San Diego Housing Bubble News and Analysis

It is an issue of insurance provider not healthcare. Anyone can walk into an emergency room and receive treatment...for free. As well as free neighborhood clinics for the impoverished.

Another variable that no one mentions is that if you are going to offer -more- healthcare to -more- people, who will provide the actual service? Do we have an abundance of docs? No. Everyone will not see doctors right away they will first have to see a physicians tech or an RN's.

Is this an improvement of service?

Nothing can be fixed until our broken economic system is stabilized. We don't even know what are capabilities are or what our money will be worth next year.

Every system we have is broken and spiraling out of control.

Trying to fix health care is like trying to fix the steering column on a car with a blown head gasket and electrical problems and cut brake cable heading for a ditch with gang bangers trying to car jack you.

After we hit the ditch and are robbed, then we can talk.

So the question becomes What do the providers and doctors say in common?

Doctors may be the wrong people to ask, because they will do their job to the best of their ability regardless of who (insurance companies vs governmet) is paying the bill. Doctors get paid either way.

Remember, this debate is about who will be paying for the healthcare, not the actual healthcare itself.

i dont know. family member's a doc. hates the system. HATES INSURANCE. won't practice for insurance reimbursement. dont' know if a new regime would eb betetr or worse, but for many docs, the insurance game makes the whole practice unpalatable. can make money doing per diems, not dealing wiht ins. co. it's a big big issue for doctors, and there are some who dont absolutely need to work who bail because they feel it's just not fair to them and constant hassle and struggle. I have no idea what the right thing to do is, except i am certian a bit more exercise, relaxation, and weight loss would take care of a big chunk of our problems. but not all...

Recent polling shows that most physicians support reform, and a public option (or even stronger) in a wider margin than the general public.

http://www.npr.org/templates/story/story...

Most doctors — 63 percent — say they favor giving patients a choice that would include both public and private insurance. That's the position of President Obama and of many congressional Democrats. In addition, another 10 percent of doctors say they favor a public option only; they'd like to see a single-payer health care system. Together, the two groups add up to 73 percent.

When the American public is polled, anywhere from 50 to 70 percent favor a public option. So that means that when compared to their patients, doctors are bigger supporters of a public option.

I dunno. May not be an unbiased sample.

IF this gets pushed through my money is on docs forming boutique private practices combining several specialities to serve a small group of local patients who, like the docs, don't want to deal with the govn't system.

If you can identify bias in the polling data, I invite you to do so.

Most all doctors (with only minor exceptions) already deal with a government payer, medicare. Most physicians can't avoid it anymore than they can avoid dealing with private insurance.

Anectdotally, most, in my experience, (as an advisor to scores of MD's over the last 30 years) are quite content dealing with the government as a third party payer, at least as content as they are with private insurance.

A friend of mine is an ENT out in Arizona and he's adamantly opposed to everything that Obama and the clowns in the house are proposing.

I know several other physicians that feel the same way. I don't know who these people are that they polled but that viewpoint sure isn't represented by any of the physicians that *I* know.

There's a data point for you...;-)

"....70% of doctors polled in a Tipp/IBD poll 2 weeks ago opposed it, 45% said they would retire or quit the profession...."

Quite the disparity.

But who is Tipp/IBD? Ah here we go...http://www.tipponline.com/index.php?option=com_content&view=article&id=2&Itemid=3

Lets see what I can find from Gallup or Pew...

I saw that a few weeks ago, and a few things jumped out at me.

First, the poll was done by mail. Highly unusual for scientific polls. I couldn't find the margin of error (I confess I didn't look real hard) but I suspect it's pretty high.

Second, it said "responses are still coming in". Huh? How can they publish poll results when they don't have a completed poll? Most any respected pollster will confirm this is both highly unusual and dubious.

Third, at least one of the questions is atrocious: "Do you believe the government can cover 47 million more people and it will cost less money and the quality of care will be better?". Good pollsters ask one question at a time. That's arguably three questions. Otherwise it's impossible to know which question the respondents are answering. It's a useless poll question.

And lastly, IBD/Tipp sounded familiar, so I looked. This is the same organization that had the presidential election a year ago a virtual dead heat 11 days before the election, with an astounding almost 12% undecided. More than double any other poll. They also had McCain winning the 18-24 demographic by a whopping 74 to 22% margin. According to the NY Times, just 11 days later, Obama won that demographic by a margin of 66 to 32%.

http://1.bp.blogspot.com/_6m0u0rGkVnc/SQ...

As a professional polling organization, IBD/TIPP sucks. Which explains why their poll results are so different than others.

Recent polling shows that most physicians support reform, and a public option (or even stronger) in a wider margin than the general public.

http://www.npr.org/templates/story/story...

..

If you can identify bias in the polling data, I invite you to do so.

How about the fact that when you go to Scripts Hospital for an MRI, you will get a discount of aproximately 30% if you pay direct with your own cash/check than if they have to deal with your insurance. Considering they are giving up somewhere around $300 just not to have to deal with insurance makes the preference quite clear.

Right, their preference is to get cash in hand ASAP. I'm guessing that 30% discount is probably just about the same (or an even smaller discount) than insurance companies and medicare have already negotiated.

But that's really not what the reform question is about. The more important question is whether they would rather deal with the federal government or private insurance. Since they already deal with medicare, almost flawlessly, the only significant question is reimbursment rate.

I think that it's all a question of economic policy.

We are spending too much of our GDP on health care and we need to cut back.

The expensive drugs and procedure have got to stop. Period.

I wish someone had to guts to come and out say it plain and simple.

Everyone should have a minimum -- say $5000 per year in coverage. Anything over and above that needs to be paid by private insurance just like auto.

Yeah I didn't catch that. Mail polls are known to be unreliable. Same with straw polls.

Here's some legislation that makes sense to me regardless of opinion from the horses mouth. HR 1583. It repeals some or all of the 1945 McCarran-Ferguson Act, which exempts the insurance industry from anti-trust laws. Here's the link;
http://www.ifebp.org/Resources/News/Regu...

The fight in congress now isnt about if extending health care coverage to everyone is a popular idea. It isnt about if extending health care to everyone is going to increase overall health. It isnt if doctors support increased health care spending.

The fight is about COST. COST of extending health care. I believe that the reason the Democrats are so intent on getting bi-partisan support for this bill is becuase they know their 'savings' are crap and will not be realized. As such, it will cost hundreds of billions to TRILLIONs of dollars over the next decade to do what they are proposing.

When added ontop of the trillions in deficit spending we are spending each year, it is a mind numbing reality. If they can claim bi-partisan support, even alittle, they stand a chance when the blowback comes politically. If not then it will be 1994 all over again.

I have heard of some saying to allow interstate competition.

What is that about?

I agree it is an issue of INSURANCE and not healthcare. I remember listening to some argument, I think on KPBS, about whether illegal aliens should have access to this insurance. One side was saying no. The other side was saying yes, b/c more people will lower the insurance and actually cost taxpayers less b/c otherwise the illegal aliens will go to the emergency room and taxpayers will pay for it anyway, only more.

Exactly as ucodegen mentioned about the 30% off on the MRI. Have any of you gone to a doctor w/out insurance and they cut you a break on the price? I say insurance IS the reason healthcare is so expensive.

With regard to bipartisan support, I had posted this on a thread, Nixon's plan for healthcare reform. I guess Democratic congress was against it. Here we are 35 years later still dealing w/it, only roles reversed.

Nixon was to the left of Obama. There is no left in the US

Right, their preference is to get cash in hand ASAP. I'm guessing that 30% discount is probably just about the same (or an even smaller discount) than insurance companies and medicare have already negotiated.

No its not. I talked to them about it. Go through insurance, charge is full price, period. In addition, 30% is not equivalent to the time-value-of-money for the reimbursement period in question. Besides, why present one amount as the cost when using insurance cost while the real cost for using insurance is done under the table? Does not make sense.

This same thing has happened with auto insurance... driving up repair costs. People only see the large bills, not the steady drip-drip-drip coming from their pockets. This is also why house prices are framed in terms of monthly payment.. not total price when talking about affordability.

I assume you have seen the TV commercials out for auto repair insurance.. showing that if you have a big repair, ie ECU (Engine Control Unit), you have to pay a lot of money and with their insurance, you have to pay nothing.. what they fail to mention is that with insurance, you have been paying every month for that ECU, whether or not you really end up needing to use the coverage. Insurance companies end up making money off of holding your money for a period of time and by making sure that the total amount they pay off in claims is less than the total amount the receive in premiums for a given time period. After all, insurance is a business, run for profit.

But that's really not what the reform question is about. The more important question is whether they would rather deal with the federal government or private insurance. Since they already deal with medicare, almost flawlessly, the only significant question is reimbursment rate.

Actually it is what the reform question is about, and medicare reimbursement is not in any way flawless. In fact, the entire Medicare insurance system is nearly bankrupt and the paperwork can be a nightmare(from the doctors point of view). The discussion is actually 3 way; self-pay, private insurance or public(gov) insurance. Insurance companies want to frame it in terms of private vs. gov insurance with the gov insurance 'taking away your rights'. They don't want people to look at self-pay because people will realize that the insurance companies are basically ripping people off.

Hopefully you misunderstand what I'm saying, otherwise you're just wrong. Insurance companies do not pay full charges. For both HMO's and Perferred Provider plans, rates for services are specifically negotiated. (That's how physicians, hospitals and other allied health services get on to the insurance companies "approved" lists.) Most have negotiated rates anywhere from 30 to 90% of what cash customers are charged (before discounts) depending on the specific service. Most non HMO and non preferred provider plans also provide that they will reimburse "reasonable and customary" charges, which are almost invariably lower than full charges that doctors or hospitals will quote.

MRIs are a limited resource.. with a limited number of machines. It is very hard for insurance to negotiate these down.

For HMO/PPOs it depends on whether you get to choose your own doctor or use a plan doctor on how much potential discount through the plan. Service may also suffer w/ the plan doctors.

In doing self-pay vs comparison of what I would normally pay for with insurance (including the monthly payment), self-pay easily wins. What ever savings there may be in negotiated fees for some services, easily gets eaten up in the insurance company's overhead. I included what I would pay for dental. I have had to have considerable dental work (lost track of the number of crowns), to the point that I would have gotten close to busting the lifetime cap on some dental insurance plans. BTW before you jump in on it, the reason why I had to have so much dental work was because of a dentist, not because the lack of one.

The degree of discount on rates is largely a fallacy. An easy way to check would be to figure out how much is being paid in for a GP's office using self-pay rates and then calculate out what the effective earnings would be (subtracting office overhead, support personnel wages and insurance, malpractice insurance). The numbers end up not working out for a large discount. I even ran this for my GP.

Why would GPs and groups like Scripts give discounts to cash payers? Maybe because they don't have to carry overhead to manage the insurance on these. I don't think 'charity' fits here, certainly when you are dealing with a client who can whip out the checkbook and cover a $3000 bill without breaking a sweat.

http://www.cbsnews.com/stories/2004/04/0...

Paragraph 4-7 is interesting here, read all:
http://www.articlesbase.com/insurance-ar...

http://www.nctimes.com/business/article_...

There is a field within an insurance company's 10K/Q that you may want to look at. I don't remember the exact name is, but it equates to the ratio of claims paid out vs premiums paid in. Usually this number is less than one. During the time between the premium being paid in and the claim being paid out, the insurance co has use of that money for investing.

It's not a fallacy, it's real. I just checked my summary of charges for 2008. My total charges were $3,884. My insurance (Aetna) paid $1,972.91, and I paid $170. Providers (for this year, coincidentally, it was 100% Scripps Clinic) took a discount of $1,741.90 or 44.8%. For 2009, the numbers are similar (total of $2827, insurance paid $1606, i paid $90, net discount of $1131 or 40%). I have no idea how the providers overhead and expenses are related to this issue. Those are mostly incurred regardless of cash payers or third party payers. (There would be some savings obviously if they didnt have to process all the insurance/medicare stuff.)

The term you're looking for is loss ratio. The % of premium dollars that are paid directly for health care. It is always less than 1. If it was anywhere near 1, we wouldn't need reform. That's a huge part of the problem. In the late 80's to early 90's, when I did health care financing consulting for small medical groups and non-profit hospitals, (when capitations for primary care physicians was becoming common place) loss rations were in the very high 80's to mid 90's. (I remember one year when, i think it was Blue Cross, bragged about getting their loss ration below 90%) They're now in the high 70's to low 80's and getting worse for consumers, better for insurance companies. All that extra profit is going directly to the bottom line of insurance companies. The system is irreparably broken.

Medical insurance is claims incurred insurance. Since most policies call for monthly or bi-monthly premiums, use of the premiums prior to payment of claims is not material as it is in life, disability or even professional liability insurance, where payment of claims are deferred.

Doctors are a diverse group and I don't think there is a common voice. I am a physician and would be thrilled to have a universal payer system. Currently there is way too much overhead in dealing with so many insurance companies. We're already paying for the healthcare of the uninsured (through emergency care, disability checks to those whose disability could have been prevented, and community clinic subsidized by state/federal programs)so I don't see why we don't do it in a way that makes sense and would be cheaper (ie preventative care).

just my two cents....

Insurance is the reason that health care costs are so high and quality is subpar (at least 100K deaths from hospital infections/mistakes)
It is well laid out in this long article below which is titled
"How American Health Care Killed My Father". Highly recommended for anyone who cares to understand the issues.

Simple solution: Require catastrophic insurance for everyone (subsidy for poor) and have users pay (edit-) cash for everything else. This will increase competition, increase quality of care, and reduce costs.

If you don't believe this, come to dark side and I will show the best (simple, low-to-medim risk) investment over last 25 years. Yep, Vanguard Healthcare Fund, nearly 17% annualized return over last 25 years by my friend Edward P. Owens. There has been a lot of profit made in that sector that came from the insured.

A solution that even sduude can support!

http://www.theatlantic.com/doc/200909/he...

It's not a fallacy, it's real. I just checked my summary of charges for 2008. My total charges were $3,884. My insurance (Aetna) paid $1,972.91, and I paid $170. Providers (for this year, coincidentally, it was 100% Scripps Clinic) took a discount of $1,741.90 or 44.8%. For 2009, the numbers are similar (total of $2827, insurance paid $1606, i paid $90, net discount of $1131 or 40%).

You also did not include what you are paying per month for the insurance. What were the charges for? Your total is a lot higher than what I spent when I had 'complications'.. you have kids?.. just trying to figure out how you incurred $3,884.

Those are mostly incurred regardless of cash payers or third party payers. (There would be some savings obviously if they didnt have to process all the insurance/medicare stuff.)

The insurance involves more than 'some' of the overhead. This is why several doctors are going cash pay.

If it was anywhere near 1, we wouldn't need reform.

And people are falling for the same argument that was applied to no-fault auto insurance... if everybody was insured the costs would be lower. This proved to be untrue and the insurance commissioner position was created in California to try to address that.

Ucodegan, it appears you're arguing against having insurance, that it's cheaper just to pay discounted rates for care instead. In some cases I'm sure that's correct. The whole idea of insurance (any kind of insurance) is to cover otherwise unaffordable losses. Anyone that has had to actually pay for hospital stays, or costs related to significant injury or illness understands this. Most people wouldn't buy homeowners insurance to cover a baseball going through a windows. They buy it to cover the house burning down. It's an entirely different discussion than I was having. But I'll try to address your points.

What I am paying per month has nothing to with whether or not insurance companies pay full charges, which is what I believe you originally said. At least that's what I was responding to. If I misunderstood you, we've totally been talking around each other.

Those charges were just mine. They didn't include my prescription drug charges, which would run about $280/month, i pay $50. My employer pays approximately $450 per month for my premiums. After comissions and costs, I suspect the insurance company loses a small bit money on me every year. Which is why, if I lost my employer sponsored insurance, I would probably be uninsurable due to pre-existing conditions (all very controllable, but require regular maintenance. It's a bitch getting old.) if I had to buy my own policy. Though I don't think any of this is really material.

Processing insurance company claims is just "some" of the costs of running an office. It's not immaterial, but it typically is less than 10% of revenues in small offices, much less for large organization. Doctors who complain that it costs more than that are doing it wrong. (I "taught" them how to do it for many years.)

Your final statement about the loss ratio is not even an argument I've ever seen made in the reform debate. Nor does it make any sense. Too much premium dollar goes to insurance company bottom line. That is the problem. That is why we need competition. It really is that simple.

Latest CBO report on the Baucus Bill: http://www.cbo.gov/doc.cfm?index=10642