The Audacity of Greed: Profiteering in American Medicine

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With the advancements in medical science and technology, why do Americans still suffer the brunt of an ineffective health care system? The patient is not the priority in today's medical world. The Doctor is not heeding the Hippocratic Oath --- but instead is motivated by money. Medical profiteering has driven medical costs to unsustainable levels while eroding the quality of care.

Russell Andrews' book Too Big to Succeed: Profiteering in American Medicine   provides an interesting analysis of this trend. He reveals the rotten core of health care system hidden from outsiders. Discover why health care costs are increasing while medical benefits are dwindling.

Problems arise when there is a mismatch between reality and our perception of reality. In the scientific world, there are paradigms that guide the pursuit of knowledge. Experiments are constructed based on rules (guidelines based on prior experiences) to further support or disprove those paradigms. Based on how ingrained a paradigm is (“Is it based on fact or on ideology?”), changing the paradigm can be very difficult. Examples of paradigm shifts from the scientific world include the shift from “the earth is flat” to “the earth is round” and the shift from “the earth is the center of the solar system” to “the sun is the center of the solar system.” People have paid dearly for their correct but unpopular point of view (e.g., Galileo was placed under house arrest for insisting that the sun, not the earth, was the center of the solar system). Scientific paradigms may not shift easily, as documented by Thomas Kuhn in The Structure of Scientific Revolutions.1

Similar problems arise in the socioeconomic world when there is a mismatch between reality and our perception of reality. Here there is not only ideology that may hinder acceptance of the mismatch, but also one’s perception of his or her own personal economic benefit. In the game of life, societal good rarely trumps personal gain (or, perhaps more accurately, one’s perception of personal gain). This appears The current health-care system in the United States has a significant mismatch between the reality of the health care provided to the populace as a whole and the perception of that reality—at least the perception in the minds of many people in this country.

Though we spend 50% more on health care per capita than other developed countries, a multitude of measures—such as life expectancy and infant mortality—indicate that we in the United States are not getting health-care value for our money. Yet many argue, often with religious fervor, against change in our health-care system. One must have “choice” (more accurately, perceived choice rather than actual choice) not “socialized medicine” (whatever “socialized medicine” means) at all costs—even if adequate health care becomes a dream for the majority of Americans because of the phenomenal personal expense. When an industiy constitutes upward of one-fifth

Medicine today in the United States is big business. To see how far it has deviated from its origins in the Western tradition, we do well to consider the Hippocratic Oath:

Understand how we can change the trend in doctor-patient relationships all over the country, where individuals can start to realize that great emphasis should be placed on “the healing art and science of medicine,” instead of on the profitability of the health care delivery system.

We need to learn how the profit has trumped the patient in American medicine, and fight back.  Profit is now the most imporant agent of change for real health care in America, which corrupts the whole system. We need to know the typical pitfalls and fight against them. In the US medical system the patient life is often depends on how well he/she understand the ropes. Yes, your life depends on it! It is very early to gat expensive and unnecessary surgery in the USA those days. Which can be deadly. The number of  cardiologists sentenced to jail in the USA is in dozens. And they are just the tip of the iceberg. Cardiatic stents are probably the most glaring example. But other "lucrative" areas, in such field as gastroenterology exists too.  Another huge area is pharmacology abuse ("big-pharma" corrupting influence).

Dave Zweifel, The Capital Times (Madison, WI)

Here's another one to remember when someone tells you that our "private" health care system works: The Wall Street Journal ran a front-page story last week with the headline that said it all: "As Patients, Doctors Feel Pinch, Insurer's CEO Makes a Billion." The story, datelined Minnetonka, Minn., was about William McGuire, a doctor who stopped practicing in 1986 to take a management job with UnitedHealth Group Inc., one of the largest HMOs in the country.

He's now the chief executive officer of the corporation, makes $8 million a year in salary plus bonus, has personal use of the company's private jet and has amassed what the Journal describes as "one of the largest stock options fortunes of all time." According to the newspaper, those options total $1.6 billion.

"Even celebrated CEOs such as General Electric Co.'s Jack Welch or International Business Machines Corp.'s Louis Gerstner never were granted so much during their time at the top," the WSJ story said.

But the gist of the story is that while McGuire and other UnitedHealth execs are raking in millions, their company is putting the squeeze on everyone else.

"Dr. McGuire's story shows how an elite group of companies is getting rich from the nation's fraying health care system," the bible of the business world reported. "Many of them aren't discovering drugs or treating patients. They're middlemen who process the paperwork, fill the pill bottles and otherwise connect the pieces of a $2 trillion industry."

The newspaper's research shows that UnitedHealth has particularly benefited in recent years as health care inflation eased somewhat.

Insurers still raised premiums at double-digit rates. At UnitedHealth, for example, its stock price tripled from January of 2003 to January of this year and its net income rose to $3.3 billion. Hence, the nice board-of-director-approved windfall for McGuire. (Interestingly, former UW-Madison Chancellor Donna Shalala is a member of UnitedHealth's board.)

"In Minnesota, such riches have infuriated some people," the story continued. "Joel Albers, a Minneapolis pharmacist, regularly impersonates Dr. McGuire at state fairs, donning a tuxedo, holding up an enlarged picture of Dr. McGuire on a stick and handing out leaflets denouncing corporate greed."

Of course, this is just one more anecdote that serves to describe our broken health care system, which leaves more than 40 million Americans without coverage and an embarrassment of riches for those who know how to milk that system.

On one hand we have Medicare, which provides universal single-payer coverage to all Americans over age 65 at about a 2 percent administrative cost. On the other hand we have a hodge-podge of plans with layer after administrative layer that gobbles up close to 20 percent in overhead costs (Dr. McGuire's just a piece of that) and leaves millions out in the cold.

How hard can it be to choose in which direction we need to go?

Dave Zweifel is editor of The Capital Times. E-mail: [email protected]

Copyright 2006 The Capital Times

Source: The Capital Times (Madison, WI)
http://www.madison.com/tct/opinion/column/index.php?ntid=81491&ntpid=0

The HMOs and their managed care systems  ballooned from a headache to a plague

November 13, 2003 Home Doug Dowd Economic Historian by Doug Dowd

The HMOs and their managed care systems -- first supported in the Nixon years -- ballooned from a headache to a plague beginning about ten years ago. Their pitch was that they would end the inefficiencies of the past.  However, the period in which they have come to dominate the health care system is precisely that in which its costs -- and its inefficiency (unless you count mountains of paperwork something other than waste -- began the acceleration that continues.

Some of the rising costs were due to factors other than the HMOs, not least the gouging prices set by the pharmaceutical giants. OK, but all of them are part and parcel of the "for-profit health care system." Nonetheless, the HMOs have done at least their share in bringing about today's mountainous costs.

What started out as annual one-digit overall cost increases became two-digit as the 1980s ended, rising to 15.3 percent for 2002. Not good enough: In mid-2002 the NYT reported that "Health maintenance organizations are demanding rate increases of 22 percent in their ongoing negotiations with employers for 2003... which will be passed on to consumers." They were "passed on," and they continue to be.

As the tendency of always higher costs and prices continues, it needs repeating that the provision of health care to the average person has decreased both quantitatively and qualitatively. What's good for their profits is bad for our health.

What is it about the HMOs that such is the case? What was the system they presumed to replace with great savings to all, and profits to them as a reward? It was called the "fee-for-service" system: Other than those covered by Medicare and Medicaid, health insurance for those who had it was selected and paid by one's employer, which used to be so for about two-thirds of workers.

As the numbers of insured rose from the 1950s on, so did doctors' incomes: the insured could choose their own doctors and the doctors soon realized that the more treatments they gave the better off they -- but not necessarily their patients -- were. As Ellen Frank pointed out two years ago, "American doctors performed invasive tests and procedures at rates far exceeding international norms....Caesarean sections, surgerized ulcers, hysterectomies and tonsillectomies far above the rates in other countries, etc." (Dollars & Sense, 5/6, 2001)

Adding to that, past and present, is the friendly corruption between doctors and labs and drug companies. The pleasant consequence for doctors from 1960 to 1990 was that their incomes rose two to three times faster than the nation's, bringing them up to a lovely $200,000 annual average. So that's what the Hippocratic Oath was about!

One might think that such an evolution -- or, better, devolution -- would have led everyone but the doctors and labs and drug companies to open their minds to a national health service/single-payer system. But that overlooks certain large facts:

1) Employers as a whole tend to have a knee-jerk negative reaction against anything do with government (unless it is in the nature of a subsidy), and just as "instinctive" a response in favor of "private enterprise," which is what HMOs are;

2) the average citizen lives in the same society, and has been taught to think in much the same way, if not for the same reasons;

3) the major insurance companies have always been opposed to any form of social insurance -- beginning with their adamant fight against social security from 1935 to the present; and

4) this created a new industry for thousands of lobbyists. They have been very successful indeed in their efforts on behalf of the "Big Five" insurance companies (Aetna, Cigna, Metropolitan, Prudential and Travelers) and related managed care companies -- which, taken together, now "cover" 90+ percent of those receiving care. Here a lucid and crisp summary review of what brought us to our present state, and how it happened (as related by Ellen Frank):

The early 1990s saw a wave of mergers and acquisitions among health insurers that left large regions of the country with only two or three competing health plans. Their superior bargaining power allowed insurers to negotiate sharp reductions in fees, which were passed on to employers in the form of lower premiums. In 1994 the average health-insurance premium /paid by employers/ fell for the first time in years; premiums increased at or below the inflation rate for the rest of the 1990s.

Hospitals, facing lower reimbursement rates, cut staff and beds for traditional inpatient care while expanding facilities for expensive services like outpatient surgery. Still, hospitals throughout the country suffered operating losses. Large urban hospitals in low-income areas were especially hard-hit.../some like that of Los Angeles, closing entirely/. For-profit hospital chains moved in quickly, buying up scores of non-profit community hospitals.

So, with patients and providers (doctors, labs, and hospitals) getting the dirty end of the stick, that leaves the HMOs, drug companies, and top insurance companies getting the sweet end -- their owners, their CEOs and their countless lobbyists, that is.

Business being business, another rising tendency is that of HMOs dropping Medicare patients, more than 2.5 million 1998 to the present. Plus, "Medicare patients can expect 'major changes -- that is, reductions of -- benefits, even if they are still enrolled: cutbacks in drug coverage /already cruelly inadequate/, and increases in premiums and co-payments." (ibid.)

So there we are. Or are we? Although there is a rising tide of anger, frustration, and worry among our people at the costs of medical care in the USA, with some emerging movement toward universal coverage, most still see the U.S. system, though costly, as the best.

The best is none too good: "According to a recent study of the Institute of Medicine, medical errors in hospitals kill up to 98,000 patients yearly, while injuring perhaps a million more." (Washington Post, Editorial, "America's medical scandal," 12-10-02). Such deaths and injuries are called "iatrogenic"; that is, caused by the docs themselves.

That was a few years ago. Now, as the USA's entire health care system becomes always more privatized and always more expensive to those needing it, those years are coming to look like paradise lost; and we ain't seen nothin' yet.


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[Jul 21, 2021] Patients to Be Protected From Surprise Billing Under New Rule by Stephanie Armour

Highly recommended!
Jul 01, 2021 | www.wsj.com

Patients receiving emergency medical care would no longer get surprise medical bills from providers outside their insurance network under a rule issued Thursday by the Biden administration.

The long-awaited rule is the first to follow the so-called No Surprises Act, passed in December 2020 by Congress that sought to protect patients from receiving significant medical bills when they are unwittingly treated by an out-of-network doctor, lab, or other type of provider.

The rule seeks to implement key parts of the legislation protecting patients from being billed by out-of-network doctors who provide treatment at in-network hospitals, as well as protecting them from surprise bills for both emergency and nonemergency care. The interim final rule will undergo 60 days of public comment and largely go into effect on Jan. 1, 2022, when the law takes effect.

"No patient should forgo care for fear of surprise billing," said Health and Human Services Secretary Xavier Becerra in a statement. "Health insurance should offer patients peace of mind that they won't be saddled with unexpected costs."

Congress and policy makers have sought to tackle surprise medical bills because patients are paying more out-of-pocket for their care, and many out-of-network charges can occur when patients are unaware that they are being treated by a provider who isn't covered by their health insurance.

Out-of-network charges have added to medical debt and rising out-of-pocket payments for consumers: An April 2021 study in the journal Health Affairs found that patients receiving a surprise out-of-network bill for emergency physician care paid more than 10 times as much as in-network emergency patients paid out-of-pocket .

The interim final rule is expansive. Emergency services, regardless of where they are provided, would have to be billed at lower, in-network rates without requirements for prior authorization.

The rule also bans higher out-of-network cost-sharing, such as copayments, from patients for treatment they receive either in an emergency or nonemergency situation. Under the rule, any coinsurance or deductible can't be higher than if such services were provided by an in-network doctor.

The interim final rule also stipulates that patients can't be charged out-of-network for "ancillary" care, which can happen when an out-of-network anesthesiologist or assistant surgeon provides treatment at an in-network hospital.

Regulations that will be released at a later time will implement a procedural process so medical providers and insurers can arbitrate out-of-network payment disputes, a solution that was so contentious it threatened to scuttle passage of the No Surprises Act. Insurers raised concerns that arbitration could put them at a disadvantage and instead favored linking out-of-network reimbursement to a benchmark rate.

The legislative fight over the No Surprises Act that spurred the interim rule was contentious. The American Medical Association and some state medical associations worried it could financially hurt small physician practices that were still reeling from the pandemic. The American Hospital Association supported the arbitration provision but raised concerns about the possibility for uneven enforcement of the law.

The bill will lead to "dangerous, unintended consequences, right in the middle of a surging pandemic," according to a Dec. 15, 2020, letter to then-Senate Majority Leader Mitch McConnell (R., Ky.) from conservative groups such as Action for Health.

Cost-sharing includes deductibles, copayments paid at the time of treatment, and coinsurance, which is the percentage of a bill that consumers pay that isn't covered by insurance. Patients are paying increasingly more for their own care because cost-sharing has increased over time, research shows. Most workers also face additional cost-sharing for a hospital admission or outpatient surgery. Sixty-five percent of workers with employer-sponsored coverage have coinsurance and 13% have a copayment for hospital admissions, according to a 2020 survey by the Kaiser Family Foundation.

Out-of-network charges from anesthesiologists, pathologists, radiologists and assistant surgeons increase spending by $40 billion annually, according to researchers at the Yale School of Public Health.

Congress in its legislation sought to protect patients from unknowingly receiving care from an out-of-network provider. To that end, the rule bans other out-of-network charges without advance notice.

The regulations issued Thursday will take effect for healthcare providers and facilities Jan. 1, 2022. For group health plans, health-insurance issuers and Federal Employees Health Benefits program carriers, the provisions will take effect for plan, policy or contract years beginning on or after Jan. 1, 2022.

Write to Stephanie Armour at [email protected]

Copyright ©2020 Dow Jones & Company, Inc. All Rights Reserved. 87990cbe856818d5eddac44c7b1cdeb8

Appeared in the July 2, 2021, print edition as 'Rule Aims to Stop Surprise Health Bills.'

[Jul 21, 2021] Lab company charged NJ Medicaid up to $1,500 for a $3 drug test for years, state alleges

Jul 21, 2021 | www.msn.com

Truetox Laboratories of Garden City Park performed tests for drugs in urine on more than 140,000 samples between Jan. 1, 2015 and June 30, 2018, the audit said. It is one of Medicaid's highest paid providers of laboratory services.

While Truetox was charging other payers $3 per test, it billed the New Jersey Medicaid program between $1,300 and $1,500 for the same test, the state's audit found. Medicaid didn't pay the full charges, but it paid Truetox $250 for each test.

Start the day smarter. Get all the news you need in your inbox each morning.

State law prohibits Medicaid providers from charging Medicaid higher fees than other payers for the same service.

Repayment of the overcharges to the state is "especially important given New Jersey's ongoing opioid crisis," said the acting State Comptroller, Kevin D. Walsh. "By our office recouping these funds, more money will go back to the Medicaid program, which will in turn provide more services for this population in suffering."

Lindy Washburn is a senior health care reporter for NorthJersey.com. To keep up-to-date about how changes in the medical world affect the health of you and your family, please subscribe or activate your digital account today.

[Jul 06, 2021] Medical-Debt Charity to Buy, Wipe Out $278 Million of Patients' Hospital Bills by Stephanie Armour

June 25, 2019
Non-profits hospitals are actually wolfs in sheep skin. Hospital administrators are basically real estate developers, and that is where the profits go. They have become monsters, quite uninterested in serving the public good. The average CEO makes well more than an order (or two) of magnitude more than the average physician and has much less time and money invested in training. Most of the CEO's are grossly over compensated.
It is time to rein in aggressive tactics used by nonprofit hospitals to collect unpaid bills, including suits and garnishing of wages. The fees are not published. The rates for procedures are unknown until you get the bill. The bill, when it finally arrives, has absolutely stupid figures on it, such as $700 for 1 bag of intravenous saline. Which actually costs about $1. At such prices any discout is meaningless and actually is a cruel joke on sick people.
It is asinine that hospitals don't provide pricing information before you have treatment (obviously, emergencies would be an exception).
Nonprofits in 2016 received an estimated $9 billion in federal tax breaks
Another issue is why those people do not have health insurance. With Medicaid expansion and liberalization there is no excuse for not having it. The one thing Obamacare did was give people the opportunity to get insurance. There is a difference between "can't" pay and "I want to spend my money on something else besides my medical insurance."
Jul 06, 2021 | www.wsj.com

Maryland recently added new restrictions on hospital debt collection , after a state report said hospitals wiped out less than half of their charges to patients who were eligible for free care under state law in 2018.

Washington state's attorney general sued hospitals over patients' access to financial aid. Under a 2019 consent decree, nonprofit hospitals refunded about $1.6 million to patients.

Hospitals nationally face ongoing scrutiny for their billing and pricing practices, with new rules this year requiring hospitals to publish prices they have previously negotiated in secret with insurance companies. The Trump administration policy sought to boost transparency for consumers, but many hospitals haven't complied . According to Turquoise Health Co., a startup working with the newly public pricing data, Ballad hospitals have generally complied with the new transparency regulations.

Hospitals can sell unpaid bills to debt buyers in the secondary debt market, where RIP Medical Debt typically buys portfolios for pennies on the dollar. Terms of the deal with Ballad weren't disclosed.

... ... ...

Federal requirements for nonprofit hospitals to provide financial assistance and inform patients about it are limited. Nonprofits have freedom to set eligibility as they choose, and can also create their own process and forms, said Jenifer Bosco, an attorney at the National Consumer Law Center. They are supposed to take steps to alert patients, including making their policies widely available on their websites, Ms. Bosco said. State rules for nonprofit hospital financial aid vary.

[Jul 06, 2021] Hospitals Often Charge Uninsured People the Highest Prices, New Data Show by Melanie Evans , Anna Wilde Mathews and Tom McGinty

Please not that stent insertion is often unnecessary procedure performed not to save the life of the patient but to earn money. The system is criminal indeed.
Non-profits hospitals those day are also governed by Wall-street sharks.
Please note that Abdominal CT scan with insurance like CIGNA would cost you $300-$600 out of the pocket depending on the facility.
Notable quotes:
"... abdominal and pelvic scan at Avera St. Luke's cost $6,422, the highest out of a wide range of rates the Avera hospital charges for that service ..."
"... Some dominant local and regional nonprofits, including Mass General Brigham, based in Boston, and Avera, based in Sioux Falls, S.D., billed the uninsured at their general hospitals some of their highest prices while also setting some of the most restrictive financial-aid policies for free care nationwide, according to tax filings, Turquoise data and patients' medical bills. ..."
"... "It's really criminal, the mess that our current system is in," said Mary Daniel, chief executive of ClaimMedic, which helps patients negotiate payment with hospitals. "It is a deliberate attempt for these hospitals to gouge the uninsured." ..."
"... for expensive procedures like angioplasty and drug-coated stenting, the difference in the cash price within a single county can be over $100,000. ..."
"... The cash prices for patients who must pay for their own care can be equal to the sticker prices or sometimes represent a percentage lopped off that top rate. Sometimes, those cash rates are also applied to people who have some form of insurance but get a service that the insurance doesn't cover. ..."
"... The quarter of hospitals with the most generous free-care policies write off the entire bill for those with monthly incomes under about $2,600 a month, and even up to roughly $6,400 a month, for a one-person household, the Journal found. ..."
"... Those that rank in the quarter of hospitals with the most-restrictive policies draw the line at or below about 160% of the federal threshold for poverty, disqualifying for free care patients with monthly income of more than around $1,700 for a one-person household, according to a Journal analysis of nonprofit hospital tax filings. ..."
"... A patient paying cash at the hospital for the stenting procedure is charged $84,792. Local insurer Fallon Health spends $36,755 for the procedure under one of its health-maintenance organization plans. A Medicare insurance plan from Aetna, part of CVS Health Corp. , pays $16,648. ..."
"... Patients who don't qualify for financial aid at nonprofit hospitals also aren't protected by pricing limits under federal law. The Affordable Care Act requires nonprofit hospitals to cap prices for patients who qualify for financial aid. ..."
"... Hospitals apply financial aid and discount policies inconsistently, say consumer advocates and patients. Offers may be one-time-only, or discounts may emerge only when a skilled negotiator is pushing for them. ..."
"... In January 2018, Joannie Berthiaume spent two days at Broward Health Imperial Point hospital in Fort Lauderdale, Fla., and got emergency surgery to remove her appendix. She was uninsured and the hospital charged Ms. Berthiaume its highest prices. Her bill totaled about $42,000, including a $6,033 abdominal CT scan. For that same scan, an Aetna subsidiary gets a 24% break, according to the newly public data from Broward Health. That discount would have meant a fee of around $4,600 for the scan, based on the price charged in 2018. ..."
"... "If you charge me $42,000 and your costs are justified, how can you knock it in half in a matter of minutes," Ms. Berthiaume says. "You must be overcharging." ..."
"... High cash prices inflate bills that uninsured patients often struggle to pay. Hospitals collected 5% of the amount they billed uninsured patients before writing off bills after a year of seeking payment, according to Crowe LLP, an accounting, technology and consulting firm, based on an analysis of 600 client hospitals. That is compared with collecting 40% of bills sent to patients with insurance for amounts owed under deductibles, copays and other out-of-pocket costs, based on a separate analysis by Crowe of about 1,500 hospitals. ..."
"... Hospitals closely track their "payer mix," or the mix of patients with commercial insurance, Medicare, Medicaid and the uninsured, who might be unlikely to ever pay for their treatment. That could play a role in how hospitals set prices. ..."
"... Resolve also offered about $8,000, or slightly more than the company estimated Medicare would pay, for Mr. Macias's $24,800 emergency-room bill at Avera St. Luke's, Mr. Pan said. The hospital said no, and despite denying financial aid, offered to reduce the bill by 50%, Mr. Pan said. The amount excluded another $34,994 he owes Avera's heart hospital. ..."
"... Have you or someone you know faced a challenging hospital billing situation? Tell us about your experience in the form below. ..."
Jul 06, 2021 | www.wsj.com

... ... ...

The 32-year-old's abdominal and pelvic scan at Avera St. Luke's cost $6,422, the highest out of a wide range of rates the Avera hospital charges for that service based on the new data. The price billed to Mr. Macias was roughly three times the best deal negotiated by an insurance company.

Another scan of his chest came to $4,194, approximately $280 to $2,800 more than any prices negotiated between St. Luke's and an insurer. The prices for identical scans performed at Avera's heart hospital were also among the highest that the hospital charged. His total hospital bills came to $59,800.

... ... ...

Services including emergency-room visits, imaging scans and procedures such as an angioplasty and stenting often performed on heart-attack patients have been identified by researchers and federal data as commonly needed in emergencies by those without insurance.

The analysis used data compiled by Turquoise Health Co., a pricing-transparency startup. At least 44% of the country's roughly 4,900 short-term, rural and children's hospitals hadn't published data that complied with the January rule as of June 18, according to Turquoise.

The Journal analysis looked at the 1,550 hospitals in the Turquoise data that released both insurance and cash-payment rates.

Among the Journal's findings:

In Shelby County, Tenn., home to Memphis, the spread for that type of ER visit is $2,054. It would cost an uninsured patient $884 at any of the three Baptist Memorial Health Care hospitals; $1,480 at Regional Medical Center; $2,653 at Saint Francis Hospital-Memphis; and $2,938 at Saint Francis Hospital-Bartlett.

... ... ...

Hospitals that offer additional discounts for the uninsured don't always automatically make the cuts to patient bills, leaving cash-pay patients with significantly higher charges, the Journal found. It can take long negotiations, often by hiring lawyers or professional advocates, to bring about reduced charges.

... ... ...

Those discounts slash bills by an average of 85% off its top price, the company said in a recent statement to the Journal. But patients must apply to receive the discount. The vast majority of cash prices for emergency services at Tenet hospitals reviewed by the Journal instead reduced bills by 20% to 30%.

"It's really criminal, the mess that our current system is in," said Mary Daniel, chief executive of ClaimMedic, which helps patients negotiate payment with hospitals. "It is a deliberate attempt for these hospitals to gouge the uninsured."

About 11% of U.S. residents under age 65 were uninsured in 2019, or about 29 million people, according to an analysis of federal data by the Kaiser Family Foundation.

... ... ...

The differences between the prices for uninsured people and insurance companies can be wide.

At Ephraim McDowell Regional Medical Center in Danville, Ky., an uninsured person getting a stent after a heart attack could be billed around $66,226 for the procedure. An Anthem Inc. health-maintenance organization plan would pay just $17,895 at the hospital, and the insurer's Medicare plan even less -- $12,445.

Ephraim McDowell Health said the cash prices are the highest rates but that it offers discounts and bill forgiveness for those who qualify for financial assistance. In a written statement, the hospital system said, "it is rare that an uninsured patient would pay the total gross charge amount due to the variety of financial assistance programs available."

Eligibility under the program cuts off at three times the federal poverty level, according to the hospital system, which is an annual income of $38,640 for a single person.

Prices typically haven't been publicly available before now. Yet for expensive procedures like angioplasty and drug-coated stenting, the difference in the cash price within a single county can be over $100,000.

The reasons for high cash prices are complex and, even to many healthcare experts, baffling.

Hospitals typically have a sticker price, often called the "chargemaster" price, that can be the starting point for negotiations with insurers. Discounts off that sticker price tend to be steeper for those that bring large volumes of patients. Insurance plans offered under government programs like Medicare and Medicaid get even lower rates, tied to prices mandated by federal and state agencies.

The cash prices for patients who must pay for their own care can be equal to the sticker prices or sometimes represent a percentage lopped off that top rate. Sometimes, those cash rates are also applied to people who have some form of insurance but get a service that the insurance doesn't cover.

Will Fox, who advises hospitals on pricing as an actuary with Milliman Inc., says hospitals often keep cash prices above the rates negotiated by big insurers.

"They don't want to give away too much of a discount because they really want the best discounts to go to these larger volume negotiated insured rates," he said. "Somebody walking off the street, we'll give you a 20% discount, but we're going to give our favorite customer, who sends us millions or even billions of dollars in business, we're going to give them a much bigger discount."

Yale New Haven Health offers cash prices that represent a discount off sticker rates, but it keeps them above all of the prices negotiated by insurers, says Pat McCabe, the system's senior vice president of finance. "We didn't want there to be that tension, for an insurer to look at that data and say, 'you're providing better rates to uninsured patients than you are to our insureds, how do we justify that to our members and/or employer partners?' "

For individuals who struggle to pay, financial aid is hard to get at some hospitals with high cash prices, the Journal analysis found. That is true even among the nearly 3,000 nonprofit hospitals that get tax breaks on the condition they give back to the community.

Hospitals typically set household income limits for financial aid, with free care for patients below a cutoff.

The quarter of hospitals with the most generous free-care policies write off the entire bill for those with monthly incomes under about $2,600 a month, and even up to roughly $6,400 a month, for a one-person household, the Journal found.

Those that rank in the quarter of hospitals with the most-restrictive policies draw the line at or below about 160% of the federal threshold for poverty, disqualifying for free care patients with monthly income of more than around $1,700 for a one-person household, according to a Journal analysis of nonprofit hospital tax filings.

Brigham and Women's Hospital, affiliated with Harvard Medical School, falls in this most-restrictive group, with income cutoffs for free care at $1,610 a month for a one-person household. For 12 of 17 emergency services at Brigham and Women's reviewed by the Journal, its highest rates are for uninsured patients, and insurance companies pay significantly less.

Brigham and Women's Hospital, in Boston, Mass., is among the group of nonprofit hospitals with the most-restrictive income cutoffs for free care.

A patient paying cash at the hospital for the stenting procedure is charged $84,792. Local insurer Fallon Health spends $36,755 for the procedure under one of its health-maintenance organization plans. A Medicare insurance plan from Aetna, part of CVS Health Corp. , pays $16,648.

Mass General Brigham, the system that includes Brigham and Women's, said in a written statement it has policies to prevent someone without insurance from paying full price.

Some hospitals, including Brigham and Women's, also partially discount patients' bills for some who earn too much for free care. Others write off bills that are large relative to a patient's income. But policies vary widely. The most-restrictive quarter of hospitals cut off discounts at 2.5 times the federal poverty level, the Journal found.

Patients who don't qualify for financial aid at nonprofit hospitals also aren't protected by pricing limits under federal law. The Affordable Care Act requires nonprofit hospitals to cap prices for patients who qualify for financial aid.

Hospitals apply financial aid and discount policies inconsistently, say consumer advocates and patients. Offers may be one-time-only, or discounts may emerge only when a skilled negotiator is pushing for them.

In January 2018, Joannie Berthiaume spent two days at Broward Health Imperial Point hospital in Fort Lauderdale, Fla., and got emergency surgery to remove her appendix. She was uninsured and the hospital charged Ms. Berthiaume its highest prices. Her bill totaled about $42,000, including a $6,033 abdominal CT scan. For that same scan, an Aetna subsidiary gets a 24% break, according to the newly public data from Broward Health. That discount would have meant a fee of around $4,600 for the scan, based on the price charged in 2018.

Ms. Berthiaume, who is Canadian but was living in Florida at the time of her illness while finishing graduate school, went in person to Broward Health to ask about the bill. She was told it could be cut in half, to about $21,000 total -- if she paid in full right then. Ms. Berthiaume, then working in a part-time bookkeeping job, says she couldn't do that. The hospital later continued to seek the full amount, including in letters sent by a law firm and reviewed by the Journal.

"If you charge me $42,000 and your costs are justified, how can you knock it in half in a matter of minutes," Ms. Berthiaume says. "You must be overcharging."

Ms. Berthiaume hired attorney Jacqueline Grady to negotiate on her behalf, and in October 2019 the hospital offered to accept $20,000, in addition to $2,000 she had already paid, if she paid within 16 days. Ms. Berthiaume declined.

Broward Health declined to comment on the details of Ms. Berthiaume's case, although she signed a consent form allowing the hospital system to do so. The hospital system said that U.S. citizens and people with a permanent U.S. residence who come to its hospitals for unplanned care, and don't qualify for its financial assistance program, are offered a discounted rate.

In the pricing data files Broward Health has disclosed under the federal transparency requirement, the cash prices are shown as Broward's highest rates. However, the hospital system pointed the Journal to a consumer tool on its website that displays lower prices for self-pay patients. Broward Health said in a written statement that the tool "provides the most current pricing for consumers," and "discounted prices may not be reflected" in the data files. The system didn't respond to questions about the reasons for the discrepancy.

High cash prices inflate bills that uninsured patients often struggle to pay. Hospitals collected 5% of the amount they billed uninsured patients before writing off bills after a year of seeking payment, according to Crowe LLP, an accounting, technology and consulting firm, based on an analysis of 600 client hospitals. That is compared with collecting 40% of bills sent to patients with insurance for amounts owed under deductibles, copays and other out-of-pocket costs, based on a separate analysis by Crowe of about 1,500 hospitals.

Hospitals closely track their "payer mix," or the mix of patients with commercial insurance, Medicare, Medicaid and the uninsured, who might be unlikely to ever pay for their treatment. That could play a role in how hospitals set prices.

For Mr. Macias, debt from Avera hospitals plus other bills related to his November hospitalization amount to about 75% of his annual income, according to Resolve Advocates, one of a growing number of companies that patients hire to negotiate hospital medical bills on their behalf.

Mr. Macias, a superintendent for a construction company, suffered a potentially life-threatening tear in the lining of his largest artery. He said he has largely recovered.

Avera's hospital in Aberdeen charged him the highest price for some emergency room services, according to a review of medical bills for Mr. Macias and the Journal's analysis of Avera's negotiated rates with insurers.

Avera in some cases has multiple contracts with a single insurer and said the prices it made public are the average price it charges an insurer for each service.

The Avera Heart Hospital of South Dakota, in Sioux Falls, gave Mr. Macias a 20% discount. Even with the discount, some of the heart hospital prices were in the top third of what the hospital charged patients with insurance for some services.

Mr. Macias, a superintendent for a construction company, earned too much for free care at Avera, where the income cutoff is among the lowest nationally for nonprofit hospitals, ranking in the bottom quarter, according to the Journal analysis.

But he appears to qualify for other financial assistance, such as a partial discount based on income or because Mr. Macias's medical debts are large when compared with his household finances, said Resolve's chief executive, Braden Pan.

Avera rejected the request, saying that Mr. Macias could have had workplace health benefits but didn't enroll, according to Resolve. Mr. Macias said in an interview that he missed the sign-up after miscommunication with his former employer. Buying insurance in the marketplace was too costly, he said.

Avera also rejected an appeal, after factoring in his assets alongside his income, according to Resolve. Mr. Macias said he needs his years of savings for a house down payment.

Resolve also offered about $8,000, or slightly more than the company estimated Medicare would pay, for Mr. Macias's $24,800 emergency-room bill at Avera St. Luke's, Mr. Pan said. The hospital said no, and despite denying financial aid, offered to reduce the bill by 50%, Mr. Pan said. The amount excluded another $34,994 he owes Avera's heart hospital.

Mr. Macias, citing his unhappiness about the fight, told the Journal he wouldn't give Avera permission under federal privacy laws to speak about his interactions with it.

"Health care delivery comes with a cost -- and when individuals have the means to pay, it allows us resources to help those most in need," Lindsey Meyers, a spokeswoman for Avera, said in a written statement. "We have thoroughly reviewed the case you have mentioned and identified that all processes were followed as described, and we made every effort to work with the patient."

Mr. Macias said he has largely recovered with new blood-pressure medication and months of rehab exercises he devised on his own. He now lives in Austin, Texas, with his fiancée and their children, ages 6 and 3. Avera's debt collectors call constantly, he said. "They're still blowing me up."

[Jul 02, 2021] Mom details 12-year-old daughter's extreme reactions to COVID vaccine, says she's now in wheelchair

Notable quotes:
"... De Garay explained that after receiving the second coronavirus vaccine dose, her daughter started developing severe abdominal and chest pains. Maddie described the severity of the pain to her mother as "it feels like my heart is being ripped out through my neck." ..."
"... The Ohio mother added her daughter experienced additional symptoms that included gastroparesis, nausea, vomiting, erratic blood pressure, heart rate, and memory loss. "She still cannot digest food. She has a tube to get her nutrition," De Garay said to Carlson. "She also couldn't walk at one point, then she could I don't understand why and [physicians] are not looking into why...now she's back in a wheelchair and she can't hold her neck up. Her neck pulls back." ..."
"... De Garay said she had joined a Facebook support group to help people cope with the unexpected events happening from the coronavirus vaccine trial, and she said it was shut down. "It's just not right," she said. ..."
"... Sen. Ron Johnson , R-Wis., has sent letters to the CEOs of Pfizer and Moderna seeking answers about adverse reactions to the COVID-19 vaccine following a June 28 press conference with affected individuals. The conference in Milwaukee included stories from five people, including De Garay ..."
"... The Wisconsin senator noted that some adverse reactions were detailed in Pfizer's and Moderna's Food and Drug Administration (FDA) emergency use authorization (EUA) memorandums following early clinical trials ..."
"... Those reactions included nervous system disorders and musculoskeletal and connective tissue disorders for the Pfizer EUA memo. The Moderna EUA memo included reactions such as nervous system disorders, vascular disorders and musculoskeletal and connective tissue disorders, according to Johnson's letter. ..."
"... You missed the whole point! The issue is that the government is not acknowledging and and not reporting these side effects of the vaccine. Instead they are lying about the safety. If you are young, you are much more likely to get sick and injured by the vaccine than COVID. ..."
"... anyone under 25 should not get the vaccine because the percentages are about the same or worse having a negative impact from the vaccine versus the actual virus. ..."
"... With the Covid19 mortality rate among the children why even vaccinate? As a Chemist / Biochemist I learned that there is always unintended consequences. ..."
"... Vaccines may have long term effects that are not known today. ..."
"... The CDC's generic guidelines for getting a vaccine for any reason are very restrictive, first being, the disease you're getting vaccinated against has to pose a real, immediate danger. CV-19 poses virtually no danger whatsoever to kids under 14. Of all the deaths of children 14 and under in the last 18 months only .8% of them had a case of CV-19. That's 367 deaths out of over 46,000. (Data from CDC website) Forcing them to take an experimental vaccine that they absolutely don't need is criminal. As a parent, allowing your child to take the vaccine without spending a few hours doing some research is criminally negligent. This is like some terribly warped Kafka novel but it's real. ..."
Jul 02, 2021 | www.foxnews.com

Mom details 12-year-old daughter's extreme reactions to COVID vaccine, says she's now in wheelchair Stephanie De Garay shares story with Tucker Carlson By Stephanie Giang-Paunon | Fox News Facebook Twitter Flipboard Comments Print Email

https://static.foxnews.com/static/orion/html/video/iframe/vod.html?v=20210701170943#uid=fnc-embed-1 Mom describes daughter's bad COVID vaccine reaction, says she's now in wheelchair

Mother Stephanie De Garay joins 'Tucker Carlson Tonight' to discuss how her 12-year-old daughter volunteered for the Pfizer vaccine trial and is now in a wheelchair.

An Ohio mother is speaking out about her 12-year-old daughter suffering extreme reactions and nearly dying after volunteering for the Pfizer coronavirus vaccine trial.

Stephanie De Garay told "Tucker Carlson Tonight" Thursday that after reaching out to multiple physicians they claimed her daughter, Maddie De Garay, couldn't have become gravely ill from the vaccine.

"The only diagnosis we've gotten for her is that it's conversion disorder or functional neurologic symptom disorder, and they are blaming it on anxiety," De Garay told Tucker Carlson. "Ironically, she did not have anxiety before the vaccine."

De Garay explained that after receiving the second coronavirus vaccine dose, her daughter started developing severe abdominal and chest pains. Maddie described the severity of the pain to her mother as "it feels like my heart is being ripped out through my neck."

Video

The Ohio mother added her daughter experienced additional symptoms that included gastroparesis, nausea, vomiting, erratic blood pressure, heart rate, and memory loss. "She still cannot digest food. She has a tube to get her nutrition," De Garay said to Carlson. "She also couldn't walk at one point, then she could I don't understand why and [physicians] are not looking into why...now she's back in a wheelchair and she can't hold her neck up. Her neck pulls back."

Carlson asked whether any officials from the Biden administration or representatives from Pfizer company have reached out to the family. "No, they have not," she answered.

"The response with the person that's leading the vaccine trial has been atrocious," she said. "We wanted to know what symptoms were reported and we couldn't even get an answer on that. It was just that 'we report to Pfizer and they report to the FDA.' That's all we got."

After her heartbreaking experience, the Ohio mother said she's still "pro-vaccine, but also pro-informed consent." De Garay mentioned she's speaking out because she feels like everyone should be fully aware of this tragic incident and added the situation is being "pushed down and hidden."

De Garay said she had joined a Facebook support group to help people cope with the unexpected events happening from the coronavirus vaccine trial, and she said it was shut down. "It's just not right," she said.

"They need to do research and figure out why this happened, especially to people in the trial. I thought that was the point of it," De Garay concluded. "They need to come up with something that's going to treat these people early because all they're going to do is keep getting worse."

Sen. Ron Johnson , R-Wis., has sent letters to the CEOs of Pfizer and Moderna seeking answers about adverse reactions to the COVID-19 vaccine following a June 28 press conference with affected individuals. The conference in Milwaukee included stories from five people, including De Garay.

The Wisconsin senator noted that some adverse reactions were detailed in Pfizer's and Moderna's Food and Drug Administration (FDA) emergency use authorization (EUA) memorandums following early clinical trials.

Those reactions included nervous system disorders and musculoskeletal and connective tissue disorders for the Pfizer EUA memo. The Moderna EUA memo included reactions such as nervous system disorders, vascular disorders and musculoskeletal and connective tissue disorders, according to Johnson's letter.

Pfizer and Moderna did not immediately respond to inquiries from Fox News about Johnson's letters.

J jeff5150357 6 hours ago

My daughter had the same thing happen to her after getting a flu vaccine 9 years ago. Within days of getting it, she went from being as healthy as an ox to years of awful, unexplained illness. The short version is they concluded that she had a severe adverse reaction to the vaccine, but from the delivery chemicals, not the flu content itself. Formaldehyde was the likely major cause. Now she is getting ready to begin college and is being required to get the Covid vaccine by her university and the NCAA for athletics. It is causing her, my wife and I horrible anxiety and we feel like we are being railroaded into something that could be very dangerous for her. Any discussion or concern expressed on social media is immediately blocked. I know from years of working in the research grants office at Yale University that the big pharma industry is powerful and will go to great lengths to control the narrative. What I don't understand is why mainstream media and social media are so willing to help them these days!

jeff5150357 4 hours ago

While the college experience is great for a young adult. I would look at getting a degree online. Her future earnings will be based on her merit, not where she went to school. If someone was telling me what to do with my personal health, and I was uncomfortable with their prescription, I would follow my instincts.

LoraJane92649 jeff5150357 5 hours ago

If her flu vax is well documented she should be able to get a waiver. Hopefully you have an able bodied family physician or medical team to advocate on your behalf.

G gunvald 7 hours ago

You know when you take it that there can be adverse reactions. So, in that sense, you are informed. Any one of us could be the odd person. That said, I have a problem with any child getting these vaccines, especially when most people recover from the disease. It's one thing for me as an elderly person to make the decision to take it as covid affects the elderly person more and I wanted to avoid that ventilator. Most of my life has been lived and that's how I evaluated it. This will always come down to putting it in God's hands.

TheTruthAsItIs gunvald 6 hours ago

You missed the whole point! The issue is that the government is not acknowledging and and not reporting these side effects of the vaccine. Instead they are lying about the safety. If you are young, you are much more likely to get sick and injured by the vaccine than COVID.

D DontDestoryUSA gunvald 4 hours ago

It's not being informed when you are forced to take a vaccination that they clearly had trouble with past vaccination sounds like a lawsuit for the university is on the horizon. With a big pay day

Tony5SFG 7 hours ago

"Ohio mother said she's still "pro-vaccine, but also pro-informed consent." " And as a pediatrician for over 40 yrs (retired now) and a 10 year member of my medical school's Institutional Review Board (which had to approve all human research), THAT is a problem I have been bringing up As far as requiring all young people, such as entering or in college, to get the vaccine Children are a protected class and the informed consent for research on them is much more strenuous than for adults And, requiring young people to take these new vaccines is the equivalent of doing research on them. The issue of myocarditis is quite troubling. And while it has been seen in natural infections, I have not yet seen an adequate risk - benefit evaluation regarding risking natural infection versus vaccination And people say that the myocarditis is not severe, no one can be sure of the long term effects of a young person getting it. The vaccines that we give children have been used for decades and the risks/benefits have been well established

D DallasAmEmail Tony5SFG 6 hours ago

A friends daughter who just went through internship as Physicians assistant based on the percentages in age groups believes anyone under 25 should not get the vaccine because the percentages are about the same or worse having a negative impact from the vaccine versus the actual virus. Yes, older age groups the percent having negative impact from the virus is much greater than the vaccine, so yes older age groups should get the vaccine. What really is bothersome is when Youtube removes Dr. Robert Malone video who helped create the mrna vaccine express concern that normal testing has not happened and be cautious about taking it, especially for the young.

marinesfather601 Tony5SFG 5 hours ago

With the Covid19 mortality rate among the children why even vaccinate? As a Chemist / Biochemist I learned that there is always unintended consequences.

Hilltopper9 7 hours ago

Vaccines may have long term effects that are not known today. The same could be said of all the chemicals we apply to our body daily through shampoos, hair dyes, body lotions, and suntan lotions. Life's a gamble. It's up to each individual to make the best decisions possible given the facts available.

A akbushrat Hilltopper9 6 hours ago

The CDC's generic guidelines for getting a vaccine for any reason are very restrictive, first being, the disease you're getting vaccinated against has to pose a real, immediate danger. CV-19 poses virtually no danger whatsoever to kids under 14. Of all the deaths of children 14 and under in the last 18 months only .8% of them had a case of CV-19. That's 367 deaths out of over 46,000. (Data from CDC website) Forcing them to take an experimental vaccine that they absolutely don't need is criminal. As a parent, allowing your child to take the vaccine without spending a few hours doing some research is criminally negligent. This is like some terribly warped Kafka novel but it's real.

F Fauxguy930 Hilltopper9 5 hours ago

☢️ N-butyl-N-(4-hydroxybutyl)nitrosamine is a nitrosamine that has butyl and 4-hydroxybutyl substituents. In mice, it causes high-grade, invasive cancers in the urinary bladder, but not in any other tissues. It has a role as a carcinogenic agent. Ingredient in all shots. How did a carcinogen get FDA approved, oh it was an emergency.

R RussellRika 6 hours ago

I have a twelve year old, and not a chance I'd allow her to volunteer for any vaccine trial, and especially not this one. She very much wanted to get a vaccine, until she started reading about some of the adverse reactions. Sorry, but I'm a child, the benefit does not outweigh the risk.

MrEd50 6 hours ago

I took the vaccine because I'm 60 years old and work with special ed kids. My 18 year old child refuses to take it and I support him on this. COVID shouldn't be an issue for most of us.

[Jul 02, 2021] The Best Health Care You Can Afford

Notable quotes:
"... While general medical care is single payer in Canada, dental services are not. For major work on teeth, it is cheaper to fly to Mexico. The downside is for Mexicans -- such practices will drive the costs up in Mexico. ..."
Nov 27, 2017 | marknesop.wordpress.com

Posted on November 27, 2017 by marknesop

"The art of medicine consists of amusing the patient while nature cures the disease."

"No, I mean I'm sorry that you've inherited such a miserable, collapsing Old Country. A place where rich Bankers own everything, where you've got to be grateful for a part-time job with no benefits and no retirement plan, where the most health insurance you can afford is being careful and hoping you don't get sick

Cory Doctorow; Homeland

"Until fairly recently, every family had a cornucopia of favorite home remedies–plants and household items that could be prepared to treat minor medical emergencies, or to prevent a common ailment becoming something much more serious. Most households had someone with a little understanding of home cures, and when knowledge fell short, or more serious illness took hold, the family physician or village healer would be called in for a consultation, and a treatment would be agreed upon. In those days we took personal responsibility for our health–we took steps to prevent illness and were more aware of our bodies and of changes in them. And when illness struck, we frequently had the personal means to remedy it. More often than not, the treatment could be found in the garden or the larder. In the middle of the twentieth century we began to change our outlook. The advent of modern medicine, together with its many miracles, also led to a much greater dependency on our physicians and to an increasingly stretched healthcare system. The growth of the pharmaceutical industry has meant that there are indeed "cures" for most symptoms, and we have become accustomed to putting our health in the hands of someone else, and to purchasing products that make us feel good. Somewhere along the line we began to believe that technology was in some way superior to what was natural, and so we willingly gave up control of even minor health problems."

Karen Sullivan; The Complete Family Guide to Natural Home Remedies: Safe and Effective Treatments for Common Ailments

No, I haven't abandoned Uncle Volodya, or shifted my focus to American administration; what follows is a guest post on the American healthcare system, by our friend UCG. As I've mentioned before – on the occasion of his previous guest post, in fact – he is an ethnic Russian living in the Golden State.

As an American in America, naturally his immediate concern is going to be healthcare in America; but there are lessons within for everyone. Don't get me wrong – doctors have done a tremendous amount of good, and medical researchers and many others from the world of medicine have made tremendous advances to which many of us owe their lives. Sadly, though, once a field goes commercial, the main focus of attention eventually becomes profit, and there are few endeavors in which the customer base will be so desperate. While there are obvious benefits to 'socialized medicine' such as Canada enjoys and American politicians scorn as 'Commie' – enough to earn the admiration of many – it results in such a backlog for major operations that those who don't like their chances of dying first, and have the money or can somehow get it, often flee to America, where you can get a good standard of medical care without running out of time waiting for it.

Without further ado, take it away, UCG!!

Healthcare in America

This article is my opinion. My hope is that others will do their own research on America's Healthcare Industry, because this is an issue that needs to be addressed, and for this article to be a mere starting point in this research. The reason for my citations is so that you, the reader, can verify them. Once again, this is my opinion. I write this in the first paragraph, so that I can avoid stating "in my opinion" before every sentence.

Let's start with Owen Davis who was charged $14,018 for going to a hospital because he sliced his hand, and they fixed it . A study published by Johns Hopkins showed that for $100 of ER treatment, some hospitals were charging patients up to $1,260 . A redditor claimed that :

I tore my ab wall a month ago and didn't think much of it until my pain kept worsening. I went to an immediate care facility to rule out a hernia (I had all the symptoms) and they told me to get to ER ASAP. I go to the ER and they give me a CT scan and one x-ray and say it's not a hernia and let me go. Fast forward to today and I got a bill for $9,200 and $3,900 of it is out of pocket. $9,200 for two tests???? No pain meds were administered; it was literally those two tests. What should I do to contest it? I will be calling tomorrow to demand an itemized bill, but is there anything else I should do in the meantime?

All of these took me a few minutes on Google to find, and another few minutes to post. The reason I chose that reddit, is because one of the readers offered an ingenious solution: Next time you hurt yourself – book a return ticket to NZ – go to accident and emergency, say you're a tourist and you hurt yourself surfing, pay nothing – fly home and pocket $8,000 in spare change. If that was me, I'd spend at least $2,000 on tourism in New Zealand. You guys have that system, so you clearly deserve the money! Anyone interested in a startup?

But I am not done with examples just yet. Shana Sweney described her experience in the emergency room : I delivered in 15 minutes. During that time, the anesthesiologist put a heart rate monitor on my finger and played on his phone. My bill for his services was $3,000. $200/minute. I talked to the insurance company about it – and since I ran my company's benefit plans, I got a little further than most people, but ultimately, that was what their contract with the hospital said so that's what they had to pay. Regardless of if he worked 15 minutes or 3 hours. Similarly, my twins were born prematurely and ended up in the NICU for 2 weeks. While the NICU was in-network for my insurance, for some mysterious reason, the neonatologists that attended the NICU were out of network. I think that bill was $16k and they stopped by to see each kid for an average of about 30 min/day.

Almost done with the examples, just please bear with me. How would you like a hospital billing you $83,046 for treating a scorpion sting , if a Mexican ER might have treated you for the same type of sting for $200? Perhaps being charged $546 for six liters of saltwater is more to your liking? $1,420 for two hours of babysitting ? $55,000 for an appendicitis operation ? $144,000 to deliver a perfectly healthy, albeit quite impatient baby? According to my interpretation of the sources linked, all of these actually happened. I encourage you to do your own research.

The World's Biggest Legalized Corruption (IMHO)

$984.157 billion. That's $984,157,000,000. That is how much money I believe the United States wastes on Healthcare. Not spends; wastes. As in money down the drain. The astute reader figured out that equates to five percent of America's 2016 GDP . Said reader is absolutely correct. How did I estimate such a gargantuan amount? According to the OECD data , in 2013 the United States spent 16.4 percent of its GDP on Healthcare; the two next biggest spenders, Switzerland and the Netherlands spent 11.1 percent. Even if one was to give the United States the benefit of doubt, and claim that the United States healthcare is just as efficient as that of Switzerland or the Netherlands – which is most likely not true according to an article from Business Insider , but even if it was – that meant that the United States wastes 5.3% of its GDP on healthcare. Wastes. I just want to make sure that the amount of this alleged legalized corruption, which will most likely reach a trillion dollars by 2020, is noted.

Let me place those funds into perspective: it's almost as much as the amount that the rest of the World spends on the military, combined . The SCO member states, including China, Russia, India, and Pakistan spent roughly $360 billion on the military . The wasted amount is equivalent to the GDP of Indonesia, and greater than the GDP of Turkey or Switzerland . In 2016, the US Federal Government spent $362 billion, or 36.8% of the wasted amount, to run all Federal Programs , including the Department of Education and NASA, with the exception of Social Security, Medicare/Medicaid, Veteran's Affairs, the military, and net interest on the US debt. All other Federal Programs were covered with the $362 billion. The US Federal Debt stands at $20.4 trillion , meaning that the debt can be paid off in 30 years, merely if the Healthcare Waste is eliminated.

But why stop there? The US Housing Crisis started partly because loans were allowed to be taken out without the 20% down payment. Could this funding, if applied directly to the housing market, stop the 2008 Great Recession? Absolutely, and all the Federal Government had to do was to gear these funds towards down payment on subprime mortgage loans to meet the 20 percent barrier. I can go on and on about what can be accomplished, like making collegiate attendance free, or at least very inexpensive, or drastically improving the quality of education, paying off the national debt, reinvesting into the economy, reinvigorating the rural sector, and so on, and so forth. A trillion dollars is a lot of money.

Lobbyists, the Media and the Waste

Any guess how much was spent on lobbying by the Healthcare, Insurance, Hospitals, Health Professionals, and HMOs? How about 10.5 billion dollars? I knew that was your guess! That's a lot of money, and that does not include "speaking fees", or when a politician who constantly made calls beneficial to the Healthcare Lobby gets $150,000 to speak in front of an audience after they retire from politics. Obama made a speech in front of Wall Street, netting $400,000 . And by pure coincidence, only one Wall Street Broker was jailed as a result of the scandal. That $10.5 billion is just a tip of the iceberg, because "speaking fees" are notoriously hard to track, and not included in said amount.

Obama genuinely tried to reform US Healthcare to the Swiss Model. He was going to let Wall Street slide, he was going to let Neocons conduct foreign policy, just please, let him have healthcare! First, the lobbyists laughed in his face. Second, they utilized the Blue Dog Coalition to block Obama's attempt at Healthcare Reform, until it was phenomenally nerfed, and we have the disaster that we have today. As a result, Obama's Legacy, Obamacare is having major issues, including the rise of racism.

Obamacare helped the poor, (mostly minorities,) at the expense of the middle class, (mostly whites,) thus transferring funding from whites to minorities. While the intent was not racial, it is being called out as racial by the mainstream media . This probably suits the lobbyists, because if the debate is about racism, one cannot have a genuine discussion about Healthcare Reform.

Racism strikes both ways. Samantha Bee came out with a "fuck you white people" message right after the election. Jon Stewart, without whom she probably wouldn't have her own show, pointed out that it was simply economics, like the healthcare insurance premium increase , that brought Donald Trump to power. Interestingly enough, James Carville made the same argument when Bill Clinton beat George Bush, but when Hillary Clinton lost, Carville was quick to blame Russia. These delusions on the Left are letting the Right mobilize stronger than ever before. And all of this takes away from the Healthcare Debate.

In an attempt to blame Trump's Election on white racism, rather than basic economics, numerous outlets simply fell flat. For instance, Eric Sasson writes : white men went 63 percent for Trump versus 31 percent for Clinton, and white women went 53-43 percent. Among college-educated whites, only 39 percent of men and 51 percent of women voted for Clinton What's more, these people hadn't suffered under Obama; they'd thrived. The kind of change Trump was espousing wasn't supposed to connect with this group.

Did this group thrive? The collegiate debt went from $600 billion to $1.4 trillion under Obama's Administration, while the health insurance increased from $13,000 to $18,000 per family . This is thriving? Was the author experimenting with medical marijuana when said article was written? Nevertheless, the parade of insanity continued, with Salon assuring us that it was blatant racism that gave us Trump . The Root, which also claimed that Russians attempted to hack election machines, pointed out that Russia exploited America's racism , and thus Trump won the election. Washington Post claimed that racism motivated white people more than authoritarianism . Comedian Bill Maher tried to sway the discussion back to economics, by pointing out that outrage over Pocahontas or Halloween should not stop the Democrats from working for the working man . Sadly, Maher and Stewart are in the minority, and instead of a Healthcare Debate, the US is now stuck in a debate over racism, which isn't even three-fifths as effective. Meanwhile the US continues to waste almost a trillion dollars on healthcare .

Who Benefits?

Let's start with the banks. Medical students graduate with an average of $416,216 in student debt . The average interest rate on said loan is seven percent. Roughly 20,055 students go through this program, per year . Presuming a twenty year loan, the banks are looking at about $7.185 billion in interest payments. It really is a small fraction of the cost. Prescription drug prices are another story. In 2014, Medicare spent $112 billion on medicine for the elderly . Oh la la! Cha-ching. I would not be surprised if at least half of that was wasted on drug price inflation. You know the health insurance companies? It's a great time to be one, since profits are booming – to the tune of $18 billion in projected revenue for 2017.

Of course the system itself is quite wasteful, with needless hours spent on paperwork, claim verification, contractual review, etc, etc, etc. Humana's revenue was $54.4 billion , Aetna's was $63.2 billion , Anthem's was $85 billion , Cigna's was $39.7 billion , and UnitedHealth's was $184.8 billion . Those are just the top five companies. None of them ia a mom-and-pop shop or small business store. Do any of these insurers support Obamacare? Even if they do, it is without much enthusiasm . They are leaving, and leaving quite quickly. Thirty-one percent of American counties will have just one healthcare insurer . Welcome to a monopoly that is artificially creating itself. And despite the waste, 28.2 million Americans remain uninsured . Mission accomplished!

Who else benefits? Those who hire illegal immigrants instead of American workers, since illegal immigrants cost the United States roughly $25 billion in Healthcare spending . Meanwhile those who hire them can avoid certain types of taxes and not have to cover their Healthcare; communism for the rich, capitalism for the rest of us. Of course that is just a rough estimate, since this spending is also quite hard to track.

The Future

The problem with changing Healthcare is that too many people have their hands in the proverbial pie. There is not a single lever of power that isn't affected by Healthcare, and most of the levers that are affected, benefit quite a bit. Insurance companies will fight to the death, because Universal Healthcare will be their death knell. Banks will defend it, because who doesn't want to make billions from student loans? Medical schools too – since it lets them charge higher and higher tuition. Pharmaceutical companies can use the increase in Healthcare expenditure to justify their own price hikes, even though a major reason for those price hikes is artificial patent based monopoly.

What is an artificial monopoly? In my opinion, it's when a patent is utilized to prevent competitors from manufacturing the same exact drug. In less than a decade, the price of Epi-Pen soared from $103.50 to $608.61. When asked the justify said increase, one of the reasons provided by the CEO was that the price went up because we were making investment; as I said, about $1 billion over the last decade that we invested in the product that we could reach physicians and educate legislatures. "Reaching" doctors and legislators; I wonder, how was said "education funding" spent? According to US News, a website that is extremely credible when it comes to internal decision making within the United States, drug companies have long courted doctors with gifts , from speaking and consulting fees to educational materials to food and drink. But while most doctors do not believe these gifts influence their decisions about which drugs to prescribe, a new study found the gifts actually can make a difference – something patient advocates have voiced concern about in the past. Do you feel educated? Would you feel more educated if I paid you a $150,000 consulting fee? What about $400,000? What? It's just consulting; no corruption here!

Everyone knows that this is going on. But there is not going to be change. Why not? The same reason that there was not change with Harvey Weinstein, until Taylor Swift came along. Remember how I said that almost everyone has their hands in the Healthcare Pie? It was not much different with Weinstein. Scott Rosenberg explained why it took so long for people to speak out against Harvey , and the reasons were numerous. First, Harvey gave many people their start in Hollywood, and treated all of his friends like royalty. That drastically increased their loyalty. Second, he ushered the Golden Age of the 1990s, with movies like Pulp Fiction, Shakespeare in Love, Clerks, Swingers, Scream, Good Will Hunting, English Patient, Life is Beautiful – the man could make phenomenal movies. Third, even if one was willing to go against his own friends, workers, mass media, and so on, there was no one to tell. There was no place to speak out. Fourth, some of the victims took hefty settlements.

That fourth reason enabled mass media to portray rape victims as gold diggers. Rape Culture is alive and well. In California, a Judge gave minimal sentencing to a convicted rapist , because he was afraid a harsher sentence would damage the rapist's mental psyche for life. Uh dude, from one Californian to another, he, uh, raped. His mental psyche is already damaged; for life. That's the kind of pressure that Rose McGowan had to deal with. She had a little kerfuffle with Amazon , and she thinks it was partially because of Harvey Weinstein. How many times had the word "socialism" been thrown around to describe Universal Healthcare? Switzerland has it – are they Socialist?

Enter Taylor Swift . In order to destroy allegations that women are filing sexual harassment claims as gold diggers, she sued her alleged sexual assaulter for a buck; one dollar. She won. Swift stated that the lawsuit was to serve as an example to other women who may resist publicly reliving similar outrageous and humiliating acts. On top of that, Weinstein was no longer as popular as he used to be, and an avenue to tell the story, an outlet was created. The additional prevalence of the internet caused the stories of Weinstein's sexual abuse to leak. Within a month, the giant fell.

Something similar is needed to change Healthcare in America. But until that comes along, racism will increase, the cost of Healthcare will rise, emergency room costs will most likely double every ten years, and the future remains bleak. As if that was not enough, more and more upper class Americans, (like yours truly,) are seeking treatment abroad. It cost me less money to lose five weeks of wages, spend three weeks partying in Eastern Europe, (Prague to be more specific,) after my two weeks of treatment, buy a roundtrip plane ticket, and stay in a five star, all-inclusive hotel, than the cost of the same treatment in the US. If anyone wants to utilize this as a startup – let me know!

Of course its effects on Healthcare will hurt, since it is a huge chunk of business that will be traveling across the Atlantic. But what can be done to stop it? One cannot stop Americans from traveling to other countries. One cannot force the poor to work for free. Perhaps this is the change that is needed to make those who benefit from the Healthcare Waste realize that this cannot continue. Perhaps not. What we do know, is that Obamacare insured the poor, at the expense of the middle class . And that is regarded as a failure in America.

Related

No Way To Slow Down - America's Foreign-Policy Dilemma In "Corruption"

How Much Of a Nobody Do You Have To Be, To Be Too Much Of a Nobody To Testify Before a Congressional Committee? In "Economy"



Northern Star , November 27, 2017 at 3:12 pm

As for Obongo Care ??:

"In trying to show that he was successfully managing the Obamacare rollout, the president last week staged a high-profile White House meeting with private health insurance executives -- aka Obamacare's middlemen. The spectacle of a president begging these middlemen for help was a reminder that Obamacare did not limit the power of the insurance companies as a single-payer system would.
****The new law instead cemented the industry's profit-extracting role in the larger health system -- and it still leaves millions without insurance."*** (THAT is the Achille's lower torso of the ACA)

https://www.healthcare-now.org/blog/single-payer-healthcare-vs-obamacare/

https://www.dailykos.com/stories/2016/2/11/1483523/-Single-Payer-Healthcare-vs-The-Affordable-Care-Act-A-Simple-Comparison

ucgsblog , November 28, 2017 at 3:58 pm
Exactly! That's why I stated that they're now oligapolizing the market, and will slowly start to increase their insurance rates and profits once again.
Northern Star , November 27, 2017 at 3:23 pm
"Prince Harry.. Do you take this American mulatto negress - aka raghead untermensch - as your lawfully wedded royal wife?*
http://www.newsweek.com/prince-harrys-worst-moments-meghan-markle-rogue-723177
https://www.sbs.com.au/guide/sites/sbs.com.au.guide/files/styles/body_image/public/nazi.jpg?itok=q1oxMi44&mtime=1503879842

Ummm Advice to Meghan .make sure the honeymoon motorcade stays clear of tunnels in Paris or elsewhere!!!

Northern Star , November 27, 2017 at 3:52 pm
Appurtenant to many of the issues raised in Mark's post:

http://www.wsws.org/en/articles/2017/11/27/pers-n27.html

(Socialist or not..the WSWS writers continue to state that which NEEDS to be hammered home)

"The vast wealth of the financial oligarchy, expressed in their ownership of massive corporations, must be seized and expropriated, while the complex technologies, supply chains, and advanced transportation systems must be integrated in an organized, planned manner to harness the anarchic force of the world economy and eliminate material scarcity.
Amazon is a prime example. Its supply lines and delivery systems could distribute goods across the world, bringing water, food, and medicine from each producer according to his or her ability, to each consumer according to his or her need.
The massively sophisticated computational power used by the technology companies to censor and blacklist political opposition could instead be used for logistical analysis to conduct rescue and rebuilding missions in disaster zones like Houston and Puerto Rico. Drones used in the battlefield could be scrapped and rebuilt to distribute supplies for building schools, museums, libraries, and theaters, and for making Internet service available at no cost for the entire world.
The ruling class and all of the institutions of the political establishment stand inexorably in the way of efforts to expropriate their wealth. What is required is to mobilize the working class in a political struggle against the state and the socio-economic system on which it is based, through the fight for socialism.
Eric London "

Particularly for American Stooges:

https://www.youtube.com/embed/F1TMsSbPszw?version=3&rel=1&fs=1&autohide=2&showsearch=0&showinfo=1&iv_load_policy=1&start=861&wmode=transparent

https://www.youtube.com/embed/mzJYXPI1hng?version=3&rel=1&fs=1&autohide=2&showsearch=0&showinfo=1&iv_load_policy=1&wmode=transparent

Patient Observer , November 27, 2017 at 5:17 pm
Advanced technology is helpful but not essential for a humane and just society. Its what we believe and feel that matters. FWIW, I like socialism on a national/international level and individual accountability on a personal level.
saskydisc , November 27, 2017 at 4:04 pm
While general medical care is single payer in Canada, dental services are not. For major work on teeth, it is cheaper to fly to Mexico. The downside is for Mexicans -- such practices will drive the costs up in Mexico.
Patient Observer , November 27, 2017 at 5:12 pm
Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.
[email protected] , November 27, 2017 at 6:02 pm
I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.
kirill , November 27, 2017 at 8:38 pm
Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

Jen , November 27, 2017 at 11:15 pm
Thanks very much UCG, for your article. Very interesting reading for us Australians as the Federal Government eventually wants to shove us kicking and screaming into a US-style privatized healthcare insurance model.

Funnily enough I'm currently considering changing my private health insurer. I'm with Medibank Private at present but considering maybe going with a smaller non-profit health fund like Australian Unity or Phoenix Health Fund.

Fern , November 28, 2017 at 7:02 am
I was just about to post along the lines of "I don't know if Jen has experienced this in Australia but here in the UK ." so I'll finish the thought. In the UK, successive governments, not just Conservative ones, have been trying to dismantle the NHS and move us to the American system. It is pure ideology – no amount of the very abundant evidence of the inefficiencies of the US system, its waste etc makes any dint in the enthusiasm of those pressing for change.
ucgsblog , November 28, 2017 at 4:17 pm
Thank you Jen! My advice: don't let the Government cajole you into wasting your money on Corporate Greed. Share the article with your fellow Australians, if you must, but don't let our wasteful system be replicated. Interestingly enough, one of my friends, Lytburger, send me a meme right after Ukraine adopted America's Healthcare System, it said: "ISIS refused to take responsibility for Ukraine's Healthcare Reform!" I'd be happy to provide other data or answer questions about the Healthcare System here.

As for insurance, I'm not sure if Australia has the in-network and out-of-network rules. Does it? Whatever insurance you get, make sure that it has good coverage. If you own a home in the US, and you end up in a hospital's emergency room that's not covered by your insurance, the hospital can take your house under certain circumstances. Ironically, even the Government cannot. All of my real property is in various Trust Accounts, just in case, and I make sure that I have insurance where all major hospitals are in-network and that's the best I can do.

James lake , November 28, 2017 at 12:21 am
This is s very interesting insight into healthcare in the USA. The cost is shocking. I live in the UK and the healthcare system is paid for from taxation. When it was established over 70 years ago the health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means.

It was the best thing in my view that government has ever done. Good healthcare should be available to all and not dependent on peoples ability to pay. However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatize it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.

Which many people do not mind.

-Elderly care was also privatised as it's the most expensive

-care for the disabled also is a issue for local councils

-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.

And yet still more and more taxation is needed for the NHS!

The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.
Ryan Ward , November 28, 2017 at 3:40 am
With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany
Patient Observer , November 28, 2017 at 5:03 pm
Quite different from my expectation of spartan if not rudimentary medical care and overworked staff in a small Russian town. The blog on schools was interesting as well. Given where Russia was in the 90's compared to now, it is easy to understand the strong popular support for the government and Putin in particular.

Off topic but just saw a 2-3 minute piece on CBS news (a very long story for an American national news show) about a Russian woman (former Playboy "model') who is challenging Putin. The reporter assured us the if she became too popular, Putin would never allow her to win. The last time Russia was allowed to protest, according to the reported was back in 2011 where the masses were demanding change. The implication being that a subsequent crackdown has suppressed further protest.

The piece showed her speaking to a group (the camera view was such that is was impossible to determine the audience size but it had to be at least 10 and possibly up to 30 people). The reporter also speculated that the woman coud be a Kremlin plant to create a fake opposition. Just a mishmash of a story all in all.

Moscow Exile , November 28, 2017 at 5:18 am
re: Health Care in Russia

Speaking as someone who has been hospitalized 3 times in Russia and still live to talk about, I have no complaints.

In the twilight years of the USSR everything was deficit, including medicine, and the hospitals were often dilapidated, understaffed and lacking modern equipment. It was socialized medicine, of course, but you only got the basics for "free". They would not let you die, but if you wanted any "extras", you had to pay or provide "gifts" to the staff. The doctors were and still are good, but were grossly underpaid.

I was first in hospital here, in isolation because I had diphtheria, in 1993. They saved me. I thought my number was up. When I was recovering, a nurse asked me when my wife would visit me.

"I have no wife."

"Your friends, then?"

"No friends. I only arrived here 3 weeks ago."

"You're going to be hungry!"

Our first child was born in 1999. The maternity wing of Moscow Hospital №1, opened 1837, was nightmarish. I paid the anaesthetist so that he could ensure that my wife did not suffer during her labour: it was a long, slow painful birth.

Our last child was born in 2008: brand new hospital; my wife had her own room; everything state-of the-art. I paid nothing. My wife came out healthy with a healthy baby. I gave the obstetrician a "present" after delivery.

A bribe? Not in my opinion: just a token of gratitude for a job well done.

I broke my left collarbone at the dacha that same year. I was in a village/small town (Ruza) hospital. It was only 2-years old. There were problems because I have broken both collarbones before. Anyway, the orthopaedic surgeon did a good job, and I didn't pay anything: emergency treatment is free for British citizens, likewise Russians in the UK. A remnant of when the UK and the USSR were glorious allies against the Beast.

