I was a controller of a medical clinic for a number of years

[upaloopa]

We were reimbursed by Medicaid, Medicare, private insurance and patient out of pocket.

Doctors were paid 40% to 60% of the revenue they generated if they were employees.

The rest of the overhead, salaries,medications, equipment, building and maintenance and admin were paid from the remainder.

We had to perform every step of the billing cycle efficiently in order to cover expenses. Anything less than efficient added to the cost. We did not determine how much we were reimbursed. Insurance companies and Medicare and Medicaid dictated how much we were paid for a procedure.

Back then Medicare paid around 80% of the amount billed. We billed our cost.

Insurance companies paid some percentage of Medicare either more or less.

We didn't contract with companies that paid less than Medicare.

Medicaid paid 50% of the amount billed.
We made up the difference by insurance reimbursements.

So we preferred patients who had insurance but we treated everyone who came.

So how would Medicare for all effect us I wonder.

We would get less reimbursement for every procedure.

Doctors and employees would have to take less income.

Hopefully medications and equipment would be cheaper.

Building costs would remain the same. The administration would be less if Medicare did all the billing.

Also more clinical staff would be needed to handle more patients.

So the main thing I see for a clinic to change to Medicare for all would be a need to cut direct costs to break even. Salaries and medicines and equipment needs to cost less.

[SheilaT]

1. How many staff were needed

to bill Medicare, Medicaid, and all the different insurances you accepted?

Those numbers would be greatly reduced in a single payer system.

I also think Medical school should be free, or very nearly free, so that doctors don't start their professional life with huge debt that they need to charge a lot of money in fees in the first place to pay it off.

[upaloopa]

2. We still need to bill Medicare

Doctors notes had to be coded by certified coders then billing staff did the billing. I don't see the cost of that changing if Medicare did it. You would just pass on the cost to Medicare.

All emoyees not just doctors would have to take less since Medicare does not cover costs.

[upaloopa]

10. You would hire government staff

[SheilaT]

11. But surely there would be far fewer staffers needed if

there were one and only one place to send bills.

Oddly enough, other countries manage to spend a lot less money on health care and often have better outcomes than we do here.

[upaloopa]

12. The higher costs are insurance premiums and

medication.

The cost of treatment less medications is probably similar.

[SheilaT]

22. Then perhaps the vastly lower insurance premiums

would mean that doctors' pay could remain the same.

[Bread and Circus]

3. I am a doctor...I like your post. Bookmarking for when I have time to reply thoroughly

EDIT: Just for the record, before I respond in full, I like that you are starting an earnest real world discussion and much of what you point out is reality. I dont agree with you conclusions exactly. But definitely would like to have the conversation.

[GeorgeGist]

4. Socialize it all.

No bills. No profits.

[Kentonio]

6. Exactly.

If you see Medicare for all as literally the current Medicare extended to everyone, then its probably a pretty weak idea. If instead the new system is genuinely a non-profit universal healthcare system then you see the problems fall away.

[mythology]

19. But which version of socialized medicine do you use?

Very few countries do a full single payer. The Netherlands for example uses a mandate to purchase non-profit health insurance with the state covering catastrophic coverage and the Netherlands ranks in the top three of health care outcomes in Europe every year for the last decade.

[joshcryer]

25. Colorado has done this to an extent with Community Health Clinics.

Teen pregnancy sank to an all time low due to free contraceptives and birth control, etc.

[FreakinDJ]

7. MRI = $600 for insurance same procedure $125 for out of pocket

They bill insurance companies 4x for the same procedure - explain that

I'll do it for you

They justify the increased cost by claiming "Unreimbursed Medical Cost" for people without insurance or under insured.

In Bernie's plan everyone would be insured at the same rate. Medical offices and groups would be rated by cost efficiency and the "LOWEST BIDDER" would be awarded the patients.

Then FAT would be trimmed

[upaloopa]

8. The insurance company determines the reimbursement

We never charge out of pocket the full cost because people usually could not pay it.

[FreakinDJ]

9. WRONG - you charge the insurance companies MORE

The insurance companies decide IF they cover the procedure or do business with that group

[upaloopa]

14. I am not wrong

Each year we contracted with each insurance comany. They each had their own reimbursement rates. No matter what we billed we got the reimbursement per the contract for a given procedure.

[FreakinDJ]

15. How many insurance companies stopped contracting with you for charging 4x more

[upaloopa]

17. I told you it doesn't matter what we billed

We do not determine reimbursements

I will say it again but I doubt you give a shit

At the beginning of the year (if it is a one year contract) we got a disc with the reimbursement rate for each procedure code. We had to accept the reimbursement rates if we wanted to contract with the insurance company.

No matter what we billed we only were paid per the contrat.

Now if you still want to play gotcha games please don't reply.

[FreakinDJ]

21. It doesn't matter as long as you can gouge the Working Class

And you do it for the owners to justify your job

[Douglas Carpenter]

24. That is exactly what they do! When the DRG's or other cost control mechanisms

came in - they immediately higher a bunch of "how to screw the system" experts. The ones that can turn the cost control mechanism into something that actually increases revenues - they are the ones whose careers flourish.

[mythology]

20. I take it you don't work in any portion of the health care or insurance industry

Because you are very wrong on this. Insurance companies contract with providers/practitioners to a mutually agreed upon price. Different hospitals/providers can charge different rates, even at different locations for the same hospital/provider.

[Human101948]

13. Other developed countries pay half of what we pay for better results....

There should be no further discussion until we put in place the best practices of those systems. It is a crime that we have this half assed crazy expensive system and we get worse outcomes than other developed countries!

Trying to fix the country system without a complete refurbishment is just plain foolish.

[FreakinDJ]

16. And recieve BETTER care

because they have access to it

[Human101948]

18. Yes...the discussion is loony...

it's like a conversation in an insane asylum.

[Douglas Carpenter]

23. And the U.S. still ranks # 37 in the world in healthcare at roughly double the cost

Last edited Tue Dec 22, 2015, 08:45 AM - Edit history (1)

What are some other countries doing right that we are doing wrong?

I personally would prefer a public healthcare system like the UK, Sweden or France to a fee-for service single payer approach such as "Medicare For All" or even the Canadian system - since that would be the most conceivable way I can imagine to get cost under control.

To me single-payer would be almost the equivalent of the voucher system for education as opposed to a public school system.

But one thing is for sure - other systems elsewhere whether comprehensive socialized public healthcare or fee-for service - single-payer - especially in the developed world are providing healthcare for everyone at a much lower cost than what the U.S. is doing.

This has now turned personal for me. I have insurance and I have savings and I have lived most of my adult life as a responsible middle class citizen - I am also a healthcare worker, a Respiratory Therapist. But I am now 61 and I also have Esophageal and upper Gastric Cancer that is metastasized and malignant. If I don't either get better or die soon - I will or could likely face almost total financial ruin in spite of my good comprehensive Aetna Insurance and what savings I have that I have worked all my life for. And yes, I am bitter about it! - I'm not going to waist any energy feeling sorry for myself though. Because I am better off and in a better position than many - if not most Americans in a similar situation. If I was British or Swedish or French or Canadian - I would still be sick - possibly terminally - but I would not have to worry about all that I worked and saved for going down the drain.

Every time someone makes a strong proposal for something that might actually work - we get hit with a combination of a litany of lies about healthcare in other Western democracies or the "sensible centers" wisdom - "Now is not the time - wait till later." They were saying that 50 years ago. Just how fucking long do we have to wait to behave and act live a civilized society that takes care of sick people?

[handmade34]

26. the assumption

that Medicare policies would stay the same if we switched to Medicare for all may not be accurate...

[rogerashton]

27. Upaloopa, what you describe is quite right, to the best of my knowledge

But it can be expressed in a different way:

We have a no-party payment system in which hospitals tax insurance companies to subsidize care for those who do not have private insurance.

That system is wildly inefficient. And the hospitals are not without bargaining power visavis the insurance companies: the contract for reimbursement rates is negotiated annually. It is clear that in metropolitan areas where there is only one or two big hospital systems, insurance reimbursements and costs are higher because of hospital monopoly power. You are in Boston, right? Lots of competition among hospitals there, which would reduce hospital bargaining power and so pinch your insurance reimbursements. Welcome to the wonderful world of competition.

Accounting cost is a squishy concept, as economists and many accountants will verify. Remember the joke about the accountant who is asked "How much is two and two" and responds "How much do you want it to be?" Now, I understand that you have enormous, real, fixed costs that have to be covered. To whom may they efficiently be billed? Years ago I knew an accounting prof who was on the FASB as a specialist in nonprofits. I asked him that question -- is there a rational way to assign fixed costs to the different services that share in them? He said no.

Now: all that said, there is one big problem with public medical care. It is that the politicians will never raise taxes enough to fund it adequately, without public pressure to do so. This has caused crises in Canada and Britain at different times. Let's see: who is promising not to raise taxes? Every Republican and one other person, I believe.

[Thinkingabout]

28. Thanks for your experienced post. Medicare for all is not free and I

Am not sure many knows this. Maybe removing the for profit insurance companies and workers may reduce the overall cost. One of my problems has been those who work in the medical industry does not get the big bucks insurance companies executives receive, the ones who spend lots to become our medical team and lots of hours are cheated by the siphoning of these other employees.

A close friend carries international insurance and his policy has a clause if he is in the US and needs emergency services to get this but if it is elective to go to some other country because if the high cost.