turns out that insurance companies collude to raise prices then we can address that problem later.
No one has claimed that this legislation is perfect, I doubt you can find any major piece of legislation that did not require amending after passed.
MedicalAdmin
(4,143 posts)We are in agreement, although the only person who seemed to be arguing from a position of assumption that the legislation was perfect or minimally flawed was you.
Why are you taking this personally? I am because it effects me and my family very personally and with finality. What skin do you have in this game?
Bob Wallace
(549 posts)I make no assumption that his legislation is perfect nor that there might not be a major flaw.
I assume it will take further action to get us where we can provide good health care to all. I don't know what that action will be because the act has not been fully implemented. To date the parts that have seem to be working. More people are getting insurance, more people are getting free testing, the donut hole is closing, etc. The insurance companies have tried one or two times to crawl through a rat hole and gotten slapped back.
I am not "taking it personally" in the sense that I think you imply. What I am is offended at how many people on the left dismiss the PPACA as "worthless" because it didn't "go all the way" to a European style health system (or whatever personal model they hold in their head). And as I interact with these people most don't have a clue what is in the legislation. It's a "Well, the box wasn't wrapped in gold paper like I wanted so I don't care to look inside" attitude.
Let me ask you something. Had the PPACA been fully in effect prior to your accident do you think your experience would have been the same?
Or might have (based on the way I anticipate the way things will work) your insurance company put its efforts into getting you treated and keeping you happy? Remember, not treating you would have increased their profits by zero dollars. And an unhappy customer could easily cost them many other customers and "20%s".
MedicalAdmin
(4,143 posts)First, why it might not be applicable. My problems started with a car accident. While recovering from that one and on a FMLA work break (my boss kept my job and kept me on insurance while she was waiting for me to get better) I was hit again, ironically while returning from PT from the first accident. I was, in my estimate about 4 weeks from returning from work. This time they pulled me out of the wreck on a body board. At this point car insurance number one pointed a finger at car insurance number 2 and said that it was their fault. Number 2 pointed at number 1 and said it was their fault. Meanwhile my personal health insurance said that whatever it was, it sure as shit wasn't their problem. My job, at that point went bye bye and along with it my health insurance. Scroll forward a few years and with no job with insurance (I have pieced together a pretty good consulting biz but I haven't really turbocharged my finances) and then BLAMMO.
So I'm not sure how the PPACA would have helped there.
One of the big flaws IMO is that coverage is linked to employment for most folks. And while that is going away, it isn't being replaced with a comparable product. This has stifled innovation by tying those with good ideas and skills to jobs that waste them or stifle their ideas. The one thing that can't be managed is risk, a thing that I am finding out in spades.
I brings me a great deal of solace that there are tenacious SOBs like you who will keep working on this diligently after I'm gone. I suspect that you are like a dog on a pant leg. You won't let go until you are good and done. And that is exactly what we need.
Please take a moment and pay attention to those of us with actual behind the scenes experience with insurance companies. They have a proven habit of ignoring laws when it suits them and only grudgingly doing the right thing when they are caught red handed and sometimes not even then. They are not to be trusted.
It's been good chatting with you. I'm sorry I wasn't a more pleasant conversationalist. I have a lot on my mind, but that is no excuse for treating a fellow traveler with less than respect. My mom used to say that those who are the hardest to love are probably those who need love the most.
Thanks.
MedicalAdmin
(4,143 posts)"If an insurance company denies a legitimate claim then they cut their profits."
No they don't. If they deny any claim they increase their profits. Income (premiums) - expenses ( admin plus claims paid) = less profit and bonuses and stock options and stock dividends.
Denied claim = 100% profit. Let's say that they are overturned by a judge later and have to pay out on the original claim some of the time. Then they still get to pocket that 20% admin charge. Plus the patient might die or give up in the mean time. And if they don't then the patient will only get 60 percent of that claim anyway (40% is the usual lawyer contingency fee). In the meantime they continue to either rack up premiums or the broom your ass and make you someone elses problem only now with a pre-existing condition.
Aha, you say! Preexisting conditions can noonday be denied. That is true, but the coverage and cost can be modified and there are no cost controls on that. So while the insurance company that you apply to ( in anti-trust exempt collusion with each other) has to offer you a policy, there is nothing that says it has to be even close to affordable. In my case I was offered a policy recently at 2000 per month with a 10000 deductible. This is more than I earn in a year. Waddafuckindeal.
Why donyou think they deny claims in the first place? It is the one control that they have over profit margin. Do you think they will just give that up?
And now they will be able to charge off any bills from Medical consultants against that 80% because it will be considered costs to detirmine appropriate care. The
Main reason that court cases are lost is that the insurance companies already outspend individuals on consultants and now they have a no reason not to increase that cost because every claim denied is another point of profit.
Bob Wallace
(549 posts)You are acting like a petulant child.
Once the PPACA is in effect denial of claims does not increase profits. There is no mechanism for insurance companies to move money from the 80% treatment category to the 20% admin/profit category.
In fact, failure to treat can cut profits.
Companies will lose customers.
And companies will pay out less in treatment costs lowering the base for their 20%.
There are no additional premium costs or differential services for sicker people.
Response to Bob Wallace (Reply #92)
MedicalAdmin This message was self-deleted by its author.
bvar22
(39,909 posts)Yeah? Which one of the other 4 BIGGIES are they going to go to?
There IS no Public Option.
"There is no mechanism for insurance companies to move money from the 80% treatment category to the 20% admin/profit category."
Untrue.
As we type, they are exploiting the many loopholes, trap doors, and escape clauses they wrote into this legislation.
If you believe they are going to Play Fair,
or that there is an adequate Enforcement Mechanism in place,
OR the WILL in Washington to apply enforcement,
you are beyond naive.
"There are no additional premium costs or differential services for sicker people."
He pointed out, for example, that "health factors" such as chronic diseases and age would continue to play into how much individuals can be charged in premiums and how many of them may be forced into high deductible plans.
"What they will be doing, what they can in the Senate bill, is charge people significantly more if they have certain health factors," Potter said. "And it would be pretty much up to the industry to decide what those health factors are. You could have high blood pressure, high cholesterol, diabetes. You could be overweight, have a history of tobacco use. There definitely would be a wide range of things that the insurance industry would be able to look at and determine whether or not to charge you more."
He also noted that the Senate bill would allow insurance companies to charge people who are older up to three times as much as those who are younger and, in the House bill, two times more than a younger person.
http://www.commondreams.org/headline/2010/01/20-5
Whistleblower Reveals How Health Insurers Can Game New Insurance Bill
http://www.commondreams.org/headline/2010/01/20-5
Bob Wallace
(549 posts)And I have 14 health insurance companies from which to choose. And more are scheduled to start providing services.
--
"As we type, they are exploiting the many loopholes, trap doors, and escape clauses they wrote into this legislation."
Yes they are. And they just got their proposal to put advertising in the 80% section by calling it "customer education" knocked down.
Call me beyond naive, but gosh-golly, enforcement just worked.
--
"There are no additional premium costs or differential services for sicker people."
"Prohibiting Discrimination Due to Pre-Existing Conditions or Gender. The law implements strong reforms that prohibit insurance companies from refusing to sell coverage or renew policies because of an individual’s pre-existing conditions. Also, in the individual and small group market, the law eliminates the ability of insurance companies to charge higher rates due to gender or health status. Effective January 1, 2014."
http://www.healthcare.gov/law/timeline/full.html
sendero
(28,552 posts)... and you sound like some sort of libertarian fool rather than someone that understands the business. If you really want to know how all of this works the info is out there, but I will give you a serious hint - it works NOTHING like you seem to think it does and it never will given the basic business model at play.
Bob Wallace
(549 posts)I'll point out that you sound like someone who has never bothered to read what the PPACA does to the "basic business model at play".
Here's two hints:
1) The rules are changing
2) You can read about the new rules here - http://www.healthcare.gov/law/timeline/full.html
Bob Wallace
(549 posts)Excluding anti-fraud efforts:
"Insurers wanted fraud control programs to be counted
as quality improvement measures. They also
wanted other activities, such as “utilization
review” (in which a company decides whether
or not to cover a particular medical treatment),
to be considered medical expenses. The
NAIC decided against both."
Page 4 - http://www.rwjf.org/files/research/71431.pdf
Sounds to me as if fraud investigations are coming out of the administration/profit 20% and not out of the services 80%.
Lots of good info on this site.
MedicalAdmin
(4,143 posts)Both of them are already considered admin costs and will remain so. Utilization review is a clerk looking to see if the language if your contract covers your problem. This is a good thing.
(btw - the NAIC is already being invaded on a state by state basis by insurance stooges - appointed by governors of the red persuasion - see recommendations: ALEC) so don't expect those rulings to keep coming.
However medical review is not that at all. It has nothing to do with contract language. It is hired medical guns who will vow under oath that the problem you have isn't a problem or that you are lying and fine. And if you are denied treatment and dont have the money to get it anyway, you won't have tangible evidence that you had a problem. If they can keep you from proving it on paper, then that is that. You are one more in a legion of the fucked.
Bob Wallace
(549 posts)Excluding anti-fraud efforts:
"Insurers wanted fraud control programs to be counted
as quality improvement measures. They also
wanted other activities, such as “utilization
review” (in which a company decides whether
or not to cover a particular medical treatment),
to be considered medical expenses. The
NAIC decided against both."
Your claim was that insurance companies were hiring armies of investigators whose job would be to deny claims and that the cost for those investigators would come from the 80% treatment segment of premiums.
There is no, zero, nada profit to be made by insurance companies by denying claims. They cannot move that money into their pockets.
If they refuse a lot of claims then that will lower their ratings and people will move to another company.
MedicalAdmin
(4,143 posts)I can't afford my pain meds these days.
I've explained the diff - you repost your post again. Let's agree to disagree.
Hoyt
(54,770 posts)http://www.gpo.gov/fdsys/pkg/FR-2011-12-07/pdf/2011-31289.pdf
Admittedly, I haven't analyzed every word/phrase -- but I don't think such expenses would be considered a medical expense.
I think the MLR accomplishes a lot. Also, one needs to consider MLR along with other aspects of "reform" such as the information the Exchanges will provide and the relative ease of moving from insurer to insurer for a better deal without their using "pre-existing conditions" exclusions.
It's definitely not as good as single-payer, but it certainly restricts insurers' ability to increase premiums and is an improvement over what we had before.
MedicalAdmin
(4,143 posts)... getting rid of the exemption to the rico laws.
Hoyt
(54,770 posts)MedicalAdmin
(4,143 posts)
Hoyt
(54,770 posts)Go read the final rule and then post something more meaningful than some vague reference to racketeering laws.
I think the final rule makes it clear how the MLR will be calculated. Can an insurer lie about it? Sure. Would it be smart in this environment fro them to do that -- I don't think so.
Finally, I think you meant anti-trust laws, rather than RICO. Maybe that is just another one of your mistakes.
Now, there's plenty of other stuff to criticize in the legislation -- like no public option, no single payer, etc.
MedicalAdmin
(4,143 posts)I really don't have the energy today to do what you want. I can't focus well given the pain today.
Its an improvement from nothing. I will celebrate for everyone who still has the money to afford to take advantage of these changes and those poor enough to get a subsidy. For myself and what will be left of my family after I die, I will mourn if you don't mind.
I think that will be my final word except for a final OP I am working on.
Cheers.
bvar22
(39,909 posts)...when 40 Million - 70 Million (projected uninsured 2014) already hard pressed Working Class Americans will be forced to BUY
"Bronze" (junk) "Insurance" from the for profit providers.
Even with a "subsidy", most of these MILLIONS will STILL be forced to dig deep into near empty pockets to write a BIG check every year to buy a "product" most will be unable to use due to High Co-Pays/Deductibles.
These MILLIONS will NOT be happy.
They WILL blame the Democrats,
and rightly so.
The Democrats passed a Republican Insurance SCAM without forcing the Republican to take ANY responsibility.
ALL the Republican have to do is sit back and say,
"YEP! We voted against it!",
and Democrats will be unelectable for a generation
Here is Candidate Obama in 2008 explaining WHY a Mandate to Purchase Insurance is BAD for America.
You will know them by their WORKS,
not by their excuses.
[font size=5 color=green][center]Solidarity99![/font][font size=2 color=green]
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woo me with science
(32,139 posts)
wakemewhenitsover
(1,595 posts)SixthSense
(829 posts)and wait 'til people find out that the medical loss ratio has very little to do with the quality of care provided
I can only imagine the distortions that the requirement to hit arbitrary figures will cause... certainly there will be fraud - just look at the way the stat is calculated, it basically leaves it up to the company to figure it out. Wouldn't terribly surprise me either if political donations could be used as a valid expense, either.
Hoyt
(54,770 posts)Looks to me like the calculation of MLR is spelled out pretty clearly in the legislation and implementing regulations.
http://www.gpo.gov/fdsys/pkg/FR-2011-12-07/pdf/2011-31289.pdf
I do agree the MLR has little to do with "quality of care." But, that is another issue.
fascisthunter
(29,381 posts)you and many others here are truly representing truth.
Oilwellian
(12,647 posts)The 2010 election should be a clue to everyone.
And along with what MedicalAdmin said upthread, the law allows serial-killer insurance companies to count investigating you for fraud as "medical care".
lumberjack_jeff
(33,224 posts)To be universal, it must be mandatory.
bvar22
(39,909 posts)One of the reasons I chose him over Hillary.
Did you watch the video?
Candidate Obama clearly stated that people don't have Health Insurance because they don't have any money.
HOW is THAT "uninsured by choice"?
Do you really believe that giving them a partial subsidy,
and STILL requiring them to cough up money that they [DON"T HAVE
for junk "bronze" policies that they can't use
is going to make them happy?
lumberjack_jeff
(33,224 posts)He eventually and belatedly found a dictionary to help.
People who don't have any money will get a subsidy to pay for it, and yes, I think that will make them (me) happy.
Bob Wallace
(549 posts)People with only a little money will get free insurance.
For the first time low income singles will receive Medicaid. A single 35 year old working 40 hour weeks, 52 weeks a year for minimum wage will receive Medicaid.
People with only modest amount of money will get health insurance for a modest monthly premium.
A 35 year old who makes $40,000 per year and has a family of four will have a premium of $165 per month.
Yes, they will have a deductible and could be hurt by additional out of pocket expenses in a bad year, but without the PPACA their premium would have been $925 a month. Plus deductible and out of pocket expenses.
It's not a perfect program, but it's pretty danged good for the 49.9 million Americans who didn't have health care in 2010.
If we elect a Democratic Congress we can make it even better. PBO has signed every single good piece of legislation that has reached his desk.
Cameron27
(10,346 posts)"For the first time low income singles will receive Medicaid. A single 35 year old working 40 hour weeks, 52 weeks a year for minimum wage will receive Medicaid."
I'm interested to see how that's written because Jan Brewer froze out medicaid for everyone except families with children this year, and she needed and got federal approval to make the cuts. So we can count on that being reversed in 2014?
I'd also like to see the chart for coverage per income plus the deductible & out-of-pocket.
Thanks
Bob Wallace
(549 posts)If you put in some low numbers ($7.25 x 40 x 52 and age 35, for example) you'll see "Medicaid" pop up.
If you put in larger income then you'll get some info on maximum out of pocket.
http://healthreform.kff.org/SubsidyCalculator.aspx
The info is also available in chart form from that page.
---------------------
And on this page, 2014 you'll see...
http://www.healthcare.gov/law/timeline/full.html
"Increasing Access to Medicaid. Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid. States will receive 100% federal funding for the first three years to support this expanded coverage, phasing to 90% federal funding in subsequent years. Effective January 1, 2014."
There's a link following this paragraph which should lead you to more information about how the law is written and to the actual law.
I don't know how Brewer's "stuff" will fly. State law does not trump federal law. A lot is unknown until things work their way through the Supreme Court.
Cameron27
(10,346 posts)I'll read through the info & hope you're right.
The Doctor.
(17,266 posts)Good to see around here. I'll remember it.
MedicalAdmin
(4,143 posts)It must be my fault. I'm to blame.
Of course it could have something to do with the fact that as a subcontractor/contractor I gross about 100k per year but my NET is about 19k after expenses and the subsidies will only take into account gross income.
Of course all of this is academic for me because I just found out about a week ago that I am terminal. I had lots of insurance but they got into a snit fit over who wasn't paying and guess what? They decided that it was the other company.
In fact ive been working toward a court case for the past 6 years and they just made a settlement offer of $2000 for paralysis, chronic pain, and loss of job due to injury. Generous of them, don't you think.
Yah - it's a good thing that we have left those generous souls in charge because they will do the right thing every time.
bvar22
(39,909 posts)We "chose" to eat instead of buying worthless Junk Insurance.
Sorry to hear about your illness.
I always enjoy your posts here.
Good Luck.
You will know them by their WORKS,
not by their excuses.
[font size=5 color=green][center]Solidarity99![/font][font size=2 color=green]
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MedicalAdmin
(4,143 posts)I think you are one of the most astute ranter on here.
stockholmer
(3,751 posts)'Obamacare' was a huge travesty. Universal single-payer is the only way to provide fairness in coverage and to keep costs contained.
Private, for-profit medical insurance and hospitals should be outlawed ASAP.
Health care is a core human right, not a product.
hughee99
(16,113 posts)When 70 million new people are forced to pay for even shitty insurance, you bet they're going to use it. What happens when you add this many new people in to the system without first making sure you have the ability to handle them (more doctors, nurses, labs, equipment)? You get shitty service for the new people and shitty service for those who already have insurance as the system tries to cope with the influx of new patients. Eventually, the system may be able to handle the necessary workload but it absolutely won't be the case at the start, and you can't just use a magic wand to make all this stuff appear.
E6-B
(153 posts)All this would be not needed br simply repealing anti-trust protection.
MedicalAdmin
(4,143 posts)The exemption to anti trust laws is the most worrisome part of this law, basically allowing the companies to price fix and collude on how best to screw human citizens with impunity.
Motown_Johnny
(22,308 posts)^snip^
Encouraging Integrated Health Systems
Effective January 1, 2012
The new law provides incentives for physicians to join together to form “Accountable Care Organizations.” In these groups, doctors can better coordinate patient care and improve the quality, help prevent disease and illness, and reduce unnecessary hospital admissions. If Accountable Care Organizations provide high quality care and reduce costs to the health care system, they can keep some of the money that they have helped save.
MedicalAdmin
(4,143 posts)while simulatioisly incentives them to not deliver care act.
That act?
Let me ask this question, how is this different from capitation?
Motown_Johnny
(22,308 posts)Shouldn't any medical practice already be responsible for their administrative costs?
I am not in the business so it may simply be my ignorance speaking but I don't see how providing incentives for physicians to join together to form “Accountable Care Organizations" equates to some type of new tax.
Maybe if you explain exactly how this is going to cost you money I might be able to proved a better answer.
I am not addressing your "while simulatioisly incentives them to not deliver care act" statement because on October 1st a change kicks in which is supposed to link payment to quality outcomes.
http://www.healthcare.gov/law/timeline/
^snip^
The law establishes a hospital Value-Based Purchasing program (VBP) in Original Medicare. This program offers financial incentives to hospitals to improve the quality of care. Hospital performance is required to be publicly reported, beginning with measures relating to heart attacks, heart failure, pneumonia, surgical care, health-care associated infections, and patients’ perception of care.
Scuba
(53,475 posts)... going to non-services, compared to about 3% with Medicare.
murphyj87
(649 posts)You still pay insurance company bureaucrats 10% to 15% to stand between you and your American physician, and you still have to stream to Canada to get the health care than American insurance company bureaucrats deny you. Canadian health care is the reason that Canadians outlive Americans with insurance-run health care by almost 4 years.
MedicalAdmin
(4,143 posts)Is between 6 and 7 percent. When you consider they cover everyone this is still way better than the USA average of 27%
murphyj87
(649 posts)Statistics show that the overhead for the pubic health care system in 2008, the last full year that statistics are currently publicly available is 1.3%. In order to reach the 6 to 7 percent you claim you must add in THE OVERHEAD OF PRIVATE INSURANCE (which in Canada is for vision care, dental care and those prescription drugs not covered by the public system - some are and some are not) which INSURANCE has an overhead of 13.2%, resulting in 6% to 7%. The overhead of government funded universal single payer health care, however, for 2008, was 1.3%.
In Canada, the government-funded, physician-run, public single payer health care has an overhead of 1.3%
In Canada private insurance (which only covers only vision care, dental care, and some prescription drugs) has overhead of 13.2%
Canada only has overhead of 6% to 7% when you add in the cost of private insurance in Canada. Overhead is 1.3% for government funded single payer health care. Overhead for private insurance in Canada is 13.2% (strictly limited to only a very minor role, and limited to vision care, dental care those prescription drugs not covered by the public system - some are and some are not, very specific limits)
Insurance-run health care in the United States has overhead nearing 40% (when counting insurance overhead in a for profit system plus physician overhead in a for profit system plus hospital overhead in a for profit system).
It is deceptive to suggest that overhead in the public health care system in Canada is any more than 1% to 3%.
According to Marcia Angell, MD of Harvard Medical School, the key elements are these:
- Health care costs per person are twice as high in the United States as in Canada. Americans pay twice as much to get half the access and quality that all Canadians get in Canada.
- The US health care system has worse outcomes, is less efficient and provides fewer of many basic services than all Canadians have in the Canadian system.
Of the ten most statistically significant studies:
Five of the ten show that outcomes are better in Canada than in the US.
Three of the ten show that outcomes are equal between Canada and the US.
Only two suggest that outcomes are better in the US than in Canada. - The United States is the only industrialized country in the whole world that treats health care as a market commodity, not as a social service, and leaves the uninsured and those who cannot pay without access to the medical care they need .
- In the United States, for-profit health care is vastly more expensive with much higher overhead costs and often of far lower quality than not-for-profit or government funded care, such as that in Canada.
- The notion that partial privatization in Canada will shorten waiting times for elective procedures (and are only for ELECTIVE procedures) is misguided.
- Partial privatization would draw off resources from the public system, increase costs overall and introduce the vast, serious, and killing inequities inherent in the US system.
- The best way to improve the Canadian health care system is to put more resources into it.
MedicalAdmin
(4,143 posts)I strongly encourage you to make it an OP.
I didn't know that and I had looked into tue subject a few times.
Thanks very much for that post.
bornskeptic
(1,330 posts)The main reason for the difference in overhead costs between Medicare and large group insurance is that the private insurers invest more in examiniing claims and combatting fraud.
Scuba
(53,475 posts)... we're talking administrative overhead and profits here.
bornskeptic
(1,330 posts)The majority of those employees are involved in claims processing and investigation of possible fraud. Private companies do experience some losses due to fraud, but not to the extent that Medicare does.
Scuba
(53,475 posts)Bob Wallace
(549 posts)We'll get settled into this model of providing Americans with health insurance. And then, as happens with all legislation, we'll tweak it.
Congress will get into a big budget cutting mood and the cost of health insurance supplements will be addressed. Some will start talking about the amount that goes to corporate overhead. That will be the time to introduce a public option, a basic opening of Medicare to non-seniors.
It can be sold as a way to create competition and bring down the cost of health insurance.
We never get to the finish line with one giant step....
LiberalAndProud
(12,799 posts)I don't understand how this isn't cost plus pricing. Doesn't it actually encourage higher health care costs at the outset? If costs of the Department of No are included as indicated above, where is the hallelujah part?
Sirveri
(4,517 posts)This is NOTHING.
bornskeptic
(1,330 posts)Profit margins for the large health insurance companies run between 3% and 6%.
http://biz.yahoo.com/p/sum_qpmd.html
Scroll down and you'll find "Health Care Plans" at 4.5% in the profit margin column.
Sirveri
(4,517 posts)have to spend 85% on health care.
Oh look they already do. So this doesn't actually do anything.
just1voice
(1,362 posts)For-profit main stream media celebrations don't change that.
Courtesy Flush
(4,558 posts)I guess New Years was a good excuse to revive the story.
tavalon
(27,985 posts)Also, I don't doubt the thieving weasels will find some way around this. Nonetheless, just for this moment. Sweet!
fasttense
(17,301 posts)There are thousands of laws on the books that are routinely ignored for fun and profit.
For example: Anti-torture laws -- water boarding anyone?
Anti-trust laws -- regional monopolies and exemptions for all corporations.
Buy American laws -- but, but this might support a Union.
Laws are merely a pretense at governing. We all know the oligarchy has full control to implement their whims.
Bragi
(7,650 posts)I have sen the future, and corporate accountants will have no problem re-profiling marketing costs as health expenditures. No problem whatsoever. And if government regulators have a problem with the new accounting methods, then many years of litigation and appeals will happily ensue. Eventually, a GOP white house/congress will overturn whatever is left of Obamacare, and no-one will live happily ever after. The end. -
spanone
(141,275 posts)
MoonRiver
(36,975 posts)TheKentuckian
(26,314 posts)Of course since the industry is supposedly already at the marks set, it shouldn't make much difference immediately but over time the cartel has only to allow higher costs to increase profits, the slack is already baked in.
Bluenorthwest
(45,319 posts)reach, pull, stretch...
ProSense
(116,464 posts)a lot more on the health care law: http://www.democraticunderground.com/100294294
RB TexLa
(17,003 posts)And they have a law requiring it be given to them.
BadgerKid
(4,972 posts)Suppose an annual policy has costed $10,000 with actual costs of 70%. This means profit is $3,000.
Now I assume insurance companies will want to maintain the same profit under a new 80% medical loss ratio. The new policy rates become 3000/0.20 = $15,000.
phleshdef
(11,936 posts)Bob Wallace
(549 posts)I don't know if you've shopped for either individual or small business health care insurance. I've done both.
It's incredibly time consuming to get quotes from a single provider and even hard to find providers who are willing to sell to you in some situations. I suspect many people simply buy from the first or second company they try.
Now, with the Exchange, you're going to be able to go on line and compare prices for a fixed set of benefits from a number of companies on a single page. Within a few months there will be independent web sites that collect performance data/customer satisfaction for those companies. In a few minutes you're going to be a well-informed customer and business will flow to those companies who deliver the best service for the lowest price.
Insurance companies are going to have to make their profits on volume, not premium retention. That is going to cause them to work at delivering a better product for a better price than what they have had to do up until now.
Companies that raise premiums will loose customers rapidly.
MedicalAdmin
(4,143 posts)You said "That is going to cause them to work at delivering a better product for a better price."
What product do insurance companies produce besides needlessly dead bodies?
Bob Wallace
(549 posts)Insurance companies collect premium dollars from a large number of people and use a portion of that money to pay for the health needs of their customers.
Prior to the PPACA the contingencies were set up so that insurance companies made more money by providing less services. Now that is hopefully turned around. Insurance companies are going to make larger profits by keeping their customers happy and alive.
(Sure, there may be other rat holes to nail tin over, that's why legislation generally requires a lot of amending over time.)
MedicalAdmin
(4,143 posts)I won't live to see it happen.
A few comments - there are no parts of this law that provide an incentive fir companies to keep patients healthy.
And denied service is the number one reason for bankruptcy even now. Every week more people die from preventable health problems in the USA than 9-11 is responsible for. Every week.
Every week. Health insurance costs are a boot on the neck of the country. This law puts a slightly smaller boot on the foot.
Bob Wallace
(549 posts)Cannot be used to judge what will happen after the bill goes into effect.
--
"there are no parts of this law that provide an incentive fir companies to keep patients healthy"
Paying Physicians Based on Value Not Volume. A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so that those who provide higher value care will receive higher payments than those who provide lower quality care. Effective January 1, 2015.
--
"And denied service is the number one reason for bankruptcy even now."
Insurance companies will not have the ability to deny services as they now do. There are defined services under the Exchange rules and a new system for contesting denials.
You really need to read the provisions in the PPACA. You seem to be railing against the pre-PPACA conditions.
http://www.healthcare.gov/law/timeline/full.html
MedicalAdmin
(4,143 posts)I've read it. I've sat on a medical board committee that looked at it in consultation with the medical board legal team.
Too much is undefined and open to interpretation. There is one example of that in the subject line.
I have admitted that this is a small step forward, but it doesn't fix the underlying structural problems. Either you see this or you think this bill is fine as it is.
Bob Wallace
(549 posts)You know damn well what the bill is attempting to do with this provision.
You know damn well that the outcome is not likely to be perfect.
You know damn well that I don't see this bill is fine as it is. I've said repeatedly that this is a great first step but we will need to amend and improve as we go along. We're still tweaking the Medicare program 50 years after that program was created. Part of the PPACA is a Medicare fix.
The "underlying structural problems" that I think have been the most damaging are the ability to deny services in order to increase profits. This problem is (almost certainly) fixed.
MedicalAdmin
(4,143 posts)Maybe you are right. I suppose I am.
I've been trying to help patients who were getting screwed by insurance companies for years. I've seen first hand just how uncaring and evil these companies are.
And there are serious problems with this law that needs fixing and that should have never been there in the first place. As a law it leaves much to be desired. As a political ploy it was a disaster that will be hung on the neck of the democratic party for a long, long time.
I'm only going to ask you to forgive me. I was screwed to the floorboards by a combination of insurance companies and I will be dying soon as a result of that. And I am one of millions of American's who will be hurt by this law by forcing them to pay for a private product that is designed to be unusable.
That is what I know damn well. Take your outrage and do something else with it.
Bob Wallace
(549 posts)Unwilling to accept that there is new legislation to deal with the problems you report.
Unwilling to enjoy the progress made with this new legislation.
Unwilling to acknowledge the improvement this legislation will bring to the lives of many.
Can you truthfully tell me that after reading through the provisions of the PPACA - http://www.healthcare.gov/law/timeline/full.html - that there is nothing in it that would have made your job of helping others easier and improved the health care of those with whom you worked?
Already over two million young adults now have insurance because they can be placed on their parents policies.
Already people with pre-existing conditions can get health insurance policies.
Is this a perfect bill, does it solve every single problem, does it make everyone's life a bed of roses? Of course not. But can you not allow yourself to see the progress made?
I am very sorry that you are experiencing what you are experiencing. But that has no bearing on the changes brought by this new legislation.
I don't buy for a moment your claim that you will be damaged by this bill. You have said, I believe, that you are in your last months and that you have private insurance. Nothing in this bill changes anything for you except that your insurance company will have to spend 80% (or 85%) of your premiums on treatment.
Your claim that the insurance people purchase will be unusable is ridiculous.
Can you step back from the anger at what you've been through?
MedicalAdmin
(4,143 posts)Does it make progress? A bit.
Does it help those who can't afford to use their insurance? No.
Does it stop insurance companies from colluding? No.
Does it control premium costs(other than your belief that the invisible hand of a dead economist will somehow correct these fundamental systemic problems)? No.
Has it helped parents with kids and with insurance and the means to pay for the extra coverage, the ability to extend that coverage to their kids? Yes. Has it helped those without those means? No.
Does it keep the premium costs of those with pre-existing conditions under control? No.
These are not SMALL problems. Can they be fixed? Yes. Would any reasonable person expect that this will happen anytime soon given gridlock in WA? Not a chance.
To clear up the confusion. I don't have insurance. I had insurance. And after my car accidents (other guys came through stop signs and went on their merry way) I lost my coverage, my job, and my health. All 3 insurance companies are still disputing that they are responsible for any coverage. It is all someone else's problem. Just this week I was finally (after 5 years) offered a settlement by one of the companies - the grand high sum of $2000. The reason I am dying is because I couldn't afford the diagnostic and medical care that I needed when I needed it.
So has there been progress. Yes. Some. I have a recent quote for health insurance just for me. the premium is $2000 a month with a 10000 deductible. Wow. Call me impressed. Even the federal pool that is available here in MN is less costly, but of course it only covers 60% of expenses and contains all sorts of deductions and exclusions and copays. I can't even afford that one and it is much cheaper at $900 per month. In short, this is useless. My choices are taking on debt and rolling the dice and leaving my family with a HUGE debt (live or die) or roll the dice and don't.
I posted a while back about not being able to afford diagnostic tests for what I suspected was a serious problem. My boss ended up donating the money for an MRI. The news was really bad. Deadly bad. It is too late for me. It is not too late for the rest of this country. Diagnostic testing without the ability to afford the follow up care is cruel.
Promise me that you will overlook my previous behavior and focus on fixing or replacing this law. No one should have leave their family this early because they can't afford care. I hope I am the last one. THat would make me happy.
Enjoy the moments of your life.
Bob Wallace
(549 posts)I'm just trying to get you to look at what has been achieved through lenses other than your personal history with insurance 'as it used to be'.
MedicalAdmin
(4,143 posts)In honesty I am.
But my concerns with this are not based in my personal experiences, but rather my experiences in fighting these companies and watching what they do to patients time in and time out. It was a huge mistake to leave them intact.
The MLR and Direct Primary Care will both help out. I've admitted that, but I can tell you that it is not near enough. The fact that these companies are exempt from anti trust laws gives them an incentive to price fix as there is no downside to doing so. ANd there aren't price controls in place.
If they get added, then fine, but until they do and until I stop breathing I shall continue to point this out.
Bob Wallace
(549 posts)(One has to leave room for inflation.)
That will create a budget problem for Congress. If there is collusion among insurance companies to price-fix that will become obvious to those who are most concerned about public spending.
Additionally all the businesses that aren't insurance companies will be complaining loudly about the price of employee insurance.
Adjustments almost certainly will be made.
One of the neat things about how this plan was designed is that it largely takes the problem of premium rates off individuals and puts it back on Congress.
--
Plus. How would insurance companies 'fix prices'? Would they go to providers and get them to raise the price of services? That's the only way that insurance companies could grow their 20% - aside from offering better services and lower premiums in order to take customers away from other companies.
MedicalAdmin
(4,143 posts)They push back at the providers to reduce payments. There is a national average of 3 full time billing specialists per doctor. No other country comes close. A friend of mine is a doctor in Canada and his nurse handles all of his billing daily in about 2o minutes online. That is efficiency. The average primary care physician spend up to 50% of their time dealing with billing or getting approval for procedures. That is inefficiency. It is a fact that doctors are leaving and not joining the profession in droves.
And then they will either raise rates where they can, and also deny claims where they can. They do it all the time every day. They are the Department of No. The one area that is helped by HCR is the fraud inherent in the current system but it is a little like a spoon holding back Katrina.
Bob Wallace
(549 posts)Insurance companies will not be able to deny claims in order to increase their profits.
Insurance certainly will raise premiums if they think they can. But they will have to spend 80% of that collected money on health care for customers.
If individual companies raise rates higher than other companies they will lose customers and their profits will fall. Health insurance will now a "volume based" industry reliant on customer satisfaction. No longer a "screw the customer for profit" based industry.
If you think that 100% of the companies will get together and collude to somehow pay more for health services in order to grow their 20% you're living in a tin foil hat world.
Within days you would have physicians reporting how insurance company reps were trying to get them to spend more for patient care, to waste money, so that insurance companies could make higher profits.
One of the places that some of us will be able to buy our health insurance is Costco. You think Costco will be willing to damage their reputation by colluding to screw its customers? Or will it seek ways to drive down the cost of health care and make its customers happy so that it gets even more customers?
---
"The average primary care physician spend up to 50% of their time dealing with billing or getting approval for procedures. That is inefficiency. It is a fact that doctors are leaving and not joining the profession in droves. "
You really should read the provisions of the PPACA - http://www.healthcare.gov/law/timeline/full.html
"Reducing Paperwork and Administrative Costs. Health care remains one of the few industries that relies on paper records. The new law will institute a series of changes to standardize billing and requires health plans to begin adopting and implementing rules for the secure, confidential, electronic exchange of health information. Using electronic health records will reduce paperwork and administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care. First regulation effective October 1, 2012"
MedicalAdmin
(4,143 posts)They will collude. They already are. That will continue.
And if you think the market will correct the power imbalances inherent in this system, well, there is always Costco to save the day.
There aren't price controls, premium controls or anti trust provisions. that hasn't changed. Even if the 80/20 works as HOPED, there are still those problems.
Like it or not. Believe it or not these are problems thathe law doesn't address. It's isn't stupidity or pigheadedness that make me mention this. And it isn't wrong to notice the problems and to want them fixed.
I had said that the 80/20 might help.
My concerns are based on readinghe law, sitting on a medical board that reviewed it, consultation with government lawyers that work in this area and years of experience working for and against insurance companies.
What expertise do you bring to the conversation? Seriously. I would like to know.
I'll reply to anything you say tomorrow. Gotta go and try to get some sleep before the 2am hemoraging starts.
Have a good night.
bvar22
(39,909 posts)No it is not.
Go to Google and type "Shop for Health Insurance".
Bob Wallace
(549 posts)And what Google gave me is links to a whole bunch of separate sites but no idea if they sell insurance in my area. And no idea how to compare them. I could spend a few hours opening each link, filling out info, and entering it into a spreadsheet.
But if I go to this page - http://www.healthcare.gov/
I can put in my state and a few other pieces of information (location/people/ages) and I get (based on the data I used) 137 different plans to choose among.
Once the Exchange is in place it will get even easier because the plans offered will be standardized.
boston bean
(36,913 posts)to make up the difference.
you surely do not think they will lose one single dime, do you?
former9thward
(33,424 posts)Health care companies run between 3% and 7% profit. So they are well under the 15%-20% ceiling already. No one will get any 'rebate' checks. This is why during the health care law debate you didn't hear one word from the insurance companies that they were going to be put out of business. No instead the mandate will bring them tens of millions of new customers.
dkf
(37,305 posts)I hope this isn't as shortsighted as i think it is.
Bob Wallace
(549 posts)If a company pays out more for health services then they can increase their premiums, take 20% of the premiums for admin costs and profits.
But IF they increase premiums customers will probably move to a less expensive provider. Remember, in the Exchange the policies will have to offer the same set of coverages. If people don't like the price or customer service they'll move and take their 20% with them.
If all insurance companies start jacking up prices then the federal budget is going to feel the pain and Congress Critters are going to be a lot more receptive to a public option designed to create more competition.
Somehow I think that having companies like Costco in the mix is going to mean that there's going to be ample competition. We'll have to wait and see....
dkf
(37,305 posts)Bob Wallace
(549 posts)When the Exchange goes into effect your employer will find it easy to pick among a number of providers.
And those who purchase their own insurance will also find it easy to shop.
icymist
(15,888 posts)Interests who only want money are going to reinburst? I want to see this happening before I give a HORAY!
spanone
(141,275 posts)Stuart G
(38,726 posts)Betty Karlson
(7,231 posts)but this little piece of it must never go away.