I have also had varicose veins removed. Only 2 days in hospital. A job well done. I gave the surgeon a present. He didn't ask me for one, but I thought it was right that I do so.

There have been great improvements in treatment and medical technology here. And the doctors and nursing staff are well trained and competent.

Not perfect -- nothing is -- but more than satisfactory.

Yes, you do hear horror stories, as you do about the British National health Service, but all in all, satisfactory.

And there is a private health system now financed by private insurance.

And I have had dental treatment here "on the state": no complaints -- and "free", paid by taxation.

An old Russian colleague of mine has lived in Germany many years now, but he comes back to Moscow to see an orthodontist.

"They are just as good as in Germany, sometimes have even trained there, and much, much cheaper", he says.

Moscow Exile , November 28, 2017 at 9:49 am
PS I paid the anaesthetist so he could get the best stuff to help a woman in labour and was unavailable on the state health service. I forget what it was called now: some German manufactured stuff, I suppose.
Patient Observer , November 28, 2017 at 3:56 pm
My wife said it was the norm in Romania to provide small gifts to bureaucrats – too small to be considered a bribe but a necessary gesture of appreciation. Its not entirely different from the custom of bringing a small gift when visiting friends (bottle of wine, flowers, box of chocolate, etc.).
marknesop , November 28, 2017 at 4:37 pm
Very much so; I'm sure I mentioned before the controversy surrounding my marriage in Russia; the waiting period that must follow an application to marry is 30 days (I guess this is a period during which anyone opposing the marriage may make their case), while a tourist visa is also for a maximum of 30 days. Therefore, I could not legally remain in Russia long enough to get married. Sveta was very matter-of-fact about it; we would just, she said, announce that she was pregnant, which is one of the exceptional conditions which will override the waiting period.

I said she would never get a doctor to sign a certificate that she was pregnant if she was not. Within a week she had her choice of three. We gave the doctor who furnished the certificate some flowers and a box of chocolates. I never considered it a bribe, and still do not, and the gift followed the act. We would have gotten the certificate anyway.

I notice that Russians typically take such a gift with them whenever they visit friends; Ukrainians do, too. They never arrive empty-handed, and it seems much more a ritualized courtesy.

Patient Observer , November 28, 2017 at 5:10 pm
It seem odds to me how Russia or Romania can be stifling bureaucratic (as ME can attest) yet rules will often be bent with hardly a blink to facilitate a reasonable request.
Cortes , November 28, 2017 at 1:42 pm
An interesting article. Thanks.

My tuppenceworth?

The healthcare system in a country probably reflects the dominant elements in said country's culture. Our family's longtime GP was a buffoon. In my interactions with him his enthusiastic "hands-on" gung-ho approach caused several problems, not least when I visited him to get a "line" certifying I was unfit for work a week after a total hip replacement operation (he insisted on examining the wound and re-dressing it with a dressing whose adhesive I had been tested for in hospital and deemed allergic to it; fun and games, anxiety and discomfort ).

Nevertheless he made an immediate decision to admit a close relative of mine for surgery on the basis of his examination of her.

In my case I could have "sued his ass."

And then? A couple of years later?

[Jun 26, 2021] Johnson Johnson Settles New York Opioid Case for $230 Million by Sara Randazzo

Jun 26, 2021 | www.wsj.com

Johnson & Johnson has agreed to pay $230 million to the state of New York to resolve an opioid lawsuit slated to go to trial Tuesday, as negotiations intensify with the company and three drug distributors to clinch a $26 billion settlement of thousands of other lawsuits blaming the pharmaceutical industry for the opioid crisis.

Johnson & Johnson's New York deal removes it from a coming trial on Long Island but not from the rest of the cases it faces nationwide, including a continuing trial in California. The New York settlement includes an additional $33 million in attorney fees and costs and calls for the drugmaker to no longer sell opioids nationwide, something Johnson & Johnson said it already stopped doing.

States have been trying to re-create with the opioid litigation what they accomplished with tobacco companies in the 1990s, when $206 billion in settlements flowed into state coffers. More than 3,000 counties, cities and other local governments have also pursued lawsuits over the opioid crisis, complicating talks that have dragged on since late 2019 and that have been slowed down by the Covid-19 pandemic.

... ... ...

[May 03, 2021] Selling booster shots every year is a great business

May 03, 2021 | www.zerohedge.com

variousmarkets PREMIUM 1 hour ago (Edited)

The current crop of vaccines only target the spike protein, which has a surprisingly high mutation rate. No disease has ever been extinguished using this approach. Key examples â€" smallpox, measles, mumps, chicken pox, polio, etc. â€" all have been eradicated using whole virus vaccines (inactivated or attenuated) that target a variety of sites on the viral surface. These traditional vaccines are effective against new variants because all sites would need to mutate simultaneously to escape human immune surveillance. Polio is a perfect example because it has an enormously high mutation rate - much higher than COVID - but the vaccine works because it targets a variety of sites that cannot all simultaneously mutate away.

f

COVID will not be defeated until a pharmaceutical company invests the time and expense to develop a live attenuated vaccine that triggers immunity against several different surface proteins. But they won't because selling "booster" shots every year is a great business.

The current variant problem began after patients were treated with convalescent plasma, which added selective pressure for the mutant strains we are struggling with now. The vaccines are simply doing the same.

Jade_Dragon 7 hours ago (Edited)

Well, everything is being run for profit with no regard for the consequences. Corps take on debt to fund share buybacks, eschewing R & D then need a bailout. Shot that may or may not kill protect you against the CV but reaps billions for the pharma companies is par for the course. It all reminds me of those shoddy Chinese trinkets you buy on Amazon that break 32 days later

sun tzu 7 hours ago

They will blame it on science instead of greed, corruption, and stupidity

[May 03, 2021] Big Pharma is parasitic. Bill Clinton was evil and it was he who lifted the ban on medicines advertizing

Notable quotes:
"... There are a lot of things to say about the medication advertising issue and never enough ways to say it. The problem of patients asking their doctors for specific medications is just one problem. In many, if not most, instances, these drugs may not be appropriate or even applicable to specific patients' problems. ..."
"... One of the biggest problems with all of the advertising--and this was supposed to change by law--is that there is no indication of what these drugs cost, especially compared to other similar drugs for the same thing. I have a friend who is a retired nurse and she gets a big kick out of looking up the costs of all the newly advertised drugs so whenever anyone talks about them, she can tell them how expensive they are. ..."
May 03, 2021 | www.zerohedge.com

Kendle C 6 hours ago (Edited) remove link

If and when you want to know who you're dealing with, I challenge you to watch the over the air channels, that's right antenna TV, specifically "ME-TV".

Some background, people who can't or won't afford cable TV, like old, retired, poor people drop it. Note, most of these folks don't have a DVR and can't pause TV, at best they'll mute the commercials, eventually they succumb and watch. They are a MARKET.

What you will learn, if you take the antenna challenge, pharmaceutical companies are predatory, deceptive and, yes, evil. Under their onslaught on the underprivileged it's causing many to "ask your doctor" about prescription medicines. Wouldn't your doctor know better about what meds you need? I hate Bill Clinton for authorizing prescription medicines advertising, again. It was banned and now it's not.

Now, think about it, can you trust such vile people?

chiquita 5 hours ago (Edited)

There are a lot of things to say about the medication advertising issue and never enough ways to say it. The problem of patients asking their doctors for specific medications is just one problem. In many, if not most, instances, these drugs may not be appropriate or even applicable to specific patients' problems. In some cases, patients must take a series of drugs before being allowed to take certain medications--for example with statins, at one time (I don't know for sure now, but this was true in the 1990s) some insurance required a patient to start with one particular statin before they could be moved onto another and so on. Right now there are a bunch of different type 2 diabetes drugs, but here again without using the original tried and true medication(s) first, a doctor is unlikely to put a patient directly on one of the newer medications just because they ask for it if they've never taken any medication for lowering their blood glucose levels.

One of the biggest problems with all of the advertising--and this was supposed to change by law--is that there is no indication of what these drugs cost, especially compared to other similar drugs for the same thing. I have a friend who is a retired nurse and she gets a big kick out of looking up the costs of all the newly advertised drugs so whenever anyone talks about them, she can tell them how expensive they are.

Last, even without all the advertising, there has always been the problem with the pharmaceutical company sales reps soliciting at the doctors' offices (and hospitals). I can't say what this is like these days because I'm removed from it, but when I was married to a doctor, I knew exactly what went on. The drug reps came in bearing gifts and boxes and boxes of samples of all kinds of company products. There was a lot of incentive given to prescribe their products. My ex was not big on prescribing anything he didn't believe in. However, I did go to a doctor for years where I got a regular allergy shot (so I was there pretty often) and I used to sit in the waiting room with the drug reps almost every visit. They're parasitic.

[Feb 14, 2021] This Is Why Hospitals Can Charge $6,000 Or $60,000 For The Exact Same Procedure - ZeroHedge

Feb 14, 2021 | www.zerohedge.com

This Is Why Hospitals Can Charge $6,000 Or $60,000 For The Exact Same Procedure BY TYLER DURDEN SATURDAY, FEB 13, 2021 - 17:00

Several months back, we pointed out how new disclosure laws would be forcing hospitals to disclose the cost of services and rates negotiated by insurers. Now, the numbers are starting to trickle in - and they're ugly.

Roughly 6,000 hospitals across the nation are starting to reveal the rates they negotiate with insurers for a number of procedures. The figures show how widely prices vary for the same procedure depending on who is paying, as highlighted by a new Wall Street Journal report .

For example, the report found that a C-section can cost between $6,241 and $60.584 - all depending on which insurer covers it. Niall Brennan, chief executive of the Health Care Cost Institute said: "It is shining a light on the insanity of U.S. healthcare pricing. It's at the center of the affordability crisis in American healthcare."

The rates are a key driver of the massive healthcare costs in the U.S., some of the highest in the world. It was a Trump administration rule that shed light on the differences in procedure pricing - some of the widest gaps in pricing of any U.S. industry. Gerard Anderson, a healthcare economist at Johns Hopkins University, commented: "These price differentials are unique to the healthcare and hospital industry."

The prices have a direct effect on consumers, as they push up premiums and deductibles . And, in a stunning revelation, "total U.S. expenditures on private health insurance have increased 50% in the past decade through 2019, according to federal figures," the Journal wrote.

The report found that a Northern California system of 24 hospitals had sometimes "extreme" pricing ranges for procedures. One cardiac procedure varied between $89,752 to $515,697, depending on insurer. For those paying out of pocket, the procedure cost $325,703. The system, called Sutter Health, did $13 billion in 2019 revenue is is known for drawing an antitrust suit from the California state AG in 2018. The system paid $575 million to settle the claims.

Sutter Chief Financial Officer Brian Dean commented: "We enter into negotiations with every health-insurance company or payer in good faith and with the end goal of providing access to quality, affordable care for patients."

"The variation in the data reflects robust competition in the markets for commercial insurance," he argued.

One former insurance executive told the Journal that they could expect the same types of wide ranges for pricing across the country:

"The California system's pricing spread for the procedures reviewed by the Journal are likely at the upper end, but similar patterns will be found at many hospitals around the country, said Alan Muney, a former Cigna Corp. executive. "This is probably typical of what you're going to see across big delivery systems," he said.

Prices paid by private insurers in the nation's $1.2 trillion hospital sector are often far higher than the amounts paid to hospitals by the Medicare program, which are set by the government. Plans offered by insurers under Medicare or Medicaid often get rates tied to those mandated prices."

Insurers have a better chance of winning better rates if they can drive more patients to a certain hospital, another former insurance executive said . Hospitals, meanwhile, sometimes set their prices with "little bearing on the actual cost or value of a service", the report says. Rather, hospitals set prices based on their own targets for margins and according to what the market will pay.

Privately insured patients drive margins typically - and hospitals that boosted margins generally didn't cut costs, but rather raised revenue by increasing rates billed to commercial insurers, one study found. Economists have found that quality is generally no better at more expensive hospitals. Michael Chernew, the Leonard D. Schaeffer Professor of Health Care Policy at Harvard Medical School, said: "We have not found evidence that price is a great signal for quality."

The new data will draw the eyes of insurers and hospitals, moreso than consumers. Elizabeth Mitchell, chief executive of the Purchaser Business Group on Health, which represents major employers, said they will use the data to help choose which hospitals to use and how to negotiate with insurers.

The Journal examined one cardiac code for cardiac-valve procedures involving catheterization performed on patients with risk factors. It confirmed that the largest spreads on pricing were in procedures that cost the most:

Seven insurers pay the lowest negotiated rate, $89,752, for their Medicare plans. The lowest price for a commercial-insurance plan, the type offered to employers, is $197,900. At the top end, the charge is $515,697 for patients whose health plans don't have the hospital in-network.

For hip- and knee replacements, Medicaid and Medicare plans paid the lowest prices at the Modesto hospital, $3,264 and $16,349, respectively. The lowest price paid by a commercial insurer totaled $51,895. The highest rate reached $81,617, again for patients whose insurance didn't include the Modesto hospital in-network.

Recall, we first brought up President Trump's plans to institute these transparency plans back in January.

The $1.2 trillion industry comprising some 6% of the country's economy is now subjected to more transparency than it has seen in decades. The point of instituting the disclosures, according to the Trump administration, was the hope that good ol' fashioned market dynamics will kick in, and help lower prices across the board.

Previously, hospital pricing was negotiated confidentially between hospitals and the employer groups and insurance companies that pay for care.

Many criticized this system for obscuring market rates and helping drive up the cost of health insurance premiums paid by employers and workers. Rising hospital prices accounted for about one-fifth of the nation's health spending growth over the last 50 years.

Now, we will see first hand if a free and open market can help solve some of the industry's problems. At least, until President Biden reverses the new rules.

[Feb 02, 2021] New Report From Rep. Katie Porter Reveals How Big Pharma Pursues 'Killer Profits' at the Expense of Americans' Health - naked

Feb 02, 2021 | www.nakedcapitalism.com

New Report From Rep. Katie Porter Reveals How Big Pharma Pursues 'Killer Profits' at the Expense of Americans' Health Posted on January 30, 2021 by Yves Smith

Yves here. Go Katie Porter! While you were busy rubbernecking over Robinhood and GameStop, some people were staying focused on issues that matter to Americans.

We have written for many years about other elements of bad faith at Big Pharma, like whining they need more profits to fund drug development, when they spend more on marketing than R&D, and also spend a lot on buybacks. From Axios :

The big picture: When billions of dollars became available to the biggest drug companies, their main priority was to juice earnings, along with the paydays of their executives and investors -- not investments in new treatments or relief for patients who can't afford their drugs.

And on top of that, for decades, the overwhelming majority of FDA "new drug applications" are actually minor reformulations of existing drugs to extend patent life.

By Brett Wilkins, staff writer at CommonDreams. Originally published at CommonDreams

Rep. Katie Porter on Friday published a damning report revealing the devastating effects of Big Pharma mergers and acquisitions on U.S. healthcare, and recommending steps Congress should take to enact "comprehensive, urgent reform" of an integral part of a broken healthcare system.

The report, entitled Killer Profits: How Big Pharma Takeovers Destroy Innovation and Harm Patients , begins by noting that "in just 10 years, the number of large, international pharmaceutical companies decreased six-fold, from 60 to only 10."

While pharmaceutical executives often attempt to portray such consolidation as a means to increase operational efficiency, the report states that "digging a level deeper 'exposes a troubling industry-wide trend of billions of dollars of corporate resources going toward acquiring other pharmaceutical corporations with patent-protected blockbuster drugs instead of putting those resources toward' discovery of new drugs."

Merger and acquisition (M&A) deals are often executed to "boost stock prices," to "stop competitors," and to "acquire an innovative blockbuster drug with an enormous prospective revenue stream."

"Instead of spending on innovation, Big Pharma is hoarding its money for salaries and dividends," the report says, "all while swallowing smaller companies, thus making the marketplace far less competitive."

https://platform.twitter.com/embed/index.html?creatorScreenName=yvessmith&dnt=false&embedId=twitter-widget-0&frame=false&hideCard=false&hideThread=false&id=1355238165515182082&lang=en&origin=https%3A%2F%2Fwww.nakedcapitalism.com%2F2021%2F01%2Fnew-report-from-rep-katie-porter-reveals-how-big-pharma-pursues-killer-profits-at-the-expense-of-americans-health.html&siteScreenName=yvessmith&theme=light&widgetsVersion=ed20a2b%3A1601588405575&width=550px

https://platform.twitter.com/embed/index.html?creatorScreenName=yvessmith&dnt=false&embedId=twitter-widget-1&frame=false&hideCard=false&hideThread=false&id=1355238166991527938&lang=en&origin=https%3A%2F%2Fwww.nakedcapitalism.com%2F2021%2F01%2Fnew-report-from-rep-katie-porter-reveals-how-big-pharma-pursues-killer-profits-at-the-expense-of-americans-health.html&siteScreenName=yvessmith&theme=light&widgetsVersion=ed20a2b%3A1601588405575&width=550px

The report calls M&As "just the tip of the iceberg of pharmaceutical companies' anti-competitive, profit-driven behaviors":

Pharmaceutical companies often claim that lowering the prices of prescription drugs in the United States would devastate innovation. Yet, as prices have skyrocketed over the last few decades, these same companies' investment in research and development have failed to match this same pace. Instead, they've dedicated more and more of their funds to enrich shareholders or to purchase other companies to eliminate competition.

"In 2018, the year that [former President] Donald Trump's tax giveaway to the wealthy went into effect, 12 of the biggest pharmaceutical companies spent more money on stock buybacks than on research and development," the report notes.

Some key findings from the report:

"Competition is central to capitalism," Porter said in a press release introducing the report. "As our report shows, Big Pharma has little incentive to invest in new, critically needed drugs. Instead, pharmaceutical giants are free to devote their resources to acquiring smaller companies that might otherwise force them to compete."

"Lives are on the line; it's clear the federal government needs to reform how it evaluates healthcare mergers and patent abuses," Porter added.

To that end, Porter's report recommends the following actions:

Elijah E. Cummings Lower Drug Costs Now Act , but must extend to include a larger class of drugs and cover all payers and the uninsured; and Preventing anti-competitive abuses of the drug patenting system. Congress should pass legislation, such as the such as the Preserve Access to Affordable Generics and Biosimilars Act , the Affordable Prescriptions for Patients Through Promoting Competition Act, and the Stop STALLING Act, to stop abuses of the regulatory process.

"It's time we reevaluate the standards for approving these mergers," the report concludes. "It's time we pass legislation to lower drug prices. And it's time we rethink the structure of leadership at big pharmaceutical companies. Together, these strategies can help us bring more innovative, and critically needed, cures and treatments to market."


P S BAKER , January 30, 2021 at 6:51 am

Katie Porter is brilliant – the total anti-Trump.
https://www.youtube.com/watch?v=yh4nhkuvuFc

ChiGal in Carolina , January 30, 2021 at 11:00 am

Okay, this I didn't expect: top recipients of Pharma $ in the senate per Open Secrets: Bernie Sanders, twice the take of his nearest competitors, Warren and McConnell
https://www.opensecrets.org/industries/summary.php ?

Everything isn't about Trump.

cnchal , January 30, 2021 at 7:00 am

Again, eclownomists are wrong.

Outsized profits has failed to draw competition to itself. Instead, outsized profits is used to kill competition. Another advantage for the bigs is using the carryforward losses of the soon to be devoured innovator to offset the big's profits, reducing taxes owed.

Sweet deal for those at the top. Taxpayer funded research -> innovative money losing company taking a risk -> devour the innovative company and use the generated losses by it to reduce your own taxes and kill the competition. Circle complete.

How is that circle to be broken when the bigs own congress?

oliverks , January 30, 2021 at 7:11 am

I think this is a wider problem that just the drug industry.

I was invited to a silicon valley party once at the partner of a big law firm. It was kind of a celebratory party for all the companies that had liquidity events that year.

I went around asking what their companies did. What struck me was how trivial most of the products these companies were making. Really most were minor upgrades to existing products.

It turns out that the healthcare industry would rather buy a minor update that do it themselves, because if they did it themselves it would be a cost. By buying the product it doesn't show up as cost (at least in the short run).

This makes everything less efficient. A small company starting from scratch takes much time and money to make this minor update. Once the acquisition occurs, the big healthcare company now has 2 products, which are similar, but made by different producers, with total different BOMs.

Bobby Gladd , January 30, 2021 at 9:37 am

I covered the health infotech VC startup space (mostly Silicon Valley) for a number of recent years. I was working in Health IT at the time (electronic medrecs, etc).

Then I watched "Silicon Valley HBO" at the urging of my kids.

I couldn't do it with a straight face after that.

Joe Brant , January 30, 2021 at 7:12 am

The content of this report of Big Pharma corruption should certainly be a national scandal, resulting in a generation of reform. But the corrupt mass media, corrupt legislature, corrupt executive, and corrupt judiciary will do nothing at all. They are the core problem.

The US needs constitutional amendments to restrict funding of mass media, political parties, and elections to limited individual donations, with very severe penalties for violations. Congress and the judiciary and most agencies must be purged and restaffed under strict controls, and monitored for life for corrupt influence. All branches and mass media corporations must be structured with multiple redundant cross-checking decision committees, with rotating memberships. Otherwise they sell out.

Steve Ruis , January 30, 2021 at 8:28 am

Hear, hear . . . but getting such legislation past the money already swamping the system will take some kind of miracle.

The Historian , January 30, 2021 at 10:20 am

"The content of this report of Big Pharma corruption should certainly be a national scandal, ."

You are absolutely right, and it is something that all Americans should know about, so I searched the major news outlets in this country to see who is carrying this story and guess what? NOT ONE! Vox is the closest to MSM coverage that I could find.

They are all carrying the Robinhood story though.

Tom Stone , January 30, 2021 at 8:38 am

Who pays at Pfizer calls the tune?

Chris Herbert , January 30, 2021 at 8:56 am

The 'small government' movement was always a total ruse. It wasn't even libertarian. It was just 'give me monopolies and tax cuts' populism for the One Percent. Meanwhile the plebes continue to believe in 'trickle down,' prosperity for themselves. A friend of mine found this quote. I think it is pertinent: "The Baltimore Evening Sun on July 26, 1920: ""As democracy is perfected, the office (of the President) represents, more and more closely, the inner soul of the people. We move toward a lofty ideal. On some great and glorious day, the plain folks of the land will reach their heart's desire at last, and the White House will be adorned by a downright moron." The only thing H.L. Mencken didn't consider when he wrote the sentiment was how many of a like mind and character would be swept into office by the wake." This is not a criticism of the new President, Joe Biden. He appears sane and maybe even quite progressive. A true populist, not the fake one we just collectively fired.

ObjectiveFunction , January 30, 2021 at 10:18 am

You can leave your dusty bottles on the shelf / An' you can keep your words of wisdom to y'self .

Codeine – The Dead South (cover)

[Nov 30, 2020] Krystal Ball- Healthcare CRIMINALS Are Gouging Covid Patients - YouTube

Highly recommended!
Nov 30, 2020 | www.youtube.com

Krystal takes it to the Medical Industrial Complex in the age of Covid.



Irene Rose art
, 5 days ago

Well, this is exactly why they HAD to stop Bernie Sanders.

Peter Sepall , 5 days ago (edited)

The american public exists as a resource to be exploited by a small group of narcissistic sociopaths.

Daniel R , 5 days ago

Oof! Krystal on point yet again. Don't lose your touch!


Eric Butler
, 5 days ago

Finally, someone is talking about this! I don't want Covid, not because I'm afraid of dying, but because I don't want to survive to see that bill!

[Nov 18, 2020] Doctor who sterilized women without consent found guilty

Nov 18, 2020 | nypost.com

A disgraced Virginia OB/GYN who for years performed unnecessary surgeries on women -- including hysterectomies -- in an insurance fraud scheme was found guilty on 52 counts for his crimes.

The former doctor, Javaid Perwaiz, faces more than 400 years in prison when he is sentenced by a federal judge next spring, the Washington Post reported .

Perwaiz, who practiced in Hampton Roads, forced women into surgeries by telling them they had cancer and used broken equipment to perform procedures, according to the report.

At his three-week trial in federal court, victims of the doctor testified how he performed hysterectomies and other permanent, life-altering surgeries on them.

Perwaiz profited from the scheme by pocketing millions of dollars from Medicaid and private insurers that paid for the unnecessary medical procedures he performed on the women.

"Doctors are in positions of authority and trust and take an oath to do no harm to their patients," Karl Schumann, an FBI agent in the Norfolk field office, told the Washington Post in a statement.

"With unnecessary, invasive medical procedures, Dr. Perwaiz not only caused enduring complications, pain and anxiety to his patients, but he assaulted the most personal part of their lives and even robbed some of their future," he added.

At trial, Perwaiz defended himself, arguing he performed the surgeries to help his patients, not siphon money from their insurers.

He's scheduled to be sentenced on March 31.

[Sep 06, 2020] Inactive fragments on virus RNA trigger false positives in most common COVID test due to way too many cycles of amplification which amplifies noise along with the signal and efffectly turns noise (inactive fragments on RNA) into signal, new study finds

Highly recommended!
From comments: "Article is poorly written by someone who does not know medical science. There are no viral "cells" so the headline is a put off right away. The comment about "sensitivity" is misplaced as PCR tests are too sensitive: ergo false positives. I believe "specificity" is the word the author was searching for. If a test lumps true positives with false positives, then it lacks specificity."
Sep 05, 2020 | www.zerohedge.com

In the past, our reports raising questions about the accuracy of COVID-19 tests have been met with accusations of 'fearmongering' and spreading 'misinformation'.

But not today.

That's because new research from the University of Oxford's Center for Evidence-Based Medicine and the University of the West of England has found that the swab-based technique used for most COVID-19 testing is at risk of returning "false positives" since copies of the virus's RNA detected by the tests might simply be dead, inactive material from a weeks-old infection. Although patients infected with COVID-19 are typically only infectious for a week or less, tests can be triggered by virus genetic material left over from a weeks-old infection.

The team's research involved analyzing 25 studies on the widely used polymerase chain reaction test. PCR tests use material collected with a swab - the most common type of test around the world, and especially in the US - then utilize a "genetic photocopying" technique that allows scientists to magnify the small sample of genetic material collected, which they can then analyze for signs of viral RNA.

What the researchers here have effectively found is that these PCR tests just aren't sensitive enough to distinguish if the viral material is active and infectious, or dead and inert.

For those who desire a more comprehensive understanding of how these tests work, the chart below can be helpful.

Professor Carl Heneghan, one of the authors of the study, said there was a risk that a surge in testing across the UK was increasing the risk of this sample contamination occurring and it may explain why the number of Covid-19 cases is rising but the number of deaths is static.

"Evidence is mounting that a good proportion of 'new' mild cases and people re-testing positives after quarantine or discharge from hospital are not infectious, but are simply clearing harmless virus particles which their immune system has efficiently dealt with," he told the Spectator.

Professor Heneghan added that international scrutiny might be required to avoid "the dangers of isolating non-infectious people or whole communities." ZKnight 14 minutes ago

Fake science. How about purify the virus first and establish a gold standard for testing first. No, of course not because the CDC has a patent for Covid-19 and nobody is allowed to try find it to see if it exists. play_arrow LogicFusion 27 minutes ago

Everybody is a Covid-19 / Coronavirus expert now!

Read about the failed coin dealer and convicted felon's performance. It's hilarious!

Martin Armstrong becomes Covid-19 Coronavirus Expert overnight play_arrow ducksinarow 59 minutes ago

Covid -19 has been so politicized that I don't believe a word of any publication for or against testing, existence of the Virus, or anything that provokes testing or issues opinions about locking down communities. Just like the riots, Covid news is just plain boring. play_arrow ominous 3 hours ago

Link to spectator.co.uk goes to home page, not this story.

Where is the original story posted? play_arrow play_arrow ominous 3 hours ago (Edited)

Perhaps this

https://www.cebm.net/covid-19/infectious-positive-pcr-test-result-covid-19/ y_arrow 1 Rabbi Blitzstein 38 minutes ago

"Give me control of a nation's money, and I care not who makes the laws" - Mayer Amschel Rothschild. play_arrow play_arrow tangent 4 hours ago remove link

People who recommend a vaccine for an entirely cured virus should lose their license to practice medicine. 99.9% cure rate applying to people who take it before being hospitalized is one of the biggest success stories in the history of medicine for HCQ. Not only that, but there are multiple other likely cures that simply have not been studied well. You'd think people would appreciate the fact that the common cold has been cured, but instead they just whine that big pharma isn't getting those bucko bucks.

I honestly expected a ticker tape parade like in the movies when that first cure study came out. But instead they took a massive **** on the study and on the doctor... ****ty world we live in. ay_arrow Pair Of Dimes Shift 2 hours ago

An exec (55+) at my company is gung ho about the vaccine.

Unfortunately, I just had to give him a "wait and see" response although I know vaccines for coronaviruses are impossible. play_arrow 2 play_arrow ThanksIwillHaveAnother 4 hours ago (Edited)

Viruses are not full cells. They are DNA/RNA wrapped with a protein the clings to a cell then the cell imports the DNA/RNA to start making its proteins. So what is inactive? If that person sneezes on another person depending on immune system status that other person could get a bad infection. y_arrow 4 CrabbyR 3 hours ago

viruses utilizes CELL structures and host DNA to replicate dna or rna according to the viruses genetic code, the protein jacket is the final product to

disguise the virus from detection and to bind on another cell after the compromised cell RUPTURES, there's more to it but if it cannot copy itself effectively it can become nonviable and unable to infect another cell. It replicates DNA inside a host cell, It is not a complete organism and cannot replicate unless it can inject its DNA into a host cell. Antibodies cling to viruses and destroy this ability to bind to a target cell. A non viable virus has a damaged coat or DNA RNA that has to many Dimers (damage or code breaks) Bacteria is more in line with what you think a virus is y_arrow onewayticket2 4 hours ago (Edited) remove link

they lost me when they changed the definition of "death" to include "presumed, untested" cases (while bI@#$% ing at me that we needed to "follow the science")....and even got busted for the laughable motorcycle accident being classified as a covid death and the Labs that were sending in 100% positive results. (until they were caught) play_arrow OutaTime43 4 hours ago remove link

The test detects RNA. Not necessarily viable virus. Also, it will detect RNA presence in an individual who may already have antibodies and may be immune. We are bombarded daily by viruses of which we already have immunity. play_arrow sun tzu 10 hours ago

Shocking news that the South Koreans already discovered and published back in May. Western big pharma driven medicine is garbage 😂😂😂

https://www.cidrap.umn.edu/news-perspective/2020/05/wha-passes-pandemic-probe-resolution-korea-clarifies-reinfection-reports

play_arrow Roger Casement 10 hours ago

WTF!!!!

World Bank exporting COVID-19 Testing Kits in 2018??????

https: // wits.worldbank.org/trade/comtrade/en/country/ALL/year/2018/tradeflow/Exports/partner/WLD/nomen/h5/product/300215 play_arrow 7 play_arrow sun tzu 10 hours ago

Interesting play_arrow play_arrow Jack Mehoff 1 more time 9 hours ago

Business as usual play_arrow play_arrow Argon1 7 hours ago

Preparation for agenda 2021 in 2017. play_arrow 1 play_arrow CrabbyR 4 hours ago

WOW.......ties a few strands from other sources together into a real ugly picture play_arrow play_arrow Welsh Bard 10 hours ago

The professor who won the Nobel prize for work in this field, said that the way this test is being operated with over forty cycles, means that any results are entirely meaningless.

In Britain, having spent over £15 billion setting up PCR testing systems and a shaky test and trace apparatus on top of that, it appears that 90% of positive results now appear to be false. This is compounded by the fact that when a hot spot develops, more testing is done to show a rapid increase in more false positive results, meaning further new lockdowns and even more testing to prove yet more false positive results ad infinitum.

Now whether this is by design or ineptitude, people must decide for themselves but the outcome is utter chaos.

For those countries who have not followed the Swedish model especially countries like Australia and New Zealand who have set up complete isolation, now face a future perpetually cut off from the rest of the world.

Okay, new techniques will and are coming along to treat the disease like HCQ when used correctly maybe as a prophylactic and a vaccine that will need to be constantly upgraded like the Flu vaccine, means that the whole world has painted itself into a corner unless drastic revision is now made to the whole sorry mess.

In the meantime, we will now be stuck with digital currency and the introduction of ID Health Cards that will limit people in how they travel where they work and access to a whole heap of things like government services.

Welcome to the new world order! play_arrow 1 KuriousKat 11 hours ago (Edited) remove link

Don't tell the Shameless Aussie gov that after arresting hundreds for simply voicing doubt on need to lockdown entire city...Next time it will be thousands and not a damn thing they can do to stop it..These people are trickling us the truth how worthless the tests are when pretty much everyone knows. play_arrow espirit 12 hours ago remove link

Lessee.

WHO

Imperial College

John Hopkins

CDC

Line all those peeps up against the wall, and the first one to rat gets to live.

I'll provide my own ammo... ay_arrow Sick Monkey 6 hours ago

Not everyone working in these agencies are dishonest but like you and I we have to work and eat.

Most of them are trapped in this mess with bills to pay threatened by NDA.


play_arrow 1 Urban Roman 12 hours ago

Not particularly new news. Been talked about since April at least -- it's an RNA virus, it has its own polymerase, and it leaves lots of RNA fragments in its wake.

The Corona family of viruses make 5 or 6 strands with partial copies of their RNA molecule. negative copies are made first, and then copied again into positive copies. Finally the one big RNA is made with the entire genome on it.

So about a dozen RNA molecules are made for each finished virus particle that is produced. And finally, a variety of different primers are used for the PCR tests, some are matched to the small partial RNA copies and others are matched to various features on the large whole-virus RNA. They can give different results for the same sample.

So, someone who registers on a PCR test has probably been exposed to the virus, but the test gives no clue as to whether it is an active infection, or the person is contagious, or they are just coming down with it, or they got over it six months ago. play_arrow 4 play_arrow 1

10 play_arrow gordo 12 hours ago remove link

Sweden, no masks, no lock downs, ALL SCHOOLS OPEN, herd immunity, no second wave.

Still think your masks and lock downs are working muppets?


1 play_arrow The 3rd Dimentia 13 hours ago

https://youtu.be/sjYvitCeMPc SARS-CoV2 and the Rise of Medical Technocracy. Lee Merritt, M.D. play_arrow 3 play_arrow hugin-o-munin 13 hours ago

I'm glad to see that many are starting to counter the official narrative.

We've been asleep for too long and allowed these agendas to fester to the point we're at now where a college dropout software salesman and a former 3rd world communist terrorist (neither of whom have any medical degree) are dictating to the world how everyone needs to get a DNA altering vaccine and a medical ID. It's completely nuts and bonkers yet more or less the entire planet's governments follow in 'lockstep' with ever more draconian laws and regulations incarcerating people in their own homes, making them wear masks causing oxygen deprivation and shutting down the entire world economy.


lay_arrow Warthog777 , 13 hours ago

Article is poorly written by someone who does not know medical science. There are no viral "cells" so the headline is a put off right away. The comment about "sensitivity" is misplaced as PCR tests are too sensitive: ergo false positives. I believe "specificity" is the word the author was searching for. If a test lumps true positives with false positives, then it lacks specificity.

Cabreado , 13 hours ago

"accusations of 'fearmongering' and spreading 'misinformation'.
But not today."

Well, much of the world has known for months now about the testing lies...

and I'd be remiss to not remind the Tylers that they indeed played a role in the fear mongering along the way; quite intently so.

Crush the cube , 13 hours ago

https://play.google.com/store/books/details/Flavio_Bell_Covid_24?id=SxrxDwAAQBAJ

Busted, published 2018, what a scam.

Digital-Anarchy , 14 hours ago

Anyone who would use the term "virus cells", has no clue what they're talking about and should be completely disregarded. Viruses are not cells. PCR tests are searching for something your body produces in response to a virus as well. They are not produced specifically for a singular virus either. The entire concept of PCR testing is garbage. This **** was a scam from the get-go.

hugin-o-munin , 13 hours ago

Yes it is evident now that this entire pandemic is false and political. The goal seems to be to vaccinate entire populations and the question people need to ask is - why? what for? Aside from the obvious economic motives there are some more sinister plans that most people will have a hard time accepting but these need to be looked at. Several years ago there were a group of doctors and researchers that died of suspicious suicides who were collaborating and studying vaccines and the link to autism.

The effort was led by Dr.Jeffrey Bradstreet who was researching the natural substance GcMAF and how this could boost the immune system. What he discovered was that many vaccines had a compound/substance called Nagalase in them that is unnatural and has a detrimental effect on the immune system and function of GcMAF (which is produced by our own bodies) and has no business at all being in vaccines. Just before he was able to blow the whistle on this he also died of a suspicious 'suicide' and today most of the clinics and research groups working on GcMAF have been destroyed and ruined. Draw your own conclusions.

snblitz , 14 hours ago

Dr. Kary Mullis invented the PCR test. He said it was ineffective for this purpose.

Though he was addressing its use in a prior virus hoax unleashed upon the world.

I bet you didn't know this scam has been used before.

That is why I was able to call out the scam right from the start. The second I saw them using the PCR again, I knew it was from the same playbook.

snblitz , 14 hours ago

So many lies.

Viruses are not alive. They have no metabolic functions. They cannot move.

Don't believe me? Get a degree is virology or microbiology or just a read a book on the subject. Or capture a wuhan-virus yourself and watch it under a microscope. It won't move. It won't consume anything. It will just sit there inert.

The problem is that you are being lied to at a scale you cannot imagine.

I know, off to the fema re-education camp for me for spreading false information about the wuhan-virus.

Though I am not the one spreading fear and hysteria.

aldousd , 13 hours ago

There article is confused, but the work of the doctor is not. Viruses use your cells to reproduce. When your immune system targets the virus it actually kills your own cell which has become host to the virus. The virus particles and markers, and the DNA of the virus can be detected in these dead cells, but dead cells cannot serve as a factory for more viruses. So it's effectively a dead virus infected cell. Not a dead virus cell.

So while the transcription of the idea here was done by an idiot, it's not an idiotic idea. The tests cannot tell if the virus came in a living cell that is actively producing more viruses or a dead host cell that has been assassinated by your immune system. That's what they're talking about here.

mstyle , 11 hours ago

what about the chromosome 8 stuff that has been mentioned lately?

(since you appear to be rather intelligent)

hugin-o-munin , 11 hours ago

Thanks. Well the chromosome 8 discovery in the PCR test specifications/details is strange and worrying because it makes you wonder why it's part of this at all. Some believe it's to get more false positive results while others believe it is what the mRNA vaccines are intended to target and if that's right then it's really sinister. What exactly is the plan? To make all of us get Downs Syndrome? I don't know but judging by all their other lies and schemes it wouldn't surprise me.

IRC162 , 14 hours ago

Fuggin progressives and their pandemic political prop. But really this reaction is the same as their reaction to 'racial injustice'. They focus on feelings before the facts are known in order to achieve their end, and then do their best to bury/ignore the facts when they are gathered later.

94% COVID deaths with multiple comorbidities.

10 unarmed blacks killed by police in 2019 (6 were in self-defense).

adr , 15 hours ago

Why didn't you mention that nearly all labs are running 35-40 cycles which guarantees a positive test, simply from noise.

The inventor of the test said if you don't find anything after 15 cycles, it probably isn't there. After 20 cycles the noise starts to be greater than any real information. By 30, the test is mostly noise. More than 35, the test is completely worthless.

Of course I've been saying this for five months, but most people didn't listen. After the NYT article came out, people I know started saying, "How did you know?"

I said, "Because I have critical thinking skills. Why didn't you believe me? Name a time I've steered you wrong."

Antiduck , 14 hours ago

333 labs in florida had 100% positivity. (stupid word.)

ZenStick , 12 hours ago

Exactly correct.
Nobody will touch this line of reasoning in public or on media.
Bastages.

Identify as Ferengi , 15 hours ago

See above, Born2Bwired.

The PCR test is not useful for what they are using it for apparently. This has been known since the beginning. Here is quote regarding AIDS:

"Kary Mullis, who won the Nobel Prize in Science for inventing the PCR, is thoroughly convinced that HIV is not the cause of "AIDS". With regard to the viral load tests, which attempt to use PCR for counting viruses, Mullis has stated: "Quantitative PCR is an oxymoron." PCR is intended to identify substances qualitatively, but by its very nature is unsuited for estimating numbers. Although there is a common misimpression that the viral load tests actually count the number of viruses in the blood, these tests cannot detect free, infectious viruses at all; they can only detect proteins that are believed, in some cases wrongly, to be unique to HIV. The tests can detect genetic sequences of viruses, but not viruses themselves.

What PCR does is to select a genetic sequence and then amplify it enormously. It can accomplish the equivalent of finding a needle in a haystack; it can amplify that needle into a haystack. Like an electronically amplified antenna, PCR greatly amplifies the signal, but it also greatly amplifies the noise. Since the amplification is exponential, the slightest error in measurement, the slightest contamination, can result in errors of many orders of magnitude."

http://www.virusmyth.org/aids/hiv/jlprotease.htm

naro , 15 hours ago

NYTimes article last week suggested that only 10% of Covid positive PCR tests are clinically significant and infectious.

[Aug 27, 2020] Trump's Executive Orders Will Make Prescription Drugs More Affordable -

Aug 27, 2020 | www.theamericanconservative.com

esident Trump recently introduced four executive orders aimed at reducing drug prices for all Americans. Affordability in health care is consistently a leading issue on the minds of the people, and the price of prescription drugs is a key component of that. Every president, regardless of party, wants to make medication more affordable. But more times than not, they fail to make much of a difference. President Trump's orders, however, should.

Insulin, a drug that has been in existence for nearly a century, continues to be cost prohibitive for many diabetics. We've all seen story after story of people having to choose between groceries and lifesaving drugs -- even at a time when the Affordable Care Act is the law of the land. Over the last 10 years, the price of Humalog, a commonly prescribed insulin, has increased from $75 to $250, with no changes to formula, packaging, or designs.

https://lockerdome.com/lad/13045197114175078?pubid=ld-dfp-ad-13045197114175078-0&pubo=https%3A%2F%2Fwww.theamericanconservative.com&rid=www.theamericanconservative.com&width=838

Over the same time frame, the list prices established by pharmaceutical companies have skyrocketed, although their profits have remained relatively flat . The middlemen and insurers, however, have seen record growth and rampant consolidation due to the large rebates they command from the manufacturers that benefit from being on the insurers' drug lists. This is a broken system; it sounds like a business model straight out of The Godfather movies.

The next EO, the International Pricing Index (also known as the "most favored nation" order), seeks to compel pharmaceutical manufacturers to charge the U.S. no more than the lowest price available among economically advanced countries for Medicare Part B drugs. Clearly, this is rate-setting and not a sustainable solution, but the order is the only one that comes with a trigger mechanism. President Trump has given Big Pharma until noon August 24 to negotiate a substantive plan to lower the cost of drugs for the American people.

If the manufacturers are unsuccessful in producing a viable plan, it will pull the trigger that initiates most favored nation status. This tactic has given the president necessary leverage to push for a deal that makes sense.

The importation order achieves the same end, but it will ultimately be up to the states to implement, should they wish to import drugs from nations with which they negotiate. Governor Ron DeSantis of Florida has been a long-time proponent of this policy and has been leading the charge for his state.

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Another order that focuses on bringing down the cost of insulin and epinephrine was issued within the network of clinics known as Federally Qualified Health Centers (FQHC). Patients that are seen in these clinics will now be able to take advantage of newly extended purchasing discounts that will allow them to get these life-saving drugs for pennies on the dollar.

The fourth and perhaps most substantive order makes rebates for Medicare patients available at the pharmacy. Insurers and other middlemen have often kept these rebates and counted them as revenue rather than passing them on to patients. This order makes Medicare patients the beneficiaries of these rebates, which will result in much greater affordability for our seniors who are often on fixed incomes.

Are the orders perfect? Perhaps not. But the absence of leadership from Congress to get this done has resulted in needed action from President Trump. The physicians and patients who attended the signing applauded this effort and encouraged the administration to press on to make health care even more affordable. We are all patients, and efforts like this are opportunities for us to unite in our effort to fix our broken health care system.

David Balat is the policy director of the Right on Healthcare initiative at the Texas Public Policy Foundation.

Victor_the_thinker 9 hours ago

I work for a Pharma company. I haven't heard anyone concerned about these EOs. If they were actually going to impact pricing, I would have heard the concern as I deal directly with upper level management.

Victor_the_thinker Victor_the_thinker 9 hours ago

Also, insulin and epinephrine are made by only a handful of companies. There are a ton more drugs around than these generic drugs. It's the on patent drugs which drive the extreme cost of healthcare. Focusing on genetics isn't remotely where the big dollars are for the industry. Yea, there is gouging going in for insulin, it's certainly not the biggest thing going on right now in pricing.

[Jun 03, 2020] Games with health accounts large corporations play

Jun 03, 2020 | features.propublica.org

Jeff , Thursday, March 22, 2018 2:05 PM

In early 2013 I was given a 3 PBC rating for my 2012 performance, the main reason cited by my manager being that my team lead thought I "seemed distracted". Five months later I was included in a "resource action", and was gone by July. I was 20 months shy of 55. Younger coworkers were retained. That was about two years after the product I worked on for over a decade was off-shored.

Through a fluke of someone from the old, disbanded team remembering me, I was rehired two years later - ironically in a customer support position for the very product I helped develop.

While I appreciated my years of service, previous salary, and previous benefits being reinstated, a couple years into it I realized I just wasn't cut out for the demands of the job - especially the significant 24x7 pager duty. Last June I received email describing a "Transition to Retirement" plan I was eligible for, took it, and my last day will be June 30. I still dislike the job, but that plan reclassified me as part time, thus ending pager duty for me. The job still sucks, but at least I no longer have to despair over numerous week long 24x7 stints throughout the year.

A significant disappointment occurred a couple weeks ago. I was discussing healthcare options with another person leaving the company who hadn't been resource-actioned as I had, and learned the hard way I lost over $30,000 in some sort of future medical benefit account the company had established and funded at some point. I'm not sure I was ever even aware of it. That would have funded several years of healthcare insurance during the 8 years until I'm eligible for Medicare. I wouldn't be surprised if their not having to give me that had something to do with my seeming "distracted" to them. <rolls eyes="">

What's really painful is the history of that former account can still be viewed at Fidelity, where it associates my departure date in 2013 with my having "forfeited" that money. Um, no. I did not forfeit that money, nor would I have. I had absolutely no choice in the matter. I find the use of the word 'forfeited' to describe what happened as both disingenuous and offensive. That said, I don't know whether's that's IBM's or Fidelity's terminology, though.

[Jun 02, 2020] Neoliberalism and relationships of care: and Neoliberalism... just doesn't care

Notable quotes:
"... "individualism ignores or misvalues the role of care" ..."
Jun 02, 2020 | www.youtube.com

Dr. Durian M.D. , 2 years ago

Super happy to see you bring up care ethics and how the existence of relationships of care undermine the individualist focus of (neo)liberalism. Have you done a video on care ethics?

If so I'll be watching it shortly. I wish you'd gone even farther and looked at the importance of un-paid or underpaid care labour in the foundation of capitalism, but I suppose that's tangential.

KuraIthys , 3 months ago div c

lass="comment-renderer-text-content expanded"> Neoliberalism is pretty much what caused me to have to leave the UK when they simply made it too difficult to survive as someone with a disability. I can consider myself unreasonably lucky in holding dual citizenship, and in the other country I have citizenship of not (yet) resorting to quite the same level of sadistic behaviour... But it certainly wasn't something that was reassuring... And I feel sorry for all the people in similar circumstances who had to somehow find a way to cope with it anyway...

42billybob , 2 years ago

"They assume that free markets mean competition. And competition means that quality is kept high, prices are kept low, and it drives innovation, distributes resources efficiently to the people that want them the most." That's... not specifically a neoliberal thing. That's capitalism in general. But OK... I'm inclined to mostly agree with this stated premise (might pick some different semantics but eh... close enough). You're going to tell me why I shouldn't. So let's see what you've got:

"Have free markets resulted in a lot of competition everywhere? Or have some markets become dominated by a very small number of companies?" Yep... oligarchies happen. Ever notice that it tends to be in the most heavily regulated markets? Big companies with fat profit margins can survive regulations, small businesses and startups can't. The more you free the market, the easier it is for literally anyone with money, charisma, and/or a brilliant idea to spring up and carve off a big piece of the big guy's market share with a better product/service/resource for everyone.

"Are resources as efficiently distributed as they could be?" Never. There's always room for improvement. But if we're to compare against existing examples capitalism does it faster, cheaper & overall better than the alternatives.

"Do they always go to the people who want them the most?" They go to people able and willing to provide something of value in exchange. There's a lot of overlap between the two groups. But no. Some people don't get the resources they want because wanting something doesn't automatically mean you get it. Although even in a ruthless capitalist society of individualism people actually do still give a shit about their fellow man. Private charities are still perfectly functional capitalist entities (for profit or otherwise).

"Is the innovation that is happening always useful?" No. People chase bad ideas all the time. But generally, people quickly lose interest and stop supporting bad ideas (or run out of money). At least in a capitalist setting bad ideas can die on their own merit of providing nothing in exchange for what you give them. Instead of being propped up by tax dollars people don't want to spend on a completely unsustainable pet project of some ego-centric politician and the slight majority he's convinced is not a bad enough reason to kick him out of office.

"Is it allowed to benefit all of human kind when it is?" Who decides what is and isn't beneficial to all of human kind? Or are you simply referring to the fact that when someone creates something useful and new, it isn't immediately somehow provided to everyone who may want it?

I can't help but notice there was weasel wording in every single one of these questions. As presented, you have to answer "no" to all of them because the question requires absolute total success in all cases in order to answer "yes" to any of them.

"individualism ignores systemic privilege" Yea... so what? In what way does someone else being rich, good looking, charismatic, smart or skilled negatively affect you? Especially someone you never interact with? What it does not ignore is systemic discrimination. Stuff that actually negatively affects people in a quantifiable way.

"individualism ignores or misvalues the role of care" Individuals still care about people. They still have friends and family. The only difference is that they are encouraged to take it upon themselves to see to the well being of themselves and the people they care about. Sure, you can be a shithead who burns every social bridge but you end up fucking yourself when hard times fall upon you. An individualist still has vested personal interest in maintaining good relationships with those around them for this very reason. Even when their motives are completely selfish. As individuals we are encouraged to make these connections ourselves as opposed to expecting some authority to forcibly extract our needs from strangers. Individuals care about other people, collectivists care about the idea of other people.

[Jun 01, 2020] Drugs, Money, and Secret Handshakes The Unstoppable Growth of Prescription Drug Prices

Jun 01, 2020 | www.amazon.com

In the warped world of prescription drug pricing, generic drugs can cost more than branded ones, old drugs can be relaunched at astronomical prices, and low-cost options are shut out of the market. In Drugs, Money and Secret Handshakes, Robin Feldman shines a light into the dark corners of the pharmaceutical industry to expose a web of shadowy deals in which higher-priced drugs receive favorable treatment and patients are channeled toward the most expensive medicines. At the center of this web are the highly secretive middle players who establish coverage levels for patients and negotiate with drug companies. By offering lucrative payments to these middle players (as well as to doctors and hospitals), drug companies ensure that inexpensive drugs never gain traction. This system of perverse incentives has delivered the kind of exorbitant drug prices - and profits - that everyone loves except for those who pay the bills.

[Jun 01, 2020] Drug Wars How Big Pharma Raises Prices and Keeps Generics off the Market

Jun 01, 2020 | www.amazon.com

David Wineberg , Reviewed in the United States on June 26, 2017

...when first we practice to deceive

A measure of just how perverse US pharmaceutical markets have become is the "reverse payment" in which the original manufacturer sues the maker of the new generic version for patent infringement, then settles by paying the generic maker to go away for several months before launching its version. If that is intriguing instead of revolting, Drug Wars is for you.

Feldman and Frondorf have researched all the Food and Drug Administration's generics files going back to the turn of the century, and found a treasure trove of manipulation, waste and greed that prove why we need an FDA in the first place. That the FDA is being crippled by all these shenanigans is criminal. To the tune of billions of dollars a year.

The name of the game is delay. Every month of delay can mean tens of millions of dollars from consumers and insurers overpaying. A year's delay can easily mean a billion dollars' profit. The frightening total is that 45% of Pharma revenues worldwide come from American patients. Because no other country lets them get away with this.

Some of the tactics Big Pharma uses:

Big Pharma fills the courts with frivolous suits, loads down the FDA with nonsenses complaints (demanding tests that are already required, for example) and applications, and stalls. A finding that a drug might be dangerous may not be filed for years – until a generic appears on the scene. Bogus applications that slow down generic approvals are routinely rejected – but they serve the purpose by taking up valuable time, at taxpayer and patient expense. While Drug Wars has a worthy conclusion packed with sensible recommendations, it is clear Congress will not act on them, and that lifesaving drugs should not be left to the "free" market.

David Wineberg

Rebecca L. Elson , Reviewed in the United States on June 28, 2017
Drug Wars

This article originally appeared on The Magical Buffet's website on 06/28/2017.

When you read that I'm about to discuss a book called "Drug Wars" your mind probably goes straight to America's "war" on illegal drugs, but you would be mistaken. There is a war involving prescription drugs going on right now that many of us had no idea existed. It's one where pharmaceutical companies always win and the public always loses.

A long time ago, before the mid-80's (I can't believe I called that a long time ago!) people realized that very few generic drugs were coming onto the market. Wait, let me back up for those of you who aren't constantly on meds like myself. So in the fashion world designer label Louis Vuitton sells its "Saint Michel" purse for $1,700. It's a bag, it holds stuff. You can also find on your better handbag websites what are subtly referred to as "knock off" versions for a couple hundred dollars. It's also a bag. It also holds stuff. That's essentially prescription drugs and their generic versions, except in this case the FDA makes sure that the bags are made of the same primary material. A prescription drug can be hundreds of dollars, but a generic drug is nearly identical at a fraction of the price. With the state of health insurance then, and now, there is an interest in generics for public consumption.

Thus in 1984 The Drug Price Competition and Patent Term Restoration Act, often called the Hatch-Waxman Act, went into effect to stimulate a generic drug market. The Hatch-Waxman Act is a great idea. It attempts to strike a balance between capitalism and the common good. When a pharmaceutical company goes to market with a new chemical that company is given 5 years of exclusivity. It also streamlined the process for companies looking to bring a generic version to the market. Thus the originator gets 5 years of market dominance to recoup research costs, etc. while providing the eventual competition of a generic to make things easier on the consumer's pocketbook and encourage pharmaceutical companies to get back to the drawing board to innovate and bring another new drug to market that again gets 5 years of competition free existence. Pretty elegant, right?

What no one saw coming, but let's face it, those in the know probably did, was that pharmaceutical companies found ways to extend their periods of exclusivity, which of course makes things harder on us sickos of America. The use of lawsuits to stall generics going to market is common, and not surprising once you're reading "Drug Wars". What was shocking was the collusion between the manufacturers of the original drug and the companies making the generics. When these companies are in litigation they can fight it out, or settle. Oddly the settlement involves the manufacturer of the original drug paying obscene sums of money to the generic, and the generic agreeing to hold off going to market for several more years. There many ways safe and effect generic drugs are delayed from becoming available, and "Drug Wars" does an amazing job highlighting them. The authors, Robin Feldman and Even Frondorf, also make recommendations on how to fix these issues.

If you're into intricate bureaucracies, healthcare in America, and a few laugh out loud absurdities then you need to read "Drug Wars: How Big Pharma Raises Prices and Keeps Generics Off the Market" by Robin Feldman and Even Frondorf.

[May 30, 2020] Democrats are fueling a corporate counter-revolution against progressives by David Sirota

Notable quotes:
"... corporate health insurance has far higher administrative costs than single-payer programs like Medicare , and even the much-vaunted Affordable Care Act allows insurers to siphon up to 20% of customers' premiums to corporate profits rather than actual medical care. ..."
"... That's probably why insurance companies have been lobbying for it . They know that such a program would boost their short-term profits, and they know that once such a program is in place, it would be politically difficult to get it repealed and replaced by progressives' far better Medicare for All program. In other words: Democrats' Cobra plan may secure insurance companies' profit-skimming position between Americans and their healthcare providers for decades to come. ..."
May 26, 2020 | www.theguardian.com

Democrats in Washington are not just passively failing to mount an opposition to Trump. They are actively helping Republicans. 'This corporate counterrevolution is easiest to see in Democrats' enthusiastic support for Republicans' legislative response to the coronavirus crisis.'

These are bleak days for America's progressive movement. The Democratic primary process handed the party's nomination to the candidate with the most conservative record. Corporate-friendly politicians like the New York governor, Andrew Cuomo, are using the pandemic to brandish their images and install billionaires to run things . Progressive lawmakers in Congress are being steamrolled, even by their own party's leadership . And a recession is battering the state and local budgets that fund progressive priorities like education and the social safety net.

Perhaps this is a temporary stall-out – a fleeting moment of retreat in a two-steps-forward-one-step-back trajectory. After all, polls continue to show that from workers' rights to universal healthcare , a majority of Americans support a progressive policy agenda.

The problem, though, is that Democrats in Washington are not just passively failing to mount a strong opposition to Donald Trump – they are actively helping Republicans try to fortify the obstacles to long-term progressive change well after this emergency subsides.

This corporate counter-revolution is easiest to see in Democrats' enthusiastic support for Republicans' legislative response to the coronavirus crisis. Democrats' entire 2018 electoral campaign told America that the opposition party needed to win back Congress in order to block Trump's regressive agenda. And yet, when the Republicans proposed a bill to let Trump's appointees dole out government cash to their corporate allies with no strings attached , this same opposition party mustered not a single recorded vote against the package. Not one.

Thanks to that, Trump appointees and the Federal Reserve can now hand out $4tn to politically connected corporations as they lay waste to our economy and steamroll progressive reforms. Private equity firms and fossil fuel companies get new tax breaks as they buy elections and try to lock in permanent climate change.

These bailouts were part of a larger legislative package that included good things like expanded unemployment benefits – and so you could argue that Democrats simply had to swallow a bitter pill and vote yes. Except, they subsequently proposed their own standalone legislation that would further strengthen the corporate opponents of progressive reform.

For example, there is the Democrats' push to alter the so-called paycheck protection program (PPP). Those loans were designed to help employees of mom-and-pop enterprises throughout the country. House Democrats' new stimulus legislation would open up the small business lending program to what they call "small nonprofits", but their language was crafted to provide the forgivable loans to industry trade associations. Those lobby groups represent the planet's biggest corporations – and their political action committees have delivered more than $191m of campaign cash to lawmakers in the last two decades.

Democrats have pitched their legislation as a "message" bill that declares their values – and in this case, they are reassuring Washington power-players that money meant for workers at neighborhood restaurants, local shops and other mom-and-pop concerns can be raided by the front groups representing giant drug companies, health insurers and Wall Street firms. If the legislation passes, it would not merely be an epic tale of greed – the new funding stream for corporate lobbying groups would bolster the very forces that make sure federal policy disempowers workers, maximizes private profit and generally protects the ruling class.

The tragedy is we're already moving in that wrong direction, and chances to change the dynamic don't come around often

It's an even worse story on healthcare. As 43 million Americans face the prospect of losing private health insurance, Democrats had a huge opportunity. After Trump himself suggested he wanted the government to pay healthcare providers directly for treating uninsured Covid-19 patients, they could have called his bluff and passed existing legislation to expand a Medicare program that provides actual medical care. Instead, House Democrats passed a bill to support lightly regulated private insurance marketplaces and to subsidize existing private insurance plans through a Rube Goldberg machine known as Cobra – and they passed this giveaway just after receiving an infusion of campaign cash collected by insurance lobbyists.

Taken together, these initiatives would route yet more public money through a corporate insurance bureaucracy in hopes that medical care eventually trickles down to Americans who desperately need it. Such a system is totally inadequate during a pandemic: it doesn't guarantee healthcare – it only only guarantees insurance coverage, which is so often denied or restricted when a medical claim is actually filed. Moreover, corporate health insurance has far higher administrative costs than single-payer programs like Medicare , and even the much-vaunted Affordable Care Act allows insurers to siphon up to 20% of customers' premiums to corporate profits rather than actual medical care.

But then, Democrats' Cobra plan is not merely a financial bailout for insurers – it is also a political bailout when the industry needs it most. At a time when popular support for Medicare for All is surging – when even a Republican president feels the need to make rhetorical (if empty) gestures toward the concept of government-funded healthcare – the Cobra plan would use public money to firm up the private health insurance industry's dominance over the healthcare system, just in time to short circuit a Medicare expansion.

That's probably why insurance companies have been lobbying for it . They know that such a program would boost their short-term profits, and they know that once such a program is in place, it would be politically difficult to get it repealed and replaced by progressives' far better Medicare for All program. In other words: Democrats' Cobra plan may secure insurance companies' profit-skimming position between Americans and their healthcare providers for decades to come.

If you get the sense that the fix is in and this is all deliberate, you're not wrong. Many of the self-styled progressive advocacy groups in Washington that posture as #resistance leaders turned a blind eye to the bill's problems and endorsed the legislation shortly after it was introduced, undercutting progressive lawmakers off the bat.

Making matters worse was the theater on the House floor. During the debate over the Democratic bill, nine progressive lawmakers made a public show of voting against the procedural measure to advance the bill, along with a tiny group of moderates. When it came to the real vote on actually passing the bill, a larger group of moderates ended up voting against it, but only one progressive lawmaker, Representative Pramila Jayapal, voted no . Had the progressives and moderates combined forces on either of the votes, they would have forced the bill back to the drawing board. Instead, their shenanigans ultimately helped secure the legislation's passage.

Taken together, the spectacle was more confirmation that whatever resistance exists in the nation's capital, it is so often performance art, rather than anything real.

"Outside groups and House lawmakers need to work together to build a populist bloc – probably inclusive of moderate Democrats and perhaps even an occasional Republican – who will stand united to force votes to ensure that our economy does right by ordinary people," said David Segal of Demand Progress, pointing to news of a potential Democratic coalition to buck the party's leadership and support a plan to float businesses' payrolls through the crisis. "We must make sure that America does not go in the wrong direction and become even more inequitable because we let unemployment soar, compel cities and states to implement austerity, force small businesses to shutter and let large corporations backstopped by the Fed roll them up."

The tragedy is that we're already moving in that wrong direction, and chances to change the political dynamic do not come around often. As Barack Obama's former chief of staff Rahm Emanuel (now an investment banker and TV talking head) said more than a decade ago during the financial crisis: "Never allow a good crisis to go to waste – it's an opportunity to do the things you once thought were impossible."

Billionaires and corporations are clearly following that advice, aiming to use the pandemic to grow their wealth and political power in previously unfathomable ways. It would be better if the opposition party put up a real fight – or at least refused to be complicit in postponing progress for yet another generation.

David Sirota is a Guardian US columnist and Jacobin editor at large who served as Bernie Sanders' presidential campaign speechwriter. He also publishes Too Much Information newsletter.

[May 24, 2020] Private Equity Is Ruining Health Care, Covid Is Making It Worse: Investors have been buying up doctor s offices, cutting costs, and, critics say, putting pressure on physicians by Heather Perlberg

Highly recommended!
So not only ambulance service was destroyed by private equity, they now added other specialties. I wonder is those criminals who insert unnecessary stents in patients are connected to private equity.
Images removed
Notable quotes:
"... "You can't serve two masters. You can't serve patients and investors" ..."
"... Morganroth's defense of pandemic Botox might seem odd, but it made perfect sense within the logic of the U.S. health-care system, which has seen Wall Street investors invade its every corner, engineering medical practices and hospitals to maximize profits as if they were little different from grocery stores. At the center of this story are private equity firms, which saw the explosive growth of health-care spending and have been buying up physician staffing companies, surgery centers, and everything else in sight. ..."
"... But some doctors say that the private equity playbook, which involves buying companies, drastically cutting costs, and then selling for a profit -- the goal is generally to make an annualized return of 20% to 30% within three to five years -- creates problems that are unique to health care. "I know private equity does this in other industries, but in medicine you're dealing with people's health and their lives," says Michael Rains, a doctor who worked at U.S. Dermatology Partners , a big private equity-backed chain. "You can't serve two masters. You can't serve patients and investors." ..."
"... Yet over the past decade, lawyers devised a structure that allows investors to buy a medical practice without technically owning it: the MSO, or management service organization. Today, when an investment firm buys a doctor's office, what it's actually buying are the office's "nonclinical" assets. In theory, physicians control all medical decisions and agree to pay a management fee to a newly created company, which handles administrative tasks such as billing and marketing. ..."
"... Businessweek ..."
"... When individual doctors sell, they generally receive $2 million to $7 million each, with 30% to 40% of that paid in equity in the group. After the acquisition, doctors get a lower salary and are asked to help recruit other doctors to sell their practices or to join as employees. ..."
"... Patients, for the most part, are in the dark. Unlike when your mortgage changes hands, you usually aren't notified when a big investment firm buys your doctor. Sometimes the sign on the door bearing the physician's name stays put, and subtle changes in operations or unfamiliar fees may be the only clues that anything has happened. ..."
"... At Advanced Dermatology & Cosmetic Surgery , the largest private equity-backed group in the field, with more than 150 locations across the U.S., that sense of discomfort came shortly after Audax Group bought a controlling stake in what was then a much smaller chain in 2011. The new management team introduced a scorecard that rewarded offices with cash if they met daily and monthly financial goals, according to a lawsuit filed in 2013 against the company by one of its dermatologists. The doctor alleged that the bonus program encouraged staff to do as many procedures as possible, rather than strictly addressing patients' medical needs. ..."
"... Most dermatologists use outside labs and pathologists, but private equity-owned groups buy up existing labs and hire their own pathologists. Then doctors are encouraged to refer patients within the group and send biopsy slides to the company-owned labs, keeping the entire chain of revenue in-house. ..."
"... Now comes the cost-cutting. This is supposed to be the hallmark of private equity, and, done right, it can work to the benefit of doctors and patients. But there are pitfalls unique to medicine, where aggressive cuts can lead to problems, some of them merely inconvenient and some potentially dangerous. ..."
"... A doctor at Advanced Dermatology says that waiting for corporate approvals means his office is routinely left without enough gauze, antiseptic solution, and toilet paper. Even before the great toilet paper shortage of 2020, he would travel with a few rolls in the trunk of his car, to spare patients when an office inevitably ran out. The company declined to comment. ..."
"... One paradox of the Covid-19 pandemic has been that even as the virus has focused the entire country on health care, it's been a financial disaster for the industry. And so, while emergency room doctors and nurses care for the sick -- comforting those who would otherwise die alone, and in some cases dying themselves -- private equity-backed staffing companies and hospitals have been cutting pay for ER doctors. These hospitals, like the big medical practices, make a large portion of their money from elective procedures and have been forced into wrenching compromises. ..."
"... For investors with capital, on the other hand, the economic fallout from the virus is a huge opportunity. Stay-at-home orders have left small practices more financially strained than they've ever been. That will likely accelerate sales to private equity firms, according to Marc Cabrera, an investment banker focused on health-care deals at Oppenheimer & Co. Independent doctors or groups that previously rebuffed offers from deep-pocketed backers "will reconsider their options," he says. ..."
"... Many doctors may ultimately come to regret cashing out, but it's hard to get out once you're in. As part of an acquisition, the private equity groups typically require doctors to sign yearslong contracts, with noncompete clauses that prevent them from working in the surrounding area. ..."
May 20, 2020 | www.bloomberg.com

Not long after Gavin Newsom, the governor of California, ordered the state's 40 million residents to stay home to stop the spread of the new coronavirus, Dr. Greg Morganroth called his team of doctors and said their dermatology group was staying open.

Morganroth is chief executive officer of the California Skin Institute , which he founded in 2007 as a single office in Mountain View. He's since expanded to more than 40 locations using a financing strategy that's become exceedingly common in American health care: private equity. In this case, he took out a loan from Goldman Sachs Group Inc. that could eventually convert to an equity stake. CSI is now the largest dermatology chain in California.

But the Covid-19 pandemic put Morganroth in a precarious position. Most medical procedures were characterized as nonessential by government officials and practitioners. Doctors were closing offices, and patients were staying away to limit their potential exposure to the virus.

CSI took a different approach. Morganroth explained his thinking on April 2 in a Zoom call with more than 170 dermatologists from around the country organized by the Cosmetic Surgery Forum, an industry conference. Contrary to what they might have heard, Morganroth told them, they should consider staying open during the pandemic. "Many of us are over-interpreting guidelines," he said.

For a moment there was an awkward silence. Doctors had thought they were signing up for advice on how to apply for government money that would help them meet payroll while they were shut down; they hadn't expected to be told not to shut down at all. Morganroth continued: "We are going to be in a two-year war, and we need to make strategic plans for our businesses that enable us to survive and to rebound."

Back at CSI, the company's front-office staff was working the phones, calling patients in some of the worst-hit areas and reminding them to show up for their appointments, even for cosmetic procedures such as Botox injections to treat wrinkles. During the videoconference, Morganroth argued that offering Botox in a pandemic wasn't so different from a grocery store allowing customers to buy candy alongside staples.

"If I had a food supply company and had to stay open, and I had meat, bread, and milk, would I stop making lime and strawberry licorice?" Morganroth asked. "I would make everything and go forward."

From a public-health point of view, some of the doctors believed, this was questionable. Common reasons for visiting a dermatologist's office -- skin screenings, mole removals, acne consultations -- aren't particularly time sensitive. Serious matters, such as suspected cancers and dangerous rashes, can be handled, at least initially, with telemedicine consultations . Then doctors can weigh the risks for their patients and determine who needs to come in. In a statement, CSI says that it followed local and state laws for staying open, while providing "necessary care" for patients, and that it had not required doctors to come to work.

"You can't serve two masters. You can't serve patients and investors"

Morganroth's defense of pandemic Botox might seem odd, but it made perfect sense within the logic of the U.S. health-care system, which has seen Wall Street investors invade its every corner, engineering medical practices and hospitals to maximize profits as if they were little different from grocery stores. At the center of this story are private equity firms, which saw the explosive growth of health-care spending and have been buying up physician staffing companies, surgery centers, and everything else in sight.

Over the past five years, the firms have invested more than $10 billion in medical practices, with a special focus on dermatology, which is seen as a hot industry because of the aging population. Baby boomers suffer from high rates of two potentially lucrative conditions: skin cancer and vanity. Some estimates suggest that private equity already owns more than 10% of the U.S dermatology market. And firms have started to expand into other specialties, including women's health, urology, and gastroenterology.

There's nothing inherently wrong with any of this. But some doctors say that the private equity playbook, which involves buying companies, drastically cutting costs, and then selling for a profit -- the goal is generally to make an annualized return of 20% to 30% within three to five years -- creates problems that are unique to health care. "I know private equity does this in other industries, but in medicine you're dealing with people's health and their lives," says Michael Rains, a doctor who worked at U.S. Dermatology Partners , a big private equity-backed chain. "You can't serve two masters. You can't serve patients and investors."

Investment firms, and the practices they fund, say these concerns are overblown. They point out that they're giving doctors a financial shelter from the rapidly changing medical environment, a particularly attractive prospect now, and that money from private equity firms has expanded care to more patients. But they've also made it next to impossible to track the industry's impact or reach. Firms rarely announce their investments and routinely subject doctors to nondisclosure agreements that make it difficult for them to speak publicly. Bloomberg Businessweek spoke to dozens of doctors at 10 large private equity-backed dermatology groups. Those interviews, along with information obtained from other employees, investors, lawyers, court filings, and company records, reveal how the firms operate, and why they sometimes fail patients.

The process is never exactly the same, but there are familiar patterns, which tend to play out in five steps.

Step 1: Marriage

The strange thing about private equity money in medicine is that for-profit investors have long been prevented from buying doctor's offices. Corporate ownership goes against a doctrine set by the American Medical Association , the main trade group for doctors in the U.S., and is prohibited by law in many states, including Texas and New Jersey. For most of the past 100 years, if you wanted to make money on a medical practice, you needed to have a medical license.

Yet over the past decade, lawyers devised a structure that allows investors to buy a medical practice without technically owning it: the MSO, or management service organization. Today, when an investment firm buys a doctor's office, what it's actually buying are the office's "nonclinical" assets. In theory, physicians control all medical decisions and agree to pay a management fee to a newly created company, which handles administrative tasks such as billing and marketing.

In practice, though, investors expect some influence over medical decision-making, which, after all, is connected to profits. "When we partner with you, it's a marriage," said Matt Jameson, a managing director at BlueMountain Capital, a $17 billion firm that recently invested in a women's health company, while speaking at a conference in New York in September. "We have to believe it. You have to believe it. It's not going to be something where clinical is completely not touched." (When contacted by Businessweek , Jameson asked to clarify his comments. "Doctors and other qualified healthcare professionals at the providers we've invested in make medical decisions," he said in a statement.)

The typical buyout starts with the acquisition of a big, popular practice, often with multiple doctors and several locations, for as much as $100 million. (Investors typically pay between 9 and 12 times annual profit.) This practice functions as an anchor, like a name-brand department store at a shopping mall, attracting patients and doctors to the new group as it expands. Then comes the roll-up: The private equity firm purchases smaller offices and solo practices, giving the group a regional presence.

As part of the new structure, investors deal with paperwork and save money by buying medical supplies in bulk. Crucially they also negotiate higher insurance reimbursement rates. One dermatologist who sold her practice to the California Skin Institute says she was surprised to find out the bigger group's payouts from insurers were $25 to $125 more per visit.

When individual doctors sell, they generally receive $2 million to $7 million each, with 30% to 40% of that paid in equity in the group. After the acquisition, doctors get a lower salary and are asked to help recruit other doctors to sell their practices or to join as employees.

At first, doctors are generally thrilled by all of this. They have financial security and can focus on treating patients without the stress of running a business. Patients, for the most part, are in the dark. Unlike when your mortgage changes hands, you usually aren't notified when a big investment firm buys your doctor. Sometimes the sign on the door bearing the physician's name stays put, and subtle changes in operations or unfamiliar fees may be the only clues that anything has happened.

Step 2: Growth

The promise of more patients is a big draw for doctors. By sharing marketing costs and adding locations, the new companies can advertise more and attract customers. Private equity-owned practices have been diligent users of social media, announcing newly added doctors and posting coupons on Twitter and Instagram. But these practices can be aggressive in ways that make some doctors uncomfortable.

At Advanced Dermatology & Cosmetic Surgery , the largest private equity-backed group in the field, with more than 150 locations across the U.S., that sense of discomfort came shortly after Audax Group bought a controlling stake in what was then a much smaller chain in 2011. The new management team introduced a scorecard that rewarded offices with cash if they met daily and monthly financial goals, according to a lawsuit filed in 2013 against the company by one of its dermatologists. The doctor alleged that the bonus program encouraged staff to do as many procedures as possible, rather than strictly addressing patients' medical needs.

In some of the company's Florida offices, the doctor alleged, medical assistants responded to the bonus structure by ticking extra boxes on exam reports, stating that doctors checked many more areas of the body than they actually had. That led to higher patient bills, defrauding the government under its Medicare program, according to the lawsuit. The federal government declined to join the case, and it was dismissed about a year after it was filed. Advanced and Audax declined to comment.

One-Stop Skin Care

By buying up labs and adding specialists, private equity-owned dermatology groups get paid at every step of a patient's treatment.

Data: Estimated Medicare reimbursement rates for the Miami area, Sensus Healthcare sales presentation

Private equity-backed practices also try to increase revenue by adding more-lucrative procedures, according to doctors interviewed by Businessweek . In dermatology, this means more cosmetics, laser treatments, radiation, and especially Mohs surgeries -- a specialized skin cancer procedure that removes growths from delicate areas like the face and neck one layer at a time, to limit scarring. The surgery involves expensive equipment and specialized doctors, so some large medical groups keep costs down by assembling traveling Mohs teams, who fly in from other states. Others create mobile labs in vans that set up in clinics' parking lots.

Most dermatologists use outside labs and pathologists, but private equity-owned groups buy up existing labs and hire their own pathologists. Then doctors are encouraged to refer patients within the group and send biopsy slides to the company-owned labs, keeping the entire chain of revenue in-house. This takes advantage of a regulatory quirk that has made dermatology, and a handful of other specialties, attractive to private equity. Under the 1989 Stark Law, doctors aren't allowed to make patient referrals for their own financial gain. An exception was made for some fields because it's more convenient for patients, explains Dr. Sailesh Konda, a Mohs surgeon and professor at the University of Florida. "But that can be abused."

Step 3: Synergy

Now comes the cost-cutting. This is supposed to be the hallmark of private equity, and, done right, it can work to the benefit of doctors and patients. But there are pitfalls unique to medicine, where aggressive cuts can lead to problems, some of them merely inconvenient and some potentially dangerous.

A doctor at Advanced Dermatology says that waiting for corporate approvals means his office is routinely left without enough gauze, antiseptic solution, and toilet paper. Even before the great toilet paper shortage of 2020, he would travel with a few rolls in the trunk of his car, to spare patients when an office inevitably ran out. The company declined to comment.

At the country's second-biggest skin-care group, U.S. Dermatology Partners , a former doctor says a regional manager switched to a cheaper brand of needles and sutures without consulting the medical staff. The quality was so poor, she says, they would often break off in her patients' bodies. Mortified, she'd have to dig them out and start over. She complained to managers but couldn't get better supplies, she says. Paul Singh, U.S. Dermatology's CEO, says the company uses a "reputable, global vendor for medical supplies." "While our group may have standardized purchasing processes, individual providers have the autonomy to procure specific supplies that they need for a particular patient situation or patient population," he says in a statement.

Doctors who join a private equity-backed group generally sign contracts that state they'll never have to compromise their medical judgment, but some say that management began to intervene there, too. Dermatologists at most of the companies say they were pushed to see as many as twice the number of patients a day, which made them feel rushed and unable to provide the same quality of care. Others were forced to discuss their cases with managers or medical directors, who asked the doctors to explain why they weren't sending more patients for surgery. Multiple practices also encouraged doctors to send home Mohs surgery patients with open wounds and have them come back the next day for stitches -- or to have a different doctor do the closure the same day -- because that would allow the practice to collect more from insurers.

That's if doctors are performing the procedures at all. At Advanced Dermatology, several doctors say they were asked to claim that physician assistants, or PAs, were under their supervision when they weren't seeing patients in the same building, or even the same town. Because PAs are paid less than dermatologists, this allowed the company to keep costs low while growing the business. In a statement, Eric Hunt, Advanced's general counsel and chief compliance officer says that having PAs on staff enables the company to "provide access to quality dermatological care to more patients."

Step 4. Rolling Up the Roll-Up

Advanced Dermatology was sold in 2016 by Audax to Harvest Partners LP , following a pattern that's typical in the industry. At some point, after costs have been cut and profits maximized, most private equity-owned medical groups will be sold, often to another private equity firm, which will then try to somehow make the company even more profitable.

Having reduced most of the obvious costs, Advanced Dermatology began skimping on more important supplies, including Hylenex, according to doctors and other employees. The drug is an expensive reversal agent used when cosmetic fillers, which are supposed to make skin look plumper, go wrong. Not having enough is dangerous: Patients who get an injection that inadvertently blocks a blood vessel can be left with dead sections of skin or even go blind if they don't get enough Hylenex in a matter of hours. The company says that it stocks Hylenex in every office that performs cosmetic procedures, and that it "has no records of any provider being denied an order for this medication."

Advanced Dermatology also started giving even more authority to PAs, according to doctors and staff. Without enough oversight some were missing deadly skin cancers, they say. Others were doing too many biopsies and cutting out much larger areas of skin than necessary, leaving patients with big scars. Doctors who complained about the bad behavior say they saw PAs moved to other locations rather than fired or given more supervision. Hunt, the company's lawyer, says that all PAs get six months of training and are supervised by experienced doctors.

The staff coined a new medical diagnosis, "pre- pre- pre-cancer"

Advanced Dermatology also put more pressure on doctors to send biopsies to in-house labs. The move made sense financially, but some of the doctors didn't trust the lab. One of its two pathologists in Delray Beach, Fla., Steven Glanz, had a history of misdiagnosing benign tumors, which led patients to undergo surgeries that were later found to be unnecessary, according to doctors who worked with him. Dermatologists who warned that Glanz was a danger to patients say that their complaints to Dr. Matt Leavitt, the group's founder and CEO, were ignored. More procedures, doctors knew, brought in more money.

Glanz, who had been with the practice since its early days, was known to read slides under a microscope with a pistol on his desk. After he was arrested with a handgun, a folding knife, and a vial of methamphetamine crystals, he was fired and Florida's state medical board fined him $10,000, requiring him to complete a five-hour course on ethics before he could resume practicing. But his former colleagues were unsettled; they knew Glanz's signature was on years of reports that determined treatment for patients. Some slides were reevaluated, and pathologists noticed mistakes. Managers told some doctors and their staff that patients, even those who'd been misdiagnosed and had unnecessary procedures, were not to be told. Glanz pleaded guilty to stalking and a firearms violation and was sentenced to probation. When a reporter called his office and identified herself, the receptionist hung up. Further attempts to reach Glanz were unsuccessful. Advanced's Hunt says that he was "formally released from employment three years ago," but did not comment further.

Of course, some doctors pushed ethical boundaries long before private equity came into the picture. But critics of the industry, including doctors and investors, say management teams put in place by private equity firms tend to look the other way as long as a medical practice is profitable. Of the dermatologists with the highest biopsy rates in the country (between 4 and 11 per patient, per year), almost 25% were affiliated with private equity-backed groups, according to Dr. Joseph Francis, a Mohs surgeon and data researcher at the University of Florida.

Medical providers may have also been blurring ethical lines at U.S. Dermatology Partners, which was until recently on its second private equity owner, Abry Partners LLC . At four of the company's offices in Texas, a doctor and his PAs were doing more biopsies than necessary, according to employees. These employees say the staff routinely called patients with benign lichenoid keratosis, small brownish blotches that usually go away on their own, and told them the growths should be removed. Under instruction from the doctor, the staff coined a new medical diagnosis, "pre- pre- pre-cancer," and then talked patients into coming in for removal, employees say. Singh, the U.S. Dermatology CEO, says that the company trusts doctors to make the right decisions and that it monitors them through routine audits.

Step 5: Sell-Off

In some cases the cost-cutting either becomes impossible or leads to compromises in care too obvious to ignore. In 2016 a DermOne LLC office in Irving, Texas, had been using a faulty autoclave machine to sterilize surgical equipment -- the state and county health departments identified 137 patients that needed to get tested for blood-borne diseases such as HIV and hepatitis. By 2018, DermOne's backer, Westwind Investors, wanted out.

Westwind had been one of the earliest firms to build a big dermatology business -- with practices in five states -- but others had grown larger. After the debacle in Irving, the Nevada-based firm sold DermOne's medical records and patient lists, as well as some of its offices, to other groups. It dissolved the remaining offices, leaving some patients abruptly without care. Westwind did not respond to repeated requests for comment. Two other private equity-backed groups, TruDerm and Select Dermatology LLC, have also gone out of business in the past two years.

The surviving chains have been saddled with large piles of debt they're now struggling to repay. In January, U.S. Dermatology Partners defaulted on a $377 million loan, meaning the private equity backer, Abry Partners, had to hand over the keys to its lenders, Golub Capital , Carlyle Group , and Ares Management , which will now oversee a chain with almost 100 locations, receiving 1 million visits from patients a year. Abry did not respond to requests for comment .

For the medical groups that make it, the game plan is to eventually sell to the largest players, such as KKR , Blackstone Group , and Apollo Global Management . Pioneering investors, including Audax, are now buying practices in other fields -- a concerning development to critics who note that the areas that are currently attracting investment, such as urology, generally involve more invasive procedures. Should doctors performing vasectomies be thinking about the dollar-rate returns for KKR -- or any private investor?

"It's ultimately going to backfire," says Dr. Jane Grant-Kels, a veteran dermatologist and professor at the University of Connecticut School of Medicine. "There's a limit to how much money you can make when you're sticking knives into human skin for profit."

One paradox of the Covid-19 pandemic has been that even as the virus has focused the entire country on health care, it's been a financial disaster for the industry. And so, while emergency room doctors and nurses care for the sick -- comforting those who would otherwise die alone, and in some cases dying themselves -- private equity-backed staffing companies and hospitals have been cutting pay for ER doctors. These hospitals, like the big medical practices, make a large portion of their money from elective procedures and have been forced into wrenching compromises.

For investors with capital, on the other hand, the economic fallout from the virus is a huge opportunity. Stay-at-home orders have left small practices more financially strained than they've ever been. That will likely accelerate sales to private equity firms, according to Marc Cabrera, an investment banker focused on health-care deals at Oppenheimer & Co. Independent doctors or groups that previously rebuffed offers from deep-pocketed backers "will reconsider their options," he says.

Many doctors may ultimately come to regret cashing out, but it's hard to get out once you're in. As part of an acquisition, the private equity groups typically require doctors to sign yearslong contracts, with noncompete clauses that prevent them from working in the surrounding area.

As governors throughout the nation ease restrictions on businesses, Advanced Dermatology is opening its most profitable offices first. The company received an undisclosed sum under the Cares Act, as part of the government relief package intended for health-care workers. Hunt, Advanced's chief compliance officer, told employees in an email earlier this month that the money would be used for protective gear, such as masks, and to replace "millions of dollars" in lost revenue.

The group had closed most of its offices since the stay-at-home orders were issued in March, cutting pay for doctors and furloughing staff. With cities and states beginning to consider reopening, doctors and PAs say they've been told they should be prepared for a full schedule. Hunt says the company is following the appropriate safety measures, but employees fear it will be nearly impossible to keep patients apart in waiting rooms. Opening in a reduced capacity, they understand, is not an option.

Read more: Private Equity Ate Finance, and Now It's Taking Over the World

[May 12, 2020] PHARMA: Greed, Lies, and the Poisoning of America

May 12, 2020 | www.moonofalabama.org

karlof1 , May 12 2020 16:01 utc | 125

Renegade Inc interview with Gerald Posner the author of PHARMA: Greed, Lies, and the Poisoning of America is lively, timely, revealing, and very informative! An excellent 25 minute investment of your time today. In the book which was written well before the COVID-19 breakout, Posner did address the issue of pandemic which this article reported on along with other aspects of PHARMA . And there's much more at his website.

[May 12, 2020] Deadly Medicines and Organized Crime

May 12, 2020 | www.moonofalabama.org

Pft , May 12 2020 23:01 utc | 186

Interesting book "Deadly Medicines and Organized Crime " published in 2013 by PETER C GØTZSCHE

He points out "Science philosopher Karl Popper in "The Open Society and Its Enemies" depicts the totalitarian, closed society as a rigidly ordered state in which freedom of expression and discussion of crucial issues are ruthlessly suppressed. Most of the time, when I have tried to publish unwelcome truths about the drug industry, I have been exposed to the journal's lawyers, and even after I have documented that everything I say is correct and have been said before by others, I have often experienced that important bits have been removed or that my paper was rejected for no other reason than fear of litigation. This is one of the reasons I decided to write this book, as I have discovered that I have much more freedom when I write books. Popper would have viewed the pharmaceutical industry as an enemy of the open society.

Rigorous science should put itself at risk of being falsified and this practice should be protected against those who try to impede scientific understanding, as when the industry intimidates those who discover harms of its drugs. Protecting the hypotheses by ad hoc modifications, such as undeclared changes to the measured outcomes or the analysis plan once the sponsor has seen the results, or by designing trials that make them immune to refutation, puts the hypotheses in the same category as pseudoscience.

In healthcare, the open democratic society has become an oligarchy of corporations whose interests serve the profit motive of the industry and shape public policy, including that of weakened regulatory agencies. Our governments have failed to regulate an industry, which has become more and more powerful and almighty, and failed to protect scientific objectivity and academic curiosity from commercial forces."

Thats about it in a nutshell. Too bad the good scientists are all muzzled. Only the politicized fraudsters get the good press.

[May 01, 2020] ONE IN SEVEN Americans would avoid Covid-19 treatment for fear of cost, even as pricey new pill shows promise against virus

May 01, 2020 | www.rt.com

Some 14 percent of US adults would forgo medical care for Covid-19 symptoms because they couldn't pay for it, a new poll has found – yet oblivious health authorities act as if the epidemic will be solved by drugs alone. One in seven American adults would avoid seeking healthcare if they or a family member experienced symptoms of Covid-19, out of concern they would be unable to afford treatment, according to a Gallup poll published on Tuesday. Even if they specifically believed themselves to be infected with the coronavirus, nine percent would forgo care for financial reasons, the poll found. Their fears are well-founded – the average cost of coronavirus treatment in an intensive care unit runs over $30,000, according to a study released earlier this month by insurance industry group America's Health Insurance Plans. Even for those who avoid the ICU, American healthcare is the most expensive in the world, and stories of coronavirus patients being whacked with gargantuan medical bills are a dime a dozen two months into the pandemic.

Making matters worse is the unemployment crisis, as about 55 percent of Americans receive healthcare through their jobs. Upwards of 30 million have filed for unemployment in the last five weeks, adding an unprecedented number of families to the ranks of the uninsured – which were already estimated in December to include 27.5 million people, more than the population of Australia. Even those lucky enough to have kept their jobs and insurance may face steep co-pays or other surprise costs.

After a handful of highly-publicized cases in which Americans died of the virus after being turned away by hospitals for lack of money, President Donald Trump ordered hospitals to pay for the cost of Covid-19 treatment, and several large insurers promised at the beginning of the month to waive all co-pays for coronavirus testing for 60 days. However, those coverage pledges do not include other costs associated with hospitalization, like ambulance transportation; outpatient treatment; or treatment for non-Covid-19 patients. Individuals seeking treatment have been tested and received the good news that they don't have the virus – only to be hit shortly thereafter with the bad news that they're on the hook for thousands of dollars in costs. Low-income respondents were much more likely to report they would not seek care for financial reasons. Perhaps more troublingly, respondents with annual income under $40,000 were almost four times as likely as those with incomes over $100,000 to report that they or a family member had been turned away from a hospital for reasons related to overcrowding or high patient volume, the Gallup poll found.

[Apr 13, 2020] American health care, as we call it today, and for all its high-tech miracles, has evolved into one of the most atrocious rackets the world has ever seen. By racket, I mean an enterprise organized explicitly to make money dishonestly by James Howard Kunstler

Highly recommended!
Apr 13, 2020 | www.zerohedge.com

Authored by James Howard Kunstler via Kunstler.com,

The ruins of Mary McClellan Hospital stand on hill overlooking the village of Cambridge, New York, in what was a "flyover" corner of the country until the planes stopped flying. The hospital cornerstone was laid July 4 1917. The USA had entered the war against Germany a few months earlier. The "Spanish" flu pandemic kicked off in January, 1918. The hospital opened in January 1919. The flu burned out a year later. The hospital shut down for good in 2003.

I've lived around here for decades and never actually got a look at the place until I went up there on a blustery spring Saturday before Easter to look around. I like to read landscapes and the human imprint upon them. This one is a ghost story, not just of the bygone souls who came and went here, but of an entire society, the nation that we used to be and stopped being not so long ago.

This is the old main building today. It's astounding how quickly buildings begin to rot when the human life within them is gone. The style was Beaux Arts Institutional, seen everywhere across America in that period in schools, libraries, museums, and hospitals, an austere neoclassicism that radiated decorum in a confident and well-run society ­– because that is what we were then. Note especially, the entrance and the beautiful bronze marquee above it. The message is this: You enter through a portal of beauty to a place of hope and trust.

This is Mary McClellan Hospital not long after it opened.

The site itself, on its hill, with views east across the state line to the Green Mountains, speaks of authority and command.

The America of 1919 was a deeply hierarchical society. Today we regard hierarchy as a bane and a curse. The truth is, it is absolutely required if you expect to live in a well-run society, and proof of that is the disordered mess of bureaucratic irresponsibility we live in today, with virtually every institution failing – well before the Covid-19 virus arrived on the scene - and nobody called to account for anything anymore.

Hierarchy must be fit to scale to function successfully. In small institutions like this, everybody knows who is responsible for what. That's what makes authority credible.

These are the ruins of the nursing school associated with the hospital (and also associated with Skidmore College in Saratoga Springs, 25 miles west).

The nurses lived here, in Florence Nightingale Hall.

In the early 20th century, the profession favored young, unmarried women whose allegiance and attention to the patients would not be distracted by the needs of a family.

Was that exploitation? Or was it simply an intelligent way to organize a hospital subculture? The nurses lived here very comfortably. The institution cared for them, literally.

There's no record available of what exactly these buildings were for. The one in the foreground has a cut stone sign that says "The Junior" on it. I infer that this may have been where a couple of young, staff, resident physicians lived, young men probably, just out of their internships, close at hand and on-call for emergencies. The building in the background is a rather grand country cottage, possibly the residence of the chief surgeon or the hospital director. The hospital was, after all, a community unto itself, and it was important that authority have a visible presence there all the time. Both buildings display architectural grace-notes that humanized and dignify that resident authority. We no longer believe in grace-notes for the things we build, so is it surprising that we live in a graceless society?

This is the power plant for the whole operation, on the premises, ensuring that the electricity would stay on at all times. In the early 20th century, electric power was the new sine qua non of advanced civilization. America's rural electrification program really didn't get underway until the 1930s, so it's likely that many of the farms outside the village were not hooked up to a grid. The hospital generators must have been driven by coal, or perhaps oil. Somebody had to attend to all that machinery. The laundry ­– hospitals produce a lot of that – was also on-premises, as was all the meal preparation. The hospital maintained a large garden to furnish some of the food. All these tasks required crews of people working purposefully and getting paid. The hospital was a complex organism, a world within a nation within a world.

Things rise and self-organize beautifully into fully-formed systems and after while they run down, even while they over-grow; authority starts working more and more for its own sake and its own benefit; hierarchy breaks down into disrespect, lack of trust, fear; and then society loses its vital institutions, which is exactly what happened at Mary McClellan Hospital in little Cambridge, New York.

It dwindled and then quickly collapsed. The town lost a part of itself, the part that welcomed people in a particular kind of trouble and cared for them, as it cared for those who did the caring. By the way, in 1919, a private room was $7-a-day (a bed on a ward was $3). Imagine that! The town also lost a vital component of its economy. And that was all of-a-piece with its decline into the flyover place it became in our time.

American health care, as we call it today, and for all its high-tech miracles, has evolved into one of the most atrocious rackets the world has ever seen. By racket, I mean an enterprise organized explicitly to make money dishonestly. This is what we've become, and the fact that we seem to be okay with that tells you more about what we have become. The advent of Covid-19, along with the extreme economic disorders it has triggered, will probably be the beginning of the end of that racket. We have no idea how medicine will re-organize itself, but I'd guess that it will happen at a much more primitive scale ­– because that's usually what happens when human societies overshoot badly. Alas, history is not exactly symmetrical.

But read these photos and meditate on what we were once capable of putting together in this land, and maybe you will find some clues about what was truly admirable about the American condition before we stopped caring.

[Apr 06, 2020] Why Do Rural Hospitals Close

Apr 06, 2020 | angrybearblog.com

run75441 | April 5, 2020 8:15 pm

One of the serious issues with healthcare today is the lack of universal availability of it across the nation. In citified areas, the availability of it mostly meets the demand of the people requiring it and is in close proximity. If you travel one to two hours outside of the city, the availability of it begins to drop off until a person in need must travel hours to get to help. The resource in more rural areas begins to drop off in a precipitous manner. Not to make light of the healthcare situation, if you watch the move " Doc Hollywood ," small community with an aging doctor, a small clinic, staff nurse, a large number of patients, and a distant hospital. Dr. Ben Stone is on his way to LA in his 356 Cabriole (almost bought one in the eighties). The resources bypass rural America mostly for monetary reasons.

Here is a list of reasons:

Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihoods of closure in rural markets. The addition of work requirements by states will negate much of the Medicaid's expansion gain.

You will hear many complaints about narrow insurance corridors. The result of Section 227 was Coops going bankrupt, insurance companies withdrawing, people having to find other plans, premiums increasing, etc. causing much of the narrowing. Rather than solve the issue, Republicans as led by Fred Upton of Michigan chose to use this in an effort to dismantle the ACA. The ACA Risk Corridor Program was to last 3 years and is similar to the Republican created Risk Corridor Program in Part D which is ongoing.

Medicare reimburses at much lower rates than does private insurance in my specialty. If you work in a place with a high percentage of Medicare (or Medicaid which is worse) like we do, you cannot come close to earning market salaries. So we, many years ago, ended up working 95th percentile or worse hours (over 70 per week) while earning in the 15th-20th percentile in income. We lost a lot of staff. The hospital had to make up the difference so that we could hire and retain people. We were fortunate that our hospital had the resources to do that.

Up north of us another hospital faced a similar situation, but they didn't have the resources to subsidize their staff. So they fired a good team and brought in another. Told them it was OK to not bill in accordance with what the hospital accepted, like the prior group did. That let the new group earn enough, for a while, to hire and retain people. Hospital eventually failed anyway and had to be bought out.

Mayo Clinic in Minnesota closed one smaller hospital and two clinics due to a lack of personnel and utilization. The result was people having to make a much longer trip to get to the hospital and staffing goes where the money is in many cases.

It is a problem begging for a solution.

More Rural Hospitals Closing in States Refusing Medicaid Coverage Expansion , Center for Children & Families (CCF) of the Georgetown University Health Policy Institute, Adam Searing, October 2018

The Quiet Crisis Of Rural Hospital Closures , Kaiser Health News, January 2020

170 Rural Hospital Closures , NC Rural Health Research Program

Michael Oder , April 5, 2020 8:51 pm

Another reason is that we've privatized our medical industry. Many hospitals used to be owned by counties and municipalities who had established them to provide healthcare for their citizens. Throughout the 90s and early 2000s, these were systematically privatized often to cover short-term budget crises. For-profit providers have different priorities in mind and providing effecting and available treatment is not at the top of the list.

Event before shuttering the hospitals they were already cutting services:
https://www.sciencedirect.com/science/article/pii/S109830151204154X

kwark , April 5, 2020 10:02 pm

This quote from the doctor sort of encapsulates what is wrong with our s0-called "system" of healthcare: "If you work in a place with a high percentage of Medicare (or Medicaid which is worse) like we do, you cannot come close to earning market salaries." Medicine has devolved into a scheme to extract absolutely the most money possible all the time regardless of the long-term outcome for society or, it appears, the short term outcome for the patient. Doctors were supposed to follow "first, do no harm" but nowadays they're forced to play with the definition of harm.

[Apr 06, 2020] What Wall Street Doesn't Want You to Know About Hospital Emergency Rooms

Apr 04, 2020 | www.nakedcapitalism.com
Yves here. We've written regularly on Eileen Appelbaum and Rosemary Batt's important investigations into how private equity has taken over more and more of hospital staffing, including of emergency rooms. This in turn has allowed them to override patient efforts to have only in-network doctors assigned to their case, as well as to engage in other practices that greatly inflate patient charges (so-called surprise billing).

The legal fig leaf that allows private equity firms like Blackstone and KKR to play doctor is that their deals are structured so that MD or group of MDs is the nominal owner of the specialty practice, even though the business is stripped of its assets and the operating contracts are widely believed to strip them of any say. The now-notorious incident of Blackstone's TeamHealth firing whistleblower Dr. Ming Lim confirms who is really in charge.

By Eileen Appelbaum, the Co-Director of the Center for Economic and Policy Research and visiting professor, School of Management, University of Leicester, UK and Rosemary Batt, the Alice Hanson Cook Professor of Women and Work, Cornell University ILR School. Produced by Economy for All , a project of the Independent Media Institute

Doctor Ming Lin is the first emergency room doctor to be fired for going public with his concerns about poor hospital emergency room safety practices and shortages of medical supplies and protective gear for health workers. He won't be the last.

Like many hospitals in the US, PeaceHealth St. Joseph Medical Center in Bellingham Washington, where Ming Lin worked for the past 17 years as an emergency room doctor, has outsourced the management and staffing of its emergency rooms. So, Lin works on-site at the hospital's emergency room, but he is employed by a physician staffing firm that runs the emergency room. These staffing firms are often behind the surprise medical bills for emergency room services that patients receive after their insurance company has paid the hospital and doctors, but not the excessive out-of-network charges billed by these outside staffing firms.

About a third of hospital emergency rooms are staffed by doctors on the payrolls of two physician staffing companies -- TeamHealth and Envision Health -- owned by Wall Street investment firms. Envision Healthcare employs 69,000 healthcare workers nationwide while TeamHealth employs 20,000. Private equity firm Blackstone Group owns TeamHealth, Kravis Kohlberg Roberts (KKR) owns Envision.

Care of the sick is not the mission of these companies; their mission is to make outsized profits for the private equity firms and its investors. Overcharging patients and insurance companies for providing urgent and desperately needed emergency medical care is bad enough. But it is unconscionable to muzzle doctors who speak out to advocate for the health of their patients and co-workers during the global pandemic that is rapidly spreading across the US.

Yet, that is what Blackstone-owned TeamHealth just did. Why would an experienced emergency room doctor be fired in the middle of a pandemic? One clue may be that Blackstone's CEO, Stephen A. Schwarzman, is part of President Trump's inner circle . He may not want to risk that relationship by allowing TeamHealth's doctors to inform the public about Washington's mishandling of the allocation of supplies and protective gear. The President might conclude that TeamHealth doctors didn't appreciate him enough, and where would that leave Schwartzman?

PeaceHealth St. Joseph Medical Center may have the distinction of being the first hospital to have a doctor outsourced from a physician staffing firm unceremoniously fired for telling the public the truth. But it won't be the last. Hospitals are now telling doctors treating coronavirus patients they will be fired if they speak to the press.

The American Academy of Emergency Medicine protested Dr. Lin's ouster and questioned how TeamHealth is allowed to provide hospital services when the law requires that physician practices must be owned by a licensed medical practitioner. TeamHealth skirts the law by owning all the assets of the physician practices it acquires -- the real estate, offices, equipment, supplies, inventory, and even accounts receivable.

On paper, the physician practices are owned by a doctor-led organization that TeamHealth has set up to comply with the law. But what does it mean to own a physician practice if the practice has no assets and no possibility to exist on its own?

The furor over patients hit by surprise medical bills revealed that TeamHealth controls the billing for the doctors it supplies to hospital emergency rooms. The firing of Doctor Ming Lin pulls back the curtain and reveals that TeamHealth controls the doctors as well.


sd , April 4, 2020 at 5:54 am

Private Equity = Non Essential

Furiouscalves , April 4, 2020 at 12:13 pm

So anyone who works for TeamHealth or Envision needs to stay home until the virus subsides Or until PE is out of ER. Right now is the time to be going after them hard. If they come out the other side of this with no changes to PE control of ER, it will be a missed opportunity to bring them to heel.

dan , April 5, 2020 at 8:54 am

Thats called group organizing. Our present gov. won't allow it. Or will they they don't seem to have much control over virus spreads.

Mel , April 4, 2020 at 12:53 pm

Way back when, an American banker named Paul Erdman tried to start an American bank in Switzerland, and wound up taken down, tried, and convicted under by a charge in Swiss law called (IIRC, this whole comment is IIRC basically) untreu Gesellshaftshandlung . He went on afterwards to write popular novels about what -- meanies -- Swiss bankers are. The one I read is really pretty good.
Anyway, although it would be really heavy lifting creating an American law against untreu Gesellshaftshandlung in the face of the modern American concept of business, a law like that could have excellent effects. It could penalize people who destroy the businesses they are pretending to manage. Think how wonderful that would be.

divadab , April 4, 2020 at 6:54 am

In what ethical system is profiteering on the sick and injured who are having a health emergency morally correct? What kind of people are these Blackstone owners? The kind of people who rob the dead and wounded on a battlefield, apparently. Ghouls. Morally depraved scum.

That Peace Health, which is owned by the Catholic Church, has contracted with these looters, is indicative of how low the Church has fallen in its mission in the world. They kicked out the nuns from any oversight of the hospital and brought in these Blackstone demons. Is it any wonder the moral authority of the Church is a thin thread when rather than supporting their flock they prey upon them? When did the Church start subcontracting to Satan?

ambrit , April 4, 2020 at 6:58 am

Oh for a reset. In olden times, often the victorious officers would mandate shoot on sight for looters caught on a battlefield.

Tom Doak , April 4, 2020 at 7:21 am

Yes, but unfortunately, that's what the "winners" in private equity are doing to us.

Off The Street , April 4, 2020 at 7:45 am

Gives new meaning to the Neo-Liberal 1-2 punch.
1. Because Markets.
2. Go Die.

hemeantwell , April 4, 2020 at 11:33 am

ambrit's suggested reset brought to mind another frame, the role of the tribunes in early Roman society. I've enthused about them before here, re their ability to block measures deemed harmful to the people, and the oath sworn to protect them, whereby anyone laying a hand on them would be hung by the rightfully enraged citizenry.

What we're seeing going on now between the administration and some of the governors is a loose fit. They are speaking out against the administration's deadly neglect and acting against it, while, hopefully, having a degree of immunity against reprisal. We'll see about a hanging, electoral or otherwise.

Billy , April 4, 2020 at 2:48 pm

Substitute " corporate board of directors ",
and or possibly, depending on the crime,
" upper level management "
for "looters."

allan , April 4, 2020 at 7:29 am

"What kind of people are these Blackstone owners?"

Steve Schwartzman is on the list of billionaires who supposedly urged Trump to reopen as soon as possible.
Given Blackstone's medical investments, that is quality talking-your-book.

NotTimothyGeithner , April 4, 2020 at 8:41 am

Start?

For the modern era, I would say john Paul II. He largely had free reign to control the bishop selection process (which for a long time was tied to local governance) and stamped out any opportunity for good or not heinous bishops to serve as counter examples or exist as threats to leadership.

tonycat , April 4, 2020 at 12:48 pm

Blackstone was a firm that was behind the stealing of houses from American homeowners in the foreclosure fraud heyday since 2008's financial crisis, I believe. I think they were owners of document-forging firms.

Ian , April 5, 2020 at 8:48 pm

tonycat,
I didn't think Blackstone had anything to do with document forgery, that was primarily the realm of LPS, ( lender processing services), who changed their name to Black Knight Services. Owned by Fidelity National , yes, the title insurance company.
Blackstone bought tens of thousands of foreclosed homes, the ones with irretrievably corrupted chains of title, formed a subsidiary to do so, and rented them all out.
If you could let me know who you have reason to believe Blackstone owned as far as document processors , or forgers, pls respond to me thanks-

Kirk Seidenbecker , April 4, 2020 at 1:21 pm

PeaceHealth . should be HealthGrift.

Billy , April 4, 2020 at 3:00 pm

Before the information is taken down, search for and file save
the board of directors. Save as a file on your hard drive. Guarantee that these same people will pop up like moles in future disasters and national looting.
https://www.blackstone.com/the-firm/our-people

Never (let them) forget.

That Peace Health, which is owned by the Catholic Church, has contracted with these looters, is indicative of how low the Church has fallen in its mission in the world. They kicked out the nuns from any oversight of the hospital and brought in these Blackstone demons."
How does the Catholic church contracting with them still allow their tax exempt status?
Care to comment?
PeaceHealth System Services
1115 SE 164th Avenue
Vancouver, WA 98683
360-729-1000

Knot Galt , April 4, 2020 at 3:21 pm

In what ethical system is profiteering on the sick and injured who are having a health emergency morally correct?

Isn't the answer obvious? It's called ObamaCare.

Am I wrong?

EoH , April 4, 2020 at 9:13 pm

Yes.

Procopius , April 5, 2020 at 6:36 am

When did the Church start subcontracting to Satan?

I believe it was around 325 A.D., when they made a deal with the Emperor Constantine. It may have been earlier, when the tax collector, Saul of Tarsus, said, "Can't get new converts? Hold my beer."

jackiebass , April 4, 2020 at 7:04 am

Where I live our local hospital emergency room is staffed by doctors and nurses that aren't hospital employees. They are employed by a private group. This has been the case for at least a decade. There are signs telling people that they will get separate bills from the doctors. My wife and I both are on traditional medicare and a supplemental policy. Fortunately this group is part of my supplemental network. Also the hospital sold its dialyses unit to a private company. They used to do their own laundry now it is done by a private company. The same is true for the janitor services. The head of the hospital used to be a doctor. Now the head is an MBA. This hospital is considered a nonprofit hospital. Since all of these changes has been happening I have noticed that care has become just another business transaction. Tho corporations own everything , even doctors who are now employees. If you need to see a doctor immediately you now have to go to one of two walk in clinics. Health care in my area has become just another money making business. This is a county in upstate NY with a population of about 100,000 people. There are only 2 corporations providing all of the care. Both operate with the same business plan. My doctor of 13 years decided to move out of the area. Instead of the health care organization hiring a replacement his patients were left out in the cold to find a new doctor. My wife has had 5 primary care doctors in the last 2 years. Health care has become just another money making business with no real competition.

Susan the other , April 4, 2020 at 1:11 pm

There are lots of dimensions to the outsourcing going on in American hospitals. My experience last summer is instructive. My husband (on Medicare) got sepsis from a carpet tack, he's diabetic so it was very dangerous and I took him to the ER on instructions from his podiatrist. The ER hemmed and hawed, tried to confirm with the podiatrist who just happened to turn off his beeper so the ER called Bill'r regular doctor. His regular doctor was playing the system like a violin: because he gets bonuses for any cost saving measures he achieves. This was one – so instead of getting Bill on an emergency IV, his doctor sent him home with some crappy antibiotics, which he threw up; we lost a good 24 hours which could have been the diff between life and death. I was furious and I called all the people I knew on the board of the new hospital to complain. We returned to the ER the next morning and I was already a cat-5 tornado. They got Bill on an IV and they literally hid from me. After 10 days he was cured but his nitwit doctor (to cover his own ass) recommended some expensive anerobic antibiotics for another 7 days – by mouth. The gave me a prescription to get filled. No pharmacy in town had the stuff – it was special order only and took up to 3 days. Long-short when I finally got my hands on the pills, I called the hospital complaint line and told them how inept they were to let a patient go from the hospital with an un-fillable prescription – and she told me that that was not hospital policy, that hospital policy was to send such a patient home with a 3 day supply for the interim. So I only wish I had had the phone number of the person paying Bill's doctor his bonus for endangering his recovery in such a callous and insouciant manner. I tried to get through to Medicare to complain about him but I was blocked every time. It's a shame because that's first class malpractice in my opinion – and the system that encourages it is unconscionable. All those cost cuts by the system are death by a thousand cuts for patients – and an equivalent amount of profits in the pockets of the corporation.

cnchal , April 4, 2020 at 7:17 am

>. . . But what does it mean to own a physician practice if the practice has no assets and no possibility to exist on its own?

Public sector pension funds are investors in Pirate Equity, in case anyone has forgotten, so you could ask them or at the Trump's press conference today, ask him. He would know.

JTMcPhee , April 4, 2020 at 11:00 am

Pensioners don't have much, if any, say in how the people who run the pension funds do what they do. The long look we have had at CalPERS gives some idea of the corruption and malfeasance that's going on, protecting the "fees" and extractions of the "advisers" who in turn get their spiffs from the "market."

Not sure what your point is. The structuring of the "deal" obviously seems to be to maximize all looting possibilities and to shed any possible "legal" avenues of either control or redress by any of the institutions of governance.

Bryan , April 5, 2020 at 9:21 am

Luring the public sector pension funds into private equity was the historical turning point. Private equity has now lashed itself to the ship of state, its main goal.

John , April 4, 2020 at 7:27 am

Private equity is too greedy and rapacious to be permitted to exist.

Tom Doak , April 4, 2020 at 8:26 am

Instead of calling them private equity "firms" and "executives ", we should start consistently labeling them in the same way The New York Times labels the dictators we don't like with unflattering terms.

Since they have a long and questionable history in medicine, I nominate the term "private equity leeches".

Billy , April 4, 2020 at 3:06 pm

Tom, Don't be such a easy going pushover, how about

"Health Criminals"
=
"War Criminals"

They should be identified, shamed and or prosecuted the same way authentic Nazis and Human Rights violators were, and are, in the U.S.

The Historian , April 4, 2020 at 7:32 am

A doctor in Boise was fired for wearing her own M95 mask that she needs because of her own health problems. Listen to the runaround she got! This doctor wasn't afraid to speak out because she works for herself!

https://www.ktvb.com/article/news/local/208/idaho-doctor-says-she-was-fired-after-trying-to-wear-a-mask-at-a-boise-hospital/277-008a2b17-fef4-4fc1-a070-672166c6286e

c_heale , April 4, 2020 at 10:29 am

This is happening in the UK too

https://www.theguardian.com/world/2020/apr/04/nhs-worker-quit-when-she-was-stopped-from-wearing-face-mask

JBird4049 , April 4, 2020 at 7:56 pm

"The list included: if you wear it, everybody will want to wear PPE and we don't have it,"

In her termination phone call, Buckalew asked to see the policy saying she couldn't wear a mask.

"I need to have it in writing that you are asking me to leave because I want to protect myself," Buckalew said.

Still, she said nobody has been able to show her that policy. She was informed though that she was officially labeled as insubordinate, incompetent, and unethical for her actions.

I wonder how the hospital would handle mass death? Financially of course seeing as ethics don't matter.

Paul Jurczak , April 4, 2020 at 10:00 pm

The most telling sign that we are firmly in the post-truth era is the non-response statement from Encompass Health:
"We are continuing to tap every resource available to provide personal protective equipment that meets the needs of our patients and staff [ bla, bla, bla]".
Corporate PR considers not addressing the issue and spewing some unrelated sugar coated BS a normal operating procedure these days. Before you think that corporations are bad people, think about bad people inside the corporations. There are thousands of middle class employees who are writing these kinds of statements on behalf of their paymasters. Humanity has a lot of rot in it.

Billy , April 4, 2020 at 10:12 pm

Call me "The Listmaster"

Keep every letter, every email, better yet, email them back and ask for clarification about who authorized, authored, directed the policy. If you phone, record the call. Look up the board of directors, save the webpage, their names.
This will be useful in the future for potential prosecutions at the judicial and activist level.

pricklyone , April 5, 2020 at 12:28 am

Sorry Billy, it IS good advice, but others have suggested similar, like "when signing the authorization for treatment, include a statement about in-network only ".
While logical, in every hospital, doctors office, clinic, etc, in my network, you sign all of these authorizations on a "signature pad" attached to a computer. No addendums or changes can be made by the patient, and the staff are not authorized to alter it either.
Anything you want as a hard copy, they tell you you can print from the "patient portal"
on the web THEIR version, of course, perhaps not the same as the one you signed.
In the case of any legal actions, their politically connected 18 lawyer team will select their preferred judge, who will promptly throw out all of your careful documentation
MBAs and automation/IT run amok.

Rod , April 4, 2020 at 8:20 am

With 8b$ in the bank a 'non-profit" Atrium compensates the top well:

Atrium Health 's top 11 executives made a combined $27.6 million in 2019, the Charlotte-based health system said on Friday. That's a nearly 15% jump from a combined $24.05 million in 2018. Atrium CEO Gene Woods was at the top of the list with $7.25 million in compensation in 2019.

Here's what Atrium Health's top executives earned in 2019
http://www.bizjournals.com/charlotte/news/2020/02/07/heres-what-atrium-healths-top-exe

Rod , April 4, 2020 at 8:40 am

Here's a trick they used to get to that Executive pay which was stopped in 2018–

The Department of Justice announced a settlement with Atrium Health, formerly known as Carolinas HealthCare System, that prohibits Atrium from using "anticompetitive steering restrictions" in contracts between commercial health insurers and its providers in the Charlotte, North Carolina metropolitan area. The settlement, revealed Thursday, also bans Atrium from seeking contract terms or acting in such a way as to prohibit, prevent, or penalize steering by insurers in the future.

KLG , April 4, 2020 at 9:32 am

Working link
https://www.bizjournals.com/charlotte/news/2020/02/07/heres-what-atrium-healths-top-executives-earned-in.html

jfleni , April 4, 2020 at 8:27 am

SUprise billing is just a pluticrat swindle that will increase by millions when Biden gets in; Bernie was right and every body knows
it. Consider every advanced country has medicare for all BUT not
here in plutocrat heaven; Bernie was totally right!!!

rd , April 4, 2020 at 5:34 pm

Other countries have systems different from Medicare for all, especially some of the European ones. But they are heavily regulated which eliminates all of the efficiencies and improvements you get with a free market .. I assume that is why we have such an inexpensive and effective system compared to the heavily regulated ones.

Noel Nospamington , April 4, 2020 at 10:38 pm

From a Canadian perspective I don't understand why the vast majority of Americans don't support political candidates which promote universal single payer healthcare.

Maybe healthcare isn't something most people think about until they have the misfortune of accidents or illnesses.

If there is one positive outcome from the current pandemic, it might be that many more Americans will be shown how badly broken their health care is, including the per capita death rate compared to other countries.

However right wing parties are masters of deception, and they are likely working on some dog whistle issues to change the focus away from health care after the pandemic settles down.

Jonathan , April 5, 2020 at 11:10 am

Because most have been brainwashed since birth and couldn't imagine better governance exists elsewhere.

From a Singaporean perspective, US is such a crappy place in terms of income versus overall cost of living + public safety + government efficiency + convenience that it makes me LOL whenever I hear Americans dissing us as "an authoritarian nanny state". Well, I say they have the freedom to keep believing whatever that floats their rotten boats.

rob , April 4, 2020 at 8:34 am

What is mind boggling is the dysfunction that can be wrought by lawyers.
It seems to me that the fulcrum under private equity's; arrogance,greed,uninhibited vile existence leading to the takeover of the public medical infrastructure ; rests on peoples ability to "BS" some excuse to a bunch of lawyers . and have it "cleaned" up into some legal footing that can be defended. Not because of the merit of the idea . but because of some standing granted to a "legal framework" of some kind.
The reality completely divorced from the effort to promote the scheme.
On all sides.
Not only the vile, morally repugnant private equity types.
But the people on the other side of the negotiation, who are enticed to make a quick buck ,by selling out the ship the passengers without a lifeboat, are floating on.
And all of this dealing is made "right" ,by lawyers .
Is it because there is some contagion in law school? that divorces people from "right and wrong" Or is it partly, sociopaths finding a setting where they fit right in?
Whether it is the prosecutors all over the country, "legally" screwing nominally guilty people of all kinds of things, making money for their systems by taking it from the general public
Or the ones who fight to allow every scumbag with a dollar to get non disclosure agreements , so they can "pay off" justice and continue to go about damaging society.
Or the ones who allow these medical ownership rule "work-arounds" by saying to private equity," now , we all know that you are looking to plunder a population but hey . we can just say "you're helping them on to their final journey" and "it all meets the requirements" . so sign here how about a round of golf ,down at the club?

Felix_47 , April 4, 2020 at 9:23 am

Great comment. That is the real cancer we are facing in this society. I note Joe Biden is a lawyer, I believe he said he was at the top of his class at Syracuse, and Sanders is not a lawyer. Americans seem to want lawyers as leaders because they know how to make everything look fine and they can keep a straight face saying it.

Schtubb , April 4, 2020 at 12:33 pm

Biden lies about his academic record:

https://apnews.com/cd977f7ff301993f7976974ba07c5495

"WASHINGTON (AP) _ Sen. Joe Biden claimed during a campaign appearance in New Hampshire last spring that he finished in the top half of his law school class, although records indicate he finished near the bottom."

sd , April 4, 2020 at 6:43 pm

Why am I not surprised.

DJ , April 4, 2020 at 10:55 am

Whatever else is going wrong, at the root we are experiencing a crisis of integrity. Such a word, "integrity." It requires that we say it like it is. "The state of being whole and undivided" the dictionary says. It is not, of course, a state that we, being human, can fully achieve. But it is something that we, as humans, must aspire to achieve. Our huckster society places no value on the simple virtue of telling the truth. It is a loser's creed, a false refuge of Pollyannas, we are told by the grizzled veterans of economic warfare. In fact, though, it is the lubricant that ensures the smooth functioning of all of society. We are awash in falsehood, victims of Bill Black's "Gresham's Dynamic." We can get back on course by punishing false representation, starting at the highest levels, where the greatest damage is done by those entrusted with the greatest responsibility, who should be punished accordingly. We should do this not out of a sense of retribution against the bad guys (a class which, in fairness, may include many of us), but as a necessary means of survival.

David in Santa Cruz , April 4, 2020 at 3:06 pm

Former SIGTARP Neil Barofsky was interviewed by Bill Moyers earlier this week. Barofsky expressed his concern that we have developed a culture of casual lying at every level of our society:

It is different. They lied then. They lied now. That hasn't changed. But the way those lies are perceived, and how people have their alternate realities, I think that's very different, and very scary as we go into this next crisis.

https://billmoyers.com/story/here-we-go-again/

The human race is entering its extinction event, and there is no longer any such thing as long-term thinking. Personal honor was the first casualty. Many people suddenly feel entitled to "get theirs" at the expense of everyone else.

I see this sort of casual lying every day now.

Billy , April 4, 2020 at 10:17 pm

That is a symptom of civic decay, not a cause. Once moral relativism is acceptable in "choices", then it becomes so in civics, then contracts then the entire society. You reap what others have sowed and you casually accepted.

eg , April 4, 2020 at 1:44 pm

Yup.

Read all about the history of this in Katharina Pistor's "The Code of Capital"

https://blogs.lse.ac.uk/lsereviewofbooks/2019/09/26/book-review-the-code-of-capital-how-the-law-creates-wealth-and-inequality-by-katharina-pistor/

pebird , April 4, 2020 at 8:57 am

Universal service
High quality
Profit

Pick 2 of 3

periol , April 4, 2020 at 2:53 pm

I'll take Universal Service and High Quality for $400, Alex

Answer: Daily Double

I'll risk everything.

Answer: How do we MAGA?

Jesper , April 4, 2020 at 9:17 am

Private equity might be leading the decline, however, the decline happens everywhere. In the public sector it might be seen less but it happens due to New Public Management (NPM): https://www.managementstudyguide.com/new-public-management.htm

As far as I can tell the story is:
Once an organisation gets large enough (private or public) then it starts to attract management accountants (often MBA degree holders). The management accountant believe they can improve efficiency using the tools that (often) worked in improving efficiency in manufacturing. Process flow-charts and statistical analysis leading to the use of Key Performance Indicators (KPI). Sadly the management accountants are often lacking in knowledge and they are often insecure so they don't dare to ask questions. Their understanding of statistics is either bad or they simply decide to torture data to get their preferred (or indeed any as they need an) answer.
The end result is often KPIs which are seldom Key and often not even Indicators of Performance.
(Their own KPI is billable hours which can and often does affect the quality/usefulness of their work)

In medicine then it might result in something like providing a doctor with a KPI of number of patients seen during a day. Seems reasonable, right?
The problem with that KPI is that the patients differ, some visits are short and some take longer. That might lead to a doctor deciding to call in patients who might as easily have been helped over the phone. The doctor needs the quick and easy visits to meet the KPI, the patient might end up with a two hour trip for something that might have been resolved over the phone but the doctor might have no choice but doing this to meet the KPI.
Or alternatively, if the KPI is about resolving queries over the phone then patients who needs to come to the office are instead refused to come in and instead treated/diagnosed (or as it happens, not) over the phone.

The drive for efficiency can lead to more waste and worse outcomes, when it comes to management accountants then my opinion is: A little knowledge (and that is all they have, a little) can be a dangerous thing. Their lack of knowledge has caused and is continuing to cause a lot of waste and a lot of problems for many people.

Oregoncharles , April 4, 2020 at 3:38 pm

What struck me about the story is that the hospital(s) are every bit as guilty as the PE's. Why would they sign these contracts? There must be some sort of kickbacks for them. Ultimately, it's nothing but a way to squeeze more blood out of the turnips – and that seems to be exactly the way they think of patients.

Technical question: are hospitals legally responsible for the quality of care and honesty of billing in their own emergency rooms? Seems to me that question should be settled by a big, expensive lawsuit by cheated patients.

Jesper , April 4, 2020 at 7:08 pm

My guess is that the hospital first tried outsourcing the canteen and the outsourcing of the canteen might have worked well so they then decided to outsource something else. Why the ER was chosen for the outsourcing might be related to wanting to be able to blame the outsourcer for things that might cause bad publicity. Surprise-billing in the ER might cause bad publicity. By outsourcing the ER the hospital might get more money from the ER and deflect blame for the surprise-billing to the outsourcer.
And I would not be surprised if another reason for signing those deals might have generated some personal benefits for the people who signed the agreement on behalf of the hospital. Probably not a common occurrence but there is a risk that it could happen.

jrkrideau , April 4, 2020 at 9:39 pm

I have worked for an industrial catering firm and properly managed by the contracting organization contracting out a peripheral function such as as food services can work well. Contracting out your key business is madness.

Billy , April 4, 2020 at 10:23 pm

Sodexo-Marriot has replaced many fine in house hospital cafeterias.

From "just OK, to excellent food" has become corporate, tasteless, expensive, profit wringing slop.

Boycott any place that tries to foist that off on you in a captive audience situation.

pricklyone , April 4, 2020 at 11:43 pm

I have been operating under the hypothesis that the escape from legal liability was key to these subcontracting deals.
I am not an insider and have not direct knowledge of such a mechanism, but JTMcPhee may have some insight, if he thinks about it for a few

JTMcPhee , April 5, 2020 at 10:45 am

There's probably no way a hospital, as a business entity, can avoid being sued In a malpractice situation. The law on this is murky and fact-driven. Plaintiffs' attorneys sue all deep pockets where there is a "colorable claim" and assets and insurance behind the defendant. The hospital corps have deep pockets that fund the best lawyers and expert opinion providers that money can buy. They can drown many victims in paper and procedure. So your lawyer can sue the hospital, but will have an uphill battle piercing through to the imposition of liability on the hospital.

Here's an article discussing the issue of entity liability in malpractice:

https://www.plaintiffmagazine.com/recent-issues/item/when-is-a-hospital-liable-for-a-physician-s-malpractice

Often a case against the hospital turns on whether "vicarious liability" can be established. As you note, the structure discussed is an effort to maximize the distance between the hospital entity and the physician. And of course the PE real-party-in-interest owners of the profitable part of the business are even further removed.

I've got to say, firing Dr. Lin was maybe unwise since it establishes a much closer link between the PE entity as controlling the physician's practice and thus makes it easier to establish agency, direct employee and vicarious liability by the PE entity. Though of course those snakes are very careful to revise their own trench-warfare defenses against personal liability in constructing their shells and disconnects.

Jeff , April 4, 2020 at 9:19 am

Yves, I don't get it. Why would a hospital not hire these docs in the ER and give up that revenue stream to a private company? If it's so profitable, why would a hospital just give that money away? I can see why a small rural hospital or single site facility might not have the consistent ER volume to justify multiple ER docs, but larger hospital groups can move er docs around in a geography to cover greater needs.

Felix_47 , April 4, 2020 at 9:55 am

As a doc the answer is management and cost control. If they have a lot of doctors they get a hefty discount on malpractice premiums which can be in the hundreds of thousands or they self insure with umbrella coverage. ER billing is a huge issue. It requires full time people and a lot of phone calls and follow up and tons of paperwork. Don't forget the insurance carriers see their job as looking for loopholes to not pay and the doctor groups see their job as bypassing those loopholes. If it is a large group and someone goes on vacation or is sick or can't make a shift coverage has to be maintained. A large pool of doctors makes that possible. A lot of ER doctors chose the specialty because they did not want to be tied down to an office and a business. They want to do the job and then have time off. For that they are willing to take a substantial cut in pay. Overhead costs could easily be over 50%. Pay for doctors has really not kept up with inflation over the last 30 years .unless they cheat .and the more the payers cut them the more that happens. And consider the risk of seeing children with fevers brought in to ERs by non English speaking people often without insurance at 3 in the morning. One case of meningitis, and a certain small percentage will have it, and you could be wiped out. The lawyers are all over it. Think about the two febrile kids who died with ICE a few months ago as they were brought over the border by the parents. Combining these sorts of high risk cases with our legal system is more than a single doc or small group can handle. For example, I alway saw the problem with the asylum wave to be more the legal risk of holding these folks than anything else. I think there were hefty settlements in those cases and I am sure the doctors did not do much wrong .just bad luck .but their careers might well have been significantly impacted. The only answer is a national health system with significant tort reform in medicine. Doctors should be on government salary just like firemen. There is no reason the payment structure should change between the most important moments of care like 911 and the next part after you go through the swinging doors of the ER. If health care is a government guaranteed right then it should be free of profiteering and should be provided by the government and that goes for the pharma and hospital industry as well. The recent primary suggests that Americans like the health care they have and the way it is done. It is no accident the health insurance stocks bumped up to 30% the day after Super Tuesday.

Rod , April 4, 2020 at 10:47 am

thanks for this insight overall.
You state the bottom line:

The only answer is a national health system with significant tort reform in medicine.

rd , April 4, 2020 at 12:21 pm

Canada

UK-NHS is similar but way underfunded compared to Canada.

Societal Illusions , April 4, 2020 at 10:11 pm

I'm not convinced the "only" answer is the one you provide – national healthcare with significant tort reform.

that said, it certainly is one answer. i wonder if most any answer could be worse than what we have currently.

wonder how the super tuesday voting would have changed if done over now?

lyman alpha blob , April 4, 2020 at 10:23 am

I had no idea that hospitals did this. Just when you think you can't get any more cynical

cripes , April 4, 2020 at 10:08 pm

lyman alpha blob:

I commend your healthy lifestyle choices that have kept you from an ER visit over the past 10 years or so and from the out-of-network double billing that is now endemic. Everywhere.

vegeholic , April 4, 2020 at 10:24 am

People have developed an exquisitely tuned sensitivity to some swindles, such as when the oil companies collude to increase gasoline prices, with or without justification. They even invented a phrase to describe the practice called "price gouging", and demand action from their elected representatives. Everyone becomes a raging, full-throated socialist when being squeezed by this particular variety of market leverage. Yet when faced by other, even more egregious looting, such as described in this post, they fall in line like compliant sheep being led to the slaughter. I don't get it. Maybe someone can explain this.

a different chris , April 4, 2020 at 11:25 am

I am not going to claim to be able to explain it, but:

I *think* it's the horrible cross-pollination of the complexity issue vs the dire outcome of the wrong choice.

You can, although most won't, find a way to save gas. It's pretty understandable, your vehicle gets X MPG and you drive so many miles. You can adjust the second usually, and also occasionally adjust the first. You have a chance (even if your in negative territory you can buffer that period with a credit card) to somehow buy time while you make the adjustments.

How the heck do you figure out if you really need to be cut open (your GP choice), who to actually cut you open (references?) and where to have him/her do it (if the surgeon works across hospitals).

And if the GP is right, the clock is ticking .

Oregoncharles , April 4, 2020 at 3:44 pm

Medicine is a massive example of market failure, for the reasons your example outlines. So all that stuff about "choice" and "markets" is just self-serving BS.

K teh , April 4, 2020 at 10:27 am

The University Hospital Complex system is the most corrupt part of the economy, and as we now see it is the weapon being employed. The curtain comes down.

Government essentially guarantees private corporate revenue, so those corporations can focus on minimizing costs, which are labor. The non-profits sow up the trap with legal exemptions, generating profit that is not taxed. The three-headed hydra is the least common denominator of herd behavior, distilling labor.

That money supply chart is essentially an implosion ripe for explosion. You want to harness that and direct parts of that energy toward some useful function.

K teh , April 4, 2020 at 10:31 am

If you gotta go, talk to the overnight secretary and get the best nurse and PA to keep an eye on you.

The doctors signed their life away when their education began.

Dean , April 4, 2020 at 10:46 am

Is there a place on the web where these relationships and transactions are published / researched? State boards of medicine? State Attorney's General? Or is this another opaque backwater where the details don't see the light of day?

jef , April 4, 2020 at 11:08 am

Private equity is like someone standing between you and the milk at the grocery store where you say "excuse me I need to get a gallon of milk" and he says "Ok, that will be six dollars" and you say "but it says four dollars right there" he says "well I say six dollars is the new price take it or leave it".

It's about time we told these a$$hole$ to get the hell out of the way.

JTMcPhee , April 4, 2020 at 11:31 am

A little anecdote from my Army basic training experience that might be a potential scenario as all this goes "healthSouth:"

Troop barracks used to be these two-story buildings with "Open plan" layout -- ten double bunks down each side, a latrine (bathroom facilities with a row of unenclosed toilets and sinks and gang showers.) If you have seen "Full Metal Jacket," you remember the drill. In any event, forty males on each floor sharing everything including microbes.

My experience was at Ft. Leonard Wood ("Fort Lost-In-The-Woods, in the state of Misery",) in the fall and early winter of 1966. Meningitis started in the troop population, so the Commanding General mandated that all the windows were alternately to be kept open 9 inches, top and bottom, to air the place out. This with outside air temps being in the 20s.

So despite the window-open attempts to limit the spread of this infectious disease in a pretty bad kind of social propinquity situation, one of the guys in in my barracks, a draftee farm kid from Iowa, started having really bad headaches and a stiff neck. He was finally allowed to go to "sick call" at the dispensary, the equivalent of the Emergency Room. He went, they gave him Tylenol, and sent him back to duty. This was repeated for three days.

On the morning of the fourth day, his squad members found him in convulsions with a raging fever and he was carted off by a GI ambulance. He died that night in the base hospital, from meningitis. We troops were then made to remove his gear and bedding which was burned, and also to "GI" ("deep clean") the whole barracks with some nasty disinfectant from a 55-gallon drum in GI green.

A week or so later, the guy's father showed up with a shotgun. He'd collected his son's body Earlier, but someone had told him about his son's failed efforts to get treatment. He wanted to find the NCOs, officers and the sick bay doctor and staff that were responsible. The MPs showed up in force and hauled him off to the stockade (jail).

I wonder if there have been episodes like this happening in our current looting-based system? For sure, they are not likely to be reported very widely.

And the corporate scum have done a pretty good job of insulating themselves from visibility, let alone responsibility and liability. Kind of unfair to shoot the ER doctor or the mope in the billing department that was "just following orders."

flora , April 4, 2020 at 11:59 am

Thanks. Yep, and the higher ups who allowed that probably got promoted. Whereas commanders (and now doctors and nurses) who do the right thing to save lives get fired.

Capt. Crozier.

https://twitter.com/mccaffreyr3/status/1246146257480908801

The heros are the one's doing the right thing in the face of threats and retaliation. Crozier is a hero. So are the ER docs.

https://www.nytimes.com/2020/04/03/opinion/coronavirus-crozier-roosevelt.html

rd , April 4, 2020 at 12:25 pm

Expect COVID-19 case numbers to spike upwards soon along with deaths attributed to it. Trump rejected re-opening Obamacare and therefore hospitals will rely on Federal CARES dollars for reimbursement of Covid testing and care. So they will have every incentive to test everything but a dog or cat that walks through their door to ensure they will get paid because they will only be assured of being paid by the Feds if it is Covid.

ambrit , April 4, 2020 at 1:35 pm

They can also test cats and dogs, since, supposedly, they can catch it from humans, and bill it to the Agriculture Department.

Knot Galt , April 4, 2020 at 3:12 pm

PPE, NOT PE.

antidlc , April 4, 2020 at 3:35 pm

About a third of hospital emergency rooms are staffed by doctors on the payrolls of two physician staffing companies -- TeamHealth and Envision Health -- owned by Wall Street investment firms. Envision Healthcare employs 69,000 healthcare workers nationwide while TeamHealth employs 20,000. Private equity firm Blackstone Group owns TeamHealth, Kravis Kohlberg Roberts (KKR) owns Envision .

Anybody know if these guys have anything to do with Envisionrx?
https://envisionrx.com/

mtnwoman , April 4, 2020 at 3:51 pm

This got a hearty Amen! from me:

Stop Silencing Doctors: A Clinical Manifesto

https://www.youtube.com/watch?v=Mvlqh0JN55M&feature=youtu.be&app=desktop

antidlc , April 4, 2020 at 5:40 pm

About a third of hospital emergency rooms are staffed by doctors on the payrolls of two physician staffing companies -- TeamHealth and Envision Health -- owned by Wall Street investment firms. Envision Healthcare employs 69,000 healthcare workers nationwide while TeamHealth employs 20,000. Private equity firm Blackstone Group owns TeamHealth, Kravis Kohlberg Roberts (KKR) owns Envision .

Same Envision as envisionrx -- or is envisionrx owned by something else?
https://envisionrx.com/

Carla , April 4, 2020 at 6:13 pm

The whole story here is that for-profit medicine won't work. And in the U.S. of A., ALL medicine is for-profit, including our beloved (which has always required supplemental insurance, and now with "Advantage" plans is increasingly crapified) Medicare system.

Capitalism and Caring Cannot Co-Exist.

Give it up!

CanCyn , April 4, 2020 at 6:17 pm

As a Canadian, I had to stop reading this article when I got to the paragraph about Dr. Ming Lin working for a staffing company. I. Can't. Even.
The entire US healthcare system is complete and utter insanity! I don't know how anyone can even try to have a rational discussion about it.
Privatization and for profit craziness is creeping around the edges of Canada's system and has f'd up our long term care system (certainly in Ontario where I live). It scares the bejeezus out of me to think that anyone in Canada would want to go down the US road and I hope I never live to see the day.
The head or our provincial, Conservative, gov is quite to the right (fun fact : he is the brother of the crazy Toronto drug using mayor, Rob Ford, whose notoriety some of you may remember from a few years back) his mother-in-law is apparently in long term care, where Covid is hitting hard here in Canada and Ontario. I am hoping (faint though the hope might be) that this personal experience wakes him up to the complete and utter wrong that is profit in healthcare.

jrkrideau , April 4, 2020 at 9:51 pm

It's hard to tell but I almost get the feeling Doug is growing up. I think the Covid-19 pandemic was a real awake call for him.

Once we are out of the worst of it he probably go back to being an ***hole but I hope a better one.

BTW, we should be able to get Dr. Ming Lin an expedited visa and provisional licensing in no time.

Tom Stone , April 4, 2020 at 10:00 pm

I have long been aware that the only way the American Healthcare system could be reformed was if it totally collapsed, which is happening now.
Lots of unnecessary pain and death.

As many of you know I have in excess of $300K in medical debt accrued in roughly 18 months, the last trip to the Hospital ran $88K and change for a 32 hour stay.

If I had any easily ascertainable assets I'd have been sued multiple times already.
Fortunately every spare penny for the last 5 years has gone to my Daughter Rosetta's 529 plan, between that and a very nice scholarship she will graduate debt free.
And yes, that really is her name.
She's cool with it and we're planning to get matching Mohawks when I'm done with Chemo, I'll likely go with the same cobalt blue I did when I knew Chemo was on the way.
A man's gotta do

Jonathan , April 5, 2020 at 1:16 pm

All of that medical debt would be $0 if you lived in Singapore and opted in to pay ~USD300 per year in cash premiums for upgraded govt insurance, assuming you are in the 30-40 age bracket Even if you didn't opted in and without employer insurance, you most likely won't fork out more than USD 20K cash copay cash after all is said and done.

Also, you would probably pay only <1% of your total yearly income in income taxes and not be blowing some USD 2-3K in rent every month.

So frankly I have NO idea how you Americans can tolerate living in that "exceptional" sh!thole called the US.

mrtmbrnmn , April 5, 2020 at 12:53 am

In Pagan days human sacrifices were thrown into the fiery pits to appease the Mad Gods & Big Nature. We may want to revisit that in the present terrible circumstances. High on the list of nominees would be the Werewolves of Wall Street & all those Hedge Fund Hooligans.

Sound of the Suburbs , April 5, 2020 at 4:47 am

In Europe, doctors are facing difficult life and death decisions they are not prepared for.
US doctors are fully prepared to make difficult decisions.
Do you have health insurance?
If not, get lost.

That's what I like to see.
Markets forces at work.
If you can't afford it, you get nothing.

[Apr 05, 2020] Drug Wars How Big Pharma Raises Prices and Keeps Generics off the Market - Kindle edition by Feldman, Robin, Frondorf, Evan. P

Apr 05, 2020 | www.amazon.com

While the shockingly high prices of prescription drugs continue to dominate the news, the strategies used by pharmaceutical companies to prevent generic competition are poorly understood, even by the lawmakers responsible for regulating them. In this groundbreaking work, Robin Feldman and Evan Frondorf illuminate the inner workings of the pharmaceutical market and show how drug companies twist health policy to achieve goals contrary to the public interest. In highly engaging prose, they offer specific examples of how generic competition has been stifled for years, with costs climbing into the billions and everyday consumers paying the price. Drug Wars is a

... ... ...

Price increases had occurred across the board, on everything from gallstone treatments to, A shocking Wall Street Journal piece revealed that between 2010 and 2014, U.S. prices for the thirty best- selling drugs rose four times faster than prescription volume, and eight times faster than inflation. 24 Put another way, 80 percent of the growth in profits of the twenty largest drug companies in 2015 resulted from price increases. 25 Put still another way, customers of CVS Health spent 12.7 percent more on drugs in 2015 than in the previous year, and more than 80 percent of that additional spending was the result of price increases. -- U.S. President Barack Obama even got into the academic mix, publishing a paper in the Journal of the American Medical Association that, in part, called attention to rising spending on prescription medication. 22 And in the days before his 2017 inauguration, the next U.S. president, Donald Trump, sharply criticized the pharmaceutical industry. "We have to . . . create new bidding procedures for the drug industry because they're getting away with murder. . . . Pharma, pharma has a lot of lobbies and a lot of lobbyists and a lot of power." --

The brunt of the pain is felt by U.S. citizens - one drug that costs less than $400 a year in some countries has a list price around $300,000 in the United States. 24 The rest of the world, however, has not been immune to the plague of skyrocketing prices...

[Mar 29, 2020] Medical Expert Who Corrects Trump Is Now a Target of the Far Right

Money quote " There is this sense that experts are untrustworthy, and have agendas that aren't aligned with the people"
That was always true about neoliberal economists. So it might well be true about mecuacl bureaucrats like Fauci. Did he disclose his stock holdingd and financial interests? Is he a part of neoliberal "medical-industrial complex" which wants to rake profits at the expense of people health?
His email to Hillary suggest that he is medical professional but a politician.
Actually any top medical honcho in Washing is compromised as they did nothing to stop "balance billing" fraud and too over of ambulance business by private equity sharks.
Notable quotes:
"... There is this sense that experts are untrustworthy, and have agendas that aren't aligned with the people ..."
"... In the email, Dr. Fauci praised Mrs. Clinton for her stamina during the 2013 Benghazi hearings. The American Thinker falsely claimed that the email was evidence that he was part of a secret group who opposed Mr. Trump. ..."
Mar 29, 2020 | www.nytimes.com

Adding that Dr. Fauci is bearing the brunt of the attacks, Mr. Bergstrom said: " There is this sense that experts are untrustworthy, and have agendas that aren't aligned with the people . It's very concerning because the experts in this are being discounted out of hand."

... ... ...

Anti-Fauci posts spiked, according to Zignal Labs. Much of the increase was prompted by a March 21 article in The American Thinker, a conservative blog, which published the seven-year-old email that Dr. Fauci had written to an aide of Mrs. Clinton.

In the email, Dr. Fauci praised Mrs. Clinton for her stamina during the 2013 Benghazi hearings. The American Thinker falsely claimed that the email was evidence that he was part of a secret group who opposed Mr. Trump.

... ... ...

In an interview, Mr. Fitton said, "Dr. Fauci is doing a great job." He added that Dr. Fauci "wrote very political statements to Hillary Clinton that were odd for an appointee of his nature to send."

...One anti-Fauci tweet last Sunday read: "Dr. Fauci is in love w/ crooked @HillaryClinton. More reasons not to trust him."

[Mar 28, 2020] The best book on big pharma criminality

Mar 28, 2020 | www.unz.com

tomo , says: Show Comment March 27, 2020 at 12:44 pm GMT

@Mustapha Mond this is the best book on big pharma criminality I have ever seen (written by an English doctor who writes for the Guardian )
You will not believe what's 'legal' for them to do in their 'research'
It's beyond criminal – but they obviously got their politicians/friends to change laws to allow what they are doing to proceed – it's really almost unbelievable
and it seems to be even worse in Europe than in the US (another thing I initially found hard to believe)

https://read.amazon.com/kp/card?preview=inline&linkCode=kpd&ref_=k4w_oembed_h8hKOfsbUkiUQn&asin=B008RLTUUA&tag=kpembed-20

[Mar 28, 2020] Neoliberalism and medicine

Mar 28, 2020 | www.unz.com

JackOH , says: Show Comment March 27, 2020 at 12:06 pm GMT

Pepe, thanks.

As I've seen it, America's medical establishment enjoys extraordinary powers of initiative and veto in its engagement with the public, and much of that originates in the asymmetric doctor-patient relationship, the bad consequences of which were noticed by Hippocrates 2500 years ago when he tried calling physicians to their better instincts with his oath.

Good health is indeed a very important factor in Big Medicine's public engagement. So, too, revenues and profits, autonomy of practice, fee for service, overwhelming influence and downright control of the distribution of medicine for its own purposes, etc. Will elements of Big Medicine sacrifice good health for those other factors?

Yes. But you have to look at discrete instances to see how Big Medicine's players are tempted to go outright criminal. See, for example, the oxycodone killings.

I can't speak to the specifics of your article, Pepe, but it sure as hell meets some minimum threshold of plausibility to warrant further investigation in my opinion. Thanks again.

[Mar 04, 2020] Why Are We Being Charged? Surprise Bills From Coronavirus Testing Spark Calls for Government to Cover All Costs by Jake Johnson

Highly recommended!
Notes of disaster capitalism in action...
Notable quotes:
"... The Centers for Disease Control and Prevention (CDC) is not billing patients for coronavirus testing, according to Business Insider . "But there are other charges you might have to pay, depending on your insurance plan, or lack thereof," Business Insider noted. "A hospital stay in itself could be costly and you would likely have to pay for tests for other viruses or conditions." ..."
"... Congress needs to immediately pass a bill appropriating funding to cover 100% of the cost of all coronavirus testing & care within the United States. We will not have a chance at containing it otherwise. @tedlieu - as my rep, can you please ensure this is brought up? ..."
"... In the case of the Wucinskis, Kliff reported that "the ambulance company that transported [them] charged the family $2,598 for taking them to the hospital." ..."
"... Last week, the Miami Herald reported that Osmel Martinez Azcue "received a notice from his insurance company about a claim for $3,270" after he visited a local hospital fearing that he contracted coronavirus during a work trip to China. ..."
"... Did anyone expect the unconscionable greed of capitalism to cease when a public health crisis emerges? This is just testing for the virus, wait until a vaccine has been developed so expensive that the majority of the US populace can not afford it at all and people are dropping like flies. Wall Street, never-the-less, will continue to have its heydays ..."
"... The very idea that the defense and "Homeland" security budgets are bloated and additional funding approved year after year but the citizens of this country are not afforded 100% health coverage In a time of global health crisis that could become a pandemic. ..."
Mar 03, 2020 | www.commondreams.org

"Huge surprise medical bills [are] going to make sure people with symptoms don't get tested. That is bad for everyone." by Jake Johnson, staff writer Public health advocates, experts, and others are demanding that the federal government cover coronavirus testing and all related costs after several reports detailed how Americans in recent weeks have been saddled with exorbitant bills following medical evaluations.

Sarah Kliff of the New York Times reported Saturday that Pennsylvania native Frank Wucinski "found a pile of medical bills" totaling $3,918 waiting for him and his three-year-old daughter after they were released from government-mandated quarantine at Marine Corps Air Station in Miramar, California.

"My question is why are we being charged for these stays, if they were mandatory and we had no choice in the matter?" asked Wucinski, who was evacuated by the U.S. government last month from Wuhan, China, the epicenter of the coronavirus outbreak.

"I assumed it was all being paid for," Wucinski told the Times . "We didn't have a choice. When the bills showed up, it was just a pit in my stomach, like, 'How do I pay for this?'"

The Centers for Disease Control and Prevention (CDC) is not billing patients for coronavirus testing, according to Business Insider . "But there are other charges you might have to pay, depending on your insurance plan, or lack thereof," Business Insider noted. "A hospital stay in itself could be costly and you would likely have to pay for tests for other viruses or conditions."

Lawrence Gostin, a professor of global health law at Georgetown University, told the Times that

"the most important rule of public health is to gain the cooperation of the population."

"There are legal, moral, and public health reasons not to charge the patients,"

Gostin said.

Congress needs to immediately pass a bill appropriating funding to cover 100% of the cost of all coronavirus testing & care within the United States. We will not have a chance at containing it otherwise. @tedlieu - as my rep, can you please ensure this is brought up?

-- William LeGate (@williamlegate) March 2, 2020

In the case of the Wucinskis, Kliff reported that "the ambulance company that transported [them] charged the family $2,598 for taking them to the hospital."

"An additional $90 in charges came from radiologists who read the patients' X-ray scans and do not work for the hospital," Kliff noted.

The CDC declined to respond when Kliff asked whether the federal government would cover the costs for patients like the Wucinskis.

The Intercept 's Robert Mackey wrote last Friday that the Wucinskis' situation spotlights "how the American government's response to a public health emergency, like trying to contain a potential coronavirus epidemic, could be handicapped by relying on a system built around private hospitals and for-profit health insurance providers."

We should be doing everything we can to encourage people with #COVIDー19 symptoms to come forward. Huge surprise medical bills is going to make sure people with symptoms don't get tested. That is bad for everyone, regardless of if you are insured. https://t.co/KOUKTSFVzD

-- Saikat Chakrabarti (@saikatc) March 1, 2020

Play this tape to the end and you find people not going to the hospital even if they're really sick. The federal government needs to announce that they'll pay for all of these bills https://t.co/HfyBFBXhja

Last week, the Miami Herald reported that Osmel Martinez Azcue "received a notice from his insurance company about a claim for $3,270" after he visited a local hospital fearing that he contracted coronavirus during a work trip to China.

"He went to Jackson Memorial Hospital, where he said he was placed in a closed-off room," according to the Herald . "Nurses in protective white suits sprayed some kind of disinfectant smoke under the door before entering, Azcue said. Then hospital staff members told him he'd need a CT scan to screen for coronavirus, but Azcue said he asked for a flu test first."

Azcue tested positive for the flu and was discharged. "Azcue's experience shows the potential cost of testing for a disease that epidemiologists fear may develop into a public health crisis in the U.S.," the Herald noted.

Sen. Bernie Sanders (I-Vt.), a 2020 Democratic presidential candidate, highlighted Azcue's case in a tweet last Friday.

"The coronavirus reminds us that we are all in this together," Sanders wrote. "We cannot allow Americans to skip doctor's visits over outrageous bills. Everyone should get the medical care they need without opening their wallet -- as a matter of justice and public health."

Last week, as Common Dreams reported , Sanders argued that the coronavirus outbreak demonstrates the urgent need for Medicare for All.

The coronavirus reminds us that we are all in this together. We cannot allow Americans to skip doctor's visits over outrageous bills.

Everyone should get the medical care they need without opening their wallet -- as a matter of justice and public health. https://t.co/c4WQMDESHU

-- Bernie Sanders (@SenSanders) February 28, 2020

The number of confirmed coronavirus cases in the U.S. surged by more than two dozen over the weekend, bringing the total to 89 as the Trump administration continues to publicly downplay the severity of the outbreak.

Dr. Matt McCarthy, a staff physician at NewYork–Presbyterian Hospital, said in an appearance on CNBC 's "Squawk Box" Monday morning that testing for the coronavirus is still not widely available.

"Before I came here this morning, I was in the emergency room seeing patients," McCarthy said. "I still do not have a rapid diagnostic test available to me."

"I'm here to tell you, right now, at one of the busiest hospitals in the country, I don't have it at my finger tips," added McCarthy. "I still have to make my case, plead to test people. This is not good. We know that there are 88 cases in the United States. There are going to be hundreds by middle of week. There's going to be thousands by next week. And this is a testing issue."

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Harry_Pjotr 13h

Did anyone expect the unconscionable greed of capitalism to cease when a public health crisis emerges? This is just testing for the virus, wait until a vaccine has been developed so expensive that the majority of the US populace can not afford it at all and people are dropping like flies. Wall Street, never-the-less, will continue to have its heydays

Smerl fern 12h

A wall street bank or private predator may own your emergency room. A surprise bill may await your emergency treatment above insurance payments or in some instances all of the bill.

An effort was made recently in congress to stop surprise billings but enough dems joined repubs to kill it. More important to keep campaign dollars flowing than keep people alive. fern Smerl 12h I know emergency rooms are being purchased by organizations like Tenet (because they are some of the most expensive levels of care) and M.D.s provided by large agencies. I'm not as up on this as I should be but a friend of mine tells me that some of this is illegal. I have received bills that were later discharged by challenge. This is worth investigating further. Atlas oldie 11h Hmmmm A virus that overwhelmingly kills the elderly and/or those with pre-exisitng conditions.

Sounds like a medical insurance companies wet dream. As well as .gov social security/medicare wet dream.

Just sayin'

Ticki 11h

The very idea that the defense and "Homeland" security budgets are bloated and additional funding approved year after year but the citizens of this country are not afforded 100% health coverage In a time of global health crisis that could become a pandemic. And as has been stated, the unconscionable idea suggested that a possible vaccine (a long way away or perhaps not developed at all) might not be affordable to the workers who pay the taxes that fund the government? That's insane.

leftonadoorstep 11h

Another example of "American Exceptionalism." China doesn't charge its coronavirus patients, neither does South Korea. I guess they are simply backward countries.

Barton 11h

I own my own home after years of hard work paying it off. It's the only thing of value, besides my old truck, that I have. If I get the virus, I will stay home and try to treat it the best I can. I can't afford to go to the hospital and pay thousands in medical bills, with the chance that they'll come after my possessions. America, the land of the _______. Fill in the blank. (Hint: it's no longer free).

fern 1 Barton 11h

There are other ways to protect your home. Homesteading or living trust. I'm not good at this but I know there are ways to do it. Hopefully, it would never come to that but outcomes are not certain even with treatment in this case.

Giovanna-Lepore oldie 11h

As someone who lost a mother at 5 years old I can sympathize with your grief in losing a daughter-in-law and especially seeing her four children orphaned. However, I think you miss the point here: This is about we becoming a society invested in each others welfare and not a company town that commodifies everything including the health and well being of us all.

fern 1 Giovanna-Lepore 11h

I'm going by: https://www.congress.gov/bill/116th-congress/senate-bill/1129/text

As a revision it is better but flawed. It is a cost containment bill based on the same research as the republican plan with global budgets and block grants.

Edited: I encourage you to read this:
-ttps://www.rand.org/blog/2018/10/misconceptions-about-medicare-for-all.html Giovanna-Lepore 10h oldie:

Part D

Higher education is not free but they do need to become free for the students and payed by us as a society.

Part D is a scam, a Republican scam also supported by corporate democrats because of its profit motive and its privatization

Medicare only covers 80% and does not cover eye and dental care and older folks especially need these services. Medicaid helps but there are limits and one cannot necessarily use it where one needs to go. Expanded, Improved Medicare For All is a vast improvement. because it covers everyone in one big pool and, therefore, much more dignified than the rob Paul to pay peter system we have.

Social Security too can be improved. Why should it simply be based on the income of the person which means that a person working in a low paying job in a capitalist system gone wild with greed will often work until they die.

Pell grants can be eliminated when we have what the French have: publicly supported education for everyone.

The demise of unions certainly did not help but it was part of the long strategy of the Right to privatize everything to the enrichment of the few.

Yunzer SuspiraDeProfundis 10h

Thank goodness for the "/s". Poe's Law you know

The overall competence that Canada is handling this outbreak, compared to the USA, is stark. First world (Canada) versus third-world (USA). Testing is practically available for free, to any suspect person, sick or not, as Toronto alone can run 1000 tests a day and have results in 4 hours. That is far more than all the US's capacity for 330 million people.

I wonder how long before Canada closes its borders to USAns? Me and my wife (both in a vulnerable age/medical group) should seriously consider fleeing to my brother's place in Toronto as the first announced cases in Pittsburgh are probably only days away. What about our poor cat though? We could try to smuggle her across the border, but she is a loud and talkative kitty

Greenwich 10h

Don't want to discourage anyone from any protective measures – but the "low down" from my veggie store today was that a lot of health professionals shop there and they think it's being hyped by media. Did get this from my NJ Sen. Menendez –

Center for Disease and Control and Prevention (CDC)

There is currently no vaccine to prevent coronavirus disease 2019 (COVID-19). The best way to prevent illness is to avoid being exposed to this virus. However, everyday preventive actions can help prevent the spread of respiratory diseases:

  • Wash your hands often
  • Avoid close contact with people who are sick.
  • Avoid touching your eyes, nose, and mouth.
  • Stay home when you are sick.
  • Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
  • For more information : htps://www.cdc.gov/coronavirus/2019-ncov/about/prevention-treatment.html
  • How it spreads : The virus is thought to spread mainly from person-to-person. It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads. [Read more.]
    https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html )
  • Symptoms : For confirmed coronavirus disease 2019 (COVID-19) cases, reported illnesses have ranged from mild symptoms to severe illness and death. Symptoms can include fever, cough, and shortness of breath.
Seeker 9h Greenwich:

Don't want to discourage anyone from any protective measures – but the "low down" from my veggie store today was that a lot of health professionals shop there and they think it's being hyped by media.

I agree it is being hyped by the media to the point of being fear mongering. At the same time it is being ignored by the administration to such an extent that really little almost nothing is being done. At some point the two together will create an even bigger problem.

It is like the old adage: "Just because you are paranoid doesn't mean they aren't out to get you." Each over/under reach in considering the reality of the situation has its own problem, which multiply when combined. Every morning when I wake up I say a little atheistic prayer to myself before I get out of bed: "Another day and for better or worse...".

Seeker 8h

Well, two reported here in Florida tonight. One in my county, one in the county next door. And more of the "we already knew, but told you late". One person checked into the hospital on Wednesday. We hear it Monday night. Both were ignored far a long time it seems, and 84 in particular are being watched (roommates, friends, hospital workers not alerted for several days, the usual). But no one knows every place they had been since becoming infected.

Oh, and they have tested a handful of people. No worry?

I can't see anyway that this level of incompetency is an accident. Spring break is just starting usually a 100's of thousand tourist bonanza.

So the question is do they want to kill us, or just keep us in fear?

I think the later. But the end result is a crap shoot. So once again, it is a gamble with our lives.

Archie1954 7h

The business of America is business. Sometimes that can go too far and this is one of those times. Making money from the loss, distress, harm and suffering of others is perverse beyond belief.

[Mar 03, 2020] Coronavirus Systems Fragility by Rod Dreher

Highly recommended!
Notable quotes:
"... I have been a physician now for almost 30 years. It has been a career spanning the very end of the "Marcus Welby" era, and then piece by piece the complete dismantling of the medical profession by the insurance companies and now "non-profit" corporations. When I was young, the leadership structure in the hospitals was completely and utterly controlled by three groups: the physicians, the nurses, and in the case of Catholic hospitals, the church and the nuns, or in non-Catholic hospitals, philanthropic community leaders. ..."
"... There were no four-star mahogany and marble lobbies. There were no 2 million dollar annual salaries for the hospital CEOs. There were no non-profit corporate boards extracting every bit of wealth from the patients to maintain multimillion dollar salaries for the board members and the middle managers. ..."
"... In further conversation, the doctor said that we should be thinking about a world in which a large number of health care workers can't come to work because they are in quarantine or sick with the virus. We are looking at this problem right now. ..."
Mar 02, 2020 | www.theamericanconservative.com
Here's a link to an unrolled Twitter thread by former USAID official Jeremy Konyndyk. It begins:

Later in the thread:

Read the whole thread. His basic point is that the US Government did not want to see data that would indicate community transmission, so it didn't look for that. What do you think? I'm especially interested in what medical professionals in this blog's readership have to say.

I received this e-mail from Wyoming Doc a couple of days ago, and have his permission to post it:

I have just learned of the first Coronavirus Death in the USA. It is now getting real.

I would point you to the following links -- I am seeing myself -- but to a greater degree hearing about rather concerning things happening in our hospitals across the country.
The first is this video:

https://www.youtube.com/watch?v=5iz0dQbGLbE

The second is this website I showed you the other day:

https://www.oftwominds.com/blog.html

I would start first with a little background. I have been a physician now for almost 30 years. It has been a career spanning the very end of the "Marcus Welby" era, and then piece by piece the complete dismantling of the medical profession by the insurance companies and now "non-profit" corporations. When I was young, the leadership structure in the hospitals was completely and utterly controlled by three groups: the physicians, the nurses, and in the case of Catholic hospitals, the church and the nuns, or in non-Catholic hospitals, philanthropic community leaders.

The focus at the time was mostly on taking care of the most patients the best that could be done in a compassionate way with the resources available. And believe it or not, in my opinion, the care that was given in that time was far superior than what is going on now. The leaders of the hospitals were community leaders, and so was the medical and the nursing staff. To put it succinctly: they cared about their neighbors. Many, many nights while on call I would see the nuns right along side the nurses and physicians working themselves to death to take care of sick patients. These hospitals were never in debt -- the resources and the donations coming in were used for the expenses going out. There were no four-star mahogany and marble lobbies. There were no 2 million dollar annual salaries for the hospital CEOs. There were no non-profit corporate boards extracting every bit of wealth from the patients to maintain multimillion dollar salaries for the board members and the middle managers.

When I was a young medical student, a very old professor taught a course in medical ethics. In one of his most pressing lectures, he discussed the fact that the goals and ideals of medicine and public health were a complete 180 degrees from the wants and desires of a free market. He added that every time combining public health/medicine and free markets had been tried in history it ended in tears -- usually bankrupting the society. It was his fervent desire that we not allow this to happen to the profession as we entered its ranks, and to keep an eye out for this at all times.

Well, as everyone knows by now, his worst fears have been realized. Many, probably not most, members of my profession -- especially the procedure-based specialists and surgeons -- in the past 10-15 years have completely lost sight of the public well-being. Their sights are now on lucre. The one desire for many of them has been how to make more money more quickly. They have been aided and abetted by the governing agencies and Boards of all the various medical specialties. These national leadership organizations have made all the activities of being a physician so onerous and the billing so difficult that the vast majority of physicians have no choice but to become employees of these mega-corporations. The physicians have made a deal to take a back seat to these "businessmen" to keep the cash coming. The leadership of our hospital systems are no longer physicians, nurses, nuns, and philanthropists. Nope –it is all MBA all the time. Even the physicians who are nominally in charge -- ie the ubiquitous Chief Medical Officers of the corporations -- do not get considered for the jobs unless they have an MBA after their name. And the credentialing of the leadership teams are just absolutely ridiculous. Look at the websites of your local hospital and its leadership. It is usual to see things like this: John Doe, MD MBA FACP PhD FACC. The non-MD credentialing is even more hilarious -- I have no idea what 95% of these abbreviations mean -- but they have to puff themselves up anyway. The hubris and the arrogance would be hilarious, but now the crisis is upon us.

About 10-15 years ago, the change began in earnest. One by one, the physicians in charge were replaced with MBA bureaucrats. The usual committee structure in the hospital -- "Pharmacy & Therapeutics", "Patient Care Committee" etc -- had their physicians, nurses and pharmacists replaced with bureaucrats. Some of these bureaucrats were MDs and RNs -- the paycheck was awesome -- and they turned their backs on their duties and their colleagues and patients on the ground to keep the cash coming. I even lived to see the day when one of my hospitals fired the MD and RN leadership of the Medical Ethics Committee and replaced them with an MBA.

Suddenly, the only ethical thing to do was whatever was needed to maximize cash flow. And any MD or RN who did not like it? Well, you're fired -- see you later. We began to completely corporatize medical care. Advertisements and billboards everywhere, customer service feedback surveys flowing in the mail, the list is endless. Public health concerns began to be confined strictly to things that would boost revenue: colonoscopies, mammograms, labs, vaccinations, bone density studies, etc. Things that have no revenue flow -- like mental health issues, opioid abuse, elder care -- well, who cares about that? Very soon, the hospitals began to merge into gigantic corporations and then they began to collude to control the health care costs in the community. Our health care systems in all our big cities are gigantic monopolies. This despite the fact that this kind of behaviour is illegal under federal statutes. And please note: this is why insurance costs are so enormously high in this country -- and getting higher every year. Obamacare did NOTHING to stop this; it actually in many ways has made it much easier to pull off.

Because of this situation and for many other reasons, I decided to make a change in my life a few years ago. I have now moved to a very small hospital in rural America. In my life now, the corporate board has now been replaced by a board elected by the taxpayers: they are truly leaders of the community and do everything in the spirit of what the people need and are counting on from their hospital. The hospital is led by an MD -- and there are administrators -- but they too are members of the community. There is an obvious care about the community and its needs. I have spoken to colleagues across the country this week -- some big hospitals have done nothing at all to prepare for the crisis. It is no surprise to me that people in all levels at my current hospital have gone to enormous lengths to make sure everyone here is ready to go. I feel like I have stepped back in time twenty years. It is a very good feeling.

In the big city, I had become very accustomed to going to important meetings in the hospitals -- all controlled by the business leadership now -- and no medical facts or issues being discussed at all. Anything medical is distilled down to number crunching, revenue cycles, and "profit centers." Never a word is said about medical facts, public health, impact on patients, or morality like it used to be -- at least most of the time. Anyone who voices dissent is ostracized, and finds themselves disinvited and even dismissed from employment.

So the Youtube video is old hat to me. The people in charge of these critical things in our world often look like Barbie and Ken. They are cool cucumbers. They know all about branding, deceptive advertising, maximizing revenue, hiding truths, sucking up. But when actually asked questions that are critical to the issue at hand -- they often know nothing. And because they know nothing, nothing gets done. I have seen it many times before and am sure I will see it again. I read commentary online that people were shocked by that DHS Chief's answers to questions. I am not shocked -- I am very accustomed to it. Please note: our entire corporate health care system at the local hospital level in the big cities is now under the control of people just like him. They are looking for every way they can to defuse this crisis with calming advertising, words, pleasantries, smiles, and soothing statements. I am sure that they are also looking for any way they can profit financially from it as well. All I can say is: Good Luck.

A case in point was the following interaction I was told about yesterday by an old student of mine who is now a fellow at a major medical center on the East Coast. I heard the same exact recollection of the story from someone else in the room.

This was a meeting with the upper administration of the hospital system and heads of departments and multiple physicians and nurses. It occurred between the CEO and a DOC who is older and near retirement and who is an infectious disease specialist. The discussion about the current crisis went something like this:

CEO: I am not sure that we need to be preparing like this – this is obviously overblown – and is really going to damage our budget projections. The HHS seems to think this is going to go away in the spring anyway.
DOC: Why in God's name would you want it to go away in the spring?
CEO: (chuckling) What the hell are you talking about? We all want this thing to go away as soon as possible.
DOC – Historically, when pandemics are spread by aerosol droplets, and are as infectious as this one seems to be, they may recede in the spring -- but then come back in the fall with horrific fury. Remember the last one -- the Spanish Flu? The first wave was nothing, but the second and third waves turned the planet into a funeral home.
CEO: Oh for God's sake – don't you get it? That will give us time to get a vaccine -- we will not need to worry about it in October.
DOC: A vaccine? you must be kidding. It is never a good idea to rush a vaccine. Remember the first polio vaccine was rushed to market. It did not work and actually harmed many children. Remember the swine flu vaccine in the 1970s? It was not properly tested. Very few died from the swine flu. Hundreds and thousands were maimed or killed by Guillain Barré Syndrome because of it. And I doubt that half of our population would be even willing to take it. You do not understand.

CEO: Oh I understand way more than you obviously do. There is already an antiviral -- we will have that as well.

DOC: Really? Again, not really fully tested. And have you looked at the cost? Even a conservative estimate at the dosing they are using it would be $5000 a day. What is that going to do to your budget projections when you have 100 people in here in the hospital on that drug? Do we even have enough in the country for a sudden mass need? I do not know.

And then CEO looked DOC in the eye and just moved on to something else.

And DOC found out later that he would no longer be welcome at any of these meetings.

Please know this: viruses are not Republicans, they are not Democrats. Viruses are not going to respond to advertising, sweet words, or revenue cycles. They are going to accomplish their mission, and that alone. There may be things we are able to do, but we will need all the medical wisdom in the world focusing on our country as a whole and our local communities. That is just not happening to the extent it should be. We are going to fight this one with business school principles.

I again pray all the time that this virus will burn out -- that it will stop, that it will not get worse. I pray that God will have mercy and allow this to be a close call. But I am afraid that we have let our society crumble in so many ways –not just medicine -- that it is going to take a punch in the face to get our attention. This coronavirus may very well be the brass knuckles.

A follow-up e-mail from him:

This has been one of the most harrowing weeks in my career. The patients are really wigged out. Multiple times this week, I have seen patients with a cough or fever -- and we cannot ID a pathogen. That has caused a constant boogeyman to be sitting on my shoulder: fear. I can see the fear in my staff's eyes, and then on Friday, a nurse suddenly after lunch developed a 101 fever and a bad cough -- again no pathogens. I have a feeling this is happening in many other places in this country.

We have no way to test these people. I can offer little if any hope. I am telling them to stay at home, and I can see the horror in their eyes. I am now at the same level of those physicians in Milano 700 years ago –

So when I get this kind of soul crushing fear in my life, I always call one of my elder family members. My parents and grandparents are all gone now. The only one left is my 92 year old Auntie Marina. She lived through hell in Greece during the Nazi occupation and immediately thereafter. She is an amazing woman. And this is what she said to me.

"My dear, I was there when your parents handed your life and everything you are over to God. I was right on the front row. He has been preparing you every day of your life since you were a baby for the duties that you must now perform. Be brave, and sturdy, and do everything in His name. He will surround you with courage -- and fear not, if he decides this is your time to go, you will be welcomed by all the saints and angels. But here in our house, we are going to be lifting you up in prayer, multiple times a day. And I am certain that your parents are looking down and are very very proud of you."

I am a member of my community and my church. I cannot leave my post -- and I would ask that you pray for me and my staff for the bravery to continue on. I know that is a lot of drama, but we are really having fear here on the front lines. I would ask that you keep all the health care workers in America in your prayers right now.

In further conversation, the doctor said that we should be thinking about a world in which a large number of health care workers can't come to work because they are in quarantine or sick with the virus. We are looking at this problem right now.

He also recommends that people follow the coronavirus Reddit, which he says is well-moderated, and a source of solid information: https://www.reddit.com/r/Coronavirus/

[Feb 21, 2020] Private Equity's War to Preserve Surprise Billing

Notable quotes:
"... If you want proof that private equity is predatory, you need go not further than its concerted efforts to extend and intensify the devastating practice of surprise billing. ..."
"... Physicians' groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want. ..."
"... This has made physicians' practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms . ..."
"... Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not operate like an ordinary marketplace. Physicians' practices in these specialties do not need to worry that they will lose patients because their prices are too high. ..."
"... It's not only patients that are victimized by unscrupulous physicians' groups. These doctors' groups are able to coerce health insurance companies into agreeing to pay them very high fees in order to have them in their networks. ..."
"... and it needs to be annual ..."
Feb 21, 2020 | www.nakedcapitalism.com

If you want proof that private equity is predatory, you need go not further than its concerted efforts to extend and intensify the devastating practice of surprise billing.

Bad enough that patients develop afflictions or have accidents that land them in the hospital. Recovering physically is hard enough. But to then have the stress and financial damage of large and unexpected bills, which are exercises in rent extraction, is the sort of thing that creates Madame DeFarges.

Private equity experts Eileen Appelbaum and Rosemary Batt did the sleuthing to document how private equity has greatly extended and profited from this abuse. What most people do not realize is the degree to which hospitals have outsourced what most people would assume were core functions provided by doctors on the hospital's payroll, such as emergency room doctors. With many large nominally not-for-profit hospital groups run by MBAs out to justify higher pay packages for themselves, many practice areas are in fact outsourced. Private equity has hoovered up these groups. They, and not the hospital, provide the personnel for a particular case, and they make sure to get some out of network practitioners on the team to pad the bills.

One metric: a Stanford study determined that the odds of getting a surprise bill had increased from 32% in 2010 to 43% in 2016, and the average amount had risen over that time period from $220 to $628. A new study in Health Affairs found that this out of network billing raises health care costs by $40 billion per year .

Appelbaum gave a high-level overview in a op-ed in The Hill last May :

Physicians' groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want.

This has made physicians' practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms .

Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not operate like an ordinary marketplace. Physicians' practices in these specialties do not need to worry that they will lose patients because their prices are too high.

Patients can go to a hospital in their network, but if they have an emergency, have a baby in the neonatal intensive care unit or have surgery scheduled with an in-network surgeon, they are stuck with the out-of-network doctors the hospital has outsourced these services to .

It's not only patients that are victimized by unscrupulous physicians' groups. These doctors' groups are able to coerce health insurance companies into agreeing to pay them very high fees in order to have them in their networks.

They do this by threatening to charge high out-of-network bills to the insurers' covered patients if they don't go along with these demands. High payments to these unethical doctors raise hospitals' costs and everyone's insurance premiums.

Appelbaum cited Yale economists who'd examined what happened when hospitals outsourced their emergency room staffing to the two biggest players, EmCare, which has been traded among several private equity firms and is now owned by KKR and TeamHealth, held by Blackstone:

.after EmCare took over the management of emergency services at hospitals with previously low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In addition, the firm raised its charges by 96 percent relative to the charges billed by the physician groups they succeeded.

The study also described how TeamHealth extorted insurers by threatening them with high out-of-network charges for "must have" services:

in most instances, several months after going out-of-network, TeamHealth physicians rejoined the network and received in-network payment rates that were 68 percent higher than previous in-network rates.

California and the Federal government tried to pass legislation to curb surprise billing. As we noted, the California bill was yanked suddenly and no one felt compelled to offer an explanation. The bi-partisan Federal effort also failed.

Appelbaum and Batt, in a new article at CEPR, explain how private equity has been throwing money at astroturf group to keep its scam going :

Early in the summer of 2019, Congress appeared poised to protect consumers from surprise medical bills and to hold insured patients financially harmless in situations where they were unable to choose their doctor .

Two solutions, both of which take surprise charges to patients out of the equation, have been put forward. Employers, patient advocates, and insurance companies favor paying out-of-network doctors a rate "benchmarked" to rates negotiated with in-network doctors to hold down health costs. Not surprisingly, this solution is opposed by large physician staffing companies and specialist physician practices that want to continue to charge prices higher than the in-network fees. These doctors' practices, some backed by private equity firms, have been lobbying intensively for a second option that would allow doctors dissatisfied with a negotiated rate to seek a higher fee via an arbitration process that they believe will ensure higher physician pay and higher company revenues and profits.

The campaign by Physicians for Fair Coverage, a private equity-backed group lobbying on behalf of large physician staffing firms, launched a $1.2 million national ad campaign in July to push for this second approach.8 The lobbying campaign bore fruit. In July, [sponsors of the House bill] Pallone and Walden accepted an amendment to allow arbitration, but only in special cases, and it required the arbitrator to use negotiated rates instead of provider charges when deciding on disputes over payment.9 But the private equity-owned physician staffing companies were not satisfied. In late July, a mysterious group called Doctor Patient Unity launched a $28 million ad and lobbying campaign (now up to nearly $54 million) aimed at keeping any legislation to protect patients from surprise medical bills from passing. In mid-September, a representative for Doctor Patient Unity finally revealed what many observers already suspected -- that PE-owned doctor staffing firms Envision Healthcare and TeamHealth were behind the campaign

Agreement on a joint House and Senate bipartisan bill by Senators Alexander and Murray and Congressmen Pallone and Walden nearly made it into the omnibus continuing resolution that passed in December 2019. It was stymied when Massachusetts Congressman Richard Neal, Chair of the House Ways and Means Committee, offered a last-minute alternative. The Neal bill protects consumers from surprise medical bills but requires disputes between providers and insurance companies to be resolved through arbitration. This, of course, is what the PE-owned staffing firms and the doctors' practices they own lobbied for. Lack of support from the Democratic leadership in the Senate and the House delayed passage of the legislation. In his September 2019 fundraising report, Neal reported receipt of $29,000 from Blackstone, owner of TeamHealth.

The entire article is very much worth reading , since it offers more detail on how the private equity firms tightened their grip on these chokepoints. And the threat of legal curbs has had an impact. As the piece also explains, the value of the debt on Envision, the parent of EmCare, and TeamHealth both fell into junk terrain and rebounded a bit when the bills were sidelined for 2019, but remains distressed:

Appelbaum and Batt are pessimistic that anything will get done in 2020:

In the current legislative session, Congress is again working to pass legislation to protect patients from surprise medical bills. But the disagreements in Congress remain unresolved Chances of a compromise bill emerging in this session of Congress do not look good as of this writing (mid-February 2020), and relief for insured patients from unexpected medical bills does not appear to be on the horizon.

However, bond investors clearly think there's still a risk of legislation with some teeth, although the earliest possibility is 2021. Keep your fingers crossed.


jackiebass February 21, 2020 at 6:31 am

Where I live the emergency room doctors are contracted out to a private group. This has been the practice for over a decade. Recently the local hospital got rid of their dialysis services by selling it to a private company. When a person is sick they don't think about asking if the provider is in their network. They simply want treatment to help recover.Another problem is in many areas there isn't a choice. Expensive services can have only one or no providers. That means you have to go out of you area and probably your network. I'm on medicare and chose to be on traditional medicare. You aren't locked into a small network of providers. My supplemental is through my former employer. Unfortunately it's network plan. Occasionally I have services not paid because they are out of network, even though medicare covers 80%. The deductible for out of network is so high that I end up with paying the 20%. I believe there is only one reason for network heart care. It's to increase profits and has little to do with reducing costs.

Shiloh1 February 21, 2020 at 8:02 am

If Al Capone was around today he would be in this criminal enterprise.

Criminal prosecution is the solution. Not "single payer for racketeering" or "mob protection for all".

Best government money can buy.

human February 21, 2020 at 1:05 pm

Capone famously once answered a reporter that, "Capitalism is the legitimate racket of the ruling class."

flora February 21, 2020 at 4:11 pm

I was thinking of Al Capone and his almost untouchable Chicago 'enterprise'. He was untouchable in Chicago because his racket paid off the judges, prosecutors, aldermen, and politicians. It took the feds stepping in to shut Capone down.

How many more people will go bankrupt, or avoid going to the doctor or hospital for fear of bankruptcy because of this PE surprise billing racket? Several state leges are passing or trying to pass legislation to block surprise billing.

Thanks for this post.

hoonose February 21, 2020 at 9:51 am

I hope that you've been negotiating your out of network billings! A third or half off may not be unreasonable. Heck, the hospital only collects about 25% of its total billings!

flora February 21, 2020 at 4:24 pm

This is one reason we need traditional M4A. Traditional Medicare has payment limits that the provider has to accept if they bill Medicare. (Medicare fraud is a problem, but it is tracked and prosecuted.)

Note: Medicare Advantage plans do not have this surprise billing limits protection. see:
https://pnhp.org/news/kathleen-sebelius-and-bill-frist-digging-for-the-medicare-advantage-gold/

John Anthony La Pietra February 21, 2020 at 6:34 am

Maybe I'm missing something, but offhand I don't see how this can even be a thing under a single-payer health-care system. If someone knows better otherwise, please enlighten me.

If I've got that much right, could this be another part of the motivation against M4A?

human February 21, 2020 at 7:35 am

Of course it is. A single-payer system will have massive leverage to achieve fair pricing and compensation.

hoonose February 21, 2020 at 11:34 am

Of course providers are all worried that compensations will be too meager and oppressive. For instance if the docs' income expectations go unmet, then they will certainly buck!

Yves Smith Post author February 21, 2020 at 4:58 pm

But the "providers," as in the MDs, are not the beneficiaries, or at least not much. It's the companies that own the practices .which are owned by PE funds.

Cripes February 21, 2020 at 7:05 am

This reminds me of the TV ad running lately featuring a nice young couple opening their cable bill and declaring "Its a ransom note!" as if its the height of comedy that we are living in a kleptocracy where everyone is constantly subject to "your money or your life" banditry we pretend were left behind in central park muggings of the 1970s.

I have recently had multiple occasions that I needed to write on patient responsibility forms that out of network and balance billing is refused, followed with letters citing applicable state laws and CMS contracts barring conduct in my state. It's insane.
Still I have stacks of collection notices I must beat back and win every time. They only need to win once to destroy someone. Have we no prisons?

The rapine and dispossession of late-stage American crapitalism (can we finally get to End Stage?) always exceeds our worst expectations.
Crime-infested swamp of a country.

Dare we hope a movement can coalesce and endure after a decent man in his waning years is thrust into an historical opportunity to move this train wreck from disaster?

He's the community organizer Obama never was and the new dealer FDR never quite was.

In the flatness of our current political terrain, Bernie's grandfatherly menscheism makes him a moral colossus next to the sniveling careerists and the nefarious old crassus.

1776, 1860, 1932, 1968. What will we make of this year?

On to Milwaukee

John Anthony La Pietra February 21, 2020 at 7:29 am

Can you put the rebuttal into your own easily reproducible form? Either a neat page to staple thoroughly to the bills (copied/printed in needed quantities) or a big rubber stamp with blanks to fill in if applicable?

Yves Smith Post author February 21, 2020 at 5:01 pm

Yes, if you can provide it, I would make it a post. Your version with your state's language and how to find similar language in other states. This is VERY important.

Note I have heard one reader say that their doctors said they wouldn't schedule the surgery if she made an issue out of out of network MDs, that she needed to go elsewhere. So those doctors were completely on board with this practice.

DHG February 21, 2020 at 7:22 am

Anyone who has not made themselves judgment proof really is the fool. No assets, nothing for them to get.

floyd February 21, 2020 at 8:23 am

Disagree -as Chris Hedges says, those people have value as prisoners where they can generate $40K+/yr for some private prison.

flora February 21, 2020 at 5:35 pm

Yep.

"You wouldn't think you'd go to jail over medical bills": County in rural Kansas is jailing people over unpaid medical debt

https://www.cbsnews.com/news/coffeyville-kansas-medical-debt-county-in-rural-kansas-is-jailing-people-over-unpaid-medical-debt/

fnx February 21, 2020 at 1:48 pm

Doesn't mean that can't get a judgment against you! Then you spend the rest of your life trying to avoid having people send money via Paypal or other services direct to your bank account since they can take it. Or winning the lottery or buying a new car the list is endless.

TG February 21, 2020 at 12:14 pm

I am currently visiting some old colleagues in Denmark. I told them about the new practice in the United States of "surprise medical billing."

They were shocked. "Sure that's something Trump would do, but surely the Democrats would stop it?"

Hahahaha.

Susan the other February 21, 2020 at 12:48 pm

As in "Privatize Sovereignty, Socialize Property" by David Cieplay, Blackstone and its ilk have this very business model. In this case they are buying up emergency room doctors' practices – with the promise they will make more money – and passing the cost on to insurance companies (poetic justice) and the state and federal gov. Because we have no laws against this sort of corporate privateering (heaven forbid congress should suddenly remember how and why to legislate), all the costs of health care are socialized and because the PE funds are untouchable they have effectively privatized sovereignty. When we all realize their useful function in this scam is one big nothing burger, congress will have to act. It's just another testament to how venal, immoral, lazy and rotten congress is. I can smell it from here.

Howard February 21, 2020 at 1:37 pm

Besides PE, it also makes sense that the real estate sector in general would be opposed to anything that reduces financial burden (particularly anything that would lessen medical debt) on middle- and lower-middle-income households, because foreclosures and desperation fire sales would then dry up.

TimH February 21, 2020 at 1:59 pm

Here's the California situation, from https://www.dmhc.ca.gov/Portals/0/HealthCareInCalifornia/FactSheets/fsab72.pdf

The law protects consumers from surprise medical bills when:
An enrollee goes to an in-network facility such as a hospital, lab or imaging center, but services are provided by an out-of-network health provider.

An enrollee receives emergency services from a doctor or hospital that is not contracted with the patient's health plan or medical group.

JCC February 21, 2020 at 4:13 pm

Yet another anecdote

I've been a relatively healthy individual and so rarely use my insurance. I used it for the first time in 20 years for a full yearly physical (just because it was "that time", not for any health problems). The annual full checkup is, supposedly, fully covered, and I chose a local clinic in my network.

The various clinics involved ended up billing me directly, so far, for over $3500.00, and that was before the colonoscopy bill which still hasn't arrived. I checked my Insurance Portal and, sure enough, the supposed covered charges were listed as "Denied".

So, considering all these costs were supposed to be covered, I took a full day off work (6 solid hours on various phone calls) to get it straightened out. While going through all these bills and working through each charge I discovered 1 bill for a clinic appt (a subsidiary of CVS) that never happened and 1 very high bill for standard blood tests (Quest) that never happened due to a screwup initiated by the CVS-owned clinic. We'll see what happens.

But while talking with one of the Insurance Co. reps she told me a classic surprise billing horror story that happened to her. She gets occasional nosebleeds and one day got a serious one while on the highway before her exit. A CHP officer pulled up behind her after she pulled over to take care of the situation and refused to let her continue on without going to the nearest Emergency Room, so she went.

Her visit lasted 1/2 hour. She was handed a bucket of clean water and a towel. After cleaning up, she waited around for awhile, gave up waiting, washed the towel out, cleaned the bucket out and left. She went on to tell me that 30 days later she recieved a bill from the Emergency Services group at the hospital for $45,000.00. For a towel and a bucket of water.

It took her two days of unpaid time off to get it straightened out and the bill removed.

She then told me she's voting for Sanders, too.

So I've learned three lessons from this; 1) even with insurance things go wrong far too often when it comes to billing issues, and 2) Surprise Billing is far more common than I was led to believe, and 3) Health Insurance/care in this country is riddled with fraud and outright criminality.

Yves Smith Post author February 21, 2020 at 5:07 pm

Hate to tell you, but with a colonoscopy, the exam is covered by Obamacare, but any snipping of polyps is not, and that can easily run to $1000.

The US Is the only advanced economy where colonoscopies are recommended for everyone over 50. In other countries, they are recommended only for people in high risk groups.

If you get an annual ( and it needs to be annual ) fecal occult blood test (easy and cheap, MD puts gloved finger in you, wipes test panel, and tells you right there), the results in terms of detection are on par with colonoscopies.

[Feb 19, 2020] Suprise Billing To Be Resolved in February 2020 to be Enacted in 2022 by run75441

Feb 18, 2020 | angrybearblog.com

Suprise Billing To Be Resolved in February 2020 to be Enacted in 2022

run75441 | February 18, 2020 11:40 am

Healthcare I had wondered why the Senate (Schumer) had backed off on legislation controlling surprise billing. It turns out there is a House bill also and I am sure they are going back and forth on this. Recently, two bills have emerged in the House and one from the Senate. Medscape , "House Committees Advance Bills to Address Surprise Billing."

Of course if Congress's butt was on the line, a solution would have been found quickly and enacted in 2020. At the end, see which one I would back.

The House Ways and Means Committee bill passed by a voice vote bipartisan bill. It seeks to establish more use of third-party negotiators ( arbitration) for settling certain disputes about payment for out-of-network care. This bill has the support of the American Hospital Association and the American College of Emergency Physicians. The American Medical Association also praised the committee's reliance on mediation for disputes on bills.

The House Education and Labor Committee advanced a hybrid proposal seeking to use established prices in local markets to resolve many disputes about out-of-network bills. Key to this bill is the use of arbitration above a certain cost. Bills greater than $750 or in the case of air ambulance services $25,000; clinicians and insurers could turn to arbitration for an independent dispute resolution. House Education and Labor passed this bill in a 32-13 mixed vote with some Republicans and Democrats opposing and in favor.

The latest Senate Health, Education, Labor and Pensions (HELP) Committee of legislative proposals also addresses surprise medical billing. The HELP bill called for mandating that insurers reimburse out-of-network costs on the basis of their own median rates for in-network providers.

The Education and Labor Committee bill is estimated to save $24 billion, the Senate HELPS bill is estimated to save $25 billion, and the Ways and Means' bill would save almost $18 billion all over 10 years. It is suggested the greater use of arbitration in the Ways and Means' bill will result in less savings.

Read on about the private equity involved and providers.

Outside Opponents of Legislation

The American Hospital Association : "Setting a rate in statute gives insurers few incentives to develop robust networks with hospitals and physicians, and paying for emergency care at the median in-network rate would surely underpay for these services and create an incentive for insurers to avoid paying fair reimbursement for these services. This approach is an obvious windfall for the insurance industry without any assurance that health plans will pass these savings on to consumers through lower premiums."

Other physician organizations have joined the fight to make balance billing appropriate; the American College of Emergency Physicians, Envision Healthcare, US Acute Care Solutions and US Anesthesia Partners -- gave roughly $1.1 million in 2019 to members of Congress, according to a Kaiser Health News analysis of Federal Election Commission records.

Doctor Patient Unity : "We support a federal solution to surprise medical bills that makes insurance companies pay their fair share and supports patients' right to quality medical care."
"We oppose insurance-industry-backed proposals for government rate setting that will lead to doctor shortages, hospital closures and loss of access to medical care, particularly in rural and underserved communities."

Early on in 2019, Doctor Patient Unity spent more than $28 million on ads opposing legislation without disclosing its staff or its funders. It was later revealed its largest financial backers are two private equity backed firms Team Health and Envision Healthcare. Together they own physician practices and staff emergency rooms around the country according to spokesperson Greg Blair. Blackstone Group owns Team Health and KKR owns Envision Healthcare

As is typical of political ads being run to influence people, they do not tell the whole story and omit references to surprise bills. Instead, they warn of "government rate setting" harming patient care and doctor/patient relationships.

The Direct Providers

ER doctors, anesthesiologists, radiologists and other specialists who typically charge out-of-network prices are among the highest-compensated practitioners. I have found this to be true during my hospital visits. Doctors, 3rd party contracting companies, and hospitals complain Healthcare Insurance Companies have the upper hand due to size and can pay the increased costs of out-of-network pricing.

The argument by doctors, the 3rd party contracting companies, and hospitals has been made the healthcare insurance companies control the market and are able to secure better pricing from providers which is not passed along to the insured. In markets where both providers and insurers are highly concentrated, insurers have bargaining power to reduce prices for hospital admissions and visits to certain physician specialists. The Market Concentration chart for insurers and providers reveals the concentration (concentration chart) for providers is greater than it is for insurers overall. Furthermore and if we are talking about ACA policies, additional moneys gained must be used for treatment or the excess beyond 15 and 20% overhead and profit is refundable. It can be said also, when the total cost goes up, the portion (15 or 20%) of the total price increases in real dollars.

ER doctors, anesthesiologists, radiologists and other specialists who typically charge out-of-network prices are among the highest-compensated practitioners. I have found this to be true during my hospital visits. If the insurance company can not convince them to take a lesser rate, you are stuck will the bill. I have been tempted to ask at the time of need whether they are all in network and employees of the facility I am visiting that day. Countering the argument by insurance, doctors, and hospitals complain healthcare insurance companies have the upper hand due to size and market control and can pay the increased costs of out-of-network pricing. As shown chart 1, their claims are not precisely true and the market for healthcare has become less competitive as hospitals and ACOs buy up the competition.

"Providers are more concentrated than insurers in almost 60 percent of US metro areas . Health plans hold an edge in only 6 percent of local markets. National and state level studies reveal a steady rise in concentration among specialist physicians, primary care providers, and hospitals alike. As Brent D. Fulton notes, concentration of insurers fell slightly from 2010 to 2016, while concentration rose for both specialist physicians and hospitals. The evidence suggests provider organizations will retain significant bargaining leverage even after out-of-network billing reform, leaving little scope or incentive or capability for insurers to push prices down sharply. "

Meanwhile, the naysayers are battling constructive resolution with $millions in countering ads and intense lobbying of Congress to delay and/or deny resolution of overpriced surprised billing of patients of which had no choice, many more are still being hit with bills there is little explanation for except greed. We do need Single Payer. Nough said . . .

Congress has till February 22nd to resolve the deadlock before the current temporary bill expires. I would take the Education and Labor approach, which is also backed by the House Energy and Commerce Committee, and the Senate Health Committee. It would set the payment rate based on the median amount paid for that service in the geographic area with the option of going to arbitration for some higher-cost bills. It result in greater savings.

steve , February 18, 2020 5:25 pm

We (anesthesiology) are par with everything that our network accepts. I am not a fan of surprise billing, but I dont think you grasp all of the issues here. Medicare reimburses at much lower rates than does private insurance in my specialty. If you work in a place with a high percentage of Medicare (or Medicaid which is worse) like we do, you cannot come close to earning market salaries. So we, many years ago, ended up working 95th percentile or worse hours (over 70 per week) while earning in the 15th-20th percentile in income. We lost a lot of staff. The hospital had to make up the difference so that we could hire and retain people. We were fortunate that our hospital had the resources to do that.

Up north of us another hospital faced a similar situation, but they didn't have the resources to subsidize their staff. So they fired a good team and brought in another. Told them it was OK to not bill in accordance with what the hospital accepted, like the prior group did. That let the new group earn enough, for a while, to hire and retain people. Hospital eventually failed anyway and had to be bought out.

I think most of the groups that I know are surprise billing are pretty greedy and sleazy, so I stay away from them. However, there are other cases where groups are in a tough situation and pretty desperate. Especially smaller rural hospitals that have trouble finding staff to begin with.

Steve

[Feb 16, 2020] Doctor Surprise Billing: this is the same price inflation dynamic that we observe in body shops and car insurance companies. Kind of evil symbiosis that develops

Feb 16, 2020 | angrybearblog.com

likbez , February 16, 2020 11:48 am

run75441,

Thank you for this post. This is an important topic that needs to be discussed.

Again Dr. ZDogg: "Guess what's going to happen to her insurance premiums next year? They're going to go up by 10%, 15%, 20 percent. And what will happen at employers around the country who are paying most of the bill? They're going to drop or keep wages flat (happening today). Healthcare becomes a financial albatross with collusion between healthcare providers charging a bunch of money and insurance companies paying it, hospitals overbuilding, overcharging, and doing stuff we don't even need. The results of these money games are a minority of people getting rich and everybody else's wages staying stagnant. 1 in 5 Americans have collection agencies coming after them for medical bills that are inflated and unnecessary.

BTW this is the same price inflation dynamic that we observe in body shops and car insurance companies. Kind of evil symbiosis that develops. So this is a more general phenomenon than just healthcare.

See also: https://www.nakedcapitalism.com/2020/02/what-the-heck-happened-to-surprise-billing-legislation-or-its-never-too-late-for-the-lobbyists-to-win.html

[Feb 15, 2020] Doctor Surprise Billing

Highly recommended!
This is the same spiral of cost inflation that we observe in dealing with repair shops and car insurance companies. They form symbiosis that prosper by mutual inflation of costs.
Notable quotes:
"... The Insurance company must apply 80% of healthcare insurance premiums to actual care. and 20% to Overhead and Profit. Dr. ZDogg states most of the tests were not needed such as a Pan-Viral test when a rapid-strep swab would do. Dr. ZDogg contends this was a virus and the most one should do is the swab the throat or just wait to see what develops . . . this sounds familiar to me as a patient too. ..."
"... The hypothetical? Lets say at the most, what was done should be about $1000 or $800 to actual care and $200 to Overhead and Profit. Multiple this by 26 and see what it amounts to. In Dr. ZDogg's words: "What if we make the pie bigger and 3% of a bigger pie is more money? What if we actually let people overcharge for procedures they don't need? Then all we have to do next year is raise the premiums to cover the actual medical cost, which is now higher, and then we make a higher amount of profit." That was the untoward side effect of the government policy on this, which, by the way, happens with many policies that are top-down. You can't predict what happens and then it happens. " ..."
Feb 15, 2020 | angrybearblog.com

Going to her PCP located in Manhattan, a woman complains of a sore throat. Forget the Manhattan part of this as various versions (surprise billing) of this situation are happening everywhere. The doctor swabbed the throat, sent it off to the lab, ordered some tests, and then gave her a prescription for antibiotics. She took her meds and went on vacation feeling better.

The tests came back negative. She later received a bill for ~$26,000.

The lab was out of network which usually results with insurance only paying a portion of the bill and the patient the balance unless the insurance negotiates a lesser charge (hospital 3rd party employees) which they will pay. This is another version of Surprise Billing, not in a hospital setting, which we have heard so much about, and the patient gets screwed with the balance of the Surprise Billing.

More Information

The lab was out of network but it was a part of the employer the PCP worked for also. Usually doctors use the hospital they are affiliated with to run tests or do lab work which are also in network (today). I suspect more hospitals will relegate lab work to 3rd parties to cut costs and improve profits.

There was a time when I had catastrophic insurance which only paid 50% of costs. I had pneumonia and really could not afford to go to my PCP at $150 (then) as I was out of work. My PCP was not sympathetic and wrote me script to take to the hospital for imaging and another test. I called the U 0f M hospital and talked to a clerk there about cost. He finally told me to go to Quest (outside lab) and they would be half the cost in doing imaging, etc. U of M has some major Overhead to pay for today.

By the way, Blue Cross Blue Shield paid almost all of the bill for this lady with the sore throat.

Even More Information and a Hypothetical

The Insurance company must apply 80% of healthcare insurance premiums to actual care. and 20% to Overhead and Profit. Dr. ZDogg states most of the tests were not needed such as a Pan-Viral test when a rapid-strep swab would do. Dr. ZDogg contends this was a virus and the most one should do is the swab the throat or just wait to see what develops . . . this sounds familiar to me as a patient too.

The hypothetical? Lets say at the most, what was done should be about $1000 or $800 to actual care and $200 to Overhead and Profit. Multiple this by 26 and see what it amounts to. In Dr. ZDogg's words: "What if we make the pie bigger and 3% of a bigger pie is more money? What if we actually let people overcharge for procedures they don't need? Then all we have to do next year is raise the premiums to cover the actual medical cost, which is now higher, and then we make a higher amount of profit." That was the untoward side effect of the government policy on this, which, by the way, happens with many policies that are top-down. You can't predict what happens and then it happens. "

I would like to think doctors, hospitals, and healthcare insurance companies are not prone to this. Yet we have record of numerous surprise billing instances by hospitals, this one is an example of one by a doctor. Medicare Advantage plans are over billing CMS for treatments running totals up to $10 billion per year. And what about Commercial Healthcare Insurance? I have not heard of insurance pushing back on over charges. Usually, they reject a bill or a portion of it and the patient pays the balance.

And what Happens as a Result?

Again Dr. ZDogg: "Guess what's going to happen to her insurance premiums next year? They're going to go up by 10%, 15%, 20 percent. And what will happen at employers around the country who are paying most of the bill? They're going to drop or keep wages flat (happening today). Healthcare becomes a financial albatross with collusion between healthcare providers charging a bunch of money and insurance companies paying it, hospitals overbuilding, overcharging, and doing stuff we don't even need. The results of these money games are a minority of people getting rich and everybody else's wages staying stagnant. 1 in 5 Americans have collection agencies coming after them for medical bills that are inflated and unnecessary.

Dr. ZDogg recommended exposure to sunlight might cure the problem.

The patient; "I made it very clear [to the doctor's office] that I was unhappy about it." And told them I would report the doctor to New York state's Office of Professional Medical Conduct. She also reached out to "Bill of the Month," a joint project of NPR and Kaiser Health News. After a reporter started asking questions about the bill, Blue Cross and Blue Shield of Minnesota stopped payment on the check it issued and is now investigating.

The bottom line to this is, it should have never got this far or even happen.

Recently it was disclosed Michigan No Fault Accident Coverage was paying an ~289% of Medicare rates to hospitals and clinics to care for patient injuries suffered from automobile accidents. No Fault coverage will die in a few years as the new legislation sponsored by Quicken Loans Dan Gilbert and Michigan Repubs have allowed people to opt out or take lesser coverage which will now pay hospitals and clinics 220% of Medicare rates. No Fault would not disclose what it was paying caregivers. Another surprise which should have never happened . . .

This story is from December 2019 and was in NPR For Her Head Cold , Insurer Coughed Up $25,865, NPR, Richard Harris.

Paperwork: Manhattan Specialty Care
$26,000 for a Throat Swab?! , ZDoggMD, MedPage Today, February 6, 2020
The Doctors Who Bill You While You're Unconscious , The Atlantic, Olga Khazan, February 11, 2020


Chris, February 14, 2020 1:19 pm

The solution is to have one network and a single payer. Simple.

run75441 , February 14, 2020 7:49 pm

Chris:

You remind of someone else who insists it is that simple. It is not unless you have 60% of Congress inline. And if you do make the change, look forward to much of the Senate and the House being replaced as the population likes their Employer sponsored commercial healthcare insurance in spite of being screwed over by commercial healthcare, healthcare, and the pols who kiss the industries butt. What you and others are insisting on as being so simple is not so simple to enact.

davebarnes , February 14, 2020 1:39 pm

I have Kaiser Medicare Advantage and am happy.
Colon cancer fix cost me $2500 for surgery + chemo.
Perianal abscess cost me $300. Three surgeries.

EMichael , February 14, 2020 2:49 pm

Chris,

The solution is indeed simple. Getting to the solution is a huge task.

Meanwhile, It would be very simple legislation to stop this criminal treatment by providers. Person has insurance and is treated by someone out of network without giving specific orders to go out of network, is only liable for the in network charges.

Hard to vote against that, but we all know how many will, and who they are.

[Jan 14, 2020] I also think that if I call 911 and need emergency assistance, it should be provided by the city or county, not a private company

Jan 14, 2020 | angrybearblog.com

Angry Bear " Preventing Surprise Medical Bills ,

Mike B. , January 13, 2020 10:15 am

The only surprise medical bills I have received is for claims that were denied by my insurance company. Then the provider does not just demand what they would have received if the claim had been approved, but the full billed amount, which is generally 2 to 10 times the insurance amount. Providers should have to charge everyone the same price for the same thing. Now they have an incentive to order dubious tests or procedures, because if a claim is denied, they can bill for more money. I assume people without insurance are also billed for the full amount, and they can least afford it.

I also think that if I call 911 and need emergency assistance, it should be provided by the city or county, not a private company. That's true if police or fire engines are needed, and likewise it should be for EMTs or ambulances.

[Jan 12, 2020] "High-Deductible Plans Jeopardize Financial Health Of Patients And Rural Hospitals"

Jan 12, 2020 | khn.org

"Plans with annual deductibles of $3,000, $5,000 or even $10,000 have become commonplace since the implementation of the Affordable Care Act as insurers look for ways to keep monthly premiums to a minimum.

But in rural areas, where high-deductible plans are even more prevalent and incomes tend to be lower than in urban areas, patients often struggle to pay those deductibles.

That has hit patients like Flowers hard as they grapple with medical debt when emergencies happen -- but small rural hospitals like Lincoln Community are suffering, too. These facilities often stabilize critically ill patients and then transfer them to larger regional or urban hospitals for more definitive care. But when the hospitals submit their claims, bills from the first site of care generally get applied to a patient's deductible.

And if patients can't afford to cover that amount, those hospitals often don't get paid, even as the larger urban hospitals where patients were transferred get close to full payment from the health plan. 'As soon as we send them to the city, those things start being paid by the insurance company,' said Kevin Stansbury, CEO of Lincoln Community, 'while we're still chasing the patient around for collections.'"

[Jan 12, 2020] Preventing Surprise Medical Bills by run75441

Notable quotes:
"... If you are on Medicare, do not stay for observation unless you have a Plan G or Plan F. If you are on Plan N Supplemental to Medicare or lower, the plan will NOT pay 100% for Observation. You have to be admitted. You can go anywhere with Medicare for treatment. ..."
"... Medicare Advantage? You had better be in network or have some type of alternative program within your plan. ..."
Jan 11, 2020 | angrybearblog.com

The idea I have is not to be surprised. I am a careful patient who asks a lot of questions and also advocate for myself. I have refused treatment when they use drugs which may threaten my health further (Heparin). I am also not well liked by the bloodsuckers who come in to draw blood and stab me through the vein for two weeks and destroyed my left arm in the process. Ask them questions and do not be so willing to accept treatment (if cognizant) until they answer your questions and then get their name. Take names and dates. It is ok to be a forceful advocate for yourself. When all is said and done, the bill will come to you alone.

If you are on Medicare, do not stay for observation unless you have a Plan G or Plan F. If you are on Plan N Supplemental to Medicare or lower, the plan will NOT pay 100% for Observation. You have to be admitted. You can go anywhere with Medicare for treatment.

Medicare Advantage? You had better be in network or have some type of alternative program within your plan.

There are good points to this article which is why I C and P-ed it here per their request.

As taken from Preventing Debt from Surprise Medical Bills , Bankrate, Madison Blancaflor. July 19, 2019

The cost of healthcare has become a hot topic in American politics in recent years, and with good reason. A recent survey found that 22 percent of Americans are losing sleep over healthcare or insurance costs, up from 13 percent just one year ago.

One aspect in particular has even gained attention from both Congress and the President within the past two months: surprise medical bills.

Congress has proposed bi-partisan legislation that sets up consumer protections against surprise billing in certain situations. President Trump also issued an executive order in June that calls for hospitals to be more transparent upfront about prices for common tests and procedures, a measure that should go into effect later this year. ( While the House took out the 10 year exclusivities for Biologic drugs, it ended up in the Budget bill giving exclusivity for 12 years on new biologics. As I have pointed out repeatedly, risk adjusted R & D costs are recouped in a median period of 3- 5 years. It is another give-away to pharma. )

Past the leap, causes and prevention of Surprise Billing.

The cause of surprise billing

Unexpected medical bills, often outrageously expensive, can catch patients by surprise if they see a doctor who is not within their insurance network. It's a common issue, with the Wall Street Journal reporting that an estimated 51 percent of ambulance rides, 22 percent of ER visits and 9 percent of elective cases lead to surprise medical costs.

What often happens is that while the hospital or clinic might be considered in-network, a specific doctor might not be in-network (or vise versa). The legislation proposed by the Senate includes cost protections for situations such as these, plus scenarios where patients receive emergency care or follow-up care at an out-of-network facility due to travel restrictions.

While the new legislation and executive action may help patients and their families, surprise billing will persist in situations outside the purview of these new protections. ( The proposed prevention of surprise billing did not make it through the Senate this time for reasons I am not aware of today. More later .)

Preventing surprise healthcare bills

The best way to combat surprise billing is to prevent it whenever possible. This requires staying up-to-date on your insurance policies and looking at your options when scheduling appointments.

Know the details of your insurance policy

The first step is understanding your specific insurance policy. Check with your provider for a list of in-network hospitals, specialists and primary care physicians in your area so you can know ahead of time where you'll have coverage. If you have an upcoming appointment, it's worth calling your provider to double-check whether the facility and doctor you're seeing are in-network and covered.

Your provider may also require prior authorization before an appointment in order to cover some healthcare services or prescriptions, especially when visiting specialists.

Ask about costs upfront

Whether you're visiting a new primary care physician, seeing a specialist or have a planned procedure coming up, call ahead to see what out-of-pocket costs you will be responsible for paying. If you find that the facility or physician is out-of-network, you can request a referral to a facility or physician that is in-network.

For planned visits, you can also ask about the billing codes for the tests or procedures you'll be having so that you can confirm that your insurer will cover them. While many standard preventative procedures like a basic cardiac stress test or mammogram are covered by insurance policies, more advanced screenings such as a 3D mammogram may be billed under a different code that is not covered by your insurance.

Make an emergency plan

While it's impossible to predict when emergencies will happen, you can make a plan to help you prepare. If you know which emergency care providers are covered by your insurance plan, you can have an idea of where to go. While it requires some research on the front-end, you can save some stress and a lot of money in the long-run.

Understand your rights

In addition to new federal protections, many states have additional regulations regarding "balance billing," when patients are billed for out-of-network providers at an in-network facility. Don't be afraid to negotiate with hospital billing managers or doctors who billed you when you are balance billed, and keep your insurance company in the loop on the situation. Knowing your state's specific protections can help you get fees waived or lowered in these cases.

Combating debt from surprise medical bills

Unfortunately, it's impossible to entirely prevent surprise medical bills -- especially in the case of emergency services. In an emergency room, you have little to no control over which physicians you see and what tests are run. You also don't always have time to call ahead to check prices or request transfers to in-network facilities.

While it might not be possible to prevent some surprise healthcare costs, there are still steps you can take to combat debt in these cases.

1. Double check itemized medical bills.

Mistakes happen. Sometimes patients are billed for tests, procedures or medications that they didn't actually receive. Ask for an itemized bill, and ensure that you are only being charged for services received. If you find a mistake in your bill, talk to the hospital's billing department and the service provider.

In the case that a procedure or service on your bill should have been covered by your insurance provider, ask about the specific billing code the hospital used. It's possible that while the insurance provider covers a basic or general service, the billing code used may not fall under the billing code your insurance company lists as covered. Talk with both the hospital billing department and your insurance provider to see what can be done.

2. Avoid using credit cards whenever possible

Credit cards average around a 17 percent interest rate, meaning they are less-than-ideal for covering high medical costs . There are medical credit cards out there that offer short and long term financing plans to cover medical expenses with minimal interest, which is an option for those who can realistically pay off the debt within the specified time period.

When using a credit card is unavoidable, consider a credit card that offers a long intro period to help you save on interest charges, such as well known Platinum Visa Card might offer. If you end up with bills spread across multiple credit cards, a balance transfer credit card can also help you eliminate debt and save money on interest charges.

Just keep in mind that for all of these credit options, it's imperative that you can pay off the debt within the 0% interest offer period. Otherwise, you'll be subject to high interest rates that can cause even more financial stress.

For larger medical bills or debts, consider a personal loan (which offer lower, fixed interest rates) to help cover the cost.

3. Protect your credit score

If for any reason you are unable to pay your medical bills on time, it's important to take steps to protect your credit score. When you go more than 90-180 days without paying a medical debt, it could become an unpaid collection account, which can show up on your credit report and negatively affect your score. Luckily, newer credit score models such as the VantageScore 4.0 and FICO Score 9 often reduce the impact of these types of collection accounts.

If you know you'll be unable to pay medical bills, be open and honest with the hospital or provider. You might be able to set up a plan that better fits your budget. At the very least, you can explain the situation, pay as much as you can at the moment and potentially prevent them from writing off your debt as a loss and selling it to a collection agency.

4. Open a savings account for unplanned medical costs

While you can't predict unplanned medical costs, you can prepare for them by saving money for a rainy day. One option is contributing to a Healthcare Savings Account (HSA), which allows you to add pre-tax/tax-deductible money into a savings account that you can use for approved healthcare costs.

You can also set up a savings account with any bank to be used for healthcare costs. While these accounts may not be tax-exempt, you can often get a better interest rate and avoid regulations on what medical expenses you can and can't cover with the account.

Even if you only contribute $20 a month, it will add up over time and can help offset costs to make medical expenses more affordable.

The Bottom Line

While it's promising that both Congress and the President are making strides towards eliminating surprise medical bills and helping lower overall healthcare costs, sometimes surprise billing is unavoidable. These tips can help you prevent these charges or combat excessive debt that can often result from unplanned medical expenses.


davebarnes , January 11, 2020 9:28 pm

Kaiser Medicare Advantage.
Have NEVER has a strange nor bogus charge.

My colon cancer surgery + chemo was $2500 which I consider reasonable.
My 3 surgeries for a perianal abscess (trust me, you don't want one) was a few hundred bucks.

4.5 miles to the hospital/medical center/pharmacy.

run75441 , January 11, 2020 11:42 pm

That is nice. Your time will come when they will charge more for those operations. You are there forever and can not come back to Medicare. What do you think is happening with commercial healthcare today for a majority of the people who have commercial healthcare?

likbez , January 12, 2020 12:09 am

Great post on a very important in the USA topic. Thank you run75441!

I would add the danger of calling ambulance from home in non-critical cases. Taxi to the hospital is approx. 100 times cheaper and most cases is as effective :-).

In case the case is critical (like a real heart attack) be ready to pay out of network changes ($5K-$15K) for the ride in states that do not provide protection against surprise billing. Less then a half of the USA states some minimal (really minimal) protection against those sharks.

Ambulances in the USA are overtaken by private equity and venture capital firms.criminals. They are real Mafiosi. Or even worse because they profit of human sufferings. Private equity sharks circle around and if they smell blood they will devour the victim without any merci. I sometimes wonder why among around 40K of gun violence victims (39,773 in 2018) in the USA per year this category is so underrepresented 😉 .

The core of the problem is that ambulances and private insurance companies do not agree on a fair price, so the ambulance service doesn't join the insurance network. That leaves patients stuck in the middle with out-of-network charges..

See for example:

https://www.nbcnews.com/health/health-news/taken-ride-ambulances-stick-patients-surprise-bills-n824141

One patient got a $3,660 bill for a 4-mile ride. Another was charged $8,460 for a trip from one hospital that could not handle his case to another that could.

Still another found herself marooned at an out-of-network hospital, where she'd been taken by ambulance without her consent.

These patients all took ambulances in emergencies and got slammed with unexpected bills. Public outrage has erupted over surprise medical bills -- generally out-of-network charges that a patient did not expect or could not control -- prompting 21 states to pass laws protecting consumers in some situations.

But these laws largely ignore ground ambulance rides, which can leave patients stuck with hundreds or even thousands of dollars in bills, with few options for recourse, finds a Kaiser Health News review of 350 consumer complaints in 32 states.

Patients usually choose to go to the doctor, but they are vulnerable when they call 911 -- or get into an ambulance. The dispatcher picks the ambulance crew, which, in turn, often picks the hospital. Moreover, many ambulances are not summoned by patients. Instead, the crew arrives at the scene having heard about an accident on a scanner, or because police or a bystander called 911.

Betsy Imholz, special projects director at the Consumers Union, which has collected over 700 patient stories about surprise medical bills, said at least a quarter concern ambulances.

"It's a huge problem," she said.

[Dec 24, 2019] Congress refuses to ban surprise billing racket: "We've started to realize it's not us versus the hospitals or the doctors, it's us versus the hedge funds," said James Gelfand, senior vice president of health policy at ERIC, a group that represents large employers.

Dec 24, 2019 | www.nakedcapitalism.com

tegnost , December 23, 2019 at 8:49 am

As the days go by I become more convinced that the impeachment drama was used to cover up the passing of the usmca and axing of the venture capital in health care bill and containing surprise medical billing
https://khn.org/news/investors-deep-pocket-push-to-defend-surprise-medical-bills/
FTA
"We've started to realize it's not us versus the hospitals or the doctors, it's us versus the hedge funds," said James Gelfand, senior vice president of health policy at ERIC, a group that represents large employers.

Kayfabe

paddlingwithoutboats , December 23, 2019 at 9:14 am

From the KHN article on surprise billing
"surprise medical bills, which generally arise when an insured individual inadvertently receives care from an out-of-network provider."

How did "inadvertently" get in there when it is a revenue generation model? Asymmetry of information is always how profits are made.

I like to invert the model and estimate the outcomes for a lot of these fictions: if working class people controlled the upward distribution of wealth, how would society be different?

Joe Well , December 23, 2019 at 11:11 am

Yves has posted about how private equity firms specifically make this a business model.

[Dec 22, 2019] This neoliberal maggot Schumer managed to defeat 'suprise blling" legistlation

Notable quotes:
"... Where is AOC in all this? She was th e prime mover on impeachment, specifically impeachment over a phone call rather than concentration camps and genocide. And now with impeachment she gave Pelosi cover to sell the country out again. I was wondering why many libreral centrists were expreasing admiration for her, a socialist. Maybe they recognized something? ..."
Dec 22, 2019 | www.nakedcapitalism.com

flora , December 21, 2019 at 7:41 am

re:impeachment redux

Interesting, to me at least, that the rocket docket timetable of the House impeachment coincided with the deadline to pass a budget to avoid a(nother) govt shutdown. While all msm eyes were transfixed by the hyperventilating spectacle, behind the scenes the budget passed through the Dem House was filled with more tax breaks for the corporations and the .001%, more money than the admin asked for the MIC, and killed a bill that would end medical 'surprise billing' (another gift to medical PE investors and giant hospital corporations), basically a whole neolib wish list.

Interesting the two events coincided, and, that Nancy decided not to sent on the articles to the Senate at this time. What gives? Is she hold on to them for a future time when she'll need to use them as another distraction for the msm to report on? (no, that could not be the reason. ;) )

Spring Texan , December 21, 2019 at 9:44 am

Schumer and a top House Democrat with ties to private equity were instrumental in defeating the surprise medical bill legislation: https://www.commondreams.org/news/2019/12/20/schumer-revealed-key-industry-ally-defeat-effort-curb-surprise-billing
https://www.salon.com/2019/12/18/top-house-democrat-kills-effort-to-end-devastating-surprise-medical-bills/
https://slate.com/business/2019/12/surprise-medical-bills-legislation-congress-democrats.html

Pat , December 21, 2019 at 2:31 pm

Pointed this out a couple of days ago (Slate and Buzzfeed). Happy that it is not just the online press pointing out it was Democrats killing this measure, Democrats in leadership positions. I also like that few, if any, of our media is falling for the kabuki used by Neal to stick the shiv in. Everyone gets that the 'competing plan' was there strictly to derail a law that end the hugely profitable but fraudulent price gauging of healthcare by private equity.

If he keeps this up, walking POS Schumer might make me miss Al D'Amato nah Al and Chuck are just two different colors of tulle, adding illusion to the political process.

Carey , December 21, 2019 at 3:51 pm

..and they could have just passed it for the good PR and then de-fanged it
administratively, but it looks like they wanted to press the point:
"No, Proles, we're not gonna let you breathe, not a bit."

Good to know.

Joe Well , December 21, 2019 at 11:03 am

Where is AOC in all this? She was th e prime mover on impeachment, specifically impeachment over a phone call rather than concentration camps and genocide. And now with impeachment she gave Pelosi cover to sell the country out again. I was wondering why many libreral centrists were expreasing admiration for her, a socialist. Maybe they recognized something?

[Dec 08, 2019] Something to keep in Mind when you enroll in Medicare Advantage Plans

Dec 07, 2019 | angrybearblog.com
It is not a dirty or hidden little secret. Insurance companies offering MA plans do not tell you that once you are in their plan, you are there potentially forever.

Returning to traditional Medicare is ok but, getting a Medigap Plans to supplement the gap may lead to rejection or much higher premiums if you choose to come back and especially if their are pre-existing conditions.

The same as the Commercial MA companies, Medicare.gov websites are not always clear about the process of transferring out of MA to traditional Medicare and obtaining a Medigap plan.

Being unconditionally accepted by a Medigap plan is guaranteed only within the first 12 months after enrolling in Medicare at age 65.

In 2019, one-third (34%) of all Medicare beneficiaries, 22 million seniors were enrolled in Medicare Advantage (MA) plans.

As most know, Medicare consists of Part A, B, C, and D plans.

To cover the gaps in A & B and the gap, you buy supplemental insurance which is about the same as Part B in premium cost. Unless Medicare rules change, the most one can experience is changes in premiums.

In contrast, Part C or Medicare Advantage plans can cover a broad array of health services at a low cost. Unless one gets sick, the price for MA Plans can remain low. If one does gets sick, out-of-pocket costs can increase in later years . Once in an MA plan, getting out can result in less affordability. Medigap plans in all but four states can and do reject people or require higher premiums if you came back to them after Medicare Advantage Plans. Diabetes, heart disease, or even a knee replacement can be criteria for exclusion.

"After Mills underwent a mitral valve repair and suffered a mild stroke with no lasting effects, the San Diego resident's plan now charges him hundreds of dollars in monthly copays for drugs and other medical services. He had to pay $295 a night for his hospital stay.

But there was a much bigger shock. Mills, 71, learned that switching out of his MA plan he would incur exorbitantly higher costs the next time he needs a serious medical intervention. If he moves to traditional Medicare and a prescription plan, he will still need a supplemental Medigap plan to pick up his 20% copays and deductibles."

Again, this is something most people do not know, an should know before they make any move to Medicare Advantage plans. Furthermore, there are many MA plans which have narrow networks to which you must go to. In comparison, traditional Medicare pays where ever you go in the United States.

Comments (4)

davebarnes , December 7, 2019 1:25 pm

" if their are pre-existing conditions" really? perhaps if there are would be better

davebarnes , December 7, 2019 1:29 pm

All you wrote is true. But, I really like my Kaiser Advantage plan. My total cost for colon cancer (including surgery, chemo) was $2500. My total cost for a perianal abscess (3 surgeries) was $300.

run75441 , December 7, 2019 2:19 pm

My total cost for being in the hospital for 3.5 weeks and 4 doses of Rituxan was less than $1000 under Traditional Medicare and Plan N Supplemental. Medicare Advantage is problematic. Premiums can go up in Traditional but out of pocket is stable.

Carol , December 7, 2019 1:45 pm

@davebarnes i agree, but KP isn't available nationwide, and it is problematic getting the same coverage elsewhere

[Nov 26, 2019] Beware of the Medicare Disadvantage Corporate Trap Wake Up AARP by Ralph Nader

Nov 25, 2019 | chrisyeh96.github.io
While the Democratic presidential candidates are debating full Medicare for All, giant insurance companies like UnitedHealthcare are advertising to the elderly in an attempt to lure them from Traditional Medicare (TM) to the so-called Medicare Advantage (MA) – a corporate plan that UnitedHealthcare promotes to turn a profit at the expense of enrollees.

Almost one third of all elderly over 65 are enrolled in these numerous, complex MA policies the government pays so much for monthly. The health insurance industry wants more enrollees as they continue to press Congress for more advantages.

Medical Disadvantage would be a more accurate name for the programs, as insurance companies push to corporatize all of Medicare, yet keep the name for the purposes of marketing, deception, and confusion.

Elderly people enrolled in MA will experience its often merciless denials when they get sick. As hospital expert – attorney, physician, Dr. Fred Hyde put it: "It's not just what you pay, it's what you get."

Start with the cross-subsidy of MA from TM. In 2009, the Congressional Budget Office estimated these overpayments would cost the federal government $157 billion over the coming decade. Obama's Affordable Care Act started to reduce these subsidies to the giant insurers, but they still amount to many billions of dollars per year.

Add that with Medicare Disadvantage you are restricted to networks of vendors. That restricts your choice for competence and skills, and sometimes, requires you to travel longer distances for treatment. This could mean fewer enrollees will utilize their healthcare and more profits for the insurance companies.

Under Medicare Disadvantage you are subject to all kinds of differing plans, maddening trapdoor fine print, and unclear meaning to the insurers arguing no "medical necessity" when you're denied care.

The advertisements for Medicare Disadvantage stress that you can sometimes get perks – gym memberships, hearing aids, and eyeglasses, as enticements, but they avoid telling you they are not so ready to cover serious needs like skilled nursing care for critically ill patients.

Under Medicare Disadvantage, there is no Medigap coverage as there is for TM. Co-pays and deductibles can be large. Under a recent Humana Medicare Advantage Plan in Florida, your co-pay for an ambulance is up to $300, up to $100 co-pay for lab services, and another $100 for outpatient x-rays.

A few years ago, UnitedHealthcare corporations dismissed thousands of physicians from their MA networks, sometimes immediately, sometimes telling their patients before telling their physicians.

Dr. Arthur Vogelman, a gastroenterologist, said he received a termination letter in 2013 from UnitedHealthcare. He appealed, documenting his successful treatment of many patients. The company denied his appeal, with no reason, as it had for thousands of network physicians.

Dr. Vogelman called it "an outrage. I have patients in their 80s and 90s who have been with me 20 years, and I'm having to tell them that their insurer won't pay for them to see me anymore. The worst thing is I can't even tell them why." Except that the company wanted more profits.

After a lengthy protest by national and state medical societies in 2013, UnitedHealthcare began to be less aggressively dismissive.

Studies show the main reason MA enrollees return to TM is how badly the corporate insurers treated them when they became sick.

Medicare itself is getting overly complex. But nothing like the ever changing corporate rules, offerings, and restrictions of Medicare Disadvantage. How strange it is that AARP, with its Medigap insurance business run by UnitedHealthcare, doesn't advise its members to go with the obviously superior Traditional Medicare. AARP reportedly receives a commission of 4.95% for new enrollees on top of the premiums the elderly pay for the Medigap policy from United Healthcare. This money – about seven hundred million dollars a year – a significant portion of AARP's overall budget.

AARP responded to my inquiries into their Medicare Advantage policy saying that it does not recommend one plan over another, leaving it to the less informed consumer. That's one of AARP's biggest cop-outs -- they know the difference.

There is no space here to cover all the bewildering ins and outs of what corporations have done to so-called managed Medicare and managed Medicaid. That task is for full-time reporters. The government does estimate a staggering $60 billion in billing fraud annually just on Medicare – manipulating codes, phantom billing, etc. You need the equivalent of a college-level course just to start figuring out all the supposed offerings and gaps.

Suffice it to say that, in the words of Eleanor Laise, senior editor of Kiplinger's Retirement Report, "the evidence on health care access and quality decidedly favors original Medicare over Medicare Advantage, according to a Kaiser Family Foundation review of 40 studies published between 2000 and 2014."

All this anxiety, dread, and fear, all these arbitrary denials of care – prompted by a pay-or-die commercial profit motive – all these restrictions of what doctors or hospitals you can go to, do not exist in Canada. All Canadians have a Medicare card from birth; they have free choice of health care vendors. There are few American-style horror stories there; patients have better outcomes, and almost never even see a bill. The whole universal system costs half per capita of that in the U.S., where over 80 million people are uninsured or underinsured – still! (See singlepayeraction.org, for civic action to rid Americans of this perverse chaos). Join the debate on Facebook More articles by: Ralph Nader

Ralph Nader is a consumer advocate, lawyer and author of Only the Super-Rich Can Save Us!

[Nov 14, 2019] the Caribbean investment also illustrates how dramatically U.S. health care is changing. In its rapid-fire evolution, Ascension has become a leading example of a nonprofit health system that often acts like a for-profit, blurring the line between businesses and charities.

Nov 14, 2019 | www.nakedcapitalism.com

Krystyn Walentka , November 13, 2019 at 12:36 pm

Please look into Ascention healthcare if you want to know how completely effed up this whole situation is!

https://www.stltoday.com/business/local/how-a-st-louis-based-health-care-system-became-one/article_c07ada87-ab74-5175-a0b0-5219dd7b95f1.html

That dramatic growth culminates Tuesday with the grand opening in the Cayman Islands of the first phase of a $2 billion "health city" complex -- a project that seems far removed from the nonprofit health system's humble origins and its Catholic mission to serve the poor and vulnerable.

Ascension executives say they hope through this joint venture with a for-profit, India hospital chain to learn ways to reduce medical costs.

But the Caribbean investment also illustrates how dramatically U.S. health care is changing. In its rapid-fire evolution, Ascension has become a leading example of a nonprofit health system that often acts like a for-profit, blurring the line between businesses and charities. Its health ministry has drawn criticism for risk-taking and its ties to Wall Street. And some critics have raised questions about its tax-exempt status.

[Nov 09, 2019] The Managers' Coup d'Etat in Health Care Appears Complete - a Study of Top Health Care Influencers

Nov 09, 2019 | www.nakedcapitalism.com

The authors concluded that

perceived influence over US health care of chief executives of health systems is increasing. To the extent that the ranking validly reflects influence, the sharp rise in the influence of chief executive officers at the expense of representatives of patients or health professionals may underscore the increasing industrialization of health care. It is not possible to find patients, patient advocates, clinicians, or clinician advocates at the top of this list . This trend placing health care influencers within C-suites, accountable to boards mostly comprising other corporate leaders, may explain the rise of business language and thinking

They suggested that it is possible that there is a

causal association between the concentration of executive influence and problems of patient care derived from efforts to optimize operational efficiency and financial performance, for example, clinician burnout , the heavy burden of treatment afflicting patients with chronic conditions, and the erection of barriers to care to optimize 'payer mix.'

Dr Montori also said in the interview

Americans increasingly find themselves in a corporate-centric healthcare echo-chamber , one in which the public will increasingly approach tough policy decisions having heard only the viewpoint from the top.

'The primary goals of CEOs are to advance the mission of their organization,' Montori says. 'If all that influences healthcare are the ideas of people who advocate for the success of their organizations, people who are not served by them will not have their voices heard.'

Furthermore, he suggested that the public may be befuddled by the current health policy debates, including those about universal health care and the possibility of reducing the power of commercial health insurance companies because

in the rest of the narrative all that they hear is about are the successes of biotech, the successes of tech companies, and the successes of healthcare corporations who achieve high levels of innovation thanks to the bold leadership of their executives. It's why we have been calling for greater awareness of the industrialization of healthcare for some time now

Summary

The new study by Longman, Ponce, Alvarez-Villalobos and Montori adds to the evidence that health care has been taken over by business-trained managers, and in the US, especially by large commercial health care organizations run by such managers.

Since we started Health Care Renewal , we have frequently discussed the rise of generic managers, which later we realized has been called managerialism. Managerialism is the belief that trained managers are better leaders of health care, and every other sort of organization, than are than people familiar with the particulars of the organizations' work. Managerialism has become an ascendant value in health care over the last 30 years. The majority of hospital CEOs are now management trained, but lacking in experience and training in medicine, direct health care, biomedical science, or public health. And managerialism is now ascendant in the US government. Our president, and many of his top-level appointees, are former business managers without political experience or government experience.

We noted an important article in the June, 2015 issue of the Medical Journal of Australia(1) that made these points:

– businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
– this change was motivated by neoliberalism (also known as economism or market fundamentalism )
– managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
– managerialism makes short-term revenue the first priority of all organizations
– managerialism undermines the health care mission and the values of health care professionals

Generic or managerialist managers by definition do not know much about health care, or about biomedical science, medicine, or public health. They are prototypical ill-informed leadership , and hence may blunder into actual incompetence. They are trained that they have a right to lead any sort of organization, which breeds arrogance. These managers are not taught about the values of health care professionals. Worse, they are taught in their business style training about the shareholder value dogma, which states that the main objective of any organization is to increase revenue. Thus, they often end up hostile to the fundamental mission of health care, to put care of the patient and the health of the population ahead of all other concerns, which we have called mission-hostile management. (Furthermore, it appears that the shareholder value dogma is just smokescreen to cover the real goal of managers, increasing their own wealth, e.g., look here .) Finally, arrogance and worship of revenue allows self-interested and conflicted, and even sometimes corrupt leadership.

Managerialists may be convinced that they are working for the greater good. However, I am convinced that our health care system would be a lot less dysfunctional if it were led by people who actually know something about biomedical science, health care, and public health, and who understand and uphold the values of health care and public health professionals – even if that would cost a lot of very well paid managerialists their jobs.

Maybe someday the top "influencers" in health care will actually be people who know something about health care and actually care about patients' and the public's health.


1 Kings , November 9, 2019 at 4:51 am

'We've got to protect our phoney-baloney jobs, gentlemen.' William J. Le Petomane

James Miller , November 9, 2019 at 4:58 am

John Raulston Saul, in "Voltaire's Bastards", has produced an intellectual fireworks display that deals directly with the problem Dr.Poses sees pretty clearly. Endhoven proposes an attack on what he sees as a regressive medieval remnant, a Guild, an attack that has been pretty successful in a broad swath of our neoliberal world. Saul would recognize that attack immediately, and despise it. It's what he wrote about with such fiery contempt.. And in my opinion, he's right.

Managerialists, purveyors of "reason", are leaving a trail of disaster in pretty much every area where their influence is powerful. Their ivy league, MBA-dominated education seemingly has failed to provide any sense of the human feelings and needs that must be an essential part of successful planning or policy. The bottom line trumps all else, and generates disaster as well as shareholder value. Treat yourself, as well as tantalize your wits. Read it.

flora , November 9, 2019 at 5:20 am

Thanks for this post. Two quotes that sum up much of the overpriced disfunction, imo.

Managerialism is the belief that trained managers are better leaders of health care, and every other sort of organization, than are than people familiar with the particulars of the organizations' work.

Better leaders toward what goal?

– managerialism makes short-term revenue the first priority of all organizations

Brooklin Bridge , November 9, 2019 at 6:54 am

managerialism makes short-term revenue the first priority of all organizations

Except when it comes to manufacturing ideologies. There, they are quite capable of taking the long view with think tanks, generational influence (stacking) of the judical system, education, politics and policy and so on.* It's not as if they are unaware of the concept of laying foundations. But short term revenue seems to be tightly coupled in their view to what they get to put in their pockets which in turn (perhaps ironically by the foundation builders: self worth by comparative metrics) has been tightly coupled to their perceived worth as human beings.

(Ultimately, I believe, the phenomenon of comparative metrics literally projects the homeless -or in this case the paucity of care for whole segments of society- into existence and maintains their numbers in relation to those of the "managers.") Interestingly, the mix of origins, whether such seminal ideas ( "eat your vegetables, think of the starving Chineese" ) are vernacular and borrowed and repurposed or canonical and disseminated helps in no small part to obscure the process.

*Even if the managers are not always the drivers, they are aware of the value.

Synoia , November 9, 2019 at 6:12 am

When doctors graduate from medical school with $500,000 in debt, what is the primary lesson they have learned?

[Oct 27, 2019] It turns out that the real cost problem, all along, has been the other half of the spending equation: not the quantity of medical services rendered, but the prices paid by insurers for each unit of care provided

Oct 27, 2019 | www.nakedcapitalism.com

Health Care

"The Urban Institute's Single Payer Cost Estimate: False Assumptions False Conclusions" [David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H., PNHP ]. The Urban Institute study was instantly signal-boosted by CNN , the Hill , and The Atlantic , among others, and seems to have led to the "pay for" questions in the last debate, and Warren taking on the task -- not planned already? -- of writing a tax proposal for whatever she determines Medicare for All to actually be. "Administrative savings, Part 1: The UI report assumes that single-payer reform would reduce insurance overhead to 6% of claims ($234 billion) from the current level of about 10.6%. In contrast, overhead in Canada's single-payer system is only 1.8%, and overhead in the fee-for-service Medicare program is 2%. The UI group justifies its 6% estimate by claiming that a single payer system " would require a host of administrative functions to effectively operate, such as rate setting for many different providers and services of different types; quality control over care provision; development, review, and revision of regulations; provider oversight and standards enforcement; claims payments to providers; and other functions." UI's claim ignores the fact that all of these functions are currently carried out by both Canada's program and the fee-for-service Medicare program." • This is a brutal takedown of the Urban Institute study, which you should read in full.

"What the Health Care Debate Still Gets Wrong" [Adam Gaffney, The Boston Review ]. "[T]his entire edifice of reform [ObamaCare ACOs] was built on sand. Quite simply, as a nation, we actually do not use too much health care; if anything, we use fewer services than people in other high-income countries. While 'overutilization' may indeed be a major problem in some areas (and who wants an unnecessary slice from a scalpel?), it cannot, simply as a matter of basic accounting, explain our total off-the-charts spending. In particular, it cannot account for the fact that we spend more than $10,000 per capita on health care -- approximately double that of Canada -- nor for the nearly six-fold rise in inflation-adjusted healthcare spending from 1970 to 2017, according to estimates from the Kaiser Family Foundation. The real cost problem, all along, has been the other half of the spending equation: not the quantity of medical services rendered, but the prices paid by insurers for each unit of care provided. So what can? It turns out that the real cost problem, all along, has been the other half of the spending equation: not the quantity of medical services rendered, but the prices paid by insurers for each unit of care provided. This simple but crucial insight is most frequently attributed to the legendary health economist Uwe Reinhardt."

"A New Generation of Activist Doctors Is Fighting for Medicare for All" [ Time ]. "[Travis Singleton, executive vice president of Merritt-Hawkins], whose firm conducts a biennial survey of doctors' opinions, says that while there are myriad reasons for an uptick in political involvement, one of the most compelling is simple: doctors see the dysfunction of the health care system on a daily basis. As health care costs ballooned and the private insurance industry expanded, the job of being a doctor changed. Instead of just treating patients, doctors today must battle with insurance requirements, manage arcane reimbursement systems and juggle enormous administrative costs, Singleton's firm found. Much of this is a direct consequence of physicians' early opposition to health care reform, explains Beatrix Hoffman, a history professor at Northern Illinois University. By pushing back against government involvement, she says physicians created the system that is now dominated by private insurance. 'We've heard so many horror stories from doctors who have come before us about spending hours on the phone negotiating with insurance companies,' says Scott Swartz, a 28-year-old medical student in San Francisco. 'That's not how we want to spend our time.' All of these factors have combined to shift doctors' politics to the left." • But patients love their insurance companies. Right?

"We Found Over 700 Doctors Who Were Paid More Than a Million Dollars by Drug and Medical Device Companies" [ Pro Publica ]. "Back in 2013, ProPublica detailed what seemed a stunning development in the pharmaceutical industry's drive to win the prescription pads of the nation's doctors: In just four years, one doctor had earned $1 million giving promotional talks and consulting for drug companies; 21 others had made more than $500,000. Six years later -- despite often damning scrutiny from prosecutors and academics -- such high earnings have become commonplace. More than 2,500 physicians have received at least half a million dollars apiece from drugmakers and medical device companies in the past five years alone, a new ProPublica analysis of payment data shows. And that doesn't include money for research or royalties from inventions."

[Oct 05, 2019] Medicare Advantage is a hustle designed to allow for-profit corporations to suck up public dollars. For years, Republicans have shoveled money into Medicare Advantage plans and allowed them to offer benefits that traditional Medicare is forbidden from covering

Oct 05, 2019 | economistsview.typepad.com

EMichael , October 04, 2019 at 11:48 AM

They will allow trump to do anything he wants as long as he does things like this.

"
" Back
Trump's Executive Order is Backdoor Privatization of Medicare

run75441 | October 3, 2019 8:52 pm

"Trump's Executive Order is Backdoor Privatization of Medicare," Social Security Works, Nancy Altman, October 3, 2019

I had to search around for someone who is an expert on Medicare Advantage Plans and Original Medicare. Nancy is one of those experts....

"Medicare Advantage is a hustle designed to allow for-profit corporations to suck up public dollars. For years, Republicans have shoveled money into Medicare Advantage plans and allowed them to offer benefits that traditional Medicare is forbidden from covering. This is a ploy to push seniors into Medicare Advantage plans instead of traditional Medicare. Medicare Advantage is stealth privatization intended to undermine traditional Medicare, which is an effective, popular government program and therefore loathed by Republican ideologues.

Under the Trump Administration, the thumb on the scale has turned into an entire arm. They've been flooding seniors' inboxes with advertisements for Medicare Advantage. What these emails don't mention is that Medicare Advantage plans often have narrow networks, restricting which doctors and hospitals patients are allowed to use. Worse, a recent government report found tt Medicare Advantage plans improperly deny care "in an attempt to increase their profits." It's no surprise that older, seniors are more likely to drop Medicare Advantage plans.

Medicare Advantage plans are also a terrible waste of public dollars. They have overcharged Medicare by $30 billion in the past three years alone.

Today's executive order is yet another giveaway to the corporations that run Medicare Advantage plans. Ironically, the Trump Administration is framing the executive order as an attack on Medicare for All. In fact, the massive flaws of Medicare Advantage epitomize the need to get for-profit greed out of health care by improving Medicare and expanding it to cover all Americans.

Medicare, like Social Security, works. Republicans want to privatize both of them. We have to stop them and instead, expand both."

https://angrybearblog.com/2019/10/trumps-executive-order-is-backdoor-privatization-of-medicare.html#more-52393

EMichael -> EMichael... , October 04, 2019 at 11:52 AM
"The President* Is a Blight, But Watch What the Conservative Movement's Up to Behind Him

They're coming for Medicare, folks.

Even while he's floundering and crimin' his way across the landscape, El Caudillo del Mar-a-Lago still needs watching -- not just because of his many offenses against the Constitution and against human decency, but also for all the standard Republican policy goals that he's putting within reach. For example, on Thursday, the president* signed an executive order that supposedly "improved" Medicare. Then he flew to Florida to lie about it in front of an audience of the elderly. Within the executive order is a poison pill the size of a horse's head. Check out Section 3.

Section 3: Providing More Plan Choices to Seniors. (a) Within 1 year of the date of this order, the Secretary shall propose a regulation and implement other administrative actions to enable the Medicare program to provide beneficiaries with more diverse and affordable plan choices. The proposed actions shall:....

That, dear friends, is pretty much the same plan that Paul Ryan, the zombie-eyed granny starver from the state of Wisconsin, spent years trying to slime into law. It is the first big step toward Ryan's lifetime goal of privatizing the Medicare system, which, as someone who has enjoyed its benefits for almost a year, I can tell you is a terrible idea. Look at all the little buzzing land mines in there. "Competition." "Market pricing." This thing even expands Medical Savings Accounts, a terrible idea that emerged in the 1990s and that Bill Frist was going to ride into the White House in 2000.

The president* is a blight and impeachment is the only cure, but the conservative project rolls merrily on. I'm not entirely sure he knew what he was signing, because he doesn't know anything about anything, but the people who find him useful do, which is why he'll be around for a while longer."

https://www.esquire.com/news-politics/politics/a29368460/president-trump-medicare-executive-order/

ilsm -> EMichael... , October 04, 2019 at 01:47 PM
top dems, all corrupt, one unhealthy and one [self identified] false minority.... what does one do about them?
EMichael -> EMichael... , October 05, 2019 at 07:14 AM
And things like this. Imagine the lives they are going to destroy.

"Here's How We Know the Supreme Court Is Preparing to Devastate Abortion Rights

There's no other reason for the justices to take up the Louisiana abortion case.

The Supreme Court agreed on Friday to hear June Medical Services v. Gee, a challenge to Louisiana's stringent abortion restrictions. There is very little doubt that the conservative majority will use this case to overrule 2016's Whole Woman's Health v. Hellerstedt, allowing states to regulate abortion clinics out of existence. In the process, the Republican-appointed justices will set the stage for the formal reversal of Roe v. Wade. The court's decision to hear June Medical Services came with the alarming announcement that it will also consider whether to strip doctors of their ability to contest abortion laws in court. These aggressive moves augur an impending demise of the constitutional right to abortion access. ....

Because the 5th Circuit refused to adhere to binding precedent, Louisiana's abortion providers asked the Supreme Court to step in and block the law. It agreed to do so -- but only by a 5–4 vote, with Chief Justice John Roberts joining the liberals. In dissent, Kavanaugh argued that the court should allow the law to take effect and force the doctors to seek admitting privileges once again. His opinion was a rejection of Whole Woman's Health, dismissing the reality that Louisiana, like Texas before it, was trying to shutter clinics, not help women.

Given Kavanaugh's refusal to abide by precedent, the outcome of June Medical Services likely depends upon Roberts. It is true that the chief justice voted to block the law while the clinics appealed to SCOTUS. But his vote is best understood as a reminder to lower courts that they cannot flout liberal precedent just because Kennedy is off the bench. Roberts did not want the 5th Circuit to overturn Whole Woman's Health on its own -- only the Supreme Court can reverse its own precedent. But Roberts dissented in Whole Woman's Health. And when the case comes squarely before him, he will probably follow his conservative instincts, overturn or hollow out Whole Woman's Health, and allow states to impose draconian regulations on abortion providers that obligate clinics to shut their door.

The clearest indication of Roberts' vote is the fact that the court scheduled June Medical Services for oral arguments. When an appeal presents no new question of law and is clearly resolved by precedent, SCOTUS sometimes issues per curiam summary decisions. That means the justices affirm or reverse a lower court ruling without oral arguments through a brief, unsigned order. They prefer to issue these decisions when six justices sign on, but that's not a rule, and the court has issued 5–4 summary reversals before."

https://slate.com/news-and-politics/2019/10/supreme-court-louisiana-abortion-roe-v-wade.html

[Sep 29, 2019] Shares of Healthcare Costs, 2018

Sep 29, 2019 | economistsview.typepad.com

anne , September 28, 2019 at 11:44 AM

http://us.milliman.com/uploadedFiles/insight/Periodicals/mmi/2018-milliman-medical-index.pdf

May, 2018

Shares of Healthcare Costs, 2018

Employer

( $15,788) ( 56%) employer subsidy

Employee

( 7,674) ( 27) employee contributions
( 4,704) ( 17) employee out-of-pocket costs
------------- --------
( 12,378) ( 44) total employee cost and share

( 28,166) ( 100) total medical cost for a family of four under a preferred provider organization

anne -> anne... , September 28, 2019 at 11:54 AM
http://us.milliman.com/uploadedFiles/insight/Periodicals/mmi/2017-milliman-medical-index.pdf

May, 2018

Shares of Healthcare Spending, 2018

( $8,257) ( 29%) physician

( 8,631) ( 31) inpatient
( 5,395) ( 19) outpatient

( 4,888) ( 17) pharmacy

( 995) ( 4) additional
------------- --------

( 28,166) ( 100) total medical cost for a family of four under a preferred provider organization

anne -> anne... , September 28, 2019 at 01:14 PM
Correcting link:

http://us.milliman.com/uploadedFiles/insight/Periodicals/mmi/2018-milliman-medical-index.pdf

anne , September 28, 2019 at 11:47 AM
http://us.milliman.com/uploadedFiles/insight/Periodicals/mmi/2018-milliman-medical-index.pdf

May, 2018

Milliman Medical Index

The total medical spending in 2018 for a typical family of four is $28,166. *

2001 ( 8,414) Bush
2002 ( 9,235)
2003 ( 10,168)
2004 ( 11,192)

2005 ( 12,214)
2006 ( 13,382)
2007 ( 14,500)
2008 ( 15,609)
2009 ( 16,771) Obama

2010 ( 18,074)
2011 ( 19,393)
2012 ( 20,728)
2013 ( 22,030)
2014 ( 23,215)

2015 ( 24,671)
2016 ( 25,826)
2017 ( 26,944) Trump
2018 ( 28,166)

* Average annual medical spending for a typical American family of four covered by an employer-sponsored preferred provider organization program

anne -> anne... , September 28, 2019 at 11:55 AM
http://us.milliman.com/uploadedFiles/insight/Periodicals/mmi/2018-milliman-medical-index.pdf

May, 2018

Milliman Medical Index

The annual growth rate in medical spending for a family of four from 2017 to 2018 is 4.5%.

2001-2002 ( 9.8) Bush
2002-2003 ( 10.1)
2003-2004 ( 10.1)

2004-2005 ( 9.1)
2005-2006 ( 9.6)
2006-2007 ( 8.4)
2007-2008 ( 7.6)
2008-2009 ( 7.4)

2009-2010 ( 7.8) Obama
2010-2011 ( 7.3)
2011-2012 ( 6.9)
2012-2013 ( 6.3)
2013-2014 ( 5.4)

2014-2015 ( 6.3)
2015-2016 ( 4.7)
2016-2017 ( 4.3) Trump
2017-2018 ( 4.5)

[Sep 25, 2019] UK Labour Party plan for reducing drug prices includes public funding for research and having new drugs available as generics

Sep 25, 2019 | economistsview.typepad.com

anne , September 24, 2019 at 06:47 PM

https://twitter.com/DeanBaker13/status/1176657390235803649

Dean Baker @DeanBaker13

UK Labour Party plan for reducing drug prices includes public funding for research and having new drugs available as generics (patents in public domain). Maybe progressive Democratic presidential candidates can learn something

http://labour.org.uk/wp-content/uploads/2019/09/Medicines-For-The-Many.pdf

5:39 PM - 24 Sep 2019

[Sep 22, 2019] Sicko The truth about the US healthcare system The Independent

Sep 22, 2019 | independent.co.uk

https://ads.pubmatic.com/AdServer/js/showad.js#PIX&kdntuid=1&p=153141

about:blank

Sicko? The truth about the US healthcare system | The Independent <style amp-boilerplate>body{-webkit-animation:none;-moz-animation:none;-ms-animation:none;animation:none}</style> Sicko? The truth about the US healthcare system Michael Moore's new film is a damning indictment of the way the world's richest country looks after those who fall ill. Andrew Gumbel finds out whether his accusations are justified Cynthia Kline knew exactly what was happening to her when she suffered a heart attack at her home in Cambridge, Massachusetts. She took the time to call an ambulance, popped some nitroglycerin tablets she had been prescribed in anticipation of just such an emergency, and waited for help to arrive.

On paper, everything should have gone fine. Unlike tens of millions of Americans, she had health insurance coverage. The ambulance team arrived promptly. The hospital where she had been receiving treatment for her cardiac problems, a private teaching facility affiliated with the Harvard Medical School, was just a few minutes away.

The problem was, the casualty department at the hospital, Mount Auburn, was full to overflowing. And it turned her away. The ambulance took her to another nearby hospital but the treatment she needed, an emergency catheterisation, was not available there. A flurry of phone calls to other medical facilities in the Boston area came up empty. With a few hours, Cynthia Kline was dead.

We'll tell you what's true. You can form your own view.

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She died in an American city with one of the highest concentration of top-flight medical specialists in the world. And it happened largely because of America's broken health care system - one where 50 million people are entirely without insurance coverage and tens of millions more struggle to have the treatment they need approved. As a result, medical problems go unattended until they reach crisis point. Patients then rush to hospital casualty departments, where by law they cannot be turned away, overwhelming the system entirely. Everyone - doctors and patients, politicians on both the left and the right - agrees this is an insane way to run a health system.

When Elizabeth Hilsabeck gave birth to premature twins in Austin, Texas, she encountered another kind of insanity. Again, she was insured -- through her husband, who had a good job in banking. But the twins were born when she was barely six months pregnant, and the boy, Parker, developed cerebral palsy. The doctors recommended physical therapy to build up muscle strength and give the boy a fighting chance of learning to walk, but her managed health provider refused to cover it.

The crazy bureaucratic logic was that the policy covered only "rehabilitative" therapy - in other words, teaching a patient a physical skill that has been lost. Since Parker had never walked, the therapy was in essence teaching him a new skill and therefore did not qualify. The Hilsabecks railed, protested, won some small reprieves, but ended up selling their home and moving into a trailer to cover their costs. Elizabeth's husband, Steven, considered taking a new, better-paying job, but chose not to after making careful inquiries about the health insurance coverage. "When is he getting over the cerebral palsy?" a prospective new insurance company representative breezily asked the Hilsabecks. When Elizabeth explained he would never get over it, she was told she was on her own.

Everyone in America has a health-care horror story or knows someone who does. Mostly they are stories of grinding bureaucratic frustration, of phone calls and officials letters and problems with their credit rating, or of people ignoring a slowly deteriorating medical condition because they are afraid that an expensive battery of tests will lead to a course of treatment that could quickly become unaffordable.

Even when things don't go horribly wrong, it is a matter of surviving by the skin of one's teeth.

In Montana, Melissa Anderson can't find affordable insurance because she is self-employed - an increasingly common affliction. When her son Kasey came down with epilepsy two years ago, she was saved only by a recently introduced child health insurance programme specifically tailored to people who aren't poor but can't afford to pay monster medical bills. She herself remains uninsured for anything short of major care needs.

Over the past 15 years, the stories have become less about poor people without the economic means to access the system - although that remains a vast, unsolved problem - and more about the kind of people who have every expectation they will be taken care of. Middle-class people, people with jobs that carry health benefits or - as the problem worsens - people with the sorts of jobs that used to carry robust health benefits which are now more rudimentary and risk their being cut off for a variety of reasons.

This is the morass that Michael Moore has chosen to explore in his latest documentary, Sicko, which goes on release later this month. Moore spends much of the film demonstrating that there is nothing inevitable or necessary about a system that enriches insurance companies and drug manufacturers but shortchanges absolutely everyone else. His searching documentary looks at health care in France, Britain, Canada, and even Cuba - still regarded as a model system for the Third World.

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Moore has his share of ghoulishly awful stories. The film kicks off with an uninsured carpenter who has to decide whether to spend $12,000 (£6,000) reattaching his severed ring finger or $60,000 to reattach his severed middle finger. Later on, Moore focuses on a hospital worker whose husband needed a bone marrow transplant to save him from a rare disease. The couple's insurance company refused to cover the transplant because it regarded the treatment as "experimental". The husband died.

Many more stories are collected in a newly published book called Sick: The Untold Story of America's Health Care Crisis, by Jonathan Cohn. A woman in California called Nelene Fox died of breast cancer after she, too, was turned down for a bone marrow transplant by her insurance company. In Georgia, a family whose infant son went into cardiac arrest were forced to take him to a hospital 45 miles away on their insurance carrier's orders. He survived, but suffered permanent disabilities that more prompt treatment might have averted. In New York, an infant called Bryan Jones - whose case was trumpeted all over the local media at the time - died of a heart defect that went undetected because his insurance company kicked him and his mother out of hospital 24 hours after his birth, too soon to carry out the tests that might have spotted the problem.

America's health system offers a tremendous paradox. In medical technology and in the scientific understanding of disease, it is second-to-none. Since doctors are better paid than anywhere else in the world, the country attracts the best of the best. And yet many, if not most, Americans are unable to reap the advantages of this. In fact, as The New York Times columnist Paul Krugman has argued, the very proliferation of research and high-tech equipment is part of the reason for the imbalance in coverage between the privileged few and the increasingly underserved masses. "[The system] compensates for higher spending on insiders, in party, by consigning more people to outsider status --robbing Peter of basic care in order to pay for Paul's state-of-the-art treatment," Krugman wrote recently. "Thus we have the cruel paradox that medical progress is bad for many Americans' health."

Having the system run by for-profit insurance companies turns out to be inefficient and expensive as well as dehumanising. America spends more than twice as much per capita on health care as France, and almost two and a half times as much as Britain. And yet it falls down in almost every key indicator of public health, starting, perhaps, most shockingly, with infant mortality, which is 36 per cent higher than in Britain.

A recent survey by the management consulting company McKinsey estimated the excess bureaucratic costs of managing private insurance policies - scouting for business, processing claims, and hiring "denial management specialists" to tell people why their ailment is not covered by their policy - at about $98bn a year. That, on its own, is significantly more than the $77bn McKinsey calculates it would cost to cover every uninsured American. If the government negotiated bulk purchasing rates for drugs, rather than allowing the pharmaceutical companies to set their own extortionate rates, that would save another $66bn.

Astonishingly, there hasn't been a serious debate about health care in the United States since Bill Clinton, with considerable input from his wife Hillary, tried and failed to overhaul the system in 1994. That, though, may be about to change as the 2008 presidential race heats up. Everyone acknowledges the system is broken. Everyone recognises that 50 million uninsured - including almost 10 million children - is unacceptable in a civilised society.

Even the old, classically American free-market argument - that "socialised" medicine is somehow the first step on a slippery slope towards godless communism - doesn't hold water, because in the absence of a functioning private insurance regime the government ends up picking up about 50 per cent of the overall costs for treatment anyway. The indigent rely on a government programme called Medicaid. The elderly have a government programme called Medicare. And perhaps the most efficient part of the whole system is the Veterans' Administration, a sort of NHS for former servicemen.

Rather like London and Paris in the 19th century, where the authorities belatedly paid attention to outbreaks of cholera once the disease started affecting the rich and middle classes, so the American health crisis may be coming to a head because of the kinds of people who are suffering from its injustices.

Corporate chief executives, for a start, are gagging under the ever-increasing costs of providing coverage to their employees. Starbucks now spends more on health care than it does on coffee beans. Company health costs, as a whole, are at about the same level as corporate profits. In a globalised world where US businesses are competing with low-wage countries such as India and China, that is rapidly becoming unacceptable.

That explains, perhaps, why the chief executive of Wal-Mart, Lee Scott, has made common cause with America's leading service sector union - more commonly a bitter critic of Wal-Mart's labour practices - in calling for a government-run universal health care system by 2012. It's going to be a tough battle. The insurance and pharmaceutical industries bankroll the campaigns of dozens of congressmen and have so far been brutally efficient in protecting their own interests. The Clintons were defeated in 1994 in part because of the power of the industry lobbies. Doing better this time will take singular political courage.

In the meantime, we will hear ever more crazy stories like the one told by Marijon Binder, a former nun in Chicago who ended up being sued by a Catholic hospital for $11,000 because her two-night stay for a heart scare was not considered a worthy charity case. Binder, who works as a live-in companion to a disabled old woman, wrote on all her admission forms that she had no insurance and, in her telling at least, was reassured the hospital would take care of her anyway.

After a year and a monstrous bureaucratic fight that went nowhere, a civil judge promptly absolved her of responsibility for her bill - a lucky outcome, for sure. Binder said: "The whole experience was very demeaning. It made me feel very guilty; it made me feel like a criminal." She is, though, alive and solvent. Not everyone in this system catches the same break.

[Sep 22, 2019] Does America have a "Health Care System" or a Medical Delivery System that does a lousy job of delivering Health?

Sep 22, 2019 | economistsview.typepad.com

Fred C. Dobbs , September 20, 2019 at 11:32 AM

Is America's Health Care System a Fixer-Upper
or a Teardown? https://nyti.ms/34RCADP
NYT - Margot Sanger-Katz - Updated September 20

Illustrations by Tim Enthoven (at the link)

To understand the competing Democratic health care plans, consider an elaborate home construction metaphor.

Imagine the United States health care system as a sort of weird old house. There are various wings, added at different points in history, featuring different architectural styles.

Maybe you pass through a wardrobe and there's a surprise bedroom on the other side, if not Narnia. Some parts are really run down. In some places, the roof is leaking or there are some other minor structural flaws. It's also too small for everyone to live in. But even if architecturally incoherent and a bit leaky, it still works. No one would rather be homeless than live in the house.

In Democratic politics, there is agreement that the old house isn't good enough, but disagreement about just how possible -- or affordable -- fixing it will be. The biggest fault line in the debate is between candidates who think our current system can be salvaged with repairs and those who think it should be torn down and built anew. Building a dream house eases the way to simplification, but it increases potential disruption and cost.

The Pelosi plan

The most limited Democratic plan, championed by House Speaker Nancy Pelosi, for example, would deal with the house's biggest structural issues. It would lower the cost of health insurance for more people and fix some glitches in Obamacare's design -- the home construction equivalent of patching the roof, fixing a saggy porch and repainting. Residents could remain in the house while such minor repairs take place. These changes would not cost a ton of money. The house would still be weird. There would still be some people without a place to live.

The Biden plan

The next tier of health care plans, like the one from Joe Biden, would go further. Mr. Biden, too, would patch the roof and upgrade the windows. But he'd also put on a big new wing: an expansion of the Medicare program that would allow more people to join, sometimes called a public option. Everyone living in the house can stay while the renovations take place, though there might be disruptions. It would cost more, more homeless people would now fit in, and some living in the weirder wings might move into the new addition. People would pay for housing through a mixture of taxes and rent.

There are a bunch of plans in this general category, including proposals from Michael Bennet, Steve Bullock, Pete Buttigieg, John Delaney, Julian Castro, Amy Klobuchar, Beto O'Rourke and Marianne Williamson. They differ, mainly, in how many people in existing wings are allowed to move into the new wing, and how large that wing will be.

The Sanders plan

Bernie Sanders wants to tear down the weird old house entirely and build his dream home. It would be enormous and feature many wonderful amenities. When done, there would be no homeless people at all, and everyone's bedrooms would look exactly the same. The weirdness would be gone. But the entire old house would be gone, too, which some people might miss, and there could be unanticipated cost overruns in the construction. Some people might not enjoy the aesthetics of a modernist villa. While no one would have to pay rent in exchange for housing there, most people would have to pay more in taxes so the government could maintain the property.

Several candidates have signed on, in whole or part, to the single-payer dream house approach, including Cory Booker, Tulsi Gabbard, Elizabeth Warren and Andrew Yang.

The Harris plan

Kamala Harris also wants to tear down the old weird house. But she doesn't want to make everyone live in identical bedrooms. Her dream arrangement involves more choices, but most of the basic architectural features would be very similar. She would eliminate nearly every part of the existing health insurance system, and set up a new universal Medicare program that includes options from private insurers. It's like a housing development with several slightly different model homes. The basic architecture and amenities would all be the same, but families would be able to choose some custom options, like paint color, countertops and bed linens. It would also be expensive, and everyone would still need to move.

The debate

At the debate last week, you heard arguments between the teardown candidates and the fixer-upper candidates about cost -- and about change. Tearing down your current house comes with risks that many candidates don't want to take on.

Although big changes to the health care system often garner strong support in surveys, Americans frequently also tell pollsters that they like their current insurance arrangements, and would dislike giving them up. The authors of some fixer-upper plans assume that only some people are looking for a change, while other candidates assume that, over time, nearly everyone will want to opt into a form
of government-run insurance.

You also heard a debate about fairness and choice. Giving all Americans access to the same housing arrangements means that no one will have to live in a cramped attic. But it also means that some family members will have to part with some of their favorite furniture. "Of the 160 million people who like their health care now, they can keep it," said Mr. Biden, of the virtues of his fixer-upper proposal. "If they don't like it, they can leave." By contrast, Ms. Warren emphasized the universal nature of a teardown approach: "We're going to do this by saying, everyone is covered by Medicare for all; every health care provider is covered."

The "Medicare for all" system envisioned by Mr. Sanders would cover more benefits than nearly any system in the world, but it would require everyone to have the same type of insurance, with no easy workarounds for patients who aren't satisfied. Ms. Harris's plan would allow more choice, allowing private plans to operate alongside the government system. But those tightly regulated products would not be allowed to differ nearly as much as plans that exist in today's system, and would also amount to a brand-new system.

The candidates also disagree on how people should finance their ambitions. The fixer-upper candidates, for the most part, favor a system in which most Americans would still need to pay some form of rent to live in the house. The teardown candidates think everyone's housing costs should be financed by taxes instead of direct payments.

A tax-financed system would mean big changes in who pays what for health care, and how. A system that preserves a mix of taxes, premiums and direct payments like deductibles would mean less rearranging of the financing of health care, and would probably require more modest tax increases.

This is only a metaphor, of course. There are many ways the health care system is not like a residence. But if you've ever renovated or built a home, you know the emotional and budgetary stakes. The health care system is personal to many Americans, just like their home. It's no surprise the debate has been so heated.

im1dc -> Fred C. Dobbs... , September 20, 2019 at 04:01 PM
"Is America's Health Care System a Fixer-Upper
or a Teardown?"

Do you recognize the 'assumption' in the title, the fallacy?

Does America have a "Health Care System" or a Medical Delivery System that does a lousy job of delivering Health?

If the DEMS just fix what we have then we will get more of the same, i.e., a massive transfer of money from the people either out of their wallets or from taxation to the MEDICAL-INDUSTRIAL-COMPLEX that puts its profit above all patient welfare.

Go ahead and ignore my comment, after all I am just a D.C.

Fred C. Dobbs said in reply to im1dc... , September 20, 2019 at 04:14 PM
Let's say America has a "Health Care System" that is a 'Medical Delivery System that does a lousy
job of delivering Health'. Does that work for you?

Ours is after all (& over all) an economic
system that puts profit first.

ilsm -> Fred C. Dobbs... , September 21, 2019 at 04:39 AM
I agree with im1dc, we dare not recognize the US' 'health care system' for what it is.

It is a sacred market, where Milton Friedman told us markets make efficiency and also make its participants "free to choose".

PPACA did nothing but keep the profits in the "free to choose" edict.

However, the worth value, price....) of efficiency and "free to choose" is only measured from the perspective of those profiting.

Lately, some observers have been observing!

One is Binyamin Appelbaum.

David Warsh has read hos recent book.

It is somewhat critical of "free to choose" and market efficiency idolatry.

Appelbaum has observed that markets for such things and saving your life or warriors are such that the participants with demand really cannot go anywhere else.

"Free to choose" to work for the demanders must assure the choosers can leave the market and not die or work at Burger King.

Fred C. Dobbs said in reply to Fred C. Dobbs... , September 21, 2019 at 07:26 AM
This is (mostly) just semantics.
im1dc -> Fred C. Dobbs... , September 21, 2019 at 08:58 AM
Fred, this is NOT "mostly semantics" imo.

That is b/c our 'Health Care System' prioritizes profit to providers over OUTCOMES, which includes FDA oversight and rule making.

The Federal Government does not protect patients it protects Corporations, especially Big Pharma, Big Device Makers, Big Medical Groups, and Big Hospitals.

States are no better either.

The CDC imo today is chiefly operating in the public's interest most of the time, but...there are cracks forming there too.

FTR, we have superb medical scientists and superb world class Physicians that are forced to live and work in a system that denigrates and punishes them if they prioritize patients and people over profits and power.

IOW, since this is an Economics Blog, the American Health Care System practiced today prioritizes Capital over the Welfare or Commonweal of The People.

For example the Cost-Benefit Analysis in a For Profit system that pays Health Care CEO's, et. al., millions a year decays, diverts, and disrupts Health Outcomes Analysis due to a built in Profit benefit that feeds Executives that do not provide actual health care patient benefits.

Remember Pharma Bro Shkreli's 5000% price increase on Daraprim from $13.50 to $750 per tablet and the insane price increase of the epinephrine autoinjector EpiPen the Corporate CEO of that Big Pharma is the daughter of a Congressman and a DEM.

Are you aware some scientists of the FDA and CDC said they could manufacture off patent medicines cheaply and make them available to the public through the FedGovt if allowed to do so, but were turned down b/c it was thought unseemly for the FedGovt to compete with Big Pharma's Big Profits?

IOW, we are capable of drastic changes to the American Health Care System, lower costs and better outcomes for more people, but are stymied at every turn b/c Congress won't allow it due to the myth that pure Capitalism is the better way.

You should think about it instead of slavishly following the past and its built-in fallacies, tendencies, deficiencies, and errors.

And when you do you will ultimately come to the conclusion that prioritizing People over Capital in actual Health Care is the way it ought to be in the USA. We could catch up with the rest of the world in delivering Outcomes that increase our Health and longevity.

Fred C. Dobbs said in reply to im1dc... , September 21, 2019 at 09:45 AM
It *is* semantics when you insist
that there is No System when clearly
there is a system, but one that you
don't like.

Extraordinary difficulty of starting
from scratch on a new one, or making
drastic mods to the one we've got
is why it's so difficult to get
where you want to be. Which
is why we have to do the
latter, not the former.

And not too satisfying.

Not quite as tough as repealing
the 2nd amendment, but right up there.

[Sep 07, 2019] Private Equity and Surprise Medical Billing naked capitalism

Notable quotes:
"... By 2013, physician staffing firms owned by Blackstone Group and Kohlberg, Kravis Roberts & Co. (KKR) – among the largest PE firms in the country – cornered 30 percent of this market. Since then, private equity ownership of these services has continued to grow. ..."
"... The Stanford study found that the likelihood that a patient admitted to an in-network hospital would face a surprise medical bill because at least one out-of-network doctor cared for them increased from 26.3 percent 2010 to 42.0 percent in 2016. A particularly egregious instance occurred when an assistant surgeon sent a bill for $117,000 to a patient who had surgery for herniated discs in his neck. ..."
"... Commenting on EmCare's relations with hospitals, Benedic Ippolito, a research fellow in public finance and health economics at the American Enterprise Institute, noted, "Right now, EmCare surprise bills patients and hospitals effectively turn a blind eye. ..."
"... A team of Yale University health economists examined the billing practices of EmCare, Envision's physician staffing arm. [xx] They found that when EmCare took over the management of emergency departments, it nearly doubled its charges for caring for patients compared to the charges billed by previous physician groups. These egregious practices have resulted in a Congressional investigation headed by Missouri Senator Claire McCaskill, lawsuits from shareholders, and court actions involving Envision and UnitedHealth Group, the largest U.S. insurer. [xxi] ..."
Sep 06, 2019 | www.nakedcapitalism.com

September 6, 2019 by Jerri-Lynn Scofield By Eileen Appelbaum and Rosemary Batt Originally published at The Institute for New Economic Thinking website

Surprise medical billing has become a critical issue facing Americans across the country because of purposeful corporate practices designed to increase profits. As hospitals have outsourced emergency rooms and other specialty care to reduce costs, private investors have bought up specialty physician practices, rolled them into powerful national corporations, and taken over hospital emergency services. The result: large out-of-network surprise bills. The hidden actors: Leading private equity firms looking for 'outsized' returns.
Surprise medical billing made headlines in 2019 as patients with health insurance found themselves liable for hundreds or even thousands of dollars in unforeseen medical bills. When patients with urgent medical problems go to an emergency room (ER) or are treated by specialty doctors at a hospital that is in their insurance network, they expect that the services they receive will be 'in-network' and covered by their insurance. But often a doctor not in their insurance network is under contract with the hospital and actually provides the care. When this happens, patients are stuck with unexpected and sometimes unreasonably high medical bills charged by these 'out-of-network' doctors. This typically occurs when the hospital has outsourced the ER or other specialized services to a professional staffing firm or a specialty doctors' practice. This problem has exploded in recent years because hospitals are increasingly outsourcing these services to cut costs.

And more and more patients are faced with surprise medical bills -- adding substantially to the already impossible medical debt that working people face. Hospital outsourcing of emergency, radiology, anesthesiology, and other departments has provided an opening for physician practices to operate these services as independent organizations. Initially, hospitals outsourced these services to small, local doctors' groups

But over the past decade, private equity firms have become major players -- buying out doctors' practices and rolling them up into large corporate physician staffing firms that provide services to outsourced emergency rooms, anesthesiology and radiology departments, and other specialty units. By 2013, physician staffing firms owned by Blackstone Group and Kohlberg, Kravis Roberts & Co. (KKR) – among the largest PE firms in the country – cornered 30 percent of this market. Since then, private equity ownership of these services has continued to grow.

Private equity firms also own two of the three largest emergency ambulance and air transport services – another major source of surprise medical billing. Private equity ownership matters because the business model of private equity firms is to use a lot of debt in a leveraged buyout of companies they acquire and then extract as much cash as possible out of them in order to pay down the debt and reward their investors with 'outsized returns' that exceed stock market gains. They can be thought of as for-profit corporations on steroids. Buying up specialty practices is financially attractive because there is a large and growing demand for outsourced doctors, and out-of-network doctors can command a substantial premium for their services.

Emergency rooms and certain medical services provided in hospitals are not really part of a competitive 'marketplace' because patients in emergency medical situations rarely have a choice: they need immediate medical care and cannot 'shop around' for an in-network trauma doctor or radiologist.

Thus, surprise bills are difficult to avoid if patients face a medical emergency and must go to the ER or if they are hospitalized and require access to specialty medical services. How Widespread is Surprise Billing and Why Has It Grown?

Surprise medical billing is exacerbating the already serious problem of medical debt in this country, which is a leading cause of bankruptcy for American families. [i] And surprise billing is growing rapidly. Forty percent of Americans surveyed by the Kaufman Family Foundation in April, 2019, reported receiving an unexpected medical bill; and 20 percent of those surveyed said it was due to out-of-network charges – or surprise billing. [ii] A study by health researchers at Stanford University, for example, examined fees charged to patients with private insurance who were treated by the emergency department of a hospital. They reviewed 13.6 million trips to the ER that occurred over the period 2010 to 2016. About a third (32.3 percent) of these trips in 2010 resulted in a surprise medical bill. But by 2016, that figure had increased to 42.8 percent. That is, more than 4 in 10 trips to the ER ended with patients getting a surprise medical bill. [iii]

For in-patient stays, surprise billing rose from 26 percent to 42 percent, and the average costs per patient also jumped from $804 to $2,040. At this rate of increase, the estimated percent of hospital visits resulting in a surprise bill would be 48 percent in 2019 – or almost one half.

The study also found that in 2016, 86% of ER visits and nearly 82% of hospital admissions incurred surprise ambulance service bills. Similarly, another 2019 study found that patients who are admitted to a hospital from the ER are much more likely to receive an out-of-network charge -- as many as 26% of admissions from the emergency room were found to include a surprise bill. The study also found that 38 percent of Americans are 'very worried' and another 29 percent are 'somewhat worried' about being able to afford surprise medical bills.

People particularly vulnerable to these charges are those with coverage from large employers that are self-insured. And vulnerability also varied by region, with Texas, New York, Florida, New Jersey, and Kansas having higher rates of surprise billing; and Minnesota, South Dakota, Nebraska, Maine, and Mississippi having lower rates. [iv] While large surprise medical bills are typically associated with doctors in the ER or in specialties such as radiology, anesthesiology, or critical care units such as neo-natal, burn, or trauma centers, other out-of-network physicians may also issue surprise bills. For example, those who assist a patient's doctor in a procedure or hospitalists who check on patients during hospital stays can also charge separately for their services.

The Stanford study found that the likelihood that a patient admitted to an in-network hospital would face a surprise medical bill because at least one out-of-network doctor cared for them increased from 26.3 percent 2010 to 42.0 percent in 2016. A particularly egregious instance occurred when an assistant surgeon sent a bill for $117,000 to a patient who had surgery for herniated discs in his neck.

The patient's own in-network surgeon sent a bill for $133,000, but accepted a fee of $6,200 negotiated with the insurance company. The out-of-network assistant surgeon is seeking full payment of his charges. This is a particularly egregious example, but surprise bills for a few thousand dollars are not uncommon. [v]

The problem of surprise billing has grown substantially in recent years because hospitals have been under financial pressure to reduce overall costs and have turned to outsourcing expensive and critical services to third-party providers as a cost-reduction strategy. Outsourcing is not new, as hospitals began outsourcing non-medical ancillary services such as facilities management and food services in the 1980s, in response to a round of structural changes in government financing.

By the 1990s, hospitals were experimenting with the use of independent 'hospitalists' to care for patients between rounds by the local admitting doctors who had a hospital affiliation. Hospitalists' numbers increased over the next two decades as hospital staffing firms grew and provided a range of temporary or short-term professionals to fill shortages in nursing, technical, or clinical positions. [vi]

Recent outsourcing, however, has expanded to critical care areas – emergency rooms, radiology, anesthesiology, surgical care, and specialized units for burn, trauma, or neo-natal care. Now hospitals contract with specialty physician practices or professional physician staffing firms to provide these services – even if the patient receives treatment at a hospital or at an outpatient center that is in the patients' insurance network. According to one study, surprise billing is concentrated in those hospitals that have outsourced their emergency rooms. [vii] A recent report found that almost 65 percent of U.S. hospitals now have emergency rooms that are staffed by outside companies. [viii] Hospitals and healthcare systems have accelerated their outsourcing of critical care areas since 2010 in part due to declines in Medicaid and Medicare reimbursements and to incentives under the Affordable Care Act to reduce costs and improve care quality. [ix]

At the same time, on the supply side, hospitalist companies were merging and buying up practices of specialists employed mainly in hospitals. Hospitalist companies evolved into physician staffing firms and expanded to include staffing for emergency rooms (ERs), anesthesiology and radiology departments, and burn and neonatal intensive care units in hospitals across the country. The business case for hospitals to outsource was straightforward. Emergency rooms are a major point of entry for patients who are admitted to hospitals, and thus, a major conduit for the in-patient hospital stays that are critical for hospital revenue generation. But they are costly and difficult to manage as they must be adequately staffed on a 24/7 basis regardless of patient flow, which is unpredictable. Outsourcing the management, staffing, and billing of ER services shifts these management problems and the risk of underpayment for these services to the staffing firm or a specialty doctors' practice. Hospital emergency rooms cannot turn patients away if they lack adequate insurance coverage or any insurance at all; they must treat all patients. Emergency departments make money on ER visits of patients with commercial insurance, but lose money on those with Medicare or Medicaid, and see very high losses when patients have no insurance. [x]

Private Equity's Business Model: Its Role in Outsourcing and Consolidating Specialty Services Private equity firms have played a critical role in consolidating physicians' practices into large national staffing firms with substantial bargaining power vis-à-vis hospitals and insurance companies. They have also bought up other emergency providers, such as ambulance and medical transport services. They grow by buying up many small specialty practices and 'rolling them up' into umbrella organizations that serve healthcare systems across the United States. Mergers of large physician staffing firms to create national powerhouses have also occurred. As these companies grow in scale and scope and become the major providers of outsourced services, they have gained greater market power in their negotiations with both hospitals and insurance companies: hospitals with whom they contract to provide services and insurance companies who are responsible for paying the doctors' bills. Hospitals have consolidated in order to gain market share and negotiate higher insurance payments for procedures.

Healthcare costs have been driven up further by the dynamics associated with payments for out-of-network services. As physicians' practices merge or are bought out and rolled up by private equity firms, their ability to raise prices that patients or their insurance companies pay for these doctors' services increases. The larger the share of the market these physician staffing firms control, the greater their ability to charge high out-of-network fees. The likelihood of surprise medical bills goes up, and this is especially true when Insurance companies find few doctors with these specialties in a given region with whom they can negotiate reasonable charges for their services. The design of the private equity business model is geared to driving up the costs of patient care. Private equity funds rely on the classic leveraged buyout model (LBO) in which they use substantial debt to buyout companies (in this case specialty physician practices as well as ambulance services) because debt multiplies returns if the investment is successful. They target companies that have a steady and high cash flow so they can manage the cash in order to service the debt and make high enough returns to pay their investors 'outsized returns' that exceed the stock market. [xi]

Emergency medical practices are a perfect buyout target because demand is inelastic, that is, it does not decline when prices go up. Moreover, demand for these services is large – almost 50 percent of medical care comes from emergency room visits, according to a 2017 national study by the University of Maryland School of Medicine, and demand has steadily increased. [xii]

PE firms believe they face little or no downside market risk in these buyouts. Private-equity owned companies differ from publicly traded for-profit chains not only in their greater use of debt, but also because the private equity firm, via the general partner of the investment fund it sponsors, makes all investment decisions on behalf of the investor shareholders. Investors commit capital to a PE-sponsored fund, typically for 10 years, and have no say in investment decisions. Thus, the PE general partner's power is concentrated and largely unaccountable, as investors cannot 'exit' or sell their shares if they are dissatisfied – unlike shareholders in publicly traded corporations. [xiii]

In addition, PE firms charge their portfolio companies additional 'advisory fees' and 'transactions fees' that can amount to millions of dollars over time. And because PE owned companies are not publicly traded on the stock exchange, they are not required to file a detailed report to the Securities and Exchange Commission (SEC) the way that publicly traded companies must do. Their activities and their financial transactions are largely hidden from the public eye, despite the fact that they receive substantial taxpayer funding from Medicare and Medicaid for their services, though not for surprise charges. Two private-equity owned physician-staffing firms dominate the market for outsourced doctors' practices -- Envision Healthcare, owned by KKR with 69,300 employees, and TeamHealth owned by Blackstone Group with 20,000 employees. KKR also is a major owner (along with other private equity firms) of AirMedicalGroup Holdings -- one of the nation's three largest ambulance and air transport companies.

We also showcase private equity owned Air Methods medical transport company. These examples help illuminate how and why private equity firms have become national powerhouses in the provision of professional healthcare services and why their activities and those of other private equity firms in this sector are leading to higher healthcare costs for patients and the industry as a whole.

Envision Healthcare
Envision Healthcare today is the result of fifteen years of private equity transactions in buying up and consolidating emergency ambulance and specialty physicians' practices. It was formed in 2005 when private equity firm Onex took over two companies -- American Medical Response (AMR) and EmCare -- and merged them. In and out of private equity ownership since 2005, Envision most recently was acquired by KKR in October, 2018 in a public to private leveraged buyout worth $9.9 billion. Its sprawling organization employs tens of thousands of healthcare professionals; and it supplies doctors in 774 physician practices to hospitals and ambulatory surgical centers throughout the United States. It provides ER doctors, anesthesiologists, radiologists, hospitalists, and other specialists covering intensive care, medical, neo-natal, pediatrics, psychiatric, skilled nursing, rehabilitation, and other inpatient units.

Its outpatient ambulatory surgical arm (AMSURG) provides trauma and acute care general surgery in 260 facilities in 35 states. [xiv]

Between 2005 and 2018, Envision provided two types of emergency medical services: an ambulance and medical transport business through American Medical Response (AMR) and emergency physician staffing through EmCare Holdings.

Today, Envision focuses on physician staffing services as it sold the ambulance and transport business in a $2.4 billion leveraged buyout in 2018 to another private equity consortium that still includes KKR (as we detail below). The prior ownership patterns of AMR and EmCare were similar. American Medical Response was listed as a publicly traded company as of August 1992; and in February, 1997, it was acquired by ambulance company MedTrans, a subsidiary of Laidlaw International. At an undisclosed date between 1997 and 2005, PE firm Peak Capital invested an undisclosed amount in the company. Like AMR, EmCare Holdings was acquired by Laidlaw International in the summer of 1997 and subsequently received an undisclosed amount of investment from PE firm Peak Capital.

Emergency physician practices figured prominently among EmCare's 10 acquisitions and 17 sister physician staffing and management firms. [xv] In December 2005, just months after acquiring and merging AMR and EmCare, Onex brought Envision Healthcare to the public market via an IPO in which it retained a majority of the shares. Subsequent sales of shares left Onex with 31 percent of the company's equity at the time it was again taken private, this time by Clayton Dubilier & Rice with participation of PE firm Ardian through a $3.2 billion LBO in May 2011. An IPO in 2013 returned Envision Healthcare to the public market. The PE owners retained about two-thirds of the shares of the now-publicly traded company. The PE companies subsequently sold some of the stock. And in September 2017, two hedge funds – Starboard Value and Comex Management – took minority stakes in Envision Healthcare.

Between July 2006 and October 2018, Envision Healthcare acquired 39 companies. [xvi] Envision Healthcare bought out AMSURG in December 2016 after AMSURG failed in an attempt to acquire TeamHealth (described below). The deal brought together two seemingly complementary healthcare companies to form a single organization with pro forma market capitalization of $10 billion and an enterprise value including debt of approximately $15 billion. A little over $8 billion of this was new debt.

However, KKR contributed $5.57 billion to the deal, using $4.43 billion to retire Envision's prior liabilities and the remainder mainly as equity in the LBO.

Adding AMSURG's large chain of ambulatory surgical centers was supposed to make Envision Healthcare a dominant player across the outsourced medical services landscape – emergency room doctors, hospitalists, outpatient surgery, and ground and air ambulance. But integrating the two health care companies – with a combined 69,300 employees as of December 2017 – proved difficult for publicly traded Envision Healthcare. [xvii] Envision Healthcare appears to be extremely profitable, but its financials are murky, with no publicly available accounting of its transactions with each round of private equity buyouts. And under private equity ownership, when companies are taken private or pass from one private equity fund to another, there is no transparency.

Each private equity buyout, however, is typically accompanied by levering substantial debt on the target company, which must be serviced by managing for cash. Emergency medical services are attractive to private equity firms and are very lucrative because they throw off a lot of cash, and as noted earlier, demand is inelastic and the fees are not subject to competitive market pricing. The contracts negotiated between these physician staffing companies and hospitals also are not publicly available. Depending on how they are crafted, they may provide incentives to outsource even more ER departments, and in turn increase out-of-network billing. One Wall Street investor analysis, for example, highlights Envision's 'joint venture' model that raises serious questions.

A 2013 analysis by Deutsche Bank Securities described a 2012 joint venture between EmCare and the HCA Healthcare chain – with a history of private equity ownership between 2006 and 2011 and substantial PE ownership of shares following its 2011 IPO. HCA apparently agreed to give up directly charging for physicians' services and outsourced these services to EmCare in exchange for a 50-50 profit split once EmCare achieved a 13% margin threshold, according to the Deutsche Bank calculation. This allowed EmCare to " penetrate HCA's 160+ hospital portfolio more deeply with its physician offerings." As of 2014, EmCare valued its HCA joint venture at a net revenue of $124 million, with assets of $155 million and liabilities of $31 million, according to the company's SEC filing. The filing identified similar joint ventures with hospitals involving Evolution Health (also owned by Envision). [xviii]

Commenting on EmCare's relations with hospitals, Benedic Ippolito, a research fellow in public finance and health economics at the American Enterprise Institute, noted, "Right now, EmCare surprise bills patients and hospitals effectively turn a blind eye." [xix] Envision has come under heavy scrutiny for the huge out-of-network surprise medical bills it sends to ER patients.

A team of Yale University health economists examined the billing practices of EmCare, Envision's physician staffing arm. [xx] They found that when EmCare took over the management of emergency departments, it nearly doubled its charges for caring for patients compared to the charges billed by previous physician groups. These egregious practices have resulted in a Congressional investigation headed by Missouri Senator Claire McCaskill, lawsuits from shareholders, and court actions involving Envision and UnitedHealth Group, the largest U.S. insurer. [xxi]

TeamHealth

TeamHealth has also grown into a powerful national healthcare professional staffing company with 20,000 employees. It contracts with hospitals to provide doctors and other healthcare professionals as ER staff, anesthesiologists, hospitalists, and hospital specialists (OB/GYN, orthopedics, general surgery, pediatric services); and in post-acute care, ambulatory care, and behavioral health. [xxii] The company experienced successive rounds of private equity leveraged buyouts punctuated by IPOs that returned it to the public markets – only to be taken private again through another LBO. In 1999, private equity firms Cornerstone Equity Investors and Madison Dearborn Partners, with minority participation of Becken Petry O'Keefe and Company, acquired TeamHealth as a platform for a physician staffing company. According to PitchBook (an industry research and data firm), TeamHealth acquired an anesthesiology practice, a hospitalist company, and a health management business in its first two years. It made no further acquisitions until after it was acquired by the Blackstone Group in 2005 in a leveraged secondary buyout (in which one PE fund sells a company to another PE fund). TeamHealth made two more acquisitions between 2005 and 2009 – an emergency physician's group and a hospitalist company.

In 2009, Blackstone Group returned TeamHealth to the public market via an IPO, but retained possession of a majority of shares in the newly public company. Passage of the Affordable Care Act in 2010, with its promise of cost containment via capitated and bundled payments, spurred TeamHealth to go on a buying spree. Between 2010 and 2016, TeamHealth acquired 51 companies, mainly practices of emergency doctors and anesthesiologists and a few hospital management companies. One very large exception to this pattern was TeamHealth's 2015 acquisition of IPC Healthcare. [xxiii]

IPC Healthcare was a major hospitalist company. In its early years, it attracted four rounds of venture capital investments between 1998, when it was launched as IPC The Health Company, and 2002. In June 2002, IPC had an IPO and began its life as a publicly traded company. Between 2002 and 2009, IPC acquired 20 physician practices. Between 2010 and 2015, following passage of the ACA, it acquired 78 more. The companies acquired by IPC were overwhelmingly hospitalist companies with a smattering of doctor's practices in specialties such as geriatrics. [xxiv]

TeamHealth's acquisition of IPC in 2015 raised questions. There was no evident fit between TeamHealth's specialty physician practices and IPC's hospitalist companies. IPC was also in trouble with the Department of Justice, which in June 2014, had filed a civil lawsuit against the company for "knowingly engaging in systematic overbilling" for services billed to Medicare and Medicaid and other government health programs. Ultimately, TeamHealth paid $60 million plus interest to resolve these allegations. [xxv] This fueled speculation that TeamHealth, which had rebuffed AMSURG's attempt to acquire it, wanted this very large acquisition in order to protect itself from being taken over. TeamHealth's explanation was that it wanted IPC's expertise in participating in Medicare and Medicaid bundled payments programs. [xxvi]

In February 2017, Blackstone Group once again took TeamHealth private in a $6.1 billion leveraged buyout. Similar to Envision Healthcare, the financials of TeamHealth are murky. After many LBOs, its revenues, debt load, and financial stability remain unknown, as do the contracts it negotiates with the phyisician groups it has acquired and the hospitals it contracts with for services.

And like Envision, its billing practices are being scrutinized. The Yale researchers who investigated EmCare and found excessive use of surprise medical billing also examined TeamHealth's billing practices. They found that Blackstone owned TeamHealth has taken a somewhat different tack. It uses the threat of sending high out-of-network surprise bills for ER doctors' services to an insurance company's covered patients to gain high fees from the company as in-network doctors. In most cases, the researchers noted, TeamHealth emergency physicians would go out-of-network for a few months, then rejoin the network after bargaining for in-network payment rates that were 68 percent higher than in-network rates received by the previous ER doctors. [xxvii] While this avoids the situation of a patient getting a large, surprise medical bill for the services of ER doctors, it raises healthcare costs and premiums for everyone.

Emergency Ambulance and Air Transport Services

Emergency ambulance and air transport is also a lucrative target for private equity investment, which has fueled consolidation in this industry segment. Demand is inelastic – there is no competitive market pricing. And demand for air transport has grown considerably because many rural hospitals have closed or consolidated, leading to far longer distances for access to emergency care. Two of the three air transport companies that together control two-thirds of this US market are private equity owned – AirMedicalGroup Holdings and Air Methods. The third, PHI Air Medical, is privately owned. [xxviii]

Returning to the Envision story, recall that American Medical Response (AMR) was the ambulance service division that Envision spun off in 2018. Before the divestiture, however, AMR grew to a national powerhouse in the decade from 2007 to2017 through 12 acquisitions of ambulance and medical transport businesses and one air ambulance company7. In addition to these acquisitions, AMR has seven sister companies – mainly ambulance companies, including several air ambulance businesses. It was acquired in 2017 by air ambulance company, AirMedicalGroup Holdings (AMGH) -- owned by PE firms Ardian, Koch Equity Development, and KKR -- in a $2.4 billion leveraged buyout. With this acquisition, AirMedicalGroup now holds a leading position in emergency and medical transport across a range of transport modalities. [xxix] The acquisition merged the largest provider of ground ambulance services in the U.S. with a leading operator of medical helicopters, with over 320 locations in 38 states. [xxx] The combined entity creates the opportunity for KKR to substitute its more expensive medical helicopters for short trips previously done by AMR's ambulances. [xxxi]

Air Methods became private equity owned in 2017, when it was acquired by American Securities and Alpinvest Partners through a $2.5 billion public-to-private LBO. The company's air medical transport services operate out of over 300 bases in 48 states. [xxxii] The buyout came in response to pressure from activist hedge fund investor, J. Daniel Plants, founder of Voce Capital Management. Concerned about the bad publicity surrounding predatory charges by air ambulance companies, Plants wanted Air Methods to agree to be taken private by a PE firm in order to keep information about its billing practices out of public view. According to the hedge fund, Air Methods big price hikes created economic and political risks for the company. Going private would shield its financial documents from patients and insurers. The hedge fund was right to be concerned about Air Methods predatory billing practices. The average bill for being transported in one of its medical helicopters was $17,262 in 2009 and had risen to $40,766 in 2014. Air Methods calculates that it accounts for nearly 30 percent of total air ambulance revenue in the U.S. Its profit increased sevenfold from 2004 to 2014. [xxxiii]

In general, charges for out-of-network ambulance services are likely to be high. In the case of air ambulances, they are exceedingly high – not only due to the high costs of air travel, but especially because an estimated 69 percent of charges are out-of-network -- according to a 2017 US General Accountability Office (GAO) study of private insurance records for 2012-2017. That is, insured patients in these cases ended up being billed for most of the charge. The GAO study also found that the median price for helicopter service doubled between 2010 and 2014 – from roughly $15,000 to $30,000 per tri;p it also found that the average cost of an air ambulance trip is over $36,000. . [xxxiv] Another study by researchers at Johns Hopkins University found charges were likely to be – as they put it – sky high. The study found that air ambulance charges had risen substantially from 2012 to 2016, and in 2016 these charges ranged from 4 to 9 times higher than what Medicare paid for this service. Some of the largest providers had among the highest charges. Between 2012 and 2016, the median charge ratios (the charge divided by the Medicare rate) for the services increased by 46-61 percent. [xxxv]

Legislative Solutions

Some hospitals have attempted to solve the problem of surprise billing on their own by simply requiring all attending physicians in their hospitals to remain in-network – receiving payment from the insurance companies with whom the hospital has contracted. This has been the traditional approach used by hospitals in managed care networks. According to John Cascell, Senior Vice President of Managed Care at MemorialCare Health System in Fountain Valley, California, "Such stipulations were commonplace decades ago, but some experts say the practice slipped out of favor around 2000 as major physician staffing companies -- which tend to make more money when they're out of network -- gained market power." [xxxvi] MemorialCare, however, has retained this long-standing policy, which Cascell supports. The downside of this approach, however, is that it may shift bargaining power to insurance companies who will seek to set lower in-network payments for specialty services. In these cases, according to Cascell, MemorialCare takes a strong role in negotiating with insurance companies to maintain reasonable payments. [xxxvii]

More generally, the public, healthcare providers, insurers, and state and federal legislators recognize that individual solutions are only stop-gap measures and that no individual hospital can solve the pervasive problem of surprise medical billing on its own. Twenty-five states have passed legislation that aims to protect patients from surprise billing, but these laws do not fully cover all types of situations. Over seventy-five percent of Americans believe that the federal government should step in and protect them from surprise bills, according to a Kaufman Family Foundation April, 2019 national survey. The same survey found that 90 percent of Democrats, three-quarters of Independents, and 60 percent of Republicans favored federal legislation to protect patients. [xxxviii] Americans differ, however, in who they think should bear the costs of care. According to the Kaufman survey, about half say insurance companies alone should cover the costs of care (43 percent) while about half favor joint responsibility between providers and insurance companies (47 percent). [xxxix]

Two approaches to 'fixing' surprise medical bills have been put forward. One would benchmark the fees paid to out-of-network doctors to the negotiated fees received by in-network doctors in that region for the procedure performed or the service provided. This would have the effect of holding down health care costs by setting limits to what out-of-network physicians can charge. In the second approach, out-of-network doctors would immediately be paid a given amount by the patient's insurance company – possibly 125 percent of the Medicare payment or, alternatively, the median payment for that procedure or service in the geographic region – and could then take the insurance company to arbitration in an effort to collect the balance of the patient's bill.

The second approach has the potential to raise health care costs if arbitration panels award out-of-network doctors all or a major part of the fees they charge. This approach, which is favored by investor-owned physician staffing firms and by large physician practice groups, would further raise health care costs for consumers. Even if many of these physician practices became in-network doctors, as Envision now claims to be doing [xl] , the threat of going out-of-network remains. As the TeamHealth example illustrates, this allows physician staffing firms to negotiate high in-network rates that drive up premium costs for consumers.

In sum, there is growing concern over the pricing practices of companies like Envision, TeamHealth, AirMedicalGroup, and Air Methods -- leading emergency healthcare companies owned and operated by private equity firms. There is little oversight of the prices they charge, and evidence suggests that these companies are among those responsible for driving up health costs by taking advantage of the possibilities for surprise medical billing. But they are not alone, as private equity firms buy out medical services in specialties other than trauma and radiology and as large physician practices take a page from the PE playbook when setting fees. Reining in these charges is critical to efforts to slow the growth or even reduce health care costs.

[i] Mireya Villarreal. 2019. "Insurance Gap Leaves Patients on the Hook for Unexpected Hospital Bills." CBS News TMarch 18, 6:45 PM https://www.cbsnews.com/news/insurance-gap-leaves-patients-on-the-hook-for-unexpected-hospital-bills/ (last accessed August 17, 2019)

[ii] Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. 2019. "KFF Health Tracking Poll – April 2019: Surprise Medical Bills and Public's View of the Supreme Court and Continuing Protections for People with Pre-Existing Conditions." Figure 13. Kaufman Family Foundation. April 24. https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-april-2019/ (last accessed August 20, 2019)

[iii] Eric C. Sun, Michelle M. Mello, Jasmin Moshfegh, et al. 2019. "An Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in In-Network Hospitals," American Medical Association JAMA Internal Medicine, August 12. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2740802?guestaccesskey=9fba6e0c-f029-401a-9675-737db3e67b5d&utm_source=for_the_media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=081219&alert=article (last accessed August 18, 2019)

[iv] Karen Pollitz , Matthew Rae , Gary Claxton , Cynthia Cox and Larry Levitt . 2019. "An Examination of Surprise Medical Bills and Proposals to Protect Consumers from Them." Kaiser Family Foundation . June 20. https://www.healthsystemtracker.org/brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them/# (last accessed August 16, 2019)

[v] Elisabeth Rosenthal. 2014. "After Surgery, Surprise $117,000 Medical Bill from Doctor He Didn't Know," New York Times , September 20. https://www.nytimes.com/2014/09/21/us/drive-by-doctoring-surprise-medical-bills.html ; (last accessed August 12, 2019); Sun, Mello, Moshfegh, et al. 2019.

[vi] Mark A. Marinella. 2002. "Hospitalists – Where They Came From, Who They Are, and What They Do," Hospital Physician , May.

https://pdfs.semanticscholar.org/c1a1/4f8e3e2f70489380db025235661b80d84349.pdf (last accessed July 23, 2019) ,

[vii] Zack Cooper, Fiona Scott Morton and Nathan Shekita. 2018. "Surprise! Out-of-Network Billing for Emergency Room Services in the U.S.," Yale University Working Paper , March. https://isps.yale.edu/sites/default/files/publication/2018/03/20180305_oon_paper2_tables_appendices.pdf (last accessed August 1, 2019)

[viii] Mireya Villarreal. 2019.

[ix] Beckers Hospital Review. 2013. "Outsourcing is Exploding in Healthcare -- Will the Trend Last?" October 4. https://www.beckershospitalreview.com/human-capital-and-risk/outsourcing-is-exploding-in-healthcare-will-the-trend-last.html (last accessed August 25, 2019)

[x] Zack Cooper, Fiona Scott Morton and Nathan Shekita. 2018.

[xi] For a detailed explanation of the PE business model, see Chapter 2, Eileen Appelbaum and Rosemary Batt. 2014. Private Equity at Work: When Wall Street Manages Main Street , NY: Russell Sage Foundation Press.

[xii] Jeff Lagasse. 2017. "Nearly Half of Medical Care Comes from Emergency Rooms, Study Shows."

https://www.healthcarefinancenews.com/news/nearly-half-medical-care-comes-emergency-rooms-study-shows (last accessed July 13, 2019).

[xiii] Rosemary Batt and Eileen Appelbaum. 2019. "The Agency Costs of Private Equity: Why do Limited Partners Funds Still Invest?" Academy of Management Perspectives. Forthcoming.

[xiv] Envision Physician Services. https://www.envisionphysicianservices.com/; https://www.amsurg.com/ (last accessed August 22, 2019)

[xv] PitchBook_EmCare_2019_08_10_14_18_43, EmCare Company Profile dated July 27, 2019.

[xvi] PitchBook_Envision_Healthcare_2019_08_10_16_06_31, Envision Healthcare Profile dated July 27, 2019; Brooke Sutherland. 2018. "It's the Great Health Care Buyout Shuffle," Think Advisor , June 11. https://www.thinkadvisor.com/2018/06/11/its-the-great-health-care-buyout-shuffle/?slreturn=20190710143530 (last accessed August 13, 2019)

[xvii] PitchBook. 2019. Envision Healthcare Profile dated July 27, 2019.

[xviii] Susannah Luthi. 2019. "In Battle Over Surprise Bills, Senate Ponders Requiring In-Network Rates." June 12. https://www.modernhealthcare.com/physicians/battle-over-surprise-bills-senate-ponders-requiring-network-rates (last accessed August 10, 2019).

[xix] Susannah Luthi. 2019.

[xx] Zack Cooper, Fiona Scott Morton and Nathan Shekita. 2018.

[xxi] Michael J. de la Merced. 2018. "K.K.R. Said to Be Near Deal to Acquire Envision Healthcare," New York Times , June 10. https://www.nytimes.com/2018/06/10/business/dealbook/kkr-envision-healthcare-deal.html?dlbk=&emc=edit_dk_20180611&nl=dealbook&nlid=70726928_dk_20180611&te=1 ; Shelby Livingston. 2018. "UnitedHealth Hits Back at Envision over ER Billing Practices," Modern Healthcare , March 20. http://www.modernhealthcare.com/article/20180320/NEWS/180329992 ; Senator Claire McCaskill's letter to Envision can be found here https://www.hsgac.senate.gov/imo/media/doc/2017-09-20%20CMC%20Ltr%20to%20EmCare%20re%20Pricing.pdf (last accessed August 2, 2019)

[xxii] TeamHealth. 2019. Our Company. https://www.teamhealth.com/our-company/ (last accessed August 22, 2019).

[xxiii] PitchBook. 2019. Team_Health_Holdings_2019_08_09_17_21_39, TeamHealth Holdings Company Profile dated July 27, 2019.

[xxiv] PitchBook. 2019. IPC_Healthcare_2019_08_09_17_57_38, IPC Healthcare Company Profile dated July 27, 2019.

[xxv] U.S. Attorney's Office, Northern District of Illinois. 2014. "U.S. Files Lawsuit against IPC The Hospitalist Company, Alleges Overbilling of Federal Health Insurers for Physician Services," Department of Justice , June 17. https://www.justice.gov/usao-ndil/pr/us-files-lawsuit-against-ipc-hospitalist-company-alleges-overbilling-federal-health ; M.L. McLaren. 2017. "$11M Whistleblower Award on TeamHealth $60M Overbilling Medicare & Medicaid at IPC Healthcare," Whistleblower News Review , February 27. https://www.whistleblowergov.org/healthcare-and-pharma.php?article=TeamHealth-pays-60M-on-IPC-Healthcare-Upcoding-Fraud-Whistleblower-Allegations_107 (last accessed August 19, 2019)

[xxvi] Jason Carris. 2015. "TeamHealth Announces $1.6 Billion Acquisition of IPC Healthcare," The Hospitalist , August 4. http://www.the-hospitalist.org/article/teamhealth-announces-1-6-billion-acquisition-of-ipc-healthcare/ ; Steven Ross Johnson. 2015. "Why TeamHealth Plans to Pay $1.6 billion for IPC Healthcare," Modern Healthcare , August 4. http://www.modernhealthcare.com/article/20150804/NEWS/150809978 (last accessed August 16, 2019)

[xxvii] Zack Cooper, Fiona Scott Morton, and Nathan Shekita. 2018.

[xxviii] United States Government Accountability Office. 2019. "Air Ambulance: Available Data Show Privately-Insured Patients Are at Financial Risk," GAO, March. https://www.gao.gov/assets/700 (last accessed August 25, 2019)

[xxix] PitchBook. 2019. American_Medical_Response_2019_8_10_13_21_18, American Medical Response Company Profile dated July 27, 2019.

[xxx] AirMedCare Network. 2019. https://www.airmedcarenetwork.com/coverage/ (last accessed August 22, 2019)

[xxxi] Carl O'Donnell. 2017. "Exclusive: Buyout Firm KKR in Lead to Acquire Envision's Ambulance Unit – Sources," Reuters , July 14. http://www.reuters.com/article/us-envision-healthcare-m-a-kkr-idUSKBN19X309 (last accessed July 19, 2019)

[xxxii] PitchBook. 2019. Air Methods Company Profile dated August 25, 2019.

[xxxiii] Bob Herman. 2017. "Air Methods Bought Out for $2.5 Billion," Axios , March 14. https://www.axios.com/air-methods-bought-out-for-25-billion-1513300942-29d45472-f787-4c79-9eea-7f38ae92a371.html ; Peter Eavis. 2015. "Air Ambulances Offer a Lifeline and Then a Sky-High Bill," New York Times , May5. https://www.nytimes.com/2015/05/06/business/rescued-by-an-air-ambulance-but-stunned-at-the-sky-high-bill.html?_r=0 (last accessed July 28, 2019)

[xxxiv] United States Government Accountability Office. 2019.

[xxxv] Ga Bai, Arjun Chanmugam, Valerie Y. Suslow, and Gerard F. Anderson. 2019. "Air Ambulances with Sky-High Charges," Health Affairs , July: 38(7):1195-1200. https://www.ncbi.nlm.nih.gov/pubmed/31260345 (last accessed August 19, 2019)

[xxxvi] Tara Bannow. 2019. "Hospitals' Solution to Surprise Out-Of-Network Bills: Make Physicians Go In-Network." Modern Healthcare. January 12. https://www.modernhealthcare.com/article/20190112/TRANSFORMATION04/190119990/hospitals-solution-to-surprise-out-of-network-bills-make-physicians-go-in-network (last accessed August 13, 2019)

[xxxvii] Tara Bannow. 2019.

[xxxviii] Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. 2019. Figures 10-11.

[xxxix] Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. 2019. Figures 12.

[xl] Envision's website states that it is committed to negotiating contracts for 'in-network status whenever possible.' https://www.evhc.net/endsurprisecoverage (last accessed August 20, 2019)

[Sep 04, 2019] The NY Times has an article today detailing hospitals suing patients, garnishing wages, and placing liens on property for people with "access" by way of health insurance.

Notable quotes:
"... There is shortage of doctors and nurses(?) but a surfeit of administrators and executives and managers, as it was said in The Godfather, "dipping their beaks." ..."
Sep 04, 2019 | www.nakedcapitalism.com

Jason Boxman , September 3, 2019 at 3:00 pm

Also, on "access", the NY Times has an article today detailing hospitals suing patients, garnishing wages, and placing liens on property for people with "access" by way of health insurance.

What we really need in this country is clearly _more_ access, yes?

What we should be doing is nationalizing all providers. Period. Then we can vastly reduce the number of useless healthcare executives that feed upon American citizens.

Synoia , September 3, 2019 at 3:56 pm

Need a couple of well funded lawsuits, with discovery, to illustrate the lack of disclosures amd mythical charges in Hospital billing.

John , September 3, 2019 at 4:10 pm

There is shortage of doctors and nurses(?) but a surfeit of administrators and executives and managers, as it was said in The Godfather, "dipping their beaks."

Lambert Strether Post author , September 3, 2019 at 4:44 pm

Access to Debt Collectors™ -- a winning program for liberal Democrats!

pretzelattack , September 3, 2019 at 7:33 pm

for some starving seniors, access to food would be nice. hey, maybe there's a market for food insurance, cause adding a layer of predators helps efficiency.

[Aug 30, 2019] Angry Bear Purdue Offers Up $10 12 Billion to Settle All Lawsuits MedPage Update by run75441

Aug 27, 2019 | angrybearblog.com

Just revealed:

The opioid/OxyContin maker Purdue and members of the billionaire Sackler family owning the company have offered to settle thousands of lawsuits against the company for $10 to $12 billion. according to people briefed on the offer. More than 2,000 states, cities, and counties across America are pursuing the OxyContin maker over the large bills for cleaning up the opioid crisis -- and are deciding whether to accept the offer by Friday. The Financial Times is reporting on this offer from the Sacklers and Purdue.

On August 26, Purdue paid $270 million to Oklahoma and Teva Pharmaceuticals paid $75 million also to Oklahoma.

From the Financial Times: "Purdue said it believes a 'constructive global resolution is the best way forward' and is working with state attorneys-general and other plaintiffs to achieve it. While Purdue Pharma is prepared to defend itself vigorously in the opioid litigation, the company has made clear that it sees little good coming from years of wasteful litigation and appeals".

For all the harm done to this nation due to purposeful deceit and lies on the use of opioids claiming it was not addictive, someone needs to go to prison from the Sackler family.

Purdue Exposed

Medpage Today, Kristina Fiore, August 28,2019

I suspect with the new information being available, Purdue finally threw in the towel and offered a settlement. I also suspect this will impact other companies decisions to appeal as J & J is doing.

STAT News Wins Legal Fight Over Purdue Documents

A trove of documents detailing Purdue Pharma's role in the opioid epidemic will be made public, STAT News reported, as the Kentucky Supreme Court denied the company's request to review lower courts' decisions to release them.

STAT waged a 3.5-year legal battle to make those records public. While some remain under seal, the outlet posted a sought-after video deposition of Richard Sackler. It had obtained a transcript of that deposition in February, which gained further attention when comedian John Oliver hired famous actors including Bryan Cranston and Michael Keaton to re-enact it.

The documents promise new information on how Purdue promoted its oxycodone product OxyContin and what, exactly, its executives knew about its risk of addiction. Among those documents are depositions of other Purdue executives; physician testimony; emails and memos about marketing strategies; internal reports on clinical trials; and communications about earlier legal cases.

All of the documents were part of Kentucky's lawsuit against Purdue over its alleged illegal marketing of OxyContin. That suit was settled in 2015, with Purdue shelling out $24 million.

Purdue may soon be paying a far higher bill, with media including NBC News reporting that the company has pitched a $10 to $12-billion settlement in the consolidated cases set to go to trial before a federal judge in Ohio in October.

This does not bode well for Purdue, its settlement, or threat of years of litigation. The smoking gun was always there and pieces of it can be found in previous posts of mine. Relating the US Senate Joint Committee numbers to when Oxycontin was introduced after 1995 and the incremental increase in deaths from opioids, the use of a part of the Porter and Jink letter to the NEJM which said opioids were not addictive " minus the part where it said when used in a hospital setting ," the abuse of the Porter and Jink letter in the number of citations , the millions spent in lobbying state legislatures to block new laws, etc.

John Oliver uses Keaton and Cranston to portray Richard Sackler in this 20 minute Clip. It is worth watching. " the launch (Oxycontin) would be followed by a blizzard of prescriptions that will bury the competition. The blizzard will be so deep, dense, and white,."

  1. wooley , August 28, 2019 10:19 am

    Run .I am a 30 year veteran of being a sales person and at times, a sales executive in the networking industry. What these stories reveal is a sustained effort by this company and others to sell as many pills as possible without any controls or brakes on what any responsible sales executive would notice the second his point of sale report came in showing massive amounts of sales to certain individuals or areas. There is no way I can accept that this was not under the control of both sales and marketing at this company. They made bundles of money for years on sales of these highly addictive drugs. They ignored sales to abusers of prescriptions that likely formed the basis for the addiction of millions in order to make quotas and gain bonus money. This stinks to high heaven. Some blame doctors rightly so but do not let them off the hook. A point of sale report shows exactly where all these pills are being sold and Perdue sales management decided not to give a damn.

  1. mike shupp , August 28, 2019 3:03 pm

    These people at Purdue Pharma and Teva are never going to go to prison or even face individual financial penalties -- after all, they are upper class capitalists!

    My suggestion: (1) Reflect that courts have decided that "Corporations are individuals!" And decide to punish the guilty individuals -- seize the corporations. The governments of the UK and USA ought to act to take over all assets of Purdue and Teva -- including all pharmacological products they own or have rights in. Nationalize them. Pay not one cent in compensation to stock holders. Stop paying all employees, and terminate any payments to pension funds. Cease all outgoing payments to suppliers and terminate all leases and real estate transactions.

    Then either operate the seized firms as a government operation, transfer all assets to the National Institute of Health for research purposes, or sell the real property on the open market to the highest bidder, with the purchase money being diverted to compensation of individuals unwittingly addicted to opioids. No one else should benefit from the continued existence of the guilty firms.

    (2) Alternately, state governments should feel encouraged to press for as much compensation as possible from the firms AND THEIR EXECUTIVES until all forced into complete bankruptcy.

    (3) Whichever alternative occurs, economic "experts" should recount this case and its resolution in the first chapter of any ECON 101 textbook they write, or describe the details in the first week or so of freshman/sophomore economic courses. Beginning economics students need to be made really clear about what "the Free Market" actually entails in the modern world. instead of swallowing Ayn Rand-ish fantasies.

    Sigh! To think I used to call myself a libertarian.

[Aug 29, 2019] Opiod epidemic is a a neoliberal Epidemics

Notable quotes:
"... My judgement includes findings of fact and conclusions of law that the state met its burden that the defendants Janssen and Johnson & Johnson's misleading marketing and promotion of opioids created a nuisance as defined by 50 O.S. Sec. 1 , including a finding that those actions compromised the health and safety of thousands of Oklahomans. ..."
"... Specifically, defendants caused an opioid crisis that is evidenced by increased rates of addiction, overdose deaths and neonatal abstinence syndrome in Oklahoma ..."
"... "As I just stated, the opioid crisis has ravaged the state of Oklahoma. It must be abated immediately. For this reason, I am entering an abatement plan that consists of costs totaling $572,102,028 to immediately remediate the nuisance," Balkman said. "This is the amount of costs that I am constrained to order Janssen and Johnson & Johnson to pay based on the particulars of a nuisance claim and the evidence that was presented at trial. ..."
"... Gorsky also assured Johnson & Johnson's business partners the stimulants it plans to produce will be every bit as addictive as opioids and accompanied by an equally widespread misinformation campaign. ..."
Aug 29, 2019 | www.nakedcapitalism.com

Everything went according to neoliberal dogma: Greed is good

As nondoc.com reported:

"I've opted not to read the entire 42-page judgment," Balkman told a packed courtroom in Norman shortly before announcing the numbers in his verdict. "The opioid crisis is an eminent and menace to Oklahomans.

My judgement includes findings of fact and conclusions of law that the state met its burden that the defendants Janssen and Johnson & Johnson's misleading marketing and promotion of opioids created a nuisance as defined by 50 O.S. Sec. 1 , including a finding that those actions compromised the health and safety of thousands of Oklahomans.

Specifically, defendants caused an opioid crisis that is evidenced by increased rates of addiction, overdose deaths and neonatal abstinence syndrome in Oklahoma."

Balkman said the opioid crisis is a "temporary public nuisance that can be abated."

"As I just stated, the opioid crisis has ravaged the state of Oklahoma. It must be abated immediately. For this reason, I am entering an abatement plan that consists of costs totaling $572,102,028 to immediately remediate the nuisance," Balkman said. "This is the amount of costs that I am constrained to order Janssen and Johnson & Johnson to pay based on the particulars of a nuisance claim and the evidence that was presented at trial.

"Whether additional programs and fundings are needed over an extended period of time, those are determinations to be made by our legislators and policy makers. In this moment and based on this record, this is what the court can and will do to abate the nuisance."

Balkman noted that he still has jurisdiction over the case , and that he almost certainly will be asked to make additional rulings.

"So it impossible for me to make any further statements about the trial or my ruling other than what I have said today," Balkman said.

Note that a judge, not a jury set the amount of damages to be awarded. A jury would almost certainly have awarded a higher payout by J & J (although that hypothetical amount may then have been reduced after appeal).

The amount J & J must now pay the state of Oklahoma is significantly greater than the $270 million Purdue Pharma, the manufacturer of OxyContin owned by the Sackler family, and the $85 million Teva Pharmaceuticals, separately agreed previously to settle each's respective Oklahoma claims. \

Additionally, Purdue and Teva also avoided incurring the costs of contesting a trial.


John Zelnicker , August 28, 2019 at 12:25 pm

Jerri-Lynn – Thank you for keeping us updated on the progress of these lawsuits. The pharmaceutical drug dealers need to be held accountable for the damage they have caused. The claim that OxyContin was not addictive, or less so than other opioids, was laughable to anyone who had some experience with them.

There have been three prosecutions locally of doctors who were giving out opioids like candy, even letting nurses write the scrips so the "patients" could be moved through the process more quickly.

I was a patient of one of those doctors (back problems, including surgery) for a while a couple of years before he was prosecuted, lost his license, and had to do some time in prison (IIRC). He seemed to follow most of the rules (and wrote all scrips himself), but was easily persuaded to increase a patient's dosage. Fortunately, I stopped taking opioids before things got hot.

Adam1 , August 28, 2019 at 12:39 pm

Unless it comes with several decades of jail time and confiscation of all private property obtained with ill begot gains (that's what we'd hand a major heroin dealer) then it's not a reasonable settlement.

J&J the company didn't do anything. It's just a legal, non-person thing. The criminals are the people running it and they need to be the ones held liable.

Don't get me wrong. J&J as a company needs to help fix this mess, but we can't let the real criminals slither into the night and drift off on their yachts drinking champagne bought with money taken from ruined families and communities.

PKMKII , August 28, 2019 at 12:43 pm

For context, J&J's net income for 2018 was $15.29 billion. So this particular verdict represents 3.74% of J&J's annual net income.

Annieb , August 28, 2019 at 1:37 pm

To get the full extent of Purdue's criminality, read "American Overdose." The author is Chris McGreal While reading it, I thought that this opioid epidemic began and developed in a similar fashion to the subprime mortgage fiasco with the same type of warnings, collusions and criminal fraud. Huge profits for the corporate criminals. And , tragically, the resulting human consequences, financial ruin in the one case and death in the other.

notabanktoadie , August 28, 2019 at 4:16 pm

In a healthy society, i.e. one with economic justice*, the demand for drugs would be small since there would be little need to escape reality per:

Give strong drink to him who is perishing,
And wine to him whose life is bitter.
Let him drink and forget his poverty
And remember his trouble no more.

Open your mouth for the mute,
For the rights of all the unfortunate.
Open your mouth, judge righteously,
And defend the rights of the afflicted and needy.
Proverbs 31:6-9 [bold added]

*Which certainly would not include government privileges for private credit creation, i.e. for the banks and the rich, the most so-called credit worthy of what is then, in essence, the PUBLIC'S credit but for private profit.

DonCoyote , August 28, 2019 at 4:35 pm

Johnson & Johnson Pledges To Push Uppers For Couple Decades To Even Things Out (The Onion)

Gorsky also assured Johnson & Johnson's business partners the stimulants it plans to produce will be every bit as addictive as opioids and accompanied by an equally widespread misinformation campaign.

I think they forgot to mention that that's where $544 million of the $572 million settlement will go–back to J&J to produce, market, and distribute the uppers.

[Aug 25, 2019] Pruning the tree when spring starts

Aug 25, 2019 | angrybearblog.com

run75441 | August 25, 2019 8:00 pm

Healthcare Hot Topics End of month July and Pfizer is spinning off Upjohn to generic drug/device company Mylan NV. Pfizer bought 57% of the unnamed (mid – 2020) new company. This move comes under Pfizer CEO Albert Bourla who took over the reins from Ian Read in January, 2019. Bourla has been with Pfizer for 25 years. Before becoming the CEO, Bourla was the Chief Operating Officer (COO) overseeing the company's commercial strategy, manufacturing, and global product development functions.

CEO Bourla has been making strategic moves following what he has called a "pruning the tree when spring starts and Pfizer is in the spring of high growth" strategy. What caught my eye is this one comment in the Wall Street Journal about remaking Pfizer into a company focused on patent-protected prescription medicines with the potential for significant sales growth from a more diversified but slower-growing player. To me, this translate into a; "hey the Mylan EpiPen strategy worked, lets do the same with other products" strategy.

To date, he has overseen a restructuring at the company and made smaller deals to boost Pfizer's pipeline of cancer and other drugs under development. Still not the biggest deal which would make Pfizer a giant. He has been guiding the combining of a division selling Advil, vitamins, bathroom found meds with GlaxoSmithKline PLC's own consumer-health business to be spun off in a joint venture. Nothing earth-shattering there.

CEO Bourla focus for Pfizer on higher profit, exclusive, prescription drugs while moving the rest of its lower profit operations into other ventures. Off-patent drugs such as Lipitor and Viagra having lower profit margins would be targeted for joint ventures and Pfizer would still retain sizeable amounts of cash flow from these drugs to fund R&D. Pfizer is shifting the declining brands to Upjohn. The intent is to consolidate this business with Upjohn and merge Upjohn with the EpiPen company Mylan and rename the two.

The new Pittsburgh – based unnamed company is expected to be among the world's largest sellers of generic and off-patent medicines with more than $19 billion in yearly sales. Pfizer Shareholders will own 57% of the new company and Mylan shareholders would the rest. Pfizer would be paid $12 billion raised from new debt acquired from the joint venture. Upjohn would return to the US from its corporate base in Shanghai, a reversal of its earlier inversion.

To me, this is a strategic move along the lines of Pfizer selling off the marketing of EpiPen to Mylan and keeping the manufacturing of it. Pfizer owned Meridian Medical Technologies manufactured EpiPen for Mylan and it will now be a part of the sale to Mylan. EpiPen was a huge success story for Mylan. A quadrant strategy of milking of a cash cow to fund new ventures.

Including EpiPen, " Mylan's operating profit for its Specialty segment grew from about 35% in 2012 to roughly 60% in the second quarter of 2016." Most of this can be traced back to the change in design of the EpiPen (cap) , exclusivity of it due to design changes which was covered by patents, and the rejection of Teva's generic by the FDA due to a difference in application.

Add to this strategy story, Eli Lilly's Alex Azar's success profiteering off of the decades old diabetes drug Humalog and one can begin is imagine what the new "unnamed" company's role will be under CEO Albert Bourla's direction . . . more of the same.

In its analysis, World Health Organization determined the expenditure of one dollar in R&D being covered by $14.50 profit for cancer pharmaceuticals or more than enough to recoup expenditures for R&D and provide a healthy return for investors. The generics Upjohn will acquire have more than paid back the costs of R&D and are more than likely to be in a decline in producing profits. The question then becomes how to enhance the return on these generics.

Mylan changed Pfizer's EpiPen design to achieve patented exclusivity. Teva could not duplicate it as a generic because patients could not use the Mylan instructions in applying the Teva generic. According to FDA'a rules, the Teva product could not be cast as a generic for the Mylan EpiPen in the marketplace as it could "not" be used in the same manner..

EIi Lilly's Humalog, same formulation as what was made decades ago. The list price for one vial of Humalog has nearly tripled over the last decade. No new and improved or patent changes. Lilly appears to be taking increased profits from the price changes and passing on a larger slice to Pharmaceutical Benefit Managers to gain preference by healthcare insurance plans represented by the PBMs.

The same at the other diabetes med manufacturers Sanofi and Novo. Sanofi , a diabetes drug manufacturer and competitor to Eli Lilly gave insurers and pharmacy benefit managers rebates totaling more than half of its gross sales in the U.S. last year, resulting in net price declines across its portfolio despite list price hikes taken on dozens of its prescription products.

What is occurring is "shadow pricing" increases where one company raises pricing and the others follow.

A lawsuit filed in 2017 alleged three companies ( Eli Lilly , Novo Nordisk, and Sanofi) intentionally raised the list prices on their drugs to gain favorable treatment from pharmacy benefit managers, who work with health insurers and drug makers and help decide how a drug will be covered on a list of approved drugs. Insurance companies do not pay manufacturer list pricing. The PBMs negotiate a rebate to the insurance companies from which they take a portion of it for themselves. The insured gets the net price after Rebates are paid to insurance company minus the PBM bonus for negotiated price.

It is in this circus of net profits after rebates and bonuses, I believe the Upjohn/Mylan "nameless" new company battle will be fought to increase Pfizer's profit. This is not like the EpiPen medical device where a change in design of the pen can be made and a new patent secured. Some drugs may be changed which would result in a new patent. I suspect much of Upjohn/Mylan product profit improvement will be fought by getting preference from Pharmacy Benefit Managers.

CEO Albert Bourla will be watching the new company to see how successful they are in creating preference with PBMs and the resulting profit.

https://www.youtube.com/embed/aeG2lWxYO_Y Why are our drugs so Costly? Watch the YouTube Presentation to Understand why Drugs are so Expensive to You.

[Aug 08, 2019] Free Market Drugs Are a Really Big Deal

Aug 08, 2019 | economistsview.typepad.com

anne , August 03, 2019 at 07:39 AM

http://www.socialisteconomist.com/2019/08/why-arent-democrats-talking-about.html

August 2, 2019

Big Pharma Current Affairs Dean Baker United States
Why Aren't the Democrats Talking About Ending Patent-Financed Drug Research?
By DEAN BAKER

Direct Public Funding: The Alternative to Patent Monopolies.
________________________________
It would be nice to see Democrats propose plans that would stop the government from making drugs expensive in the first place.
________________________________

Many of the leading Democratic candidates, especially Bernie Sanders and Elizabeth Warren, have been putting forward bold progressive plans in a wide variety of areas. Sanders and Warren have both supported a quick transition to a universal Medicare program, with no premiums, co-pays, or deductibles. Several candidates have supported a Green New Deal, which in some versions would guarantee every worker in the country a decent paying job.

Such policies are really big deals. They would both have a huge impact on people's lives and also pose serious problems of implementation. The willingness of Democrats to think big in other areas makes their determination to think small on prescription drugs surprising. Replacing government-granted patent monopoly financing of research is both a huge deal and one that can be implemented gradually without threatening massive disruptions in a transition process.

Free Market Drugs Are a Really Big Deal

First, it is necessary to realize that having drugs available at free market prices, without patent monopolies or other forms of exclusivity, would have an enormous impact on the economy and the health care system. On the first point, we will spend more than $460 billion on prescription drugs in 2019. Without patent protection, these drugs would almost certainly sell for less than $80 billion, implying a savings of more than $380 billion. (I go through this calculation here .)

To put this $380 billion figure in context, it is more than five times the annual food stamp budget. It is more than twice the size of the Trump tax cut. If we project out the savings over the course of a decade, they would come to more than $5 trillion. That is more than three times the amount that is projected to be needed to cover the cost of full forgiveness for outstanding student loan debt. This is more than $30,000 per household. In short, there is huge money at stake by any measure.

On the first point, we will spend more than $460 billion on prescription drugs in 2019. Without patent protection, these drugs would almost certainly sell for less than $80 billion, implying a savings of more than $380 billion.

Of course this goes well beyond a dollar and cents calculation. Millions of people facing debilitating conditions or potentially fatal diseases struggle to come up with the money needed to pay for their drugs. This often requires patients and/or their families to battle with insurance companies. The need to raise money for drugs is also now a major use of GoFundMe pages.

If the research was paid in advance, so drugs could be sold as generics, it would not be a struggle to pay for even the newest and most innovative drugs. The price of generics is often less than 1.0 percent of the cost of high-priced drugs in the United States. For example, when the Hepatitis C drug Sovaldi was selling for $50,000 in the United States, a high-quality generic version was available in India for just over $300 for a 12-week course of treatment.

There would be comparable stories for breakthrough drugs and treatments in other areas, many of which now sell for more than $100,000 a year in the United States. The most expensive now cost more than $1 million. Without government-granted patent monopolies, the prices would almost certainly be less than 1.0 percent as high, and possibly closer to 0.1 percent of the current U.S. price.

The basic story is drugs are cheap. It is rare that the manufacturing and distribution process involves major costs. Prices are a problem because of government-granted monopolies.

The patent problem goes beyond prescription drugs. It applies to medical equipment and medical tests as well. An MRI or other scan would just be a couple of hundred dollars if it was a question of covering the wear and tear on the equipment and the pay for a skilled technician to conduct the scan and a doctor to read and assess the findings. It is patent monopolies that make these scans expensive. The savings from ending reliance on patent monopolies in these other areas would probably add $100 to $150 billion annually to the total, another 1.5-2.0 multiples of the annual food stamp budget.

National Public Radio recently did a piece about a woman who had a surprise bill of $94,000 for neuromonitoring services during a surgery on her spine. The reason this process could be billed for $94,000, as opposed to perhaps one-twentieth of this amount, is that the process is patented. If the neuromonitoring system had been developed with public funds, there would be no huge bill with which to surprise patients.

In short, the main reason that so many aspects of medical care are tremendously expensive is that we give companies patent monopolies. Since they are selling items that are essential for people's health or their life, these monopolies allow them to charge outlandish prices. This is the same story as if firefighters set prices based on what it is worth to have family members rescued from burning houses. Needless to say, we would all be willing to pay lots of money in such situations, especially if we could get a third party (e.g., our insurance company or the government) to foot the bill.

Direct Public Funding: The Alternative to Patent Monopolies

The pharmaceutical industry and its supporters in Congress try to pretend that we couldn't possibly develop new drugs without the incentive of patent monopolies. For some reason we are supposed to believe that, even though in all sorts of jobs people work for money, they can only develop drugs with the prospect of getting a patent. I suppose you have to be on the pharmaceutical industry's payroll to understand this logic.

The industry's argument gets even more bizarre when we consider that it is the biggest advocate of increased funding for the National Institutes of Health (NIH). NIH and other agencies get more than $40 billion a year to do biomedical research. This money is primarily spent on basic research.

Somehow we are supposed to believe that this money is well spent, but if the government were to spend more to replace the industry's patent-supported research and clinical testing, it would be the same thing as throwing the money in the toilet. The industry's argument is especially bizarre since many important drugs have actually been developed with government funding. In addition, the NIH has supported thousands of clinical trials.

One interesting comparison is the $2.6 billion that the industry claims it costs it to develop a single drug through patent monopoly financing, with the dozens of drugs and treatments that have been developed by the Drugs for Neglected Diseases Initiative with a cumulative 15-year budget that is less than half of this amount. While there are differences that make the two efforts not strictly comparable, the comparison shows why it is difficult to take seriously the pharmaceutical industry's claims that we have the best possible system for financing research.

There is a good argument for not having all research done directly by the government, but there is no reason that it could not be contracted out to private companies who would operate under long-term contracts. The condition of getting a contract would be that all findings are posted on the internet as soon as practical and that all patentable inventions would be placed in the public domain. (As a practical matter, it would probably be desirable to "copyleft" the patents. This is discussed in somewhat more detail in chapter 5 of Rigged.)

The incentives for a company operating on a long-term contract would be to try to make a case for having a contract renewed and expanded. This would mean doing as much as possible to improve public health in the areas for which they have contracted research. This includes not just developing useful drugs, but also scientific breakthroughs that could lead others to develop useful drugs or other treatments.

Under this public funding system, they would have incentive to publicize their findings as widely as possible..

In this way, the incentives are directly at odds with the patent system. Under the patent system, companies have incentive to keep their findings secret (apart from having to disclose information to get the patent) in order to be best positioned to be able to profit from them. Under this public funding system, they would have incentive to publicize their findings as widely as possible so that they could get credit if they eventually lead to the development of a product or process with important public health benefits.

Another huge advantage of this system is that it would take away the corruption that is endemic to the system of patent-supported drug research. Patent monopolies give drug companies an enormous incentive to push their drugs as widely as possible, even when they may not be the most effective drug or have harmful side effects. Purdue Pharma would not have been pushing OxyContin so vigorously if it were selling at generic prices. While the opioid epidemic is an extreme case, drug companies exaggerate the benefits of their drugs and conceal negative side effects all the time.

Going from Patent Monopolies to Free Market Drugs

There is one other important aspect to the switch away from patent monopoly-supported research to direct public funding; it can be done piecemeal. There is no reason to deny companies the opportunity to go ahead and do research with the expectation that they will recover the costs with their patent monopolies. They just would have to worry that they will be competing with a new drug that is every bit as good, or possibly even better, selling at generic prices.

We don't even have to try to displace patent-supported research all at once. There is no reason the government can't add $4 or $5 billion to its annual spending on NIH to support the development and testing of drugs in specific areas, such as cancer or heart disease. This can allow us both to see how the effectiveness of direct funding compares to patent-supported research and also to uncover whatever problems exist with this mechanism.

Given this simple story, it is difficult to see why none of the more progressive Democratic presidential candidates have taken up the cause of ending patent-monopoly financing of prescription drug research. This failure is especially peculiar, since both Sanders and Warren (along with Senators Booker, Gillibrand, and Klobuchar) were sponsors of a bill that would provide some public funding for research that would lead to new drugs being introduced as generics.

It's great to see the candidates proposing plans that would bring down the cost of prescription drugs. It would be even better to see them propose plans that would stop the government from making them expensive in the first place.

ilsm -> anne... , August 03, 2019 at 08:40 AM
why, democrats are not talking about ending the perpetual wars.... their base in not us.

[Aug 06, 2019] Marianne Williamson suggests that the antidepressants are hugely and recklessly overused.

Notable quotes:
"... My problem is not with antidepressants per se, which clearly have and do help many people. My problem is only with their overprescription, and the practices of pharmaceutical companies when drugs are marketed in predatory ways." ..."
"... I have met hundreds of people going through hell trying to get off antidepressants that should never have been prescribed to them. I've worked with people going through normal human crises since 1983. And I have seen what has been, in many cases, the devastating effects of overprescription. ..."
Aug 06, 2019 | www.nytimes.com

In books, interviews and posts on social media, Ms. Williamson has criticized the widespread use of antidepressants ; suggested they were to blame for some celebrities' suicides ; characterized treatment guidelines for postpartum depression as a way for pharmaceutical companies to make more money ; and called the distinction between ordinary sadness and clinical depression "artificial."

How widely antidepressants should be prescribed, and under what circumstances, is a real debate among psychiatrists. But Ms. Williamson has tended to make broad arguments, suggesting that the drugs are hugely and recklessly overused. Mental health experts say comments like these can increase stigma and make people less likely to seek treatment, even if that is not the intention.

... ... ...

"I have no judgment -- nor do I believe I have ever expressed any -- of anyone taking antidepressants," she added in a text message after the interview. "I'm happy for anyone who is finding the help they need for any ailment whatsoever. My problem is not with antidepressants per se, which clearly have and do help many people. My problem is only with their overprescription, and the practices of pharmaceutical companies when drugs are marketed in predatory ways."

... ... ...

She also says she has twice received diagnoses of clinical depression, and writes:

However deep my suffering, I didn't want to be anesthetized as I went through it. Like an expectant mother who wants to give birth naturally, rejecting drugs during labor because she wants to experience "natural childbirth," I wanted to be fully available to the depths of my pain. Why? Because I knew it had something to teach me. I knew that somehow, in some way, my suffering would lead to a blazing new dawn in my life -- but only if I was willing to endure the deep, dark night preceding it.

... ... ...

I have met hundreds of people going through hell trying to get off antidepressants that should never have been prescribed to them. I've worked with people going through normal human crises since 1983. And I have seen what has been, in many cases, the devastating effects of overprescription.

That's not to say that some people do not have serious -- and by the way, I have certainly had experiences where I have said, "I think you should go see a psychiatrist." I can tell you the difference.

One is, "I'm crying because my boyfriend left," and one is someone who can't even look up. I understand the difference, and when someone is showing certain symptoms, I'm the first to say, "I think you should go see a psychiatrist."

[Aug 01, 2019] Private Equity: The Perps Behind Destructive Hospital Surprise Billing

Aug 01, 2019 | www.nakedcapitalism.com

Posted on August 1, 2019 by Yves Smith I have to confess to having missed how private equity is a central bad actor in the "surprise billing" scam that is being targeted by Federal and state legislation. This abuse takes place when hospital patients, even when using a hospital that is in their insurer's network, are hit with charges for "out of network" services that are billed at inflated rack rates. Even patients who have done everything they can to avoid being snared, like insisting their hospital use only in-network doctors for a surgery and even getting their identities in advance to assure compliance, get caught. The hospital is in charge of scheduling and can and will swap in out-of-network practitioners at the last minute.

Private equity maven and co-director of the Center for Economic and Policy Research Eileen Appelbaum explained in an editorial in The Hill in May how private equity firms have bought specialist physicians' practices to exploit the opportunity to hit vulnerable patients with egregious charges:

Physicians' groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want.

This has made physicians' practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms .

Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not operate like an ordinary marketplace. Physicians' practices in these specialties do not need to worry that they will lose patients because their prices are too high.

Patients can go to a hospital in their network, but if they have an emergency, have a baby in the neonatal intensive care unit or have surgery scheduled with an in-network surgeon, they are stuck with the out-of-network doctors the hospital has outsourced these services to .

It's not only patients that are victimized by unscrupulous physicians' groups. These doctors' groups are able to coerce health insurance companies into agreeing to pay them very high fees in order to have them in their networks.

They do this by threatening to charge high out-of-network bills to the insurers' covered patients if they don't go along with these demands. High payments to these unethical doctors raise hospitals' costs and everyone's insurance premiums.

As an example, Appelbaum cites the work of Yale economists who examined what happened when hospitals outsourced their emergency room staffing to the two biggest players, EmCare, which has been traded among several private equity firms and is now owned by KKR and TeamHealth, held by Blackstone:

.after EmCare took over the management of emergency services at hospitals with previously low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In addition, the firm raised its charges by 96 percent relative to the charges billed by the physician groups they succeeded.

The study also described how TeamHealth extorted insurers by threatening them with high out-of-network charges for "must have" services:

in most instances, several months after going out-of-network, TeamHealth physicians rejoined the network and received in-network payment rates that were 68 percent higher than previous in-network rates.

We'd wondered why California legislation to combat surprise billing got yanked so quickly, with the opponents not even bothering to offer excuses . The official story was that hospitals objected, but the speed of the climbdown looks to have much more to do with the political clout of private equity donors.

The Financial Times yesterday made explicit how proposed Federal legislation would hit KKR's EmCare and other private equity health care predators :

A push on Capitol Hill to stop US patients from being caught unaware by medical bills is weighing on the debt of KKR-backed Envision Healthcare, the target of one of the biggest leveraged buyouts last year

Investors are concerned that a new so-called "surprise billing" law could crimp revenues at companies such as Envision, which employs emergency-room doctors and anaesthetists through its subsidiary EmCare .

"It is like a ransom negotiation: 'I'll hit your enrollees with giant bills unless you pay me enough money not to do that'," said Loren Adler, associate director at USC-Brookings Schaeffer Initiative for Health Policy.

The debt that has gone wobbly. Recall that so-called credit funds, also managed by private equity firms, are big buyers of the leveraged loans that private equity firms use to finance their acquisitions. And public pension funds like CalPERS invest in these credit funds:

Envision's $5.4bn loan due in 2025, sold in September when investor demand for leveraged loans was very strong, slid from almost 97 cents on the dollar at the start of May to just 87.8 cents on the dollar on Thursday, as more detail surrounding possible legislation has been released.

Leveraged loans for Blackstone's TeamHealth and private-equity-owned air ambulance companies Air Methods and Air Medical have also taken hits.

The normally cool-headed, pro-business Financial Times readers were almost without exception appalled: "..highway robbers .smacks of fraud sheer criminality .ambushing patients .criminals." Welcome to health care, USA style.

Sadly, the article says that while both parties are eager to be seen to be Doing Something about health care costs, neither wants to give the other side a win, making new Federal legislation unlikely in the current session. But exposing private equity as the hidden hand behind this extortion may lead to more inquisitiveness about the degree to which private equity finding and exploiting economic choke-points has contributed to the suffering.


Tom Stone , August 1, 2019 at 6:50 am

The Hospital that both my Primary Care Physician and my Cardiologist are affiliated with has outsourced their Emergency Room.
If you show up needing care RIGHT NOW, your choice is to scrawl an assent on their little I Pad or die.
I landed there twice this year, and the bills are just starting to show up from the first trip.
Fuck'em.
If I live long enough to bother I'll fight them on the basis that I signed under duress and if that doesn't fly there's Bankruptcy.

Christopher Herbert , August 1, 2019 at 7:26 am

One of the peculiarities of our wildly inefficient medical care industry is that there are so many 'pens' in the ink bottle that overhead costs eat up money that should be used to improve services.

I describe our medical care system as a '100 silos' system. The jumble is enormously expensive. We generously fund this industry, but we do not get anywhere near the benefit.

Mark , August 1, 2019 at 7:53 am

"Consent is for in-network services only and excludes out-of-network services"

Elisabeth Rosenthal in "An American Sickness" suggested that one add this statement to the consent forms one is required to sign as a strategy to inoculate oneself against this practice. I've not had an opportunity to try it and was wondering if anyone has done it and if there was a reaction or objection from the provider.

Also Mark , August 1, 2019 at 11:06 am

For years, I have written words to the effect of "All charges not covered by insurance will be paid at a rate to be negotiated" on health care providers' financial responsibility forms, and initialed the addition. I've never had a doctor's office or hospital challenge it. I think most don't even notice that I've done it.

I've also never had to invoke it, so I don't know how effective it is, but thinking I am at least somewhat protected from surprise bills gives me some comfort in the face of our crazy health care system.

By the way, I routinely cite "An American Sickness" when making the point to people that it's not just the pharmaceutical companies and the insurance companies. It's pretty much every part of the health care industry.

Elspeth , August 1, 2019 at 11:45 am

I do it, every time, you just need to smile when you do so they know you still love them.

Jim A. , August 1, 2019 at 8:31 am

Which brings up what I was thinking about during last night's debate: Insurance companies are only SOME of the profit seeking pigs chowing down at the healthcare trough. Even if we eliminate them in a "medicare for all" plan the rest of of them will gladly eat their share. It would take something more like a VA for all plan with hospitals run by the government to deal with some of the others.

jfleni , August 1, 2019 at 8:41 am

What a surprise the medical OFFAL will #### you to the max when you need help;
YAHOO, up ###, Medicare for ALL,RIGHT NOW!!! SCREAM it to your congress-critter!

Mark , August 1, 2019 at 8:41 am

Who 'yanked' the California legislation?

Their names would help voters to hold them accountable.

TBone , August 1, 2019 at 9:19 am

If this does not change in 2020 I'm moving to a civilized nation like Canada even if I have to walk there. Grrrrrr this is SO WRONG. How do retirees apply to move to Canada? Are they letting us in anymore???

TBone , August 1, 2019 at 9:23 am

Oh new plan necessay, I can't pay that much for 5 years.
https://www.sapling.com/8474864/can-retire-canada-citizen

TBone , August 1, 2019 at 9:26 am

I'm just gonna avoid the medical system forever and die at home of natural causes or go to New Jersey for assisted suicide if necessary. Thanks USA medical crapification you filthy greedy (family blog)

ambrit , August 1, 2019 at 10:14 am

Don't just crawl off to an obscure corner and expire passively. Take some Medical Industry execs with you when you go. /s?

hemeantwell , August 1, 2019 at 10:49 am

/s? = ?

ambrit , August 1, 2019 at 11:03 am

/s = ending sarcasm tag. So that s/ = beginning sarcasm tag.
/s? = ending sarcasm tag indicates real sarcasm?

Chris , August 1, 2019 at 10:03 am

Class action lawsuit against south western Ohio hospital's and surgeon for balance billing:

https://www.google.com/amp/s/www.daytondailynews.com/news/crime–law/lawsuit-filed-against-premier-health-surgeon/DSEkWli4T4RR7VKoE8VJfP/amp.html

softie , August 1, 2019 at 10:09 am

In 2012, a neighbor's kid stayed three days in the hospital when his motorcycle got him into an accident. The bill is almost half million dollars.

flora , August 1, 2019 at 10:27 am

Thanks very much for this post. This is a PE medical extortion racket, imo.

Off The Street , August 1, 2019 at 10:40 am

My plumber showed me a type of client rights form that he is required to present during various repairs. That form is essentially a mitigant against being extorted, given the potential for such behaviors during exigent circumstances. Drip, drip, drip turns into flooding, or no hot water turns into challenges with dishes and washing clothes. Now envision your elderly relative in that situation.

An unscrupulous repairman could make some extra money by exploiting such circumstances, turning a seemingly innocent service call into triple golden time toward that new Mercedes. Disclosure: phrase inspiration from an old Frasier episode.

ambrit , August 1, 2019 at 11:11 am

I once worked for such a dishonest plumbing service company, for a very short time. I was fired after I refused to do unnecessary work at a customers house so as to jack up the bill. That outfit, and another I briefly worked for later were both cases where investor syndicates had 'bought' the companies, with predictable implementation of maladaptive behaviours.
"For the love of money is the root of all evil." 1 Timothy 6:10

Susan the other` , August 1, 2019 at 11:37 am

Thank you. This is astonishing info. Because medicine is changing quicker than lumbering, conniving private equity can kludge together new extortion rackets. It almost feels like PE is running in place. And everybody is on to them thanks to info like this. Just FYI, our new hospital that claims it is a non-profit health care corporation has just built a new wing for "specialty clinics" housed on site. And of course it has been their billing practice from day one to inform you that you might receive additional bills from any of these physicians. So far this seems to be under control. We've had 4 same-day surgeries there and no big surprises. But there is obviously a reason to establish this loophole. The takeover of emergency rooms by KKR/EM Care and Blackstone Team Health is pure extortion. Extortion lurking in the wings. I hope PE rots in hell sooner than later.

Anon , August 1, 2019 at 12:14 pm

The intro to the post could have been an instant replay of my hospital experience. Reading the many comments about medical billing shenanigans is somewhat "comforting" in that my experience wasn't singular. However, it is important that more people recognize the hospital billing scam and that some doctors have never memorized the Hippocratic Oath. If today's modern medicine saves you, the medical billing will likely "kill" you.

sleepy , August 1, 2019 at 12:19 pm

Speak of the devil. Right now, I'm sitting in a clinic waiting room while my wife has minor surgery for a basal cell carcinoma. She went to a medicare advantage plan awhile back due to the high premiums of her medicare supplemental plan. She was assured everything was in her network. We'll see, I guess.

[Jun 30, 2019] Systems like the Liverpool Care Pathway may be evil enough to begin with and then they are administered by bureaucratic incompetents that insist they are doing as they are instructed while watching the patients become worse.

Jun 30, 2019 | www.zerohedge.com

OCnStiggs , 2 hours ago link

Couldn't be the British National Healthcare System now could it? You know, the one where elderly patients are wheeled on gurneys to wait out the weekend in darkened corridors with minimal attention. If they survive the weekend, they get a new room and more care. Most die a lonely death because the system has deemed them past their productive age. Only the best from Big Gubmint.

Just sayin'.

silent one , 1 hour ago link

One ploy, experienced by my mother 75, blood pressure too high so on meds to lower it, then set date of op 6 weeks in advance, take blood for testing 4 weeks before the op, turn up on day of op wait 2 hours for nurse to come and tell her the results of the blood test 4 weeks earlier indicate her sodium is to low and cancel the op, told to up the sodium and referred back to doctor, told by doctor nurse on holiday for two weeks creating a delay, 3 weeks later for blood test to decide how many salt pills to prescribe, delay for subsequent blood test, week before blood test hospital phone to say it has taken to long for the blood tests so have taken her off the waiting list and referred her back to the doctor to start the process all over again. My mother a little old lady is in a lot of pain, now talking about ending it all. THE ******* CUNTS

Mariposa de Oro , 1 hour ago link

So sorry to hear of this. I hope things get better for her. Also, is there a naturopathic doctor in the area you can take her too?

Umh , 59 minutes ago link

Incompetence has limits that can be exceeded by bureaucratic incompetence. Systems like the Liverpool Care Pathway may be evil enough to begin with and then they are administered by bureaucratic incompetents that insist they are doing as they are instructed while watching the patients become worse.

[Jun 22, 2019] 1 In 6 Insured Hospital Patients Get A Surprise Bill For Out-Of-Network Care

Notable quotes:
"... By Rachel Bluth, Kaiser Health News reporter. Originally published at Kaiser Health News . ..."
"... On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.) ..."
"... The research also found that when a patient is admitted to the hospital from the emergency room, there's a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill. ..."
"... Each time ..."
"... "but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher) deductibles and co-pays." ..."
"... inpatient stays ..."
Jun 22, 2019 | www.nakedcapitalism.com

1 In 6 Insured Hospital Patients Get A Surprise Bill For Out-Of-Network Care naked capitalism

Posted on June 22, 2019 by Lambert Strether Lambert here: But it doesn't matter. People love their health insurance companies! (And do note the role, entirely accidental I am sure, played by body shops outside staffing firms.)

By Rachel Bluth, Kaiser Health News reporter. Originally published at Kaiser Health News .

About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published Thursday.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.)

The research also found that when a patient is admitted to the hospital from the emergency room, there's a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill.

"Millions of emergency visits and hospital stays left people with large employer coverage at risk of a surprise bill in 2017," the authors wrote.

The researchers got their data by analyzing large-employer claims from IBM's MarketScan Research Databases, which include claims for almost 19 million individuals.

Surprise medical bills are top of mind for American patients, with 38% reporting they were "very worried" about unexpected medical bills.

Surprise bills don't just come from the emergency room. Often, patients will pick an in-network facility and see a provider who works there but isn't employed by the hospital. These doctors, from outside staffing firms, can charge out-of-network prices.

"It's kind of a built-in problem," said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don't know whether they are being treated by an out-of-network doctor while in a hospital.

"By definition, there are these circumstances where they cannot choose their provider, whether it's an emergency or it's [a doctor] who gets brought in and they don't even meet them face-to-face."

The issue is ripe for a federal solution. Some states have surprise-bill protections in place, but those laws don't apply to most large-employer plans because the federal government regulates them.

"New York and California have very high rates of surprise bills even though they have some of the strongest state statutes," Pollitz said. "These data show why federal legislation would matter."

Consumers in Texas, New York, Florida, New Jersey and Kansas were the most likely to see a surprise bill, while people in Minnesota, South Dakota, Nebraska, Maine and Mississippi saw fewer, according to the study.

Legislative solutions are being discussed in the White House and Congress. The leaders of the Senate Health, Education, Labor and Pensions Committee introduced a package Wednesday that included a provision to address it. The legislation from HELP sets a benchmark for what out-of-network physicians will be paid, which would be an amount comparable to what the plan is paying other doctors for that service.

That bill is set for a committee markup next week.

Other remedies are also being offered by different groups of lawmakers.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

https://acdn.adnxs.com/ib/static/usersync/v3/async_usersync.html

https://c.deployads.com/sync?f=html&s=2343&u=https%3A%2F%2Fwww.nakedcapitalism.com%2F2019%2F06%2F1-in-6-insured-hospital-patients-get-a-surprise-bill-for-out-of-network-care.html

https://eus.rubiconproject.com/usync.html <img src="http://b.scorecardresearch.com/p?c1=2&c2=16807273&cv=2.0&cj=1" />


Arizona Slim , June 22, 2019 at 7:26 am

Seriously, who are these people who love their health insurance?

Pat , June 22, 2019 at 8:58 am

At this point, I am pretty sure with few exceptions the people who love their insurance are top management and or the companies that negotiate these profiteering contracts with those same insurance companies. Only the bubble beltway hasn't gotten the message. Witness all those people at the Fox Town Hall with Sanders that shocked the moderators when they asked the gotcha question about their employer health insurance.

Amfortas the hippie , June 22, 2019 at 7:55 am

""It's kind of a built-in problem," said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don't know whether they are being treated by an out-of-network doctor while in a hospital."

again no menu, no price tags, no team shirts .
it ain't a "market".

(""rational actors with perfect information" lol)

we've got around 10k in debt for the first month or so of our long emergency with cancer the period before medicaid kicked in.
some of it will get paid.
most of it will likely not(something about blood and turnips )

interestingly and apparently largely unknown is that one can get a "debt consolidation loan" for credit card, mortgage, and other "consumer" debt .but not for medical debt.
you must, instead, deal with fifty bill collectors representing many medical outfits you may have never heard of -- -imaging, labs, that guy in a white coat who walked by and looked in the door --
one of the articles of faith with the neoliberal order, is that since transactions are inherently Good, it makes sense to maximise them.
so instead of the floor doctor being employed by the hospital, itself she is employed by an LLC with an anodyne, hard to remember, name.

"It's kind of a built-in problem,"

a global economy of pickpockets.
yay.

Monty , June 22, 2019 at 10:08 am

Sounds awful. The last thing you need is extra stress at a time like that. Deepest sympathies. Here's hoping it works out for you all.

NY Geezer , June 22, 2019 at 8:20 am

The problem here is not the health insurer. It is corruption in the provision of medical services by the in network hospital that permits out of network doctor staffing agencies and doctors to perform expected medical services on its premises.

I live in the Capital district area of NY. I discovered recently that almost all the hospitals here have entered into contracts with emergency care staffing corporations for the provision of medical care. In addition, Urgent care facilities staffed by only Physician's Assistants are proliferating here. This area is apparently regarded as a good target for medical profiteers.

Pat , June 22, 2019 at 8:52 am

In a rational society, you know one where the recognizes the captive or powerless entity and provides them the protection they are denied, the hospital/medical group etc would be responsible to make sure all parities working there are in network. And by law all additional out of network charges would be theirs.

Of course in a truly enlightened and rational society we would have single payer and the government would use all its power making sure that society at all levels were healthy and well cared for when they weren't. And massive profits would be on things that were truly discretionary like private jets and yachts not on emergency care.

Bobby Gladd , June 22, 2019 at 9:29 am

In 2015 I came down with sepsis after a prostate biopsy (which turned out positive for cancer). Was admitted to John Muir hospital in Walnut Creek via the ER (I was a Muir system patient at the time). Subsequently got a bill advising that the Emergency Dept at Muir was "out of your Network" (an "independent contractor"). Eye roll.

'Nuther thing I already knew, but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher ) deductibles and co-pays.

ambrit , June 22, 2019 at 9:46 am

Ah. Now that's news I can use. As I mentioned below, I spoke to a claims adjuster yesterday concerning my bus accident. One of the questions she asked was about my eligibility for Medicare. So, the question wasn't just informational in nature. Real money is involved.
Thanks for the enlightenment.

Bobby Gladd , June 22, 2019 at 10:32 am

My late daughter was a Kaiser-Permanente member. She was admitted to a KP hospital several times during her recent Stage IV pancreatic cancer ordeal (she died 15 months ago). Each time , she had to go through the ER for admission. Even Kaiser , who owns their own hospitals, subs out their ERs to "independent contractors," which, of course, raised Danielle's co-pays and "co-insurance." The only route to admission was an 8-12 hr "triage" stint in the ER.

There's hardly any such thing as a through-the-front-door "elective admission" any more.

ambrit , June 22, 2019 at 11:02 am

That's the definition of fraud, right there.
When I was on a jury hearing a "pill mill" case from Biloxi Mississippi, we were told that one definition of a "pill mill" was when the 'patient' was required to go through, and pay for, a full doctors appointment for what was essentially a renewal of a pre-existing prescription. The mandatory "triage" endurance each time a "regular" patient was admitted for an already diagnosed condition fits this definition. Perhaps a resort to the RICO provision would be salutary.
Sorry about your daughter. I hope she 'passed' peacefully.

Bobby Gladd , June 22, 2019 at 4:26 pm

Thanks. Danielle died peacefully (6 weeks into home hospice care), but her illness was anything but.

Talk about "surprise bills," the night at the ER she decided to go into hospice care rather than do another futile admit, they insisted she come home via ambulance (subbed out to the city fire & rescue dept) -- all 1.9 miles to our house. After she died, I kept getting bills for her, one of which was about $2,500 for the ambulance ride ( "Seriously?" ). Needless to say, that did not get paid. Wish in one hand, [bleep] in the other, see which one fills up faster. She died way beyond broke, there was no "estate" to be probated or attached. Not that a host of claimants didn't repeatedly try. They all came to know Bad Bobby, who, while not a lawyer, was way ready for all of them (It wasn't my first rodeo, and I didn't want anyone BS'ing my grandson into assuming any bogus liabilities).

Cal2 , June 22, 2019 at 12:54 pm

Good to know, many of my friends are getting Medicare Part B insurance solicitations from Kaiser. Will inform them to look elsewhere. My condolences to you Sir.

Everyone needs to use things like Yelp and other rating services to make such things known to the curious public.

jake , June 22, 2019 at 4:14 pm

"but most people don't: an ER encounter is an "outpatient visit" for billing purposes. For Medicare benes, that makes it a "Part-B" claim subject to different (i.e. higher) deductibles and co-pays."

I don't get it. You want ER services to fall under Part B ("out patient"), because it has a relatively small deductible. And once it's satisfied, you're clear for the year.

Part A, for hospital admissions, has a much larger deductible, and it's applied per admission, not per year.

Bobby Gladd , June 22, 2019 at 5:48 pm

Well, legally, because you're not yet admitted "to the floor," it's necessarily an outpatient encounter. People just don't know that generally. You're right about the "deductible." The co-insurance is quite another matter ( apropos of both A and B). Which is why one needs a "Medi-Gap" supp. Humana Medi-gap lost their butts on me last year. In June after Danielle died I had hernia surgery, followed by open heart aortic valve replacement ("SAVR px") in late August. My OoP for the year was nil. Thank you Humana.

In a bit of irony, I'm now Kaiser, "Medicare Advantage." My OoP caps for the year at $6,700. Though, I don't expect anything major, got all my heavy lifting done in 2015 and last year.

Oh , June 22, 2019 at 9:35 am

They prey on the weak and helpless, especially the ones that go for emergency care. This is another example of hospitals not really caring for the well being of the sick. Once they capture a victim, their aim is to suck him dry.

The insurance companies are to blame too because they allow the out of network charges to occur. The insured doesn't know what service or provider is "in network". He makes a good faith attempt to go to "in network" hospitals but then the gougers take over.

ambrit , June 22, 2019 at 9:41 am

The 'attending physician' I saw during my ER sojourn after last month's bus accident was a "Body Shop Droid." The bill I received, which was the one I described earlier, the semi-threatening one, was from an "Emergency Room Physicians Management Company LLC." I have nothing to compare it to, but it came to just over $700 dollars US, for two or three 'look see's' at my battered carcass.
The ambulance "service," a properly neo-liberalized separate commercial entity, (anyone remember when ambulances were a part of the hospital apparat?,) billed me just over $1000 dollars US. I finally reached a claims adjuster for the bus companies insurance company yesterday. One of the questions she asked me, after I had established that I had been 'ambulanced' to the hospital was, how many people were transported in that one ambulance? When I quipped about 'double dipping' on the part of the ambulance "services," she laughed and said, "If you only knew."
I have still not heard from the hospital itself.

Mark , June 22, 2019 at 10:15 am

In Elisabeth Rosenthal's excellent book "An
American Sickness" she recommends adding the following statement to any consent form you sign in the hospital "Consent is limited to in-network services only and excludes out-of-network services". My wife and I carry copies of this in our wallets just in case. Haven't had occasion to try this yet and see their reaction.

Bobby Gladd , June 22, 2019 at 10:21 am

" An American Sickness ," yes, an important read.

Oh , June 22, 2019 at 12:16 pm

Yes, a well written expose.

Cal2 , June 22, 2019 at 1:07 pm

"I read 1,182 emergency room bills this year. Here's what I learned."

https://www.vox.com/health-care/2018/12/18/18134825/emergency-room-bills-health-care-costs-america

The corollary of "Someone has to pay!" is "Someone gets it for free."

What happens locally at San Franciscan General Hospital:

Undocumented person or homeless guy;
1.Get ride to hospital in ambulance.
2. Get free translator, if needed
3. Claim no I.D.
4. Get treatment.
5. Pick up free meds at pharmacy.
6. "No hope of recovery"= "Free"

American citizen with insurance
1. Walk in hospital.
2. Spend half an hour proving I have insurance.
3. Get treatment.
4. Get bill for hundreds of thousands because they "are out of network ."

https://www.vox.com/policy-and-politics/2019/1/7/18137967/er-bills-zuckerberg-san-francisco-general-hospital

A state bill is in the works to ban this. However, taxpayers will still provide free care for indigents and now, per a new state law, not only illegals in emergency rooms, but all illegals, until age 26, get full medical inpatient insurance coverage, paid by taxpayers.

https://www.nationalreview.com/news/california-to-provide-full-health-benefits-to-illegal-immigrants-under-age-26/

Joe Well , June 22, 2019 at 3:47 pm

If you have to link to the National Review to support your opinion, maybe you should rethink your opinion.

Cal2 , June 22, 2019 at 4:28 pm

E pur si muove!
https://www.sacbee.com/news/politics-government/capitol-alert/article231310348.html
Facts
https://thehill.com/homenews/state-watch/446075-california-lawmakers-vote-to-offer-health-insurance-to-undocumented
Are
https://www.sfchronicle.com/politics/article/California-will-give-health-coverage-to-13964206.php
Facts

Synoia , June 22, 2019 at 2:00 pm

I'm with Kaiser in CA.

I just send their member services this, based on the wording by Mark above.

"Kaiser Emergency Room Consent is limited to in-network services only and excludes out-of-network services."

I will post responses from Kaiser.

samhill , June 22, 2019 at 3:22 pm

Being first gen Italian I applied for Italian citizenship back before Eurolandia was consummated just in case the rules were changed. Main reason was worries over my on and off health insurance, so just to be safe. Sure enough found myself in my fifties w/o insurance, which is a seriously unwise situation, and hesitently moved to Italy. It's been rough to say the least, the country is deep in the dumps, but the health system is WONDERFUL. Yeh, everyone moans and complains about a long list of valid problems with health care here, but they have no idea the alternative. I tell everyone here to mark my words and protect what they got from the devious, erosive neo-liberal threat.

Preaching to the choir on NC but just in case anyone has doubts the positives; no financial stress to compound health stress, no corporate bureaucracy, state system is quite well streamlined, no copays if you're unemployed or poor, outweighs ALL the negatives.

dk , June 22, 2019 at 4:55 pm

I think the title is a little inaccurate, it's not 1-in-6 patients, it's 1-in-6 visits (or stays). Two visits in a year bring an individual's odds to 1-in-3, etc.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge.

Also, note "at least," aggregation removes detail.

From the study:

Even when patients were admitted to in-network facilities, though, 16% of these stays resulted in at least one out-of-network charge for a professional service.

And out-of-network charges can occur for simple services like a blood test, this recently happened to a friend. She visited a service office listed by her insurer, but the office had contracted with an out-of-network analysis lab, resulting in a non-covered $1100+ charge. Which is a bit amazing in itself, during a recent checkup (my first in 12 years) which was covered by a Medicaid plan, I inquired about the costs for my various tests, to understand affordability; how much would this or that cost if I walked in without any coverage plan? My comprehensive blood test would have cost $183, my echo-cardiogram $118. What about the hormone-level test my friend got? Under $500. All these prices are for cash up front of course, avoiding the 25%+ in interest and finance fees that a payment plan would incur.

GroundZeroAndLovinIt , June 22, 2019 at 5:05 pm

Tangentially, I just saw an anti-Medicare for All ad on TV in my market yesterday (the DC metro area), the first such I have seen. The focus of the ad was that M4A would result in long wait times for procedures; 4 weeks for a cancer consultation, 8 weeks for a kidney replacement consultation, and so on. The ad was so patently misleading it was kind of astonishing: people already wait many many weeks for medical consultations under our gloriously inefficient "excellent" healthcare system–a fact I'm sure most Americans are familiar with. I know of people with cancer diagnoses who have had to wait months to get an appointment with a specialist. So, I'm surprised that's the tack that the lobbyists would take in their "M4A will ruin everything" scary ad. That was the whole focus of the ad: wait times. Seemed like a weak tea argument to me.

flora , June 22, 2019 at 5:16 pm

In the DC metro area?
The healthcare industry spends four times as much on lobbying as the MIC.
That ad is part of the lobbying blitz, imo.

[Jun 05, 2019] Lawmakers Push To Stop Surprise ER Billing

Jun 05, 2019 | www.nakedcapitalism.com

May 30, 2019 by Yves Smith Yves here. This article is a bit fuzzier than I'd like on the details of how the proposed California legislation to bar balanced billing would work, and past failures to halt this practice says that details matter.

However, as I read this piece, the intent is make health insurance work like old-fashioned indemnity plans, at least as far as emergency room coverage is concerned. Indemnity plans were once the norm, and the insured could go to any doctor. No network, no GP gatekeeping.

The sticky part here is the patient is supposed to be on the hook for only what he'd have to pay if he went to an emergency room that was in network. That would seem to give the upper hand to the insurance companies, since the hospital has no recourse to the patient beyond his obligation for an in-network visit. The insurer sends the same reimbursement to the out-of-network hospital as it would to an in-network hospital, and washes its hands of the matter.

One downside for the insurer is that they will now be on the hook for ER bills from any hospital. So they will wind up increasing premiums as a result. But routine care, managing chronic conditions like diabetes, and scheduled surgeries still constitute the substantial majority of what those premiums are intended to cover.

By Ana B. Ibarra, Reporter for California Healthline, based in Sacramento. Previously, she covered health in California's Central Valley for the Merced Sun-Star. She is a 2015 Center for Health Journalism fellow and a Cal Poly Pomona graduate. Originally published at Kaiser Health News

California has some of the nation's strongest protections against surprise medical bills. But many Californians still get slammed with huge out-of-network charges.

State lawmakers are now trying to close gaps in the law with a bill that would limit how much hospitals outside of a patient's insurance network can charge for emergency care.

"We thought the practice of balance billing had been addressed," said state Assemblyman David Chiu (D-San Francisco), author of the bill . "Turns out there are major holes in the law potentially impacting millions of Californians with different types of insurance."

"Balance billing," better known as surprise billing, occurs when a patient receives care from a doctor or hospital -- or another provider -- outside of her insurance plan's network, and then the doctor or hospital bills the patient for the amount insurance didn't cover. These bills can soar into the tens of thousands of dollars .

Chiu's proposal would prohibit out-of-network hospitals from sending surprise bills to privately insured emergency patients. Instead, hospitals would have to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles. Hospitals are fighting the proposal, calling it a form of rate-setting.

"If we are able to move this forward in California, it could be a model and standard for what happens around the country," Chiu said of his measure, which the state Assembly is expected to consider this week.

Surprise billing is a scourge for patients around the country.

Last year , a Kaiser Family Foundation poll found that two-thirds of Americans are "very worried" or "somewhat worried" about being able to afford a surprise bill for themselves or a family member. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

Health policy experts say the problem demands federal action rather than an inconsistent patchwork of state laws. And President Donald Trump has called on Congress to pass legislation this year to put a stop to surprise medical bills.

"In one swipe, the federal government can offer a universal approach in protecting consumers," said Kevin Lucia, a research professor with Georgetown University's Health Policy Institute.

Lawmakers in both the U.S. Senate and House have introduced bills to end surprise billing. But passing federal legislation promises to be an uphill battle because two influential lobbying groups -- health insurers and health providers -- have been unable to agree on a solution.

Frustrated by waiting for federal lawmakers to act, states have been trying to solve this issue. As of December 2018, 25 states offered some protection against surprise billing, and the protections in nine of those states were considered "comprehensive," according to the Commonwealth Fund . California, New York, Florida, Illinois and Connecticut are among the nine.

New state laws also have been adopted since, including in Nevada , which will limit how much out-of-network providers, including hospitals, can charge patients for emergency care, starting next year.

In California, a 2009 state Supreme Court ruling protects some patients against surprise billing for emergency care, and a state law that took effect in 2017 protects some who receive non-emergency care.

But millions remain vulnerable, largely because California's protections don't cover all insurance plans. The California Supreme Court ruling applies to people with plans regulated by the state Department of Managed Health Care. That leaves out the roughly 1 million Californians with plans regulated by the state Department of Insurance and the nearly 6 million people with federally regulated plans, most of whom have employer-sponsored insurance.

The state law governing non-emergency care also doesn't apply to the millions of residents with health plans regulated by the federal government.

Chiu's bill attempts to close those loopholes by targeting hospitals and their billing practices. With this strategy, a patient's health plan -- and the agency that regulates it -- would not matter, explained Anthony Wright, executive director of Health Access California, a Sacramento-based advocacy group that is sponsoring the legislation.

The proposal "extends protections to a broader set of Californians," Wright said.

The California Hospital Association opposes the measure, which would limit the amount hospitals could charge insurance plans to a certain rate for each service, varying by region .

The association believes that would equate to the state setting prices, which could discourage health plans from entering contracts with hospitals, said Jan Emerson-Shea, a spokeswoman for the association.

"We fully support the provision of the bill that protects patients. It is the rate-setting piece that is our concern," she said.

Chiu said his bill was prompted by the peculiar billing practices at Zuckerberg San Francisco General Hospital spotlighted by Vox in January.

Unlike most large hospitals, San Francisco General does not contract with private insurers. Vox found that the hospital considered patients with private insurance out-of-network, and was slapping many of them with whopping bills.

Stefania Kappes-Rocha was one of them.

On April 30, 2018, Kappes-Rocha, 23, landed in San Francisco General's emergency room with a fever and intense pain in her lower right back caused by a kidney infection. A student at Hult International Business School at the time, she had a private plan through the college.

"I didn't know it at the time, but that was the problem -- that I did have insurance," Kappes-Rocha said.

She was sent home a day later with ibuprofen. About two months later, she was billed $27,767.70.

"I couldn't move because of the pain," she said. The last thing on her mind was that she'd be on the hook for the entire cost of her hospital visit.

Her insurance eventually agreed to pay about $24,000 of her bill.

"I fought back, I pressured them every week," she said. "But some people don't know they should do that."

Skewered by media reports, the hospital announced in April that it would no longer balance-bill privately insured patients.


Joe Well , May 30, 2019 at 10:21 am

I think it is "balance billing" as in "your insurer pays part and you pay the remaining outstanding balance."

Thank you so much for this article on yet another crime against the 99%!

https://en.m.wikipedia.org/wiki/Balance_billing

Cal2 , May 30, 2019 at 11:40 am

There's a reason that this state bill originated in the civic disaster that is San Francisco.

San Francisco General, now named for the billionaire, used to be an excellent public teaching hospital affiliated with the University of California. It has one of the better trauma units in California, thanks to the proximity of nearby gang turf wars and housing projects that keep it replenished with fresh gunshot wounds.

Someone has to pick up the tab for San Francisco being a magnet for the uninsured homeless and undocumented from all over the western hemisphere. All this is very expensive.

The city has a dedicated health plan for the "undocumented."
https://healthysanfrancisco.org/en/

Billions have been spent on free health care for "homeless" people.
https://www.sfchronicle.com/bayarea/heatherknight/article/Businesses-must-contribute-more-to-city-s-13178743.php

More spending coming:
https://dailycaller.com/2018/11/01/san-francisco-homeless-spending-proposition-c/

The word among some locals, third generation Americans, who grew up in the city, even those who have insurance , if they go to the emergency room, is to claim to not be insured, give a false name and social security number for emergency treatment. That idea came from refugees flushing their passport down the toilet on the plane.

Joe Well , May 30, 2019 at 12:50 pm

OK, I actually followed the link to the SF Chronicle you posted to support the claim that in SF, one city, "billions have been spent on free health care for 'homeless' (scare quotes?? why??) people."

In fact, that article does not even use the word "healthcare" and implies the exact opposite of what you claim, stating that 2.2% of a $250 million annual budget dedicating to homelessness issues was spent on "health services" for the homeless. The vast bulk of the budget went to fight evictions and keep housed people from becoming homeless. It does not discuss emergency departments at all.

You're making stuff up, not just little things, but enormous things.

Might I add, IMHO, this kind of thing is typical of conservatives, and dovetails nicely with today's post about conservative ideology dying out.

Cal2 , May 30, 2019 at 1:21 pm

You corrected my pre-coffee error. Thank you.
People that make things up don't post a contradictory URL.

"Billions have been spent on the homeless in San Francisco", is what I meant to say. Healthcare is part of that, which includes ambulance rides, fire department calls. BTW, there's lots of debate about numbers. "Billions includes housing, subsidies etc.

Why "homeless" quotes? There are actual Homeless people who have been kicked out of public housing or who simply cannot afford rents. The majority of the "homeless" in San Francisco are recently arrived who have never had a home here, move from place to place and are mostly just junkies and drug users, who would continue to be, even if given "a home."

I'm a Bernie, Medicare for All, Peace in The Middle East, free transit, tax the wealthy "conservative", glad they are coming around.

Joe Well , May 30, 2019 at 10:10 pm

You should actually read that article you linked to.

Where is your figure for the billions that were supposedly spent on the homeless in San Francisco coming from? As that article makes clear, most of the money is being spent on people who live in apartments in San Francisco, to keep them from becoming homeless. Another huge chunk is spent on people who are homeless and in precarious temporary arrangements rather than on the street. Very little is being spent on the "visible homeless" as the article calls them.

Your general impression that SF is a net economic contributor in any way to American society is absurd. It is sucking wealth out with scam companies like Uber while it is casting out lower income people to every other corner of the state and country.

If SF did take in some homeless people and provide them a few thousand dollars a year of services, that would be a drop in the bucket compared to the damage its citizens have done. But you have not provided one word of evidence that the homeless in SF have primarily come from out of town, much less out of state. Given the Bay Area's efforts to gentrify over the decades, it seems quite likely that they were formerly housed inhabitants of the city.

Cal2 , May 31, 2019 at 8:53 pm

"Your general impression that SF is a net economic contributor in any way to American society is absurd."
You must be confusing me with someone else?
I think San Francisco is a giant black hole of exorbitant social services for "homeless", illegals, and profit sucking billionaires that often pay zero local taxes. i.e. Twitter, in it's special Mid Market Resurrection Zone. All those stock options think of the savings.
Add up the money spent over the last 25 years or so on homeless and preventing homelessness and it's in the billions.
$40,000 per "homeless" person per year. With the passage of Proposition C, to go to $70,000 per year.

Here's article with per year expenditures on homeless:
https://www.sfchronicle.com/bayarea/heatherknight/article/Businesses-must-contribute-more-to-city-s-13178743.php

I grew up in San Francisco and have been involved in local politics for half a century. So where are you from? Where are you getting your numbers? Please share. We can all learn from each other.

KevinD , May 30, 2019 at 11:54 am

As long as the people making the rules are monetarily above worrying about health care costs, the rest of us will continue to get squeezed out of existence. Put some people in charge who cannot afford today's medical costs and you will see them go down. Pretty simple actually ( at least in my head)

Anon , May 30, 2019 at 1:54 pm

I have direct experience with this sort of 'balance billing'. It's not just the hospitals that do it. Doctors are a big part of the problem, too.

My doctor recommended major surgery and so we scheduled a specific time and date with the hospital. My medical insurance required the use of in network doctors. So I explained to the chief nurse (in a long discussion prior to admittance) at the in-network hospital I needed to vet ALL doctors for their network status. Actually put it in writing. (I gave them a list of the known in-network doctors affiliated with the hospital.)

Survived the surgery (as you can tell). But to my surprise a 'balance bill' appeared in the mail. Then another. What?! I don't recognize any of these people (doctors). In California the Legislature has given the State Medical Board authority over hospital operating room procedure. The medical board 'requires' three doctors to be 'present' in the operating room for certain major surgeries; they are selected by the primary surgeon. These other two doctors, whom I was never introduced to (before or after surgery) had sent me the unexpected billing (with no discussion of the medical work they performed– or not) in the mail. Of course, they were not in-network and my insurance initially refused to pay them.

Long story shortened, I was able to convince my insurance provider to pay them in-network fees. The doctors refused it, we went to court, they got nothing (zero, nada, zilch). Written record carried the day.

Hospital care in America is a wild ride. You literally need a personal advocate every minute you are in one.

Joe Well , May 30, 2019 at 10:13 pm

Congratulations on your victory and for fighting the good fight.

I have tried hard to get as much of my healthcare as possible outside the US.

I am confident that many American specialist doctors are decent people, but too many of them are clearly greedy.

wilroncanada , May 31, 2019 at 4:53 pm

Canadian specialist doctors who are REALLY greedy may stay around and join those trying to privatize our system, or they may move to the US where greed is king. We made the mistake back in the 1970s of engaging an obstetrician at a maternity hospital in Vancouver for the birth of our first two children. For our oldest he showed up seconds before the birth, leaving a me and a resident who had not done a birth before. Of course, the nurses knew exactly what to do. His fee from medicare was, I guess, being there to catch. With our second two years later, he knew exactly what might happen–my wife would race through the transition phase of labour and almost immediately into delivery. That did not matter to him, he still arrived within seconds of delivery completion.
Our third was with a GP in a different city. He was a REAL doctor, present and supportive. It didn't matter, though, because the obstetrician had moved to Texas where he could schedule caesareans around his golf game.

baldski , May 30, 2019 at 10:29 pm

I have a Medicare PPO from Humana. The hospital selected by them for emergencies is Northern Nevada. I happened to fall off my porch and hurt my arm. I went to the emergency room and was told I had a fractured elbow. Some time later Humana denied the payment for the attending doctor because he was in the group of emergency physicians that man the emergency room and were not in Humana's network. Catch-22 – The emergency room bill is in network but the doctors are not.

Calling all lawyers: Please answer.

Is this not Agency of Estoppel on Humana's part?

The Emergency Room of Northern Nevada Hospital is writ large by a large neon sign. The doctors there are contracted with Northern Nevada and practice in their facility. I contend that the doctors are agents of the hospital and Humana is denying that agency by not paying the bill. Agency of Estoppel is illegal, I was taught in my limited business law course.

Any lawyer out there please respond.

run75441 , May 31, 2019 at 10:31 pm

baldski:

What you have just described is pretty common in Texas. These doctors do not have a contract with the hospital and are usually 3rd party. Is your PPO supplemental or are you in an Advantage (BS) Plan? If you are truly in Medicare and using a Supplemental for the 20% of Part B not covered, you are safe.

If you are in an Advantage Plan I would go back to Humana and ask them to negotiate a price. Not an attorney; but, doctors are agents of the hospital whether 3rd party and contracted or employed.

Paul P , June 1, 2019 at 2:23 am

The hospital is in network, they ask for your insurance,
and then supply out of network doctors, who don't contact you to enter into a contract to provide out of network services. i don't see how a contract has been
made with these out of network doctors.

You probably signed an ABN ("I'm responsible for what
insurance does not pay."} So, that is an "I gotcha" in favor of their right to bill you. I've been crossing out their ABNs and writing I will only be responsible for what insurance pays.

run75441 , June 1, 2019 at 9:58 pm

Paul:

When you go to the ER, you get whoever comes through the door which baldski got. Again what I will say, this is happening with greater frequency and especially in Texas where a hospital contracts the ER doctors out to a 3rd party and does not negotiate the ER rates. It is like having a vendor in your hospital who is contracted to the hospital and charges whatever price. There is a term for this and it is little more than entrapment.

Janie , May 30, 2019 at 2:25 pm

Every one of us should be concerned about this. We are vulnerable, even in our homes. Ambulances take you to the nearest hospital where there is space in Emergency, not necessarily to one in your network. You may be unconscious or incoherent.

Next issue:. Ongoing care. A friend had a pancreatitis attack while on vacation. After ER, he was admitted and told he needed immediate surgery. His insurance company refused to pay for the surgery, saying he could have returned home safely. As you can imagine, the bill was a big one. Insurance never came through, and he settled with the hospital for a large amount.

Joe Well , May 30, 2019 at 10:17 pm

I think the issue with balance billing is not whether the ER is in your network. Here in Massachusetts, for instance, health plans cover every ER visit to every ER on earth. The issue is that some of the doctors provide services which are for whatever reason not considered "emergency" for the purposes of your health plan and if that doctor is out of network, you get charged for the "balance" beyond whatever small amount the plan will pay. Oftentimes the doctors are greedy sharks and pile on the charges which understandably the insurer is unwilling to pay.

The ER admission itself is only a manageable amount, about $500 when I went. It was the fees and medications that added up.

run75441 , May 31, 2019 at 10:33 pm

Joe:

As you "may" know, they are 3rd party and contracted.

Bob Hertz , May 31, 2019 at 12:54 pm

In Yves's fine piece, a spokesman for hospitals complained that the new legislation was a form of 'rate setting."

Well heck yes. When consumers are helpless and a legitimate contract is impossible, it is accepted that courts and legislatures can regulate the fees.

For that matter, Maryland has had regulated hospital charges for several decades, and I know of no crisis that has occurred nor of a hospital that went broke.

The very idea that every hospital bill for emergencies should involve attorneys and the media is grotesque. Seeiing the hospital as a greedy, grabbing institution that sets fees at $100,000 and accepts $10,000 would be considered idiotic in most nations. In Germany, a bargaining unit for all hospitals meets annually with a bargaining unit for all insurers and they set all the fees. In America, hospitals
"bargain" esssentially by financial terrorism.

run75441 , May 31, 2019 at 10:53 pm

Bob:

That is Maryland which does regulate pricing.

The other 49 states do not regulate pricing and set market rates. Places like University of Michigan hospital charge more than other generic hospitals, As hospitals consolidate, there is less competition as the most recent Commonwealth Fund funded Health Affairs study determined in their findings. Indeed from 2007 to 2014, hospital-prices for inpatient care grew 42% compared to 18 percent for physician-prices for inpatient hospital care. For hospital-based outpatient care, hospital-prices rose 25 percent compared to 6 percent for physician-prices.

If you go to a hospital with 3rd party doctors, they can balance bill you. We are not in Germany and it varies state by state what can be done.

You being an insurance guy like ME should already know this as you expound about it over at Charles Gaba's site.

[May 30, 2019] Trump: Today I'm announcing principles that should guide Congress in developing bipartisan legislation to end surprise medical billing

Notable quotes:
"... May 9 - surprise medical bills will be outlawed ..."
May 30, 2019 | www.moonofalabama.org

powerandpeople , May 29, 2019 6:45:22 PM | 8

Regarding a candidate addressing a really important domestic issue in USA, Pres. Trump has drawn the teeth (to an extent) on that one, and put the Democratic party in the position of either supporting the Republican initiative, or throwing sand in the wheels of a measure which will be very popular with the American public:

May 9 - surprise medical bills will be outlawed

"...Today I'm announcing principles that should guide Congress in developing bipartisan legislation to end surprise medical billing...we have bipartisan support, which is rather shocking..."

powerandpeople , May 29, 2019 6:49:29 PM | 9

website URL for press release info on ending surprise medical billing and provision for cheap generics

https://www.whitehouse.gov/briefings-statements/remarks-president-trump-ending-surprise-medical-billing

[May 21, 2019] CounterPunch

May 21, 2019 | www.counterpunch.org

May 20, 2019 Private Equity is a Driving Force Behind Devious Surprise Billings by Eileen Appelbaum Surprise medical bills are in the news almost daily. Last Thursday, the White House called for legislation to protect patients from getting surprise doctor bills when they are rushed to the emergency room and receive care from doctors not covered by insurance at an in-network hospital.

The financial burden on patients can be substantial -- these doctor charges can amount to hundreds or even thousands of dollars.

What's behind this explosion of outrageous charges and surprise medical bills? Physicians' groups, it turns out, can opt out of a contract with insurers even if the hospital has such a contract. The doctors are then free to charge patients, who desperately need care, however much they want.

This has made physicians' practices in specialties such as emergency care, neonatal intensive care and anesthesiology attractive takeover targets for private equity firms.

As health reporter Bob Herman observed , acquisition of these health services "exemplifies private equity firms' appetite for buying health care providers that wield a lot of market power."

Emergency rooms, neonatal intensive care units and anesthesiologists' practices do not operate like an ordinary marketplace. Physicians' practices in these specialties do not need to worry that they will lose patients because their prices are too high.

Patients can go to a hospital in their network, but if they have an emergency, have a baby in the neonatal intensive care unit or have surgery scheduled with an in-network surgeon, they are stuck with the out-of-network doctors the hospital has outsourced these services to.

This stands in stark contrast to other health-care providers, such as primary-care physicians, who will lose patients if they are not in insurers' networks.

It's not only patients that are victimized by unscrupulous physicians' groups. These doctors' groups are able to coerce health insurance companies into agreeing to pay them very high fees in order to have them in their networks.

They do this by threatening to charge high out-of-network bills to the insurers' covered patients if they don't go along with these demands. High payments to these unethical doctors raise hospitals' costs and everyone's insurance premiums.

That's what happened when private equity-owned physician staffing firms took over hospital emergency rooms.

A 2018 study by Yale health economists looked at what happened when the two largest emergency room outsourcing companies -- EmCare and TeamHealth -- took over hospital ERs. They found:

" that after EmCare took over the management of emergency services at hospitals with previously low out-of-network rates, they raised out-of-network rates by over 81 percentage points. In addition, the firm raised its charges by 96 percent relative to the charges billed by the physician groups they succeeded."

TeamHealth used the threat of sending high out-of-network bills to the insurance company's covered patients to gain high fees as in-network doctors. The researchers found:

" in most instances, several months after going out-of-network, TeamHealth physicians rejoined the network and received in-network payment rates that were 68 percent higher than previous in-network rates."

What the Yale study failed to note, however, is that EmCare has been in and out of PE hands since 2005 and is currently owned by KKR. Blackstone is the once and current owner of TeamHealth, having held it from 2005 to 2009 before buying it again in 2016.

Private equity has shaped how these companies do business. In the health-care settings where they operate, market forces do not constrain the raw pursuit of profit. People desperate for care are in no position to reject over-priced medical services or shop for in-network doctors.

Private equity firms are attracted by this opportunity to reap above-market returns for themselves and their investors.

Patients hate surprise medical bills, but they are very profitable for the private equity owners of companies like EmCare (now called Envision) and TeamHealth. Fixing this problem may be more difficult than the White House imagines.

This column first appeared on The Hill .

[Apr 24, 2019] Is Dentistry a Science - The Atlantic

Apr 24, 2019 | www.theatlantic.com

The Truth About Dentistry

It's much less scientific -- and more prone to gratuitous procedures -- than you may think.

Arsh Raziuddin

I n the early 2000s Terry Mitchell's dentist retired. For a while, Mitchell, an electrician in his 50s, stopped seeking dental care altogether. But when one of his wisdom teeth began to ache, he started looking for someone new. An acquaintance recommended John Roger Lund, whose practice was a convenient 10-minute walk from Mitchell's home, in San Jose, California. Lund's practice was situated in a one-story building with clay roof tiles that housed several dental offices. The interior was a little dated, but not dingy. The waiting room was small and the decor minimal: some plants and photos, no fish. Lund was a good-looking middle-aged guy with arched eyebrows, round glasses, and graying hair that framed a youthful face. He was charming, chatty, and upbeat. At the time, Mitchell and Lund both owned Chevrolet Chevelles, and they bonded over their mutual love of classic cars.

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Lund extracted the wisdom tooth with no complications, and Mitchell began seeing him regularly. He never had any pain or new complaints, but Lund encouraged many additional treatments nonetheless. A typical person might get one or two root canals in a lifetime. In the space of seven years, Lund gave Mitchell nine root canals and just as many crowns. Mitchell's insurance covered only a small portion of each procedure, so he paid a total of about $50,000 out of pocket. The number and cost of the treatments did not trouble him. He had no idea that it was unusual to undergo so many root canals -- he thought they were just as common as fillings. The payments were spread out over a relatively long period of time. And he trusted Lund completely. He figured that if he needed the treatments, then he might as well get them before things grew worse.

Meanwhile, another of Lund's patients was going through a similar experience. Joyce Cordi, a businesswoman in her 50s, had learned of Lund through 1-800-DENTIST. She remembers the service giving him an excellent rating. When she visited Lund for the first time, in 1999, she had never had so much as a cavity. To the best of her knowledge her teeth were perfectly healthy, although she'd had a small dental bridge installed to fix a rare congenital anomaly (she was born with one tooth trapped inside another and had had them extracted). Within a year, Lund was questioning the resilience of her bridge and telling her she needed root canals and crowns.

Cordi was somewhat perplexed. Why the sudden need for so many procedures after decades of good dental health? When she expressed uncertainty, she says, Lund always had an answer ready. The cavity on this tooth was in the wrong position to treat with a typical filling, he told her on one occasion. Her gums were receding, which had resulted in tooth decay, he explained during another visit. Clearly she had been grinding her teeth. And, after all, she was getting older. As a doctor's daughter, Cordi had been raised with an especially respectful view of medical professionals. Lund was insistent, so she agreed to the procedures. Over the course of a decade, Lund gave Cordi 10 root canals and 10 crowns. He also chiseled out her bridge, replacing it with two new ones that left a conspicuous gap in her front teeth. Altogether, the work cost her about $70,000.

In early 2012, Lund retired. Brendon Zeidler, a young dentist looking to expand his business, bought Lund's practice and assumed responsibility for his patients. Within a few months, Zeidler began to suspect that something was amiss. Financial records indicated that Lund had been spectacularly successful, but Zeidler was making only 10 to 25 percent of Lund's reported earnings each month. As Zeidler met more of Lund's former patients, he noticed a disquieting trend: Many of them had undergone extensive dental work -- a much larger proportion than he would have expected. When Zeidler told them, after routine exams or cleanings, that they didn't need any additional procedures at that time, they tended to react with surprise and concern: Was he sure? Nothing at all? Had he checked thoroughly?

In the summer, Zeidler decided to take a closer look at Lund's career. He gathered years' worth of dental records and bills for Lund's patients and began to scrutinize them, one by one. The process took him months to complete. What he uncovered was appalling.

W e have a fraught relationship with dentists as authority figures. In casual conversation we often dismiss them as "not real doctors," regarding them more as mechanics for the mouth. But that disdain is tempered by fear. For more than a century, dentistry has been half-jokingly compared to torture. Surveys suggest that up to 61 percent of people are apprehensive about seeing the dentist, perhaps 15 percent are so anxious that they avoid the dentist almost entirely, and a smaller percentage have a genuine phobia requiring psychiatric intervention.

When you're in the dentist's chair, the power imbalance between practitioner and patient becomes palpable. A masked figure looms over your recumbent body, wielding power tools and sharp metal instruments, doing things to your mouth you cannot see, asking you questions you cannot properly answer, and judging you all the while. The experience simultaneously invokes physical danger, emotional vulnerability, and mental limpness. A cavity or receding gum line can suddenly feel like a personal failure. When a dentist declares that there is a problem, that something must be done before it's too late, who has the courage or expertise to disagree? When he points at spectral smudges on an X-ray, how are we to know what's true? In other medical contexts, such as a visit to a general practitioner or a cardiologist, we are fairly accustomed to seeking a second opinion before agreeing to surgery or an expensive regimen of pills with harsh side effects. But in the dentist's office -- perhaps because we both dread dental procedures and belittle their medical significance -- the impulse is to comply without much consideration, to get the whole thing over with as quickly as possible.

The uneasy relationship between dentist and patient is further complicated by an unfortunate reality: Common dental procedures are not always as safe, effective, or durable as we are meant to believe. As a profession, dentistry has not yet applied the same level of self-scrutiny as medicine, or embraced as sweeping an emphasis on scientific evidence. "We are isolated from the larger health-care system. So when evidence-based policies are being made, dentistry is often left out of the equation," says Jane Gillette, a dentist in Bozeman, Montana, who works closely with the American Dental Association's Center for Evidence-Based Dentistry , which was established in 2007. "We're kind of behind the times, but increasingly we are trying to move the needle forward."

Consider the maxim that everyone should visit the dentist twice a year for cleanings. We hear it so often, and from such a young age, that we've internalized it as truth. But this supposed commandment of oral health has no scientific grounding. Scholars have traced its origins to a few potential sources, including a toothpaste advertisement from the 1930s and an illustrated pamphlet from 1849 that follows the travails of a man with a severe toothache. Today, an increasing number of dentists acknowledge that adults with good oral hygiene need to see a dentist only once every 12 to 16 months.

Many standard dental treatments -- to say nothing of all the recent innovations and cosmetic extravagances -- are likewise not well substantiated by research. Many have never been tested in meticulous clinical trials. And the data that are available are not always reassuring.

The Cochrane organization , a highly respected arbiter of evidence-based medicine, has conducted systematic reviews of oral-health studies since 1999. In these reviews, researchers analyze the scientific literature on a particular dental intervention, focusing on the most rigorous and well-designed studies. In some cases, the findings clearly justify a given procedure. For example, dental sealants -- liquid plastics painted onto the pits and grooves of teeth like nail polish -- reduce tooth decay in children and have no known risks. (Despite this, they are not widely used, possibly because they are too simple and inexpensive to earn dentists much money.) But most of the Cochrane reviews reach one of two disheartening conclusions: Either the available evidence fails to confirm the purported benefits of a given dental intervention, or there is simply not enough research to say anything substantive one way or another.

Fluoridation of drinking water seems to help reduce tooth decay in children, but there is insufficient evidence that it does the same for adults. Some data suggest that regular flossing, in addition to brushing, mitigates gum disease, but there is only "weak, very unreliable" evidence that it combats plaque. As for common but invasive dental procedures, an increasing number of dentists question the tradition of prophylactic wisdom-teeth removal; often, the safer choice is to monitor unproblematic teeth for any worrying developments. Little medical evidence justifies the substitution of tooth-colored resins for typical metal amalgams to fill cavities. And what limited data we have don't clearly indicate whether it's better to repair a root-canaled tooth with a crown or a filling. When Cochrane researchers tried to determine whether faulty metal fillings should be repaired or replaced, they could not find a single study that met their standards.

"The body of evidence for dentistry is disappointing," says Derek Richards , the director of the Centre for Evidence-Based Dentistry at the University of Dundee, in Scotland. "Dentists tend to want to treat or intervene. They are more akin to surgeons than they are to physicians. We suffer a little from that. Everybody keeps fiddling with stuff, trying out the newest thing, but they don't test them properly in a good-quality trial."

The general dearth of rigorous research on dental interventions gives dentists even more leverage over their patients. Should a patient somehow muster the gumption to question an initial diagnosis and consult the scientific literature, she would probably not find much to help her. When we submit to a dentist's examination, we are putting a great deal of trust in that dentist's experience and intuition -- and, of course, integrity.

When Zeidler purchased Lund's practice, in February 2012, he inherited a massive collection of patients' dental histories and bills, a mix of electronic documents, handwritten charts, and X‑rays. By August, Zeidler had decided that if anything could explain the alarmingly abundant dental work in the mouths of Lund's patients, he would find it in those records. He spent every weekend for the next nine months examining the charts of hundreds of patients treated in the preceding five years. In a giant Excel spreadsheet, he logged every single procedure Lund had performed, so he could carry out some basic statistical analyses.

The numbers spoke for themselves. Year after year, Lund had performed certain procedures at extraordinarily high rates. Whereas a typical dentist might perform root canals on previously crowned teeth in only 3 to 7 percent of cases, Lund was performing them in 90 percent of cases. As Zeidler later alleged in court documents, Lund had performed invasive, costly, and seemingly unnecessary procedures on dozens and dozens of patients, some of whom he had been seeing for decades. Terry Mitchell and Joyce Cordi were far from alone. In fact, they had not even endured the worst of it.

Dental crowns were one of Lund's most frequent treatments. A crown is a metal or ceramic cap that completely encases an injured or decayed tooth, which is first shaved to a peg so its new shell will fit. Crowns typically last 10 to 15 years. Lund not only gave his patients superfluous crowns; he also tended to replace them every five years -- the minimum interval of time before insurance companies will cover the procedure again.

More than 50 of Lund's patients also had ludicrously high numbers of root canals: 15, 20, 24. (A typical adult mouth has 32 teeth.) According to one lawsuit that has since been settled, a woman in her late 50s came to Lund with only 10 natural teeth; from 2003 to 2010, he gave her nine root canals and 12 crowns. The American Association of Endodontists claims that a root canal is a "quick, comfortable procedure" that is "very similar to a routine filling." In truth, a root canal is a much more radical operation than a filling. It takes longer, can cause significant discomfort, and may require multiple trips to a dentist or specialist. It's also much more costly.

Read: Americans are going to Juarez for cheap dental care

Root canals are typically used to treat infections of the pulp -- the soft living core of a tooth. A dentist drills a hole through a tooth in order to access the root canals: long, narrow channels containing nerves, blood vessels, and connective tissue. The dentist then repeatedly twists skinny metal files in and out of the canals to scrape away all the living tissue, irrigates the canals with disinfectant, and packs them with a rubberlike material. The whole process usually takes one to two hours. Afterward, sometimes at a second visit, the dentist will strengthen the tooth with a filling or crown. In the rare case that infection returns, the patient must go through the whole ordeal again or consider more advanced surgery.

Zeidler noticed that nearly every time Lund gave someone a root canal, he also charged for an incision and drainage, known as an I&D. During an I&D, a dentist lances an abscess in the mouth and drains the exudate, all while the patient is awake. In some cases the dentist slips a small rubber tube into the wound, which continues to drain fluids and remains in place for a few days. I&Ds are not routine adjuncts to root canals. They should be used only to treat severe infections, which occur in a minority of cases. Yet they were extremely common in Lund's practice. In 2009, for example, Lund billed his patients for 109 I&Ds. Zeidler asked many of those patients about the treatments, but none of them recalled what would almost certainly have been a memorable experience.

In addition to performing scores of seemingly unnecessary procedures that could result in chronic pain, medical complications, and further operations, Lund had apparently billed patients for treatments he had never administered. Zeidler was alarmed and distressed. "We go into this profession to care for patients," he told me. "That is why we become doctors. To find, I felt, someone was doing the exact opposite of that -- it was very hard, very hard to accept that someone was willing to do that."

Zeidler knew what he had to do next. As a dental professional, he had certain ethical obligations. He needed to confront Lund directly and give him the chance to account for all the anomalies. Even more daunting, in the absence of a credible explanation, he would have to divulge his discoveries to the patients Lund had bequeathed to him. He would have to tell them that the man to whom they had entrusted their care -- some of them for two decades -- had apparently deceived them for his own profit.

Arsh Raziuddin

The idea of the dentist as potential charlatan has a long and rich history. In medieval Europe, barbers didn't just trim hair and shave beards; they were also surgeons, performing a range of minor operations including bloodletting, the administration of enemas, and tooth extraction. Barber surgeons , and the more specialized "tooth drawers," would wrench, smash, and knock teeth out of people's mouths with an intimidating metal instrument called a dental key : Imagine a chimera of a hook, a hammer, and forceps. Sometimes the results were disastrous. In the 1700s, Thomas Berdmore, King George III's "Operator for the Teeth," described one woman who lost "a piece of jawbone as big as a walnut and three neighbouring molars" at the hands of a local barber.

Barber surgeons came to America as early as 1636. By the 18th century, dentistry was firmly established in the colonies as a trade akin to blacksmithing ( Paul Revere was an early American craftsman of artisanal dentures). Itinerant dentists moved from town to town by carriage with carts of dreaded tools in tow, temporarily setting up shop in a tavern or town square. They yanked teeth or bored into them with hand drills, filling cavities with mercury, tin, gold, or molten lead. For anesthetic, they used arsenic, nutgalls, mustard seed, leeches. Mixed in with the honest tradesmen -- who genuinely believed in the therapeutic power of bloodsucking worms -- were swindlers who urged their customers to have numerous teeth removed in a single sitting or charged them extra to stuff their pitted molars with homemade gunk of dubious benefit.

In the mid-19th century, a pair of American dentists began to elevate their trade to the level of a profession. From 1839 to 1840, Horace Hayden and Chapin Harris established dentistry's first college, scientific journal, and national association. Some historical accounts claim that Hayden and Harris approached the University of Maryland's School of Medicine about adding dental instruction to the curriculum, only to be rebuffed by the resident physicians, who declared that dentistry was of little consequence. But no definitive proof of this encounter has ever surfaced.

Whatever happened, from that point on, "the professions of dentistry and medicine would develop along separate paths," writes Mary Otto, a health journalist, in her recent book, Teeth . Becoming a practicing physician requires four years of medical school followed by a three-to-seven-year residency program, depending on the specialty. Dentists earn a degree in four years and, in most states, can immediately take the national board exams, get a license, and begin treating patients. (Some choose to continue training in a specialty, such as orthodontics or oral and maxillofacial surgery.) When physicians complete their residency, they typically work for a hospital, university, or large health-care organization with substantial oversight, strict ethical codes, and standardized treatment regimens. By contrast, about 80 percent of the nation's 200,000 active dentists have individual practices, and although they are bound by a code of ethics, they typically don't have the same level of oversight.

Read: Why dentistry is separate from medicine

Throughout history, many physicians have lamented the segregation of dentistry and medicine. Acting as though oral health is somehow divorced from one's overall well-being is absurd; the two are inextricably linked. Oral bacteria and the toxins they produce can migrate through the bloodstream and airways, potentially damaging the heart and lungs. Poor oral health is associated with narrowing arteries, cardiovascular disease, stroke, and respiratory disease, possibly due to a complex interplay of oral microbes and the immune system. And some research suggests that gum disease can be an early sign of diabetes, indicating a relationship between sugar, oral bacteria, and chronic inflammation.

Dentistry's academic and professional isolation has been especially detrimental to its own scientific inquiry. Most major medical associations around the world have long endorsed evidence-based medicine. The idea is to shift focus away from intuition, anecdote, and received wisdom, and toward the conclusions of rigorous clinical research. Although the phrase evidence-based medicine was coined in 1991, the concept began taking shape in the 1960s, if not earlier (some scholars trace its origins all the way back to the 17th century). In contrast, the dental community did not begin having similar conversations until the mid-1990s. There are dozens of journals and organizations devoted to evidence-based medicine, but only a handful devoted to evidence-based dentistry.

In the past decade, a small cohort of dentists has worked diligently to promote evidence-based dentistry, hosting workshops, publishing clinical-practice guidelines based on systematic reviews of research, and creating websites that curate useful resources. But its adoption "has been a relatively slow process," as a 2016 commentary in the Contemporary Clinical Dentistry journal put it. Part of the problem is funding: Because dentistry is often sidelined from medicine at large, it simply does not receive as much money from the government and industry to tackle these issues. "At a recent conference, very few practitioners were even aware of the existence of evidence-based clinical guidelines," says Elliot Abt, a professor of oral medicine at the University of Illinois. "You can publish a guideline in a journal, but passive dissemination of information is clearly not adequate for real change."

Among other problems, dentistry's struggle to embrace scientific inquiry has left dentists with considerable latitude to advise unnecessary procedures -- whether intentionally or not. The standard euphemism for this proclivity is overtreatment . Favored procedures, many of which are elaborate and steeply priced, include root canals, the application of crowns and veneers, teeth whitening and filing, deep cleaning, gum grafts, fillings for "microcavities" -- incipient lesions that do not require immediate treatment -- and superfluous restorations and replacements, such as swapping old metal fillings for modern resin ones. Whereas medicine has made progress in reckoning with at least some of its own tendencies toward excessive and misguided treatment, dentistry is lagging behind. It remains "largely focused upon surgical procedures to treat the symptoms of disease," Mary Otto writes. "America's dental care system continues to reward those surgical procedures far more than it does prevention."

"Excessive diagnosis and treatment are endemic," says Jeffrey H. Camm, a dentist of more than 35 years who wryly described his peers' penchant for " creative diagnosis " in a 2013 commentary published by the American Dental Association. "I don't want to be damning. I think the majority of dentists are pretty good." But many have "this attitude of 'Oh, here's a spot, I've got to do something.' I've been contacted by all kinds of practitioners who are upset because patients come in and they already have three crowns, or 12 fillings, or another dentist told them that their 2-year-old child has several cavities and needs to be sedated for the procedure."

Trish Walraven, who worked as a dental hygienist for 25 years and now manages a dental-software company with her husband in Texas, recalls many troubling cases: "We would see patients seeking a second opinion, and they had treatment plans telling them they need eight fillings in virgin teeth. We would look at X-rays and say, 'You've got to be kidding me.' It was blatantly overtreatment -- drilling into teeth that did not need it whatsoever."

Studies that explicitly focus on overtreatment in dentistry are rare, but a recent field experiment provides some clues about its pervasiveness. A team of researchers at ETH Zurich, a Swiss university, asked a volunteer patient with three tiny, shallow cavities to visit 180 randomly selected dentists in Zurich. The Swiss Dental Guidelines state that such minor cavities do not require fillings; rather, the dentist should monitor the decay and encourage the patient to brush regularly, which can reverse the damage. Despite this, 50 of the 180 dentists suggested unnecessary treatment. Their recommendations were incongruous: Collectively, the overzealous dentists singled out 13 different teeth for drilling; each advised one to six fillings. Similarly, in an investigation for Reader's Digest , the writer William Ecenbarger visited 50 dentists in 28 states in the U.S. and received prescriptions ranging from a single crown to a full-mouth reconstruction, with the price tag starting at about $500 and going up to nearly $30,000.

A multitude of factors has conspired to create both the opportunity and the motive for widespread overtreatment in dentistry. In addition to dentistry's seclusion from the greater medical community, its traditional emphasis on procedure rather than prevention, and its lack of rigorous self-evaluation, there are economic explanations. The financial burden of entering the profession is high and rising. In the U.S., the average debt of a dental-school graduate is more than $200,000. And then there's the expense of finding an office, buying new equipment, and hiring staff to set up a private practice. A dentist's income is entirely dependent on the number and type of procedures he or she performs; a routine cleaning and examination earns only a baseline fee of about $200.

In parallel with the rising cost of dental school, the amount of tooth decay in many countries' populations has declined dramatically over the past four decades, mostly thanks to the introduction of mass-produced fluoridated toothpaste in the 1950s and '60s. In the 1980s, with fewer genuine problems to treat, some practitioners turned to the newly flourishing industry of cosmetic dentistry, promoting elective procedures such as bleaching, teeth filing and straightening, gum lifts, and veneers. It's easy to see how dentists, hoping to buoy their income, would be tempted to recommend frequent exams and proactive treatments -- a small filling here, a new crown there -- even when waiting and watching would be better. It's equally easy to imagine how that behavior might escalate.

"If I were to sum it up, I really think the majority of dentists are great. But for some reason we seem to drift toward this attitude of 'I've got tools so I've got to fix something' much too often," says Jeffrey Camm. "Maybe it's greed, or paying off debt, or maybe it's someone's training. It's easy to lose sight of the fact that even something that seems minor, like a filling, involves removal of a human body part. It just adds to the whole idea that you go to a physician feeling bad and you walk out feeling better, but you go to a dentist feeling good and you walk out feeling bad."

Arsh Raziuddin

In the summer of 2013, Zeidler asked several other dentists to review Lund's records. They all agreed with his conclusions. The likelihood that Lund's patients genuinely needed that many treatments was extremely low. And there was no medical evidence to justify many of Lund's decisions or to explain the phantom procedures. Zeidler confronted Lund about his discoveries in several face-to-face meetings. When I asked Zeidler how those meetings went, he offered a single sentence -- "I decided shortly thereafter to take legal action" -- and declined to comment further. (Repeated attempts were made to contact Lund and his lawyer for this story, but neither responded.)

One by one, Zeidler began to write, call, or sit down with patients who had previously been in Lund's care, explaining what he had uncovered. They were shocked and angry. Lund had been charismatic and professional. They had assumed that his diagnoses and treatments were meant to keep them healthy. Isn't that what doctors do? "It makes you feel like you have been violated," Terry Mitchell says -- "somebody performing stuff on your body that doesn't need to be done." Joyce Cordi recalls a "moment of absolute fury" when she first learned of Lund's deceit. On top of all the needless operations, "there were all kinds of drains and things that I paid for and the insurance company paid for that never happened," she says. "But you can't read the dentalese."

"A lot of them felt, How can I be so stupid? Or Why didn't I go elsewhere? " Zeidler says. "But this is not about intellect. It's about betrayal of trust."

In October 2013, Zeidler sued Lund for misrepresenting his practice and breaching their contract. In the lawsuit, Zeidler and his lawyers argued that Lund's reported practice income of $729,000 to $988,000 a year was "a result of fraudulent billing activity, billing for treatment that was unnecessary and billing for treatment which was never performed." The suit was settled for a confidential amount. From 2014 to 2017, 10 of Lund's former patients, including Mitchell and Cordi, sued him for a mix of fraud, deceit, battery, financial elder abuse, and dental malpractice. They collectively reached a nearly $3 million settlement, paid out by Lund's insurance company. (Lund did not admit to any wrongdoing.)

Lund was arrested in May 2016 and released on $250,000 bail. The Santa Clara County district attorney's office is prosecuting a criminal case against him based on 26 counts of insurance fraud. At the time of his arraignment, he said he was innocent of all charges. The Dental Board of California is seeking to revoke or suspend Lund's license, which is currently inactive.

Many of Lund's former patients worry about their future health. A root canal is not a permanent fix. It requires maintenance and, in the long run, may need to be replaced with a dental implant. One of Mitchell's root canals has already failed: The tooth fractured, and an infection developed. He said that in order to treat the infection, the tooth was extracted and he underwent a multistage procedure involving a bone graft and months of healing before an implant and a crown were fixed in place. "I don't know how much these root canals are going to cost me down the line," Mitchell says. "Six thousand dollars a pop for an implant -- it adds up pretty quick."

Joyce Cordi's new dentist says her X‑rays resemble those of someone who had reconstructive facial surgery following a car crash. Because Lund installed her new dental bridges improperly, one of her teeth is continually damaged by everyday chewing. "It hurts like hell," she says. She has to wear a mouth guard every night.

What some of Lund's former patients regret most are the psychological repercussions of his alleged duplicity: the erosion of the covenant between practitioner and patient, the germ of doubt that infects the mind. "You lose your trust," Mitchell says. "You become cynical. I have become more that way, and I don't like it."

"He damaged the trust I need to have in the people who take care of me," Cordi says. "He damaged my trust in mankind. That's an unforgivable crime."

[Apr 05, 2019] Pelosi Accused of Deploying 'Most Dishonest Argument' Against Medicare for All by Jake Johnson

Pelosi: Sock Puppet For the Insurance Industry
Apr 05, 2019 | www.commondreams.org
described as "probably the most dishonest argument in the entire Medicare for All debate."

"People who love their employer-based insurance do not get to hold on to it in our current system. Instead, they lose that insurance constantly, all the time. It is a complete nightmare."
-- Matt Bruenig, People's Policy Project

In an interview with the Washington Post , the Democratic leader said she is "agnostic" on Medicare for All and claimed, "A lot of people love having their employer-based insurance and the Affordable Care Act gave them better benefits."

Matt Bruenig, founder of the left-wing think tank People's Policy Project, argued in a blog post that Pelosi's statement "implies that, under our current health insurance system, people who like their employer-based insurance can hold on to it."

"This then is contrasted with a Medicare for All transition where people will lose their employer-based insurance as part of being shifted over to an excellent government plan," Bruenig wrote. "But the truth is that people who love their employer-based insurance do not get to hold on to it in our current system. Instead, they lose that insurance constantly, all the time, over and over again. It is a complete nightmare."

To illustrate his point, Bruenig highlighted a University of Michigan study showing that among Michiganders "who had employer-sponsored insurance in 2014, only 72 percent were continuously enrolled in that insurance for the next 12 months.

"This means that 28 percent of people on an employer plan were not on that same plan one year later," Bruenig noted.

me title=

"Critics of Medicare for All are right to point out that losing your insurance sucks," Bruenig concluded. "But the only way to stop that from happening to people is to create a seamless system where people do not constantly churn on and off of insurance. Medicare for All offers that. Our current system offers the exact opposite. If you like losing your insurance all the time, then our current healthcare system is the right one for you."

All On Medicare -- a pro-Medicare for All Twitter account -- slammed Pelosi's remarks, accusing the Democratic leader of parroting insurance industry talking points:

The Speaker's alternative to the Medicare for All legislation co-sponsored by over 100 members of her caucus is a bill to strengthen the Affordable Care Act (ACA), which she introduced last week .

"We all share the value of healthcare for all Americans -- quality, affordable healthcare for all Americans," Pelosi told the Post . "What is the path to that? I think it's the Affordable Care Act, and if that leads to Medicare for All, that may be the path."

The nation's largest nurses union was among those who expressed disagreement with the Speaker's incrementalist approach.

In a statement last week, National Nurses United president Zenei Cortez, RN, said Pelosi's plan would "only put a Band-Aid on a broken healthcare system."

"National Nurses United, along with our allies, will continue to build the grassroots movement for genuine healthcare justice and push to pass Medicare for All," Cortez concluded.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

[Mar 25, 2019] Trump betrayed all three his election time promises about changes to Obamacare: everybody got to be covered, no cuts to Medicaid, and Every bit as good on pre-existing conditions as Obamacare

Highly recommended!
Jun 28, 2017 | economistsview.typepad.com

im1dc June 25, 2017 at 09:27 AM

Here is a 5 day old article on Trump deregulating Big Pharma that directly impacts the skyrocketing costs of American Health Care to go with the above posts re the Republican Party's AHCA cutting of coverage and transfer of wealth to the wealthiest in America

Trump is the #1 problem with American Health Care today, he works for the interests of the corporations not the people's

https://www.nytimes.com/2017/06/20/health/draft-order-on-drug-prices-proposes-easing-regulations.html

"Draft Order on Drug Prices Proposes Easing Regulations"

By SHEILA KAPLAN and KATIE THOMAS...JUNE 20, 2017

"In the early days of his administration, President Trump did not hesitate to bash the drug industry. But a draft of an executive order on drug prices appears to give the pharmaceutical industry much of what it has asked for - and no guarantee that costs to consumers will drop.

The draft, which The New York Times obtained on Tuesday, is light on specifics but clear on philosophy: Easing regulatory hurdles for the drug industry is the best way to get prices down.

The proposals identify some issues that have stoked public outrage - such as the high out-of-pocket costs for medicines - but it largely leaves the drug industry unscathed. In fact, the four-page document contains several proposals that have long been championed by the industry, including strengthening drugmakers' monopoly power overseas and scaling back a federal program that requires pharmaceutical companies to give discounts to hospitals and clinics that serve low-income patients.

Mr. Trump has often excoriated the drug industry for high prices, seizing on an issue that stirs the anger of Republicans and Democrats alike. He has accused the industry of "getting away with murder," and said that he wanted to allow the federal government to negotiate directly with drug companies over the price of drugs covered by Medicare.

But the proposed order does little to specifically call out the drug industry and instead focuses on rolling back regulations, a favorite target of the administration..."

im1dc -> im1dc... , June 25, 2017 at 09:37 AM
Additional evidence of Trump lying about his and the Republican AHCA repeal of Obamacare

https://www.usatoday.com/story/news/politics/2017/06/24/promises-trump-made-health-care-repeal-plans/426089001/

"3 promises Trump made about health care that repeal plans haven't kept"

Eliza Collins , USA TODAY ...June 24, 2017

"...Here are three promises Trump made that will not come true under the current bills moving through Congress:

  1. 'Everybody's got to be covered.'...
  2. 'No cuts' to Medicaid"...
  3. 'Every bit as good on pre-existing conditions as Obamacare.'...
im1dc -> pgl... , June 25, 2017 at 11:53 AM
Cuts, cuts, and more cuts to reimbursement that's the Trump Republican AHCA in a nutshell.

All it will accomplish is to transfer $Billions to 'Trump's People', his fellow $Billionaires and MegaMillionaires.

It will not deliver on any Promise Trump made on Health Care and when he and the Republicans say it does they are lying, pure and simple.

More care does not come from far less money spent especially as the need increases due to population and need.

im1dc -> im1dc... , June 25, 2017 at 09:45 AM
I don't know the reason for persistence at attempts to understand the Economics of Trump's and the Republican various remake of the American Economy from an academic Economics perspective by this blog.

It is not possible to do any such rational analysis, b/c as Paul Krugman has pointed out recently and pointedly, there is no rhythm or reason to what they are doing except to obtain the sole single outcome of a major transfer of wealth to the wealthiest Americans in the form of a huge tax cut for most of America's Billionaires and Mega-Millionaires by eliminating as much as possible of the American Safety Net and other protections from the 99%.

[Mar 21, 2019] We can spend endless amounts of money on the NSA, wars overseas, political campaigns and bailing out banks, tha we canaffort single payer healthcare system

Highly recommended!
Jun 28, 2017 | economistsview.typepad.com

Christopher H. , June 28, 2017 at 08:10 AM

We can spend endless amounts of money on the NSA, wars overseas, political campaigns and bailing out banks, but PGL and the weak tea centrists demand "how are we going to pay for it???" now that single-payer is becoming a real possibility. Every other advanced nation does it better with massive savings for their taxpayers.

http://www.latimes.com/opinion/op-ed/la-oe-pollin-single-payer-healthcare-healthy-california-20170621-story.html

Op-Ed Single-payer healthcare for California is, in fact, very doable

by Robert Pollin

June 21, 2017

The California Senate recently voted to pass a bill that would establish a single-payer healthcare system for the entire state. The proposal, called the Healthy California Act, will now be taken up by the state Assembly. [not]

The plan enjoys widespread support - a recent poll commissioned by the California Nurses Assn. found that 70% of all Californians are in favor of a single-payer plan - and with good reason. Under Healthy California, all residents would be entitled to decent healthcare without having to pay premiums, deductibles or copays.

But as critics of the bill have pointed out, a crucial question remains: Is Healthy California economically viable? According to research I conducted with three colleagues at the University of Massachusetts, Amherst, the answer is yes.

Enacting Healthy California would entail an overhaul of the state's existing healthcare system, which now constitutes about 14% of California's GDP. In particular, it would mean replacing the state's private health insurance industry with government-managed insurance. Our study - which was also commissioned by the California Nurses Assn. - concludes not only that the proposal is financially sound, but that it will produce greater equity in the healthcare sector for families and businesses of all sizes.

California will spend about $370 billion on healthcare in 2017. Assuming the state's existing system stayed intact, the cost of extending coverage to all California residents, including the nearly 15 million people who are currently uninsured or underinsured, would increase healthcare spending by about 10%, to roughly $400 billion.

That's not the full story, though. Enacting a single-payer system would yield considerable savings overall by lowering administrative costs, controlling the prices of pharmaceuticals and fees for physicians and hospitals, reducing unnecessary treatments and expanding preventive care. We found that Healthy California could ultimately result in savings of about 18%, bringing healthcare spending to about $331 billion, or 8% less than the current $370 billion.

How would California cover this $331-billion bill? For the most part, much the same way it covers healthcare spending right now. Roughly 70% of the state's current spending is paid for through public programs, including Medicare and MediCal. This funding - totaling about $225 billion - would continue, as is required by law. It would simply flow through Healthy California rather than existing programs.

The state would still need to raise about $106 billion a year to cover the cost of replacing private insurance. This could be done with two new taxes.

First, California could impose a gross receipts tax of 2.3% on businesses, but with an exemption for the first $2 million of revenue. Through such an exemption, about 80% of all businesses in California - small firms - would pay nothing in gross receipts tax, and medium-sized businesses would pay an effective tax rate of less than 1%.

Second, the state could institute a sales tax increase of 2.3%. The tax would not apply to housing, utilities, food purchased for the home or a range of services, and it could be offset for low-income families with a 2% income tax credit.

Relative to their current healthcare costs, most Californian families will end up spending less, even with these new taxes, and some will even enjoy large gains. Net healthcare spending for middle-income families would fall by between 2.6% and 9.1% of income. Most businesses would also see a drop in spending. Small firms that have been providing health insurance for their workers will see costs fall by 22% as a share of payroll. For medium-sized firms, costs will fall by an average of between 6.8% and 13.4% as a share of payroll. Even most large firms will see costs fall, by an average of between 0.6% and 5% of payroll.

At the moment, about 2.7 million of California's residents, or about 8% of the population, have no health insurance. Another 12 million residents, or about 33% of the population, are underinsured. A large proportion of the remaining 60% of the population who are adequately insured still face high costs, as well as anxiety over President Trump's proposal to repeal and replace Obamacare.

Healthy California is capable of generating substantial savings for families at most income levels and businesses of most sizes. These savings are in addition to the benefits that the residents of California will gain through universal access to healthcare.

[Mar 05, 2019] On origin of the phase There ain't no such thing as a free lunch

Mar 20, 2017 | economistsview.typepad.com

RC AKA Darryl, Ron -> mulp ... "...TANSTAAFL" March 20, 2017 at 04:59 AM

https://en.wikipedia.org/wiki/There_ain%27t_no_such_thing_as_a_free_lunch

"There ain't no such thing as a free lunch" (alternatively, "There is no such thing as a free lunch" or other variants) is a popular adage communicating the idea that it is impossible to get something for nothing.

The acronyms TANSTAAFL, TINSTAAFL, and TNSTAAFL, are also used. Uses of the phrase dating back to the 1930s and 1940s have been found, but the phrase's first appearance is unknown.[1]

The "free lunch" in the saying refers to the nineteenth-century practice in American bars of offering a "free lunch" in order to entice drinking customers.

The phrase and the acronym are central to Robert Heinlein's 1966 science-fiction novel The Moon Is a Harsh Mistress, which helped popularize it.[2][3]

The free-market economist Milton Friedman also popularized the phrase[1] by using it as the title of a 1975 book,[4] and it is used in economics literature to describe opportunity cost.[5]

Campbell McConnell writes that the idea is "at the core of economics".

[I was a bigger fan of Robert Heinlein's than I was of Milton Friedman and even then it was "Stranger in a Strange Land" and "The Unpleasant Profession of Jonathan Hoag" rather than later works that appealed to me.]

[Feb 26, 2019] It is illegal for any insurer to offer a bare bones catastrophic plan that doesn't cover Obama's hopey-changey list of progressive surgical procedures.

Feb 26, 2019 | www.unz.com

Bragadocious , says: February 26, 2019 at 2:49 pm GMT

@animalogic I don't know if you live in the US, sounds like you don't, but one could argue that the healthcare system has already been nationalized. Consumers must shop for policies that meet Obamacare standards which include coverage for gender reassignment and other things that 10 years ago no private insurer would dream of paying for. This is a direct result of government's boot on the market's throat. (And the market likes it, based on HMO stock prices)

It is illegal for any insurer to offer a bare bones catastrophic plan that doesn't cover Obama's hopey-changey list of progressive surgical procedures. 15 years ago, those catastrophic plans were everywhere, and very affordable.

And to your point about providing healthcare to people who can't afford it. We already have that, it's called Medicaid. When those receiving it die, the government comes in and grabs all of their estate's assets, because they used a government program that was forced on them. Like I said, it's been taken over.

[Feb 22, 2019] How Stupid Do They Think We Are - Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo

Notable quotes:
"... I've lived in the US and the UK for extended periods so can compare and contrast. I actually think that due to the structure of the US system that the US medical system builds a dependency on subscribing more and more drugs to people because MDs and pharmas get the money (not a shocking statement). ..."
"... Exactly. The phrase "providing access" is nauseating. It really means "preventing access" unless you pay. ..."
Feb 22, 2019 | www.nakedcapitalism.com

How Stupid Do They Think We Are? – Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo Posted on February 22, 2019 by Yves Smith By Roy Poses , MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Originally published at Health Care Renewal

In the early 21st century, the debate about health care reform in the US ramped up. The result ultimately was the Patient Protection and Affordable Care Act (PPACA, ACA, "Obamacare"), which arguably improved access to health care, made some reforms in the regulation of health care insurance, but did not affect the fundamental reliance of the US on employer-paid, for-profit health care insurance to finance health care for many patients. Nor did it really affect the issues we discuss on Health Care Renewal (look here for details).

After the tumultuous election of President Donald Trump, the debate started up again with his and his party's attempt to "repeal and replace" Obamacare. Arguably, Obamacare ended up damaged but not repealed. Once again, the issues we discuss on Health Care Renewal were ignored, including threats ot the integrity of the clinical evidence base, deceptive marketing, distortion of health care regulation and policy making, bad leadership and governance, concentration of power, abandonment of health care as a calling, perverse incentives, the cult of leadership, managerialism, impunity enabling corrupt leadership, and taboos, or the anechoic effect. (Look here for a detailed discussion. )

It is time once again to discuss health care reform in the US. Now the push is from the Democrats and the left, with the stated goals of making care more universal, and perhaps decreasing or even ending the role of for-profit commercial health care insurance companies.

It is no surprise that those who benefit the most from the current system (even as modified by Obamacare) are rushing to its defense.

Dark Money to Defend Commercial Health Insurance

We already discussed how large health care corporations, including pharmaceutical and biotechnology companies, have been using dark money to funnel money for distinctly partisan purposes, to defeat whom they perceive as too left-leaning politicians, almost all Democrats. They seem to fear such politicians might promote health care reform efforts that would be based on "anti-free-market, anti-business ideology," that is efforts to decrease the role of commercial, for-profit health insurance in financing health care.

More recently, the focus has shifted to Democratic proposals for government run single-payer, or "Medicare for all" health insurance. In early January, 2019, the Hill reported

Thomas Donohue, the president and CEO of the Chamber of Commerce, on Thursday vowed to use all of the Chamber's resources to fight single-payer health care proposals.

'We also have to respond to calls for government-run, single-payer health care, because it just doesn't work,' Donohue said during his annual 'State of American Business' address.

The US Chamber of Commerce historically has had many executives of big health care corporations on its board. We listed 10 such members in 2015. It also historically has received financial support from some corporations. We listed 17 in 2018.

Then later in January, The Hill reported that a group called Partnership for America's Health Future started digital ads attacking "Medicare for All." The Hill stated its

members include major industry players such as America's Health Insurance Plans and the Pharmaceutical Research and Manufacturers of America

So here we have the leaders of big health care corporations funneling corporate money into propaganda campaigns to defeat government run single payer health insurance, an old policy idea that suddenly is looking politically credible. Current US regulation and practice allows them to hide the exact amounts spent on such campaigns by processing them through dark money organizations.

Such stealth health policy advocacy is now not new. What is surprising now is how some top leaders are willing to jump into the debate themselves, rather than just trying to manipulate public opinion through public relations/ propaganda proxies. Here are some telling examples. in chronological order.

Quest Diagnostics CEO Attacks "Medicare-for-All" Using an Appeal to Authority, an Argument by Gibberish, the Non Sequitur Fallacy, (and an Incomplete Comparison)

On January 24, 2019, Yahoo Finance reported

A top health care CEO is sounding the alarm on 'Medicare for All,' an idea gaining steam in political circles, including from newly-elected Rep. Alexandria Ocasio-Cortez (D-NY).

' Most people don't understand the basics of health-care economics in the United States ,' said Steve Rusckowski, chairman & CEO Quest Diagnostics (DGX), in an interview with Yahoo Finance editor-in-chief Andy Serwer at the World Economic Forum in Davos, Switzerland .

Mr Rusckowski implied that he knows a lot more about health care economics than most people, so most people should listen to him. Thus, he began with an implied logical fallacy, the appeal to authority .

He then presented the justification for his argument.

'The majority of people get their health care from their employers, and the majority of healthcare costs are paid by employers and employees,' he said. 'If you look at the $3.5 trillion spent on healthcare costs, that portion is actually funding the Medicare and Medicaid programs throughout this country.'

The syntax was fractured, and so this was incoherent and confusing. In particular, it was not clear to what "this portion" referred. $3.5 trillion? Health care costs paid by employers and employees?

The context of his use of that phrase did not help. Note that US total health spending was reported to be approximately $3.5 trillion in 2017 by the US Center for Medicare and Medicaid Services (CMS) . However, that was total health spending, not just the amount spent by Medicare and Medicaid. Furthermore, Medicare and Medicaid are funded by sources other than employers and their employees. While employers and employees pay tax on employee income to fund Medicare, general funds from the federal government, and from state governments funds Medicaid. Furthermore, many employers pay parts of their employees' private health insurance premiums, while the employees make up the difference in premiums. Self-employed people may may for their own insurance, etc, etc.

Mr Ruskcowski, not to put to fine a point on it, seemed to speaking gibberish, and would use this gibberish to justify his next point. So in formal terms, he used the logical fallacy of an argument by gibberish .

When incomprehensible jargon or plain incoherent gibberish is used to give the appearance of a strong argument, in place of evidence or valid reasons to accept the argument.

In any case, Mr Rusckowski went on to argue that he

remained skeptical of a Medicare-for-all plan funded by corporations and employees. ' I don't think [corporations and employees] can afford to provide that access as described.'

However, not only were his earlier statement gibberish, they were not clearly arguments in support of his contention that corporations and employees cannot "afford to provide that access as described." So this appeared to be an example of the logical fallacy of the non-sequitur .

Mr Rusckowski's total compensation as CEO of Quest was over $10 million in 2017, as estimated by Bloomberg News . So it is perhaps not surprising that is self-interest in preserving the status quo was strong enough to motivate him to jump into the debate. One would think, however, that someone who managed to become a rich CEO of a medical diagnostic company could manage to be a bit more logical.

Anyway, he has some strange bed-fellows in this cause, including two billionaires who are not directly involved in health care corporations, but who have obviously benefited from the current economic status quo.

Michael Bloomberg and Howard Schultz Used the Incomplete Comparison Fallacy

Two billionaires provided striking examples of one logical fallacy.

First, from t he New York Times, January 29, 2019 :

Mr. Bloomberg, the former New York City mayor who is considering a 2020 bid on a centrist Democratic platform, rejected the idea of 'Medicare for all,' which has been gaining traction among Democrats.

'I think you could never afford that. You're talking about trillions of dollars ,' Mr. Bloomberg said during a political swing in New Hampshire, which holds the nation's first primary in 2020.

'I think you can have 'Medicare for all' for people that are uncovered,' he added, 'but to replace the entire private system where companies provide health care for their employees would bankrupt us for a very long time .'

Second, from CNN on January 30, 2019 :

'Why do you think Medicare-for-all, in your words, is not American?' CNN's Poppy Harlow asked Schultz on Tuesday.

'It's not that it's not American,' Schultz said. ' It's unaffordable .'

'What I believe is that every American has the right to affordable health care as a statement,' Schultz said, lauding the Affordable Care Act, otherwise known as Obamacare, as 'the right thing to do.'

He added, 'But now that we look back on it, the premiums have skyrocketed and we need to go back to the Affordable Care Act, refine it and fix it.'

He argued that the Democratic progressive platform of providing Medicare, free college education and jobs for everyone is costly and as 'false as President Trump telling the American people when he was running for president that the Mexicans were going to pay for the wall.'

So both billionaire Bloomberg and billionaire Schultz stated that Medicare-for-all would cost too much. Yet neither addressed how much our current health care system costs. However, as a subsequent op-ed in the Washington Post by Paul Waldman pointed out, it only makes sense to talk about affordability in the context of a comparison with a reasonable alternative, say, the current health care system:

there is one thing you absolutely, positively must do whenever you talk about the cost of a universal system -- and that journalists almost never do when they're asking questions. You have to compare what a universal system would cost to what we're paying now.

there have been some recent attempts to estimate what it would cost to implement, for instance, the single-payer system that Sen. Bernie Sanders (I-Vt.) advocates; one widely cited study, from a source not favorably inclined toward government solutions to complex problems, came up with a figure of $32.6 trillion over 10 years.

That's a lot of money. But you can't understand what it means until you realize that last year we spent about $3.5 trillion on health care, and under current projections, if we keep the system as it is now, we'll spend $50 trillion over the next decade.

Again, you can criticize any particular universal plan on any number of grounds. But if it costs less than $50 trillion over 10 years -- which every universal plan does -- you can't say it's 'unaffordable' or it would 'bankrupt' us, because the truth is just the opposite.

These are text-book examples of the fallacy of incomplete comparison .

By the way, buried amongst his use of gibberish and non-sequiturs, Quest Diagnostics CEO Rusckowski also opined that Medicare-for-all would be unaffordable without any reference to the costs of the status quo, and hence also provided an example of an incomplete comparison.

The Waldman op-ed noted

The fact that these two highly successful businessmen -- whose understanding of investments, costs and benefits helped them become billionaires -- can say something so completely mistaken and even idiotic is a tribute to the human capacity to take our ideological biases and convince ourselves that they're not biases at all but are instead inescapable rationality.

Maybe. However, it may also be a tribute to their arrogance bred by decades of public relations (which Bernays thought sounded better than "propaganda ") and disinformation meant to soften up the minds of the public so that they will follow the lead of the rich and powerful.

Schultz Also Added an Appeal to Tradition (or to Common Practice)

Also on January 29, the Washington Post reported that

Schultz referred to a town hall hosted Monday night by CNN in which Harris embraced a 'Medicare-for-all' single-payer health insurance system and said she would be willing to end private insurance to make it happen.

'That is the kind of extreme policy that is not a policy that I agree with,' Schultz said on 'The View,' adding that doing away with private insurers would lead to major job losses.

' That's not correct. That's not American ,' Schultz said on CBS. 'What's next? What industry are we going to abolish next? The coffee industry?'

Presumably, by saying "that's not American," Schultz means that is not what we have always done, that is not what has been traditional American practice, begging the question of whether that practice could be ill-advised. Thus Schultz appeared to ladle on an appeal to common practice, otherwise known as an appeal to tradition .

As an aside, the quote also suggests that Schultz's real concern is not with the affordability of Medicare-for-all, particularly in comparison with that of the current system, but with the financial health of the insurance industry. But that is for another day .

Summary

So, to protect against the dread "Medicare for all," that is, proposals for a government single-payer health insurance system to replace our current practice of financing health care through large, mainly for-profit insurance companies, we see an acceleration of public relations/ propaganda paid by undisclosed donors, that is, via dark money. We also see prominent multi-millionaire and billionaire executives laying down a barrage of logical fallacies to support the status quo.

It is hard to believe that the defenders of the current system are not mostly self-interested. That status quo has made some people very rich.

It is also hard to believe they are stupid. However, a close reading of their arguments suggests they may think we are stupid, or at least befuddled by repeated public relations/ propaganda/ disinformation campaigns.

In 2011, we wrote ,

Wendell Potter, author of Deadly Spin , has provided a chilling picture of health care corporate disinformation campaigns and the tactics used therein.

In particular,

Mr Potter recounted how deceptive PR campaigns subverted the health care reform plans of US President Bill Clinton, reduced the impact of Michael Moore's movie, 'Sicko,' and helped to remodel the recent health care reform bill to reduce its threat to commercial health insurers. He further noted how PR distracted public attention from the growing faults of a health care system based on commercial health insurance, and how practical and legal safeguards against abuses by insurance companies were eroded.

Furthermore, Mr Potter

described 'charm offensives;' the deliberate creation of distractions, including the planting of memes for short-term goals that went on to have long-term adverse effects; fear mongering; the use of front groups, including 'astroturf,' (faux disease advocacy and/or grass roots organizations), public policy advocacy groups, and tame (and conflicted) scientific/professional groups; and intelligence gathering. He provided some practical advice for detecting such tactics. For example, be very suspicious of policy advocacy by groups with no apparent address or an address identical to that of a PR firm, or with anonymous leaders and/or anonymous financial backing.

Now it is 2019, once again health care reform is in the air, and once again the defenders of the status quo are hard at work. Now, they are even wealthier than they were 10 years ago, and have even more sophisticated tools, like social media and its hacks, at their disposal. Still, however, their arguments are ultimately built on sand.

As I did in 2011 , it makes sense to quote Wendell Potter

onslaught drastically weakened health-care reform and how it plays an insidious and often invisible role in our political process anywhere that corporate profits are at stake , from climate change to defense policy.
[Potter, Huffington Post]

So,

The onslaughts of spin will not stop, the distortions will not diminish, and the spin will not slow down. To the contrary, spin begets spin, as the successes of corporate PR functionaries increase the revenues of their employers, further funding their employers' efforts to create a more hospitable climate for their business interests. Americans are thus being faced with increasingly subtle but effective assaults on their beliefs and perceptions. Their best defense right now is to understand and to recognize the sophisticated tactics of the spinners trying to manipulate them.

Most important is a singular mandate: Be skeptical .
[Potter, Huffington Post]

I still hope that summarizing some of Mr Potter's amazing points will help us all to be much more skeptical.

You heard it here first.


Disturbed Voter , February 22, 2019 at 4:26 am

Can any system of incentives work, for both the patients and the care providers? The tendency is for patients to seek professional help over over-the-counter remedies when it is unnecessary (hypochondria) and for care providers to over-test and over-medicate (avoid malpractice and promote snake oil). Either you use market-based incentives or bureaucratic incentives. And the bureaucratic incentive can be public or outsourced to commercial enterprise. There is no spontaneously self regulating system, it has to be designed-in.

Yves Smith Post author , February 22, 2019 at 6:26 am

Bullshit. Every other advanced economy had a fully or heavily government funded system. Their costs are 50-60% in GDP terms compared to ours with generally better health outcomes.

Hypochondria is present in only 1-5% of the population. That isn't a "tendency". The overtesting is due mainly to bad norms and bad economic incentives like it being perceived to be normal to have an EKG every year with your annual physical (another questionable practice in healthy people) when only people at heart disease risk need an EKG. MDs own the EKG equipment, so this is a profit center for them. Similarly, I knew instinctively that annual mammograms and annual Pap smears were overkill and I'd refuse those tests and get lectured for that. My take has now been confirmed. But those MDs were driven by bad collective beliefs as to what good medical practice was at the time, and not some personal liability fear.

As for overprescribing, again my perception is that this is more patient that MD driven (save possibly for elderly people who tend where they should be taken off certain meds for a month or two and tested to see if they are still needed). You forget that Big Pharma now advertises on TV and tells patient to ask their doctors about their wares! But the real sins like prescribing antibiotics for flus comes (as in with other cases) with patients wanting the doctor to Do Something.

I lived in Australia and MDs were very much of the "let's monitor this" (as in do nothing right now) school, which says that patients are perfectly fine with that if the doctor seems confident and also make clear that he'll change course if warranted.

MDs ought to be allowed to prescribe placebos or aspirin at real med prices with some mystery med name and have the pharmacy plan quietly rebate virtually all the price months later for the patients with real problems where meds are indicated (the problem need to run its course and the most that is called for is palliatives).

Redlife2017 , February 22, 2019 at 6:54 am

+1000
From my own experience I completely agree. In particular with your point about the Doctors being in the "let's monitor this" school of thought outside of the US.

I've lived in the US and the UK for extended periods so can compare and contrast. I actually think that due to the structure of the US system that the US medical system builds a dependency on subscribing more and more drugs to people because MDs and pharmas get the money (not a shocking statement).

In the UK a doctor will never overprescribe – even if you want them to. It's just not a thing at all since there is no incentive except to be a, uh, doctor. They are trying to make sure you either get or stay healthy.

The system is built to make sure people have healthcare without weird profit incentives. They even have signs at the GP stating that if you have flu you should just rest, drink lots of fluids and stay home – don't get other people sick.

And to pre-empt someone noting that the NHS is having lots of problems – that is completely the choice of the current government (and the government in their ConDem days of 2010 – 2015). The NHS would be in much better shape if they

  1. stopped all the stealth privatisation (it's shocking what is going on) and
  2. just made sure local services were properly funded.

Amfortas the hippie , February 22, 2019 at 7:55 am

aye. the stealthy neoliberal colonisation of NIH, and all the scandinavian happy places is studiously ignored.

with my own experience with healthcare -- 6 1/2 years to get a hip to replace the literally dead one i was hobbling around on and now, all the time i've spent in and around the gleaming medical center for my wife's cancer .talking to all and sundry listing to all and sundry from wastrels at the bus stop to suits riding the elevator with me healthcare is a Right, dammit. there is no place at all for markets, privatisation or profit. it is immoral to profit off the suffering of a human being, period.

that moral argument is what will win the day even the suits acknowledge it, before passing off responsibility to the System("well, yes but we can't do anything, because the Great God Moloch must be appeased")

I am a sacrificial victim to that cruel deity. I'll be in pain for the rest of my life because i couldn't get timely care i still walk around on an ankle that is an enervated bag of gravel, since no ankle guys in texas take medicaid (and i'm kicked off that, now, too,lol)

I am thankful for my hip, hard won as it was. and i am more than grateful for the level of care my wife is getting but damn.

let these ceo's walk a mile or two in bloody shoes before they lecture about affordability and access.

their sin is gross indifference to suffering in the service of their own greed.
fie.

Susan the Other , February 22, 2019 at 12:18 pm

Exactly. The phrase "providing access" is nauseating. It really means "preventing access" unless you pay.

This is nothing more than an obfuscation of blatant extortion. Do any of these patriotic capitalists understand capitalism? I don't think so. Too much liike a priest understanding god. Is god otherwise unaffordable, if you don't have a pious priestly middleman to do spiritual arbitrage? For a small fee, of course.

They really do think we are stupid. But they forget The Reformation. There just comes a point in time when you can't politely ignore the lies and destruction. It takes on a life of its own and is unstoppable.

This post is encouraging because there is a guy out there named Roy Poses who is connected with something called Health Care Renewal and there is another guy, Paul Waldman who works for the WaPo; and we are reminded of the wonderful Mr. Wendell Potter. And a whole nation on the march. Hope your hip and your wife are feeling better.

GF , February 22, 2019 at 12:29 pm

Here's a retweet from Bernie about the latest big pharma price gouge:

"Bernie Sanders
‏Verified account @SenSanders
Feb 20

Bernie Sanders Retweeted CNN Health

Catalyst's decision to raise the price of a life-saving drug from $0 to $375,000 is causing patients to suffer and ration their medication. Outrageous! Catalyst must immediately lower the price of Firdapse."

PlutoniumKun , February 22, 2019 at 10:37 am

A relative of mine is actually nearly through research on exactly the topic of prescribing differences between Europe and the US. He says he found a very different culture among US doctors (if and when its published I'll certainly let Yves know, it might make an interesting article or link here).

As you and Yves says, there is very little evidence of overprescribing or overtreatment in 'free' or heavily subsidised health systems. On the contrary, there is evidence of massive overtreatment in the US for people willing to pay and / or with good insurance.

Here in Ireland there were problems in hospitals because it used to be free to be an out-patient, so the poor/hypochondriac, etc., would clog up waiting rooms instead of going to their local doctor where they would have to pay. They introduced a charge solely to stop this. It was crude, but it worked. It would of course have been much better to co-ordinate charges or put a better system in place to triage real patients from those who just want a bit of sympathy.

Most GP's will tell you that about 5% of their patients represent 90% of their workload. Some people either need lots of care, or they are just demanding and go to the doctor for every little ache and pain, while others practically have to have a limb falling off before they'd go. That's just the way it is, and all systems come up with ways to deal with it.

Nearly all doctors will give prescriptions even when not needed, because they know people feel better for it. The doctors I know invariably give mild painkillers on prescription for minor things like colds and backaches. Its really a form of acceptable placebo. I'm lucky to have a really good local doctor who runs a small team who are very firm on explaining to people why they don't always need treatment or prescriptions, even to the point of it being a little annoying sometimes – he refused to burn off a wart I had some time ago, telling me just to go to a pharmacy and buy an over the counter freeze tab. And when I had a diagnosis for mild arthritis in my hip he told me to walk lots and eat natural anti-inflammatory foods – again, no prescription, even something very mild. He seemed surprised that I didn't argue the point.

That said, being strict on prescriptions can backfire. I know of a young man who died from a rare bone cancer. He was from a very poor background and looked like a typical junkie – pale skin, skinny, Nike sweat pants (he wasn't, he just looked like one). His doctor thought he was trying to scam opiates and told him the pain was all in his head.

He was a little bit innocent and believed her.

It was when he literally collapsed while visiting his girlfriend in hospital that he was examined and diagnosed – it was too late by then.

Carla , February 22, 2019 at 12:05 pm

Yves, thank you so much for calling bullshit on Disturbed Voter's comment. After spending more than two decades as a single-payer supporter, I cannot improve upon your response.

Disturbed Voter , February 22, 2019 at 12:33 pm

i work in medicine, do you? Mind you, you can have single-payer or Medicare-for-all but it isn't free (not free in Cuba or other locations).

And medical care will always be triaged on some basis so expect delay or denial of care.

What you see is dishonest accounting, moving costs from one column to another, and hiding the change.

And providers won't work for free either, unless you intend to enslave them. I am happy France etc has good open access care. You might ask how that is done, it isn't magic. The answer is, they pay high taxes, and don't spend that on things they don't want (like endless warfare). As far as drug prices go, Americans subsidize the cheaper prices found elsewhere (not that I agree do this).

AdamK , February 22, 2019 at 12:35 pm

+100000. It is also very common to create a package of services that are provided by the government insurance and leave the rest to private insurance. This package is revised every few years according to scientific reviews and adds or drops services. Plastic surgeries are out unless there's significant affects to the person'e quality of life. If a patient is interested in an experimental, or not proven, innovation, he can shop for it himself as long as there's solution that is covered. The same way private insurance deals with such cases presently. As for meds, with big data you can pinpoint to a patient that over uses or a physician who over prescribes, and use this info for integrative medicine purposes to optimize the use of meds to better results. Those methods do not go well with the healthcare industry of course. No one now has an incentive to cut services or meds.

In general every method has it wastes and frauds which cannot be quantified in advance, the issue here isn't just cost, it is first and foremost MORAL.

Mark , February 22, 2019 at 6:04 am

As a non American, I find it quite bizarre when claims like this are made. Universal health care and free/affordable quality education is available in many countries that are far less prosperous than the United States.

If only the US could look outside it's bubble and take a few hints from how things are done elsewhere. However being the "leader" of the "free world" seems to make the USA blind to looking outside its own sphere for how things could be done better.

(Not that the US is alone here. But it probably is one of the stronger examples.)

notabanker , February 22, 2019 at 7:30 am

The isolation that Americans live in is a problem when it comes to this. I use the Alice in Wonderland on the other side of the lookinglass metaphor frequently to describe my expat experiences. Being immersed in a different culture, you see first hand how 'normal' is so relative.

Americans do live in bubbles, and within the US there are bubbles, the country is so vast and it's media is captured. I find it encouraging when people like yourself speak up and call bullshit. I've seen some of Sanders healthcare threads on twitter completely ratio'd with Canadian, British and Aussie's calling BS on the US propagandists that try to attack their systems. We need more of that.

Kurtismayfield , February 22, 2019 at 9:49 am

The isolation that Americans live in is a problem when it comes to this. I use the Alice in Wonderland on the other side of the lookinglass metaphor frequently to describe my expat experiences. Being immersed in a different culture, you see first hand how 'normal' is so relative.

You have to consider their news sources as well.. my theory is that the only point of the 5 and 6 O'clock news is to feed into middle class anxiety or advertise a product. The corporate run media wants people scared and to buy buy buy. I would love to see a politician start a campaign where they discuss 20 different country's health care systems that are better and cheaper than ours, and see how deafening the silence will be from the corporate media.

As I have said here many times before, just get someone to propose the Swiss system . Anyone that argues that the Swiss are some bastions of communist thought can be laughed at entirely.

notabanker , February 22, 2019 at 11:36 am

I did mention the media being captured. And unlike the UK, there is no European influence to counter / add breadth to the BBC. Brits and Europeans have a far more global-centric view of things, if for no other reason than geography.

Phacops , February 22, 2019 at 10:01 am

Having to work in other countries provides a swift reality check regarding ways of social organization and doing things. I count such experiences as saving me from believing conservative propaganda here in the US.

notabanker , February 22, 2019 at 11:54 am

I am so very glad my kids spent crucial formative years outside of the US. It's the best possible gift I could have ever given to them.

Phacops , February 22, 2019 at 9:53 am

What do you expect for a people who actually hate to travel except for pre-programmed experiences or resorts walled off from the surrounding community? That, and the lack of adequate holiday time to even enjoy their own country. I don't wonder at the ignorance of the American public about better ways of providing human services and better health outcomes, though I think some such ignorance is deliberate.

Buzz , February 22, 2019 at 12:02 pm

How very, very true Mark. I've yelled and screamed this same meme over and over to no avail. Look around, we're not the only country on this planet and we DON'T always have the right answers !

Grant , February 22, 2019 at 12:40 pm

On so many issues though in this country, when we talk about the "US", we should be clear about what we are talking about. The opinions of rich people in the media, rich and corrupt politicians, strongly ideological people with a class bias that are appointed by politicians, and paid propagandists and "think tanks" don't constitute the country. I don't think that those groups have anything to learn about other countries because I think most of them are fully aware that they are not being logically factual or honest in what they say on healthcare, the critiques they give of single payer, etc. Some people maybe are (willfully) ignorant, but I think most of it is gaslighting. It doesn't matter that every single payer system has lower overhead, is more efficient, has far less social costs, is cheaper as a percentage of GDP and on a per capita basis. It doesn't matter the reasons why this is the case. There was a WHO study in 2010 that showed that administrative overhead in private systems around the world is three times higher than overhead in public systems, and why that is the case. It doesn't matter how many studies show massive aggregate savings from adopting single payer here. The data on overhead with traditional Medicare versus private insurance, polls showing that the public parts of the healthcare system (the VA, Medicare, Medicaid) are all more popular than private insurance or things like the Rand study showing that care at VA hospitals are often better than the care veterans get at private healthcare providers. None of it matters, if any person on TV actually cared about factual accuracy on stuff like this, they wouldn't be on TV. Someone else that was willing to manipulate people and lie would be in their place, and they would be paid well to do so instead of them. You can't tell me that Jake Tapper isn't fully aware of what he is doing when he "fact checks" single payer like he has done.

The public, however, does seem to get it, especially when things are described accurately to the public. Kaiser does polls, they are opposed to single payer, and so they frame their questions in really biased ways. For example, they will ask, would you support single payer if it raised taxes? Well, some respondents say not, although there is still majority support. Beyond the MMT arguments of not needing to raise taxes, let's just assume that we are trying to make single payer as revenue neutral as possible, for arguments sake. Wouldn't a more accurate question be, would you support single payer if it raised taxes, but the tax increases were more than offset by a reduction in out of pocket expenditures? Polls show strong majorities of the country support single payer, and that is with very little of those in power and with big microphones supporting the idea. We all know the studies showing the large gap between popular opinion and what the state does on policy. Like every other issue, people want one thing, and worthless people in power want another, and our system doesn't make it so that those worthless people are really directly controlled by us collectively nearly as much as donors and other interests control them.

greg , February 22, 2019 at 6:34 am

Since it is becoming increasingly obvious that our current management team of wealthy white males are both too venal and too incompetent to sustainably manage a global economy, perhaps we should start looking for alternatives.

It is delusional to think that US healthcare, or any of the problems which beset both the United States and the world, will be effectively dealt with as long as they are in charge.

It is unreasonable to expect that the over exploitation of natural resources, or sustaining the environment, addressing global warming, and so forth, will happen under their management. This is simply because they are the ones who control the earth's resources, and they are the ones who most profit from their unregulated exploitation and destruction.

It is unreasonable to expect that pollution will be effectively dealt with, because the wealthy make a profit from every ounce of pollution, and every scrap of litter, that has ever been, or will ever be, produced.

Every ounce of CO2 produced, is profit for some wealthy businessman.

Overpopulation is profitable for the wealthy. It both expands their market for goods and services, and lowers their price for labor.

Have you not noticed that we have been aware of all of these problems for over 50 years, and nothing has actually been accomplished with any of them?

Nothing effective will be done, with any of these problems, while they are in charge. It's all been talk, talk, talk, and from the wealthy, always the seeds of confusion and division.

Once a problem has been solved, it is no longer an opportunity for profit. As long as a problem festers, there is money to be made.

Every cost imposed on society is a profit opportunity for someone with wealth and power. There is money to be made, as civilization declines and collapses.

Mac na Michomhairle , February 22, 2019 at 9:23 am

You seem to start of suggesting that things would be fine, if it were not for wealthy white males being in charge.

That is a peculiar perspective that appears to attempt to divert attention from the actual horrifying system itself, and divert potential energy from attempts to change that system, to focus on a mere feature of the system.

As though, if an investment house screwed over my parents, I devote myself to bettering the world by fighting the men of Connecticut wherever I encounter them, because the house agent who was point person was from Connecticut.

If individuals in the system stand to profit from it, of course they have a stake in its continued existence; any individuals do.

Mike Mayer , February 22, 2019 at 7:39 am

Why don't businesses in the USA want to have the burden of providing health insurance taken away from them? It is a cost they bear because they need to find, negotiate, buy and administer the health plan. I am surprised most businesses are not lobbying to have the government provide it.

voteforno6 , February 22, 2019 at 9:44 am

On the other hand, the system of employer-based health insurance does offer additional ways for employers to keep the serfs in line.

rd , February 22, 2019 at 10:50 am

I tend to align with incompetence and neglect in lieu of conspiracy theories if the former can explain it, because it takes a lot of effort and smarts to pull off a conspiracy and both of those are usually in short supply across a large population.

I think we have most companies for whom the health insurance system is just something they have to have and they just go along with the flow because their competitors based in the US have similar costs.

The one organized group on this is the healthcare industrial complex that are lobbying against any nationalization type of change and even want to get more into the VA and Medicare than they already are. This IS their business and they are focused on it like a laser beam. so the conspiracy theory works for their sector.

BTW – I am surprised that the inexpensive healthcare in the rest of the developed world hasn't been a talking point of Trump's as a "subsidy" to their businesses justifying retaliatory tariffs by the US. The difference between what the US and the rest of the developed countries spends on healthcare is bigger than the entire US military budget as a percent of GDP, never mind the delta between US military spending and the other G-20 countries. So if we could drop our health care per capita spending to a bit below Switzerland's (next highest), we would have paid for the entire US military budget. If we could drop it down to Canada's level, we would have saved a year and a half's US military budget every year.

And "American Exceptionalism" pretty much ensures that nobody will look outside the US borders for solutions. If we are doing it, then it must be the best way. End of story. No further research required.

jrs , February 22, 2019 at 1:03 pm

besides the fact that it only makes a little bit of sense even as a conspiracy theory, a few people work just for healthcare and would retire otherwise (they are of course comparatively well off it goes without saying, and yes they SHOULD be able to retire, make room for those who actually NEED to work!).

But most work for survival day to day and if healthcare comes with it that's great, but many work without any form of employer provided healthcare at all (because they still need money to survive). I've heard 30-40% of the working population has NO employer provided healthcare. The serfs are still kept in line just by even more basic needs like food, shelter, and climate control, or they wouldn't show up for such jobs, but of course they do.

tegnost , February 22, 2019 at 9:59 am

IMO it's because they like the captive employees who won't quit because health care

Jim Thomson , February 22, 2019 at 12:51 pm

Bingo.

antidlc , February 22, 2019 at 10:18 am

As mentioned by other posters, companies want to use healthcare to keep employees captive. They don't want employees to leave for smaller firms or start their own companies. It's a way to limit competition.

Companies also have a vested interest in keeping the employer-based insurance model:
https://www.wsj.com/video/why-big-tech-wants-access-to-your-medical-records/F9C51DC8-5238-4D0C-B8BD-73F0FAC92048.html

They want to be able to use your medical history to decide whether to hire or fire you. The video is quite alarming.

oaf , February 22, 2019 at 8:00 am

" the financial health of the insurance industry"

Perhaps Government should mandate the profitability of all sectors of the Economy
..or justify why they pick *favorites*

Got to keep the trough full; that's an important pig!

oaf , February 22, 2019 at 8:17 am

lest we throw out the Baby with the bathwater; let's bathe in it a while longer!

zagonostra , February 22, 2019 at 8:19 am

> It is also hard to believe they are stupid. However, a close reading of their arguments suggests they may think we are stupid, or at least befuddled by repeated public relations/ propaganda/ disinformation campaigns.

Unfortunately, I think in the aggregate both are true: They are not stupid, rather cunning and evil, we are stupid, or rather easily manipulated by a very sophisticated propaganda machine that goes back to Edward Bernays. If you repeat a lie often enough it doesn't matter if it's true or not, and by the processes of association (socialism/Venezuela) we are wired in ways that makes us susceptible to blaring lies (some of Koestler's works come to mind).

There has to be a tipping point where enough people have built up defenses to the propaganda that enable "we" to go after the bloody bastards.

tegnost , February 22, 2019 at 10:16 am

I think it's less a matter of defenses and more the numbers game, the PTB have been pretty successful winnowing the field. Say a 1000 people work in an industry, someone of those 1000 figures that 100 of those can be replaced (h1b, computers, undocumented immigrants) but the amount they charge stays the same, or more likely is increased to reflect the leaner machine being more productive. Big bonus to top guy. Then it's well we have 900 employees, we could do the same with 700 employees etc and on down the line. This has worked really great for the 40 years since reagan. Add crippling student loan debt, winnow out some more people as they have been effectively neutered, basically only able at best to maintain as a steadily depreciating labor unit (hmmm, we need that persons shoes to touch the ground in a medical establishment so the gov can pay us, since that poor schlub obviously can't, thanks ACA, and once again imo, the whole reason for the medicaid aspect of the ACA) the end result is fewer and fewer successful lives being led, and more and more precarious lives being led. In 2016 the dogs wouldn't eat the dogfood. Nothing about the numbers have changed so the dogs are going to be more grumpy and indeed some of those dogs which sat on the sidelines last time might be grumpy enough to vote in 2020.

katiebird , February 22, 2019 at 8:39 am

It seems like there is a logical fallacy somewhere in this story. .

Arizona college student could die because she can't get copies of her medical records

The files are locked away in a repossessed electronic-records system while creditors of bankrupt Florence Hospital at Anthem and Gilbert Hospital bicker over who should pay for access to them.

.

The medical records are the only thing standing between her and a lifesaving surgery by a top physician at Johns Hopkins Hospital.

The doctor has refused to perform the operation without a complete understanding of Secrist's health history, including what her pancreas looked like when she was originally diagnosed, she said.

Every week that goes by, the danger increases of another attack of acute pancreatitis that could cause her organs to shut down.

"Without those records, we can't go forward. We can't make me better," said Secrist, who lives with her parents in Florence. "Having my life, practically, in the hands of a judge and people I don't even know, who don't even know my situation, it's upsetting."

Secrist and her primary-care physician sent letters this week to Maricopa County Superior Court urging swift release of her records. Federal and state law require medical facilities to send patients copies of their medical records within 60 days of a request.

taunger , February 22, 2019 at 9:00 am

Thank you for this post that clearly identifies the logical fallacies. This can be useful in conversations #fieldwork

Norb , February 22, 2019 at 9:04 am

In the long run, Medicare-for-all lays the groundwork for a more healthy and productive society. Healthy citizens require less healthcare, so there is potential savings over time. Healthcare is most efficient when built around a healthy society. But healthy citizens must be the primary goal, not some abstract argument about affordability and jobs protection. The jobs created by the system must be oriented toward societal health, not the profit generation for a few plutocrats. No wonder they are bemoaning the cost- they have been impoverishing the citizenry for 40 years and sooner or later that bill has to be paid.

The plutocrats, always attempting to hide their true motives, now seek to obfuscate their abject disdain for working people by using arguments of cost to continue restricting access to healthcare. Their inhumanity must be driven home and called out, but the social discourse is still in "polite" mode. Using the term 'stupid' to describe the plutocrats falls in this category. They know exactly what they are doing, and are given a social pass to continue acting in an inhumane and antisocial manner. Chants of USA USA are obscene in this context. The longer this trend continues, only decline can result.

If people are not responsive to a moral argument, the argument for comparative costs is the strongest one that needs to be constantly driven home. We are already paying- and as pointed out, will be paying much more in the future for less. Everyone can understand that and can see it in their own pocketbooks.

The moral bankruptcy of the current leadership must be called out. The propaganda bubble that Americans live enshrouded in is showing signs of weakness. That bubble will burst when pricked from forces outside the impirum- and there are many- failure is everywhere and the rest of the world is not as delusional as most Americans.

a different chris , February 22, 2019 at 9:19 am

Do these billionaires realize that, in this case the word "unaffordable" specifically means "go die"? Wow.

bassmule , February 22, 2019 at 9:27 am

As Lambert has frequently pointed out, NeoCon policy regarding health is this:

1. "Because markets!'
2. "Go die!"

voteforno6 , February 22, 2019 at 9:46 am

That's NeoLib The NeoCons are the ones who want to bomb everything, everywhere, because America.

polecat , February 22, 2019 at 11:19 am

Put the two together, and you have two wretched greedy fingers locked in avaricious embrace !

JBird4049 , February 22, 2019 at 12:15 pm

The two sets have been merging to where they would be almost the same in a Venn diagram. Almost the entire Washington establishment agrees on what is call the Washington Consensus which is cutting taxes, reducing regulations, free trade, and now apparently the Forever Wars.

Most of the differences that remains are cosmetic and focus on the social issues so that the selected base will organize, donate, and vote for them.

For example, gun control, LGBT rights, and pro-choice (abortion) for the Democratic Party and gun rights, religion, and pro-life (anti-abortion). Note that the goal is not to solve or even ameliorate any issue, but rather to inflame them so that they can be used as cover, distraction, and agitation.

Carolinian , February 22, 2019 at 9:46 am

It's all about the Benjamins–logic has nothing to do with it and never has. The largest business in my county is the hospital system which also has the highest paid CEO. And they just became even larger by buying a smaller competing hospital. Yves has pointed out how fearsome the DC health lobby is and, as cited above, the Chamber of Commerce is fully on board. There's been some excitement because announced Dem pres candidates support Medicare for all but Dem candidates always say they are for reform whereas in reality we get Hillary care in the '90s or Obamacare after both he and Hillary campaigned on the issue. Probably none of this will stop unless the economy crashes to the point that the medical complex has to accept reform and reality.

justsayknow , February 22, 2019 at 10:14 am

''That is the kind of extreme policy that is not a policy that I agree with,' Schultz said on 'The View,' adding that doing away with private insurers would lead to major job losses.

'That's not correct. That's not American,' Schultz said on CBS. 'What's next? What industry are we going to abolish next? The coffee industry?'

I'd say Shultz gives the game away as he reveals he sees the current "system" as a make-work-make profit center.
I imagine he and Bloomberg et al have significant investments in the health industrial complex. Otherwise wouldn't it benefit all other commerce sectors to have customers with lower health costs thereby freeing up money that could be spent with them.

Eclair , February 22, 2019 at 12:22 pm

"What industry are we going to abolish next?"

Great question, Schultzie! Where were you (or your ilk) when we 'abolished' the US textile industry? Or our furniture industry? Or our electronics industry? Or our clothing industry? Or our rail car manufacturing industry?

And the jobs that went with them.

antidlc , February 22, 2019 at 10:23 am

More from Wendell Potter:

How to be ready for the health care industry lie factory
https://www.tarbell.org/2019/02/be-ready-for-the-health-care-industry-lie-factory/

antidlc , February 22, 2019 at 10:26 am

Meet the propaganda outfit fighting against Medicare for All (podcast)

Why do we believe the things we do? Whistleblower, New York Times best selling author and Tarbell.org founder Wendell Potter, along with millennial co-host Joey Rettino, are joined by politicians, activists, journalists and pretty much everybody else to figure it out.

https://www.tarbell.org/2019/02/the-potter-report/

Summer , February 22, 2019 at 10:26 am

I laugh when they say they are worried about "jobs" of people in the health insurance industry. They aren't worried about the jobs, but exec pay. Everytime I look up there are articles about more automation and tech in the administrative and medical pafts of the industry.
It's like Uber claiming to worry about drivers while claiming their future is driverless cars.
So a good number of people that staff the health insurance industry (talking to you non-wealthy execs) need to get on board now and get their health care covered.

There aren't too many industries that aren't salivating overways to have fewer employees and then you hear all this BS from the same industry "leaders" touting how employer based system is the only thing imaginable.

rd , February 22, 2019 at 11:12 am

BTW – latest number I can find

Canada military spending 1.0% of GDP; healthcare spending 10.4%: Total military + healthcare = 11.4% of GDP

US military spending 3.5% of GDP; healthcare spending 16.9%: Total military + healthcare = 20.4% of GDP

So between those two economic sectors, Canada has an extra 9% of GDP to spend on other priorities. No wonder they can have an inflated housing market as well as paid parental leave.

Disturbed Voter , February 22, 2019 at 12:41 pm

Exactly. To reallocate resources, you have to look at the whole picture, not just the health industry. That is a huge question. What you do with a particular allocation, is pertinent.

D , February 22, 2019 at 11:13 am

i always wonder if they are really thinking through when the say that the government (us) but that if we let patients and insurance can pay for it?? Really????

Susan the Other , February 22, 2019 at 12:45 pm

Thanks for this post, Yves. It was really good. It did all the demolishing for us. Deconstructing the whole building. I love the phrase (whether facetious or not) "argument by gibberish." I mean, it could be a necessary part of a logic curriculum – please analyze this argument for gibberish – because we were once so oblivious. So, more accurately, the pushers are now the oblivious ones. The full court press against "socialism" and "unaffordable health care" and holding up the decrepit free market isn't going to work much longer.

Hepativore , February 22, 2019 at 12:58 pm

One thing that I also hope that gets changed in the US, is combining dental care with a Medicare For all Program. It is ridiculous that people have to carry both dental and health insurance as good dental care and physical well-being are related. Left untreated, oral maladies can quickly become serious and more expensive to treat. Effective dental care is far from a vanity service.

[Feb 22, 2019] Angry Bear Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals

Feb 22, 2019 | angrybearblog.com

Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals

run75441 | February 21, 2019 10:00 pm

Healthcare Hot Topics This should come as no surprise as I have written on the topic of Healthcare Costs and Its Drivers before. In particular, the overriding statistic from an earlier post was 50% of the increase in healthcare costs was due solely to price increases between 1996 and 2013 (JAMA, Factors Associated With . . . . Adjusting for inflation, "annual health care spending on inpatient, ambulatory, retail pharmaceutical, nursing facility, emergency department, and dental care increased from $1.2 trillion to $2.1 trillion or $933.5 billion between 1996 and 2013." This was broken down into 5 fundamental factors contributing to rising healthcare costs.

– Increased US population size was associated with a 23.1% increase or $269.5 billion
– An aging population was associated with an 11.6% increase or $135.7 billion
– Changes in disease prevalence or incidence (inpatient, outpatient, ED) resulted in spending reductions of 2.4% or $28.2 billion
– Changes in service utilization (inpatient, dental) were not associated with a statistically significant change in spending
– Changes in service price and intensity were associated with a 50.0% increase or $583.5 billion.

Five fundamental factors (Population size, Population aging, Disease prevalence or incidence, Service Utilization, and Service Pricing) were collectively associated with a $933.5 billion increase in annual US health care spending between 1996 through 2013. Represented pictorially, stated objectively, and categorized numerically, I can not make it any more obvious.

Some Explanation

The change in disease prevalence or incidence was associated with a spending reduction of 2.4%, or $28.2 billion while the change in service utilization did not result in a statistically significant change in spending. Said another way, these two factors had little or no impact on the rising cost of healthcare.

The increased healthcare costs from 1996 to 2013 were largely related to Healthcare Service Price and Intensity and secondarily impacted by Population Growth and Population Aging in order of impact. The bar chart reflects all of the impact in changes.

So the aging tsunami of baby boomers has not hit yet and population growth has not greatly impacted the results of this study. In patient stays at hospitals are down as well as out patient use of facilities. The big issue is the change in pricing for inpatient hospital stays and pharmaceuticals. Hospital/clinic consolidations leads to the former even though insurance has been fighting for a reduction in stays. Pharmaceutical has instituted new pricing strategies which we have all read about in the news. Old drugs such as Humalog, Viovo, and the infamous Epipens as well as others are now more expensive. This study points to pricing for pharma and service as the issues.

An example?

There is a tendency to challenge the lifestyle practices of people who indulge in too much. One factor did come out in the increased cost of healthcare. The increase in annual diabetes spending between 1996 and 2013 was $64.4 billion of which $44.4 billion of this increase was pharmaceutical spending. Said another way, two-thirds of the increase in treating diabetes was due simply to the increased pricing of pharmaceutical companies.

And yes, there should be time spent on changing habits where it can be changed and providing the means to do so. However, in 1996 Eli Lilly's Humalog was $21 per vial. By 2017, the price increased to $275 (700%) for a vial which equates to a one-month supply.

Why has the cost of Humalog increased? "The truth is the improvements in new formularies of old versions which are marginally different, and the clinical benefits of them over the older drugs have been zero." Just like slapping "new and improved" on the labels of food products with a change of ingredients (which qualifies under USDA and FDA labeling regs)., pharmaceuticals can play the same game and they do.

As the article ("Eli Lilly Raised U.S. Prices Of Diabetes Drug 700 Percent Over 20 Years ") explains, "most patients do not pay the full cost/price of a drug up front and absorb their portion of the cost via an increase in monthly healthcare premiums." This leads to pharmaceutical companies charging as much as the U.S. insurance companies will let them. Both parties profiting from increased prices. Perhaps Alex Azar the Secretary of Healthcare can explain it better as he was an officer of Eli Lilly when Humalog began its ascend?

Another Study via Health Affairs

A shorter time period extending one year longer than the Jama study, the Health Affairs study supports what is being said in the JAMA study. According to data from the Henry J. Kaiser Family Foundation, total health spending on the privately insured in the United States increased in real terms by nearly 20 percent from 2007 to 2014.

A more recent study funded by the Commonwealth Fund and published by Health Affairs examined other costs impacting healthcare. Commonwealth Fund supported researchers recently analyzed hospital and physician prices for inpatient and hospital-based outpatient services as well as for four high-volume services: cesarean section, vaginal delivery, hospital-based outpatient colonoscopy, and knee replacement. Its findings were as follows:

– From 2007 to 2014, hospital-prices for inpatient care grew 42 percent compared to 18 percent for physician-prices for inpatient hospital care
– For hospital-based outpatient care, hospital-prices rose 25 percent compared to 6 percent for physician-prices
– There was no difference in results between hospitals directly employing physicians and indirectly employing physicians
– Hospital prices accounted for over 60 percent of the total price of hospital-based care.
– Hospital prices accounted for most of the cost of the four high-volume services included in the study. The hospital component ranged from 61 percent for vaginal deliveries to 84 percent for knee replacements.

Sound familiar? The JAMA study looked at both in and out patient costs/prices associated with hospital services and said they were up. The Health Affairs study looks at in patient services for four high volume inpatient services stating they have increased significantly from 2007 to 2014.

What the Health Affairs study Showed

The Health Affairs study also presents a comparison of hospital pricing growth rates as compared to physician pricing growth rates. The study is only a few weeks old and I am surprised I am able to access as much information as I have. While Health Affairs admits the study is a start and more work differentiating other aspects must be done, the study suggests there are significant growth in the bargaining leverage of hospitals as compared to physicians.

If you recall Rusty "Tom" and I engaged in a number of different conversations on healthcare with one of them being hospital consolidations (2013). It is a power grab, as Rusty pointed out, for more market segment and pricing control with those having name-recognition gaining the most. Maggie Mahar also referenced the same issue.

In my own commentary On the Horizon After Obamacare (2014): As it stands and even with its faults, the ACA is a viable solution to many of the issues faced by the uninsured and under-insured; but in itself, it only addresses the delivery-half of the healthcare problem. The other half of the problem rests with the industry delivering the healthcare and the control of pricing through the inherent monopolistic power coming and pushing the industry into greater integration of delivery. As Longman and Hewitt posit,

"the message from Department of Health and Human Services stresses the vast savings possible through a less 'fragmented and integrated' health care delivery system. With this vision in mind, HHS officials have been encouraging health care providers to merge into so-called accountable care organizations, or ACOs"; "while on the other side of the Mall, 'pronouncements from the FTC are about the need to counter the record numbers of hospitals and doctors' practices merging and using their resulting monopoly power to drive up prices."

Two different messages from government, greater efficiencies in healthcare through consolidations as ACOs versus monopolistic pricing control in healthcare by large hospital and pharmaceutical corporations an unintended result. There is large amounts of inefficiencies, waste, and rent-taking in healthcare as well as in Medicare which is touted as the go-to by politicians and advocates of it. Lets not make a similar mistake, the creation of any forthcoming healthcare system must first address the costs of healthcare and then the delivery of it not ignoring the quality of the product and its outcome after treatment. Again Maggie Mahar was big on promoting this result emanating from any new system.

While Physician fees grew at a compounded annual rate of 6% for baby deliveries and 1% for office visits between 2003 and 2010, hospitals fees during a similar period grew at 17%.

A measurement of the competitiveness of a hospital within a certain area of the country is done utilizing the Herfindahl-Hirschman Index (HHI) . It has been used to measure competition in and around cities. The results of the HHI revealed an increase in the concentration of hospitals from mergers and acquisitions, going from moderately concentrated in 1990 with an HHI numeric of 1570, to more concentrated in 2009 with a HHI of 2500, and with some cities purely monopolistic at 10,000.

Rigorous action by the FTC would certainly go a long way in improving compositeness; however, the FTC has been purposely understaffed by cutting its funding. In place at the FTC is a staff 22 lawyers and economists to monitor a $3 trillion healthcare industry. It is too understaffed to take on such a large industry which would overwhelm it with legalese and paper. Maybe in the next election will bring forth the right person to take on healthcare.

Resources

Hospital Prices Grew Substantially Faster Than Physician Prices For Hospital-Based Care In 2007–14, Zack Cooper, Stuart Craig, Martin Gaynor, Nir J. Harish, Harlan M. Krumholz, and John Van Reenen, HealthAffairs, February 2019

Zack Cooper Hospital Care Prices Rose Faster Than the Cost of Physician Services, February, 2019

After Obamacare Phillip Longman and Paul S. Hewitt, Washington Monthly, January – February 2014


Mike Kimel , February 22, 2019 5:46 am

I have the impression that it has gotten harder to see a doctor or get a prescription filled over time. A couple of decades ago either your insurance paid or it didn't. Now it seems to me that most people have stories about arguing with insurance companies. It is sort of expected to be a part of the process. Time costs like this aren't counted with a dollar value but they surely contribute to the negative experience, and they require additional admin people at both medical providers and insurance companies. That in turns leads to more documentation and paperwork, requiring even more admin people. It's one thing if the extra personnel are a force multiplier allowing more people to be serviced. It's another if they are an impediment and an added cost.

Denis Drew , February 22, 2019 11:28 am

The political forum is too "understaffed" on all topics to fight back against (a nation of) scams because of (you know what I'm going to say) the disappearance of labor unions. Late Dean of the Washington press corps, David Broder, told a rookie reporter that when he came to DC the lobbyists were all union.

Nice to get real -- math broken down -- info beginning to tell why we pay twice as much for health care as any other country. When you add the hospitals overcharging, the drug companies bleeding us literally to death and the private insurance paper work overload, maybe we are finally sorting it out, at least a bit.

likbez , February 22, 2019 3:35 pm

The relationship between hospitals and heaths insurance companies currently somewhat resembles criminal cartel.

Often hospitals perform on the patient procedures that are best paid by the insurance companies, even if they are unnecessary, or even harmful.

An epidemic of unnecessary cardiac stents insertions in the USA is a nice illustration of the trend for costly and unnecessary (or even dangerous for the patient) procedures . Hospital cardiologists are pushed by financial incentives

"chief cardiologist Steven Nissen at the renowned Cleveland Clinic noted that doctors are paid per procedure rather than on a salary basis, while the Mayo Clinic's chief of cardiology, Raymond J. Gibbons, also cited the financial incentive of performing procedures."

And only few cardiologists that practice this racket went to jail.

That somewhat resembles relations between the car insurers and the body shops ;-)

[Feb 05, 2019] Trump and His Golfing Buddies Continue Neoliberalism s Assault on the Veteran s Administration by Lambert Strether

Notable quotes:
"... By Lambert Strether of Corrente . ..."
"... It's almost like there's a neo-liberal playbook, isn't there? No underpants gnomes , they! (1) Defund or sabotage, (2) Claim crisis, (3) Call for privatization (4) Profit! [ka-ching]. Congress underfunds the VA, then overloads it with Section 8 patients, a crisis occurs, and Obama's first response is send patients to the private system . ..."
"... Assuming that wait time is a function of resources, you can easily see how the playbook would work: (1) Reduce resources, (2) whinge about wait time, and (3) drain patients from the VA system, for profit! (Note that while Democrats are ostensibly jumping on board the #MedicareForAll train, they are, in the main, silent -- Warren and Sanders being the only notable exceptions -- about the destruction of an existing ..."
"... "This is nothing short of a steady march toward the privatization [1] of the VA," Sanders said. "It's going to happen piece by piece by piece until over a period of time there's not much in the VA to provide the quality care that our veterans deserve." ..."
"... Now, just because privatizing the Veterans Administration is a project of the political class as a whole doesn't mean that the Trump Administration hasn't brought its own special mix of corruption and buffoonery to the table. Indeed it has! Who, we might ask, were the actual factions in the Republican administration pushing for VA Mission? Three of Trump's squillionaire golfing buddies at Mar-a-Lago[2], as it all-too-believably turns out. From Pro Publica, " The Shadow Rulers of the VA ": ..."
"... The wretched excess of Trump's policy-by-golfing buddies aside, I don't see why privatiizing the Veterans Administration shouldn't become a major campaign issue, especially given Sanders' presence on the relevant committee. We send our children off to die in wars for regime change where the only winners are military contractors. ..."
Feb 03, 2019 | www.nakedcapitalism.com

February 3, 2019 By Lambert Strether of Corrente .

With the release of new proposed eligibility rules under the VA Mission Act, we see that privatization at the Veterans Administration (VA) continues to unfold, as outlined in the neoliberal playbook , to which we have alluded before:

The stories intertwine because they look like they're part of the neoliberal privatization playbook , here described in a post about America's universities:

It's almost like there's a neo-liberal playbook, isn't there? No underpants gnomes , they! (1) Defund or sabotage, (2) Claim crisis, (3) Call for privatization (4) Profit! [ka-ching]. Congress underfunds the VA, then overloads it with Section 8 patients, a crisis occurs, and Obama's first response is send patients to the private system .

Congress imposes huge unheard-of, pension requirements on the Post Office, such that it operates at a loss, and it's gradually cannibalized by private entities, whether for services or property. And charters are justified by a similar process.

(I've helpfully numbered the steps, and added 'sabotage' alongside defunding, although defunding is neoliberalism's main play, based on the ideology of austerity.)

We can see this process play out not only in public universities, public schools, the Post Office, and the TSA , but in Britain's NHS, a national treasure that the Tories are systematically and brutally dismantling .)

The political class has been trying to privatize the VA across several administrations -- " Veterans groups are angry after President Obama told them Monday that he is still considering a proposal to have treatment for service-connected injuries charged to veterans' private insurance plan" -- although it is true that the Trump administration has brought its own special brand of crassness to the project, as we shall see. As we might expect , the project has nothing to do with the wishes of veterans :

Nearly two-thirds of veterans oppose "privatizing VA hospitals and services," according to a poll released Tuesday by the Vet Voice Foundation. And some 80 percent of the veterans surveyed believe veterans "deserve their health care to be fully paid for, not vouchers which may not cover all the costs."

A plurality of veterans, or 42 percent of those surveyed, agreed with the statement that the VA "needs more doctors," according to the poll, indicating they believe the VA's problems are at least partly due to a personnel shortage [Step (1)].

Although Vet Voice is a progressive organization, the poll of 800 veterans was jointly conducted by a Democratic polling firm and a Republican one.

And the Veterans are right, because VA hospitals provide better care. Besides many anecdotes , we have this in Stars and Stripes, " Dartmouth study finds VA hospitals outperform others in same regions ":

A new study by Dartmouth College that compares Department of Veterans Affairs hospitals with other hospitals in the same regions found VA facilities often outperform others when it comes to mortality rates and patient safety.

Researchers compared performance data at VA hospitals against non-VA facilities in 121 regions. In 14 out of 15 measures, the VA performed "significantly better" than other hospitals, according to results from the study.

"We found a surprisingly high, to me, number of cases where the VA was the best hospital in the region," said Dr. William Weeks, who led the study. "Pretty rarely was it the worst hospital." "One has to wonder whether outsourcing care is the right choice if we care about veterans' outcomes," Weeks said. "The VA is, for the most part, doing at least as well as the private sector in a local setting, and pretty often are the best performers in that setting."

"One has to wonder" indeed! Be that it may, the new VA eligibility rules accelerate privatization. USA Today :

Nearly four times as many veterans could be eligible for private health care paid for by the Department of Veterans Affairs under sweeping rules the agency proposed Wednesday.

VA officials estimated the plan could increase the number of veterans eligible for private care to as many as 2.1 million – up from roughly 560,000 .

And here are the rules (apparently modeled after TriCare Prime , the military's insurance plan):

Assuming that wait time is a function of resources, you can easily see how the playbook would work: (1) Reduce resources, (2) whinge about wait time, and (3) drain patients from the VA system, for profit! (Note that while Democrats are ostensibly jumping on board the #MedicareForAll train, they are, in the main, silent -- Warren and Sanders being the only notable exceptions -- about the destruction of an existing , and highly functional, single payer system. So how do we get to this point? A previous iteration of the neoliberal playbook, of course!

* * *

Our story begins with the " hastily enacted " Veterans Choice Program of 2014 :

The program, which began in 2014, was supposed to give veterans a way around long waits in the VA. But veterans using the Choice Program still had to wait longer than allowed by law. And according to ProPublica and PolitiFact's analysis of VA data, the two companies hired to run the program [TriWest and Health Net] took almost $2 billion in fees, or about 24 percent of the companies' total program expenses .

More on those fees from Pacific Standard :

According to the agency's inspector general, the VA was paying the contractors at least $295 every time it authorized private care for a veteran. The fee was so high because the VA hurriedly launched the Choice Program as a short-term response to a crisis. Four years later, the fee never subsided -- it went up to as much as $318 per referral .. In many cases, the contractors' $295-plus processing fee for every referral was bigger than the doctor's bill for services rendered, the analysis of agency data showed.

Ka-ching! So, step (3) -- profit! -- worked out very well for TriWest and Health Net, piling up $2 billion in loot. ( Step (2) was a scandal of "35 veterans who had died while waiting for care in the Phoenix VHA system," step (1) being the usual denial of resources/sabotage). The VA Mission Act was the legislative response to Veterans Choice debacle. Naturally, it moved the privatization ball down the field. The American Prospect :

Only two of the 42 members on the House and Senate Veterans Affairs Committee opposed Mission last year , when it came up for a vote.

In other words, privatizing the Veterans Administration has strong bipartisan support. But:

One of those lawmakers, Bernie Sanders, the Vermont Democrat, reiterated his opposition to Mission in December.

"This is nothing short of a steady march toward the privatization [1] of the VA," Sanders said. "It's going to happen piece by piece by piece until over a period of time there's not much in the VA to provide the quality care that our veterans deserve."

Now, just because privatizing the Veterans Administration is a project of the political class as a whole doesn't mean that the Trump Administration hasn't brought its own special mix of corruption and buffoonery to the table. Indeed it has! Who, we might ask, were the actual factions in the Republican administration pushing for VA Mission? Three of Trump's squillionaire golfing buddies at Mar-a-Lago[2], as it all-too-believably turns out. From Pro Publica, " The Shadow Rulers of the VA ":

[Bruce Moskowitz, is a Palm Beach doctor who helps wealthy people obtain high-service "concierge" medical care] is one-third of an informal council that is exerting sweeping influence on the VA from Mar-a-Lago, President Donald Trump's private club in Palm Beach, Florida. The troika is led by Ike Perlmutter, the reclusive chairman of Marvel Entertainment, who is a longtime acquaintance of President Trump's. The third member is a lawyer named Marc Sherman. None of them has ever served in the U.S. military or government .

The arrangement is without parallel in modern presidential history.

Everything is like CalPERS.

The Federal Advisory Committee Act of 1972 provides a mechanism for agencies to consult panels of outside advisers, but such committees are subject to cost controls, public disclosure and government oversight. Other presidents have relied on unofficial "kitchen cabinets," but never before have outside advisers been so specifically assigned to one agency. During the transition, Trump handed out advisory roles to several rich associates, but they've all since faded away. The Mar-a-Lago Crowd, however, has deepened its involvement in the VA.

In September 2017, the Mar-a-Lago Crowd weighed in on the side of expanding the use of the private sector. "We think that some of the VA hospitals are delivering some specialty healthcare when they shouldn't and when referrals to private facilities or other VA centers would be a better option," Perlmutter wrote in an email to Shulkin and other officials. "Our solution is to make use of academic medical centers and medical trade groups, both of whom have offered to send review teams to the VA hospitals to help this effort."

In other words, they proposed inviting private health care executives to tell the VA which services they should outsource to private providers like themselves. It was precisely the kind of fox-in-the-henhouse scenario that the VA's defenders had warned against for years.

While it is true that the ideological ground for privatization was laid by the Koch Brothers , among others, the actual vector of tranmission, as it were, seems to have been the Mar-a-Lago crowd. There has been pushback against them, in the form of a Congressional request for a GAO investigation , and a lawsuit by veterans , but as we have seen, the neoliberal play continues to run.

* * *

The wretched excess of Trump's policy-by-golfing buddies aside, I don't see why privatiizing the Veterans Administration shouldn't become a major campaign issue, especially given Sanders' presence on the relevant committee. We send our children off to die in wars for regime change where the only winners are military contractors.

Then, when our children come home, we're going to send them into a health care system that's been as crapified as everybody else's (and that's before we get to PTSD, homelessness, and suicide). Surely a pitch along those lines would play in the heartland? If Sanders doesn't pick up the ball and run with it, Gabbard should.

NOTES

[1] More from Sanders. Common Dreams :

[SANDERS:] No one disagrees that veterans should be able to seek private care in cases where the VA cannot provide the specialized care they require, or when wait times for appointments are too long or when veterans might have to travel long distances for that care. The way to reduce wait times is to make sure that the VA is able to fill the more than 30,000 vacancies it currently has. This bill provides $5 billion for the Choice program. It provides nothing to fill the vacancies at the VA. That is wrong . My fear is that this bill will open the door to the draining, year after year, of much needed resources from the VA.

In other words, the way to solve the problem is not to take Step 1: Give the VA the resources that it needs.

[2] I continue to believe that golf play, or knowledge of golf play, should be a disqualification for high office.

[Jan 21, 2019] The Social Contract According to Elizabeth Warren

Notable quotes:
"... Uber passengers were paying only 41% of the actual cost of their trips; Uber was using these massive subsidies to undercut the fares and provide more capacity than the competitors who had to cover 100% of their costs out of passenger fares. ..."
"... Warren Supports Medicare for All Only Nominally ..."
"... Never mind that Warren can say, virtually in the same breath, that insurance companies "still make plenty of money" and "we have plenty of work to do to bring down health care spending." RomneyCare was the beta version of ObamaCare. We tried it, as a nation, starting in 2009, and here we are.[5] Is that's what Warren wants, fine, but why not simply advocate for it? ..."
"... Except, perhaps, one distinctly slanted toward insiders. " Work hard and play by the rules " is a Clintonite trope ..."
"... but only through the institutional framework of unions ..."
"... Warren's emphasis on the economic market for health "care?" (insurance companies making plenty of money ..."
"... I've long ago disabused myself of the notion that E. Warren is more than "lipstick" on the usual "pig", but it was good to have written support for that thesis and I will save it for my reference. ..."
"... Non-profit health insurance Company – https://www.democratandchronicle.com/story/money/business/2014/04/25/former-excellus-ceo-package-total-m/8155853/ The final retirement package for former Excellus BlueCross BlueShield CEO David Klein likely will exceed -- by millions -- the $12.9 million the company reported to the state in March. $29.8 Million in retirement. Non-profit for who? It's a complete misnomer and a huge problem in the discourse of healthcare. Hospitals are usually non-profits too. They non-profitly charge you $80,000 for a few stitches and some aspirin. ..."
"... The transcript could easily have been a speech by Hillary (and even delivered to Goldman Sachs if Hillary had had the foresight to realize that every speech would become known to everybody in the Internet age -- before Russiagate was leveraged into Social media banning of anti-establishment speech). ..."
"... The Eric Schmidt who took Google down the primrose part of spying on everybody. Warren is centrist. ..."
"... Warren 2020 campaign is DOA. If you want Trump for another four years go with Warren 2020. Bernie would have won. ..."
"... " Elizabeth Warren is Hillary Clinton reborn, and they're both unlikable, because they're both inauthentic scolds who suffer from hall monitor syndrome. They spent their entire lives breaking every rule they could find while awkwardly fantasizing about running every tiny detail of everyone else's lives . ..."
Jan 21, 2019 | www.nakedcapitalism.com

Posted on January 20, 2019 by Lambert Strether New America (board chair emeritus Eric Schmidt , President the aptronymic Anne-Marie Slaughter ), a nominally center-left Beltway think tank ( funding ) " took up the mission of designing a new social contract in 2007 and was the first organization [anywhere?] to frame its vision in these terms." On May 19, 2016, New America sponsored an annual conference (there was no 2017 iteration) entitled "The Next Social Contract." Elizabeth Warren, presidential contender, was invited to give the opening keynote ( transcript , whicn includes video). Warren shared a number of interesting ideas. I will quote portions of her speech, followed by brief commentary, much of it already familiar to NC readers, in an effort to situate her more firmly in the political landscape. But first, let me quote Warren's opening paragraph:

It is so good to be here with all of you. And yes I will be calling on people. Mostly those of you standing in the back. I always know why people are standing in the back. That's what teachers do.

Professional-class dominance games aside, it's evident that Warren is comfortable here. These are her people. And I would urge that, no matter what policy position she might take on the trail, these policies and this program are her "center of gravity," as it were. Push her left (or, to be fair, right) and, like a bobo doll , she will return to this upright position . So, to the text (all quotes from Warren from the transcript ). I'll start with two blunders, and then move on to more subtle material.

Warren Does Not Understand Uber's Business Model

Or, in strong form, Warren fell for Uber's propaganda.[1] Warren says:

Thank you to the New America Foundation for inviting me here today to talk about the gig economy You know, across the country, new companies are using the Internet to transform the way that Americans work, shop, socialize, vacation, look for love, talk to the doctor, get around, and track down ten foot feather boas, which is actually my latest search on Amazon .

These innovations have helped improve our lives in countless ways, reducing inefficiencies and leveraging network effects to help grow our economy. And this is real growth . The most famous example of this is probably the ride-sharing platforms in our cities. The taxi cab industry was riddled with monopolies, rents, inefficiencies. Cities limited the number of taxi licenses

Uber and Lyft, two ride-sharing platforms came onto the scene about five years ago, radically altered this model, enabling anyone with a smartphone and a car to deliver rides . The result was more rides, cheaper rides, and shorter wait times.

The ride-sharing story illustrates the promise of these new businesses. And the dangers. Uber and Lyft fought against local taxi cab rules that kept prices high and limited access to services .

And while their businesses provide workers with greater flexibility, companies like Lyft and Uber have often resisted efforts of those very same workers to try to access a greater share of the wealth that is generated from the work that they do. Their business model is, in part , dependent on extremely low wages for their drivers.

"In part" is doing rather a lot of work, there, even more than "the wealth that is generated," because NC readers know, Uber's business model is critically dependent on massive subsidies from investors, without which is would not exist as a firm. Hubert Horan (November 30, 2016):

Published financial data shows that Uber is losing more money than any startup in history and that its ability to capture customers and drivers from incumbent operators is entirely due to $2 billion in annual investor subsidies. The vast majority of media coverage presumes Uber is following the path of prominent digitally-based startups whose large initial losses transformed into strong profits within a few years.

This presumption is contradicted by Uber's actual financial results, which show no meaningful margin improvement through 2015 while the limited margin improvements achieved in 2016 can be entirely explained by Uber-imposed cutbacks to driver compensation. It is also contradicted by the fact that Uber lacks the major scale and network economies that allowed digitally-based startups to achieve rapid margin improvement.

As a private company, Uber is not required to publish financial statements, and financial statements disseminated privately are not required to be audited in accordance with generally accepted accounting principles (GAAP) or satisfy the SEC's reporting standards for public companies.

The financial tables below are based on private financial statements that Uber shared with investors that were published in the financial press on three separate occasions. The first set included data for 2012, 2013 and the first half of 2014 The second set included tables of GAAP profit data for full year 2014 and the first half of 2015 ; the third set included summary EBITAR contribution data for the first half of 2016. .

[F]or the year ending September 2015, Uber had GAAP losses of $2 billion on revenue of $1.4 billion, a negative 143% profit margin. Thus Uber's current operations depend on $2 billion in subsidies, funded out of the $13 billion in cash its investors have provided.

Uber passengers were paying only 41% of the actual cost of their trips; Uber was using these massive subsidies to undercut the fares and provide more capacity than the competitors who had to cover 100% of their costs out of passenger fares.

Many other tech startups lost money as they pursued growth and market share, but losses of this magnitude are unprecedented; in its worst-ever four quarters, in 2000, Amazon had a negative 50% margin, losing $1.4 billion on $2.8 billion in revenue, and the company responded by firing more than 15 percent of its workforce. 2015 was Uber's fifth year of operations; at that point in its history Facebook was achieving 25% profit margins.

Now, in Warren's defense, it is true that she, on May 19, 2016, could not have had the benefit of Horan's post at Naked Capitalism, which was published only on November 30, 2016. However, I quoted Horan's post at length to show the dates: The data was out there; it wasn't a secret; it only needed a staffer with a some critical thinking skills and a mandate to do the research to come to the same conclusions Horan did, and Uber's lack of profitabilty, easily accessible, is a ginormous red flag for anybody who takes the idea that Uber "generates wealth" seriously. How is it that the wonkish Warren is recommending policy based on what can only be superfical research in the trade and technical press? Should not the professor have done the reading?[2]

Warren Does Not Understand How Federal Taxation Works

The second blunder. Warren says:

First, make sure that every worker pays into Social Security, as the law has always intended. Right now, it is a challenge for someone who doesn't have an employer that automatically deducts payroll taxes to pay into Social Security. This can affect both a worker's ability to qualify for disability insurance after a major [injury], and it can result in much lower retirement benefits. If Social Security is to be fully funded for generations to come, and if all workers are to have adequate benefits, then electronic, automatic, mandatory withholding of payroll taxes must apply to everyone , gig workers, 1099 workers, and hourly employees.

It is laudable that Warren wants to bring all workers in the retirement system. But as NC readers know, Federal taxes do not "pay for" Federal spending, and hence Warren's thinking that Social Security will be "fully funded" through "payroll taxes" is a nonsense (and also reinforces incredibly destructive neoliberal austerity policies). I will not tediously rehearse MMT's approach to taxation, but will simply quote a recent tweet from Warren Mosler:

me title=

And if Mosler isn't good enough, here's John Stuart Mill on currency issuers:

me title=

Again, is it too much to ask that a professor do the reading? After all, MMT gotten plenty of traction, even in 2016. The Sanders staff, for example, could have been helpful to her .

Warren Supports Medicare for All Only Nominally

Warren is indeed a co-sponsor of Sanders' ( inadequate ) S1804. But read the following passages, and you will see #MedicareForAll not where her passion lies:

As greater wealth is generated by new technology, how can we ensure that the workers who support the economy can actually share in the wealth?

(The idea that workers "support" "the" [whose?] "economy," instead of driving or being the economy, is interesting, but let that pass.)

Warren then proceeds to lay out a number of policies to answer that question. She says:

Well, I believe we start with one simple principle. All workers, no matter where they work, no matter how they work, no matter when they work, no matter who they work for, whether they pick tomatoes or build rocket ships, all workers should have some basic protections and be able to build some economic security for themselves and their families. No worker should fall through the cracks. And here are some ideas about how to rethink and strengthen the worker's bargain.

So, she's not just laying out policy for the gig economy (the occasion of the speech); she's laying out a social contract (the topic of the speech). Picking through the next sections, here is the material on health care:

We can start by strengthening our safety net so that it catches anyone who has fallen on hard times, whether they have a formal employer or not. And there are three much-needed changes right off the bat on this.

I hate the very concept of a "safety net." Why should life be like a tightrope walk? Who wants that, except crazypants neoliberal professors, mostly tenured? She then makes recommendations for three policies, and sums up:

These three, Social Security, catastrophic insurance, and earned leave, create a safety net for income.

Hello? Medical bankruptcy ?[3] She then moves on from the "safety net" for income to benefits, which is the aegis under which she places health care:

Now, the second area of change to make is on employee benefits, both for healthcare and retirement. To make them fully portable. They belong to the worker, no matter what company or platform generates the income, they should follow that worker wherever that worker goes. And the corollary to this is that workers without formal employers should have access to the same kinds of benefits that some employees already have.

I want to be clear here. The Affordable Care Act is a big step toward addressing this problem for healthcare. Providing access for workers who don't have employer-sponsored coverage and providing a long term structure for portability. We should improve on that structure, enhancing its portability, and reducing the managerial involvement of employers.

Remember, this is a Democratic audience, and what do we get? "Portability," "access", and reduced "managerial involvement." That's about as weak as tea can possibly get, and this is a liberal Democrat audience. ("The same kinds of benefits that some employees already have." Eeesh.) But wait, you say! This speech iis in 2016, and in 2018, Warren supports #MedicareForAll! For example, " Health care: Supports the "Medicare for All" bill led by Bernie Sanders " (PBS, January 17, 2019). But notice how equivocal that support is. Quoting PBS again, Warren "called that approach 'a goal worth fighting for.'" Rather equivocal! And folliowing the link to that quote, we find it's from a speech Warren gave to Families USA's Health Action 2018 Conference :

I endorsed Bernie Sanders' Medicare for All bill because it lays out a way to give every single person in this country a guarantee of high-quality health care. Everybody is covered. Nobody goes broke because of a medical bill. No more fighting with insurance companies. This is a goal worth fighting for, and I'm in this fight all the way.

There are other approaches as well I'm glad to see us put different ideas on the table.

So, we have a gesture toward #MedicareForAll. But then, Warren, instead of going into detail about how #MedicareForAll would work, immediately backtracks and emits a welter of detail about minor fixes improvements, on the order of "portability," "access," and reduced "managerial involvement." (Different details, but still details). Then she moves on to Massachusetts. Read this, and it's clear where Warren's heart is:

Massachusetts has the highest rate of health insurance coverage in the nation. We are the healthiest state in the nation[4].

That didn't just happen because we woke up one morning and discovered that insurance companies had just started offering great coverage at a price everyone could afford.

We demanded that insurance companies live up to their side of the bargain. Every insurer participating in our exchange is required to offer plans with standard, easy-to-compare benefits and low up-front costs for families. Last year, we had the second-lowest premiums in the ACA market of any state in the country. Massachusetts insurers pay out 92% of the dollars they bring in through premiums to cover costs for beneficiaries – not to line their own pockets.

The rules are tough in Massachusetts, but the insurance companies have shown up and done the hard work of covering families in a responsible way. We have more than double the number of insurers participating on our exchanges, compared to the average across the country. They show up, they serve the people of Massachusetts, and they still make plenty of money.

Look, we still have plenty of work to do, particularly when it comes to bring down health spending, but we're proud of the system we have built in Massachusetts, and I think it shows that good policies can have a real impact on the health and well-being of hard working people across the country.

Never mind that Warren can say, virtually in the same breath, that insurance companies "still make plenty of money" and "we have plenty of work to do to bring down health care spending." RomneyCare was the beta version of ObamaCare. We tried it, as a nation, starting in 2009, and here we are.[5] Is that's what Warren wants, fine, but why not simply advocate for it?

Warren Has No Coherent Theory of Change

Except, perhaps, one distinctly slanted toward insiders. " Work hard and play by the rules " is a Clintonite trope, but let's search on "rules" and see what we come up with. More from the transcript:

But it is policy, rules and regulations, that will determine whether workers have a meaningful opportunity to share in the wealth that is generated.

Here, workers are passive , acted upon by rules, and those who create them. But Warren contradicts herself: "Lyft and Uber have often resisted efforts of those very same workers." Here, workers are active. But if workers are active in the second context, they are also active in the first! Where does Warren think change comes from? The generosity of Uber and its investors? More:

Antitrust laws and newly-created public utilities addressed the new technological revolution's tendency toward concentration and monopoly, and kept our markets competitive. Rules to prevent cheating and fraud were added to make sure that bad actors in the marketplace couldn't get a leg up over folks who played by the rules.

Note the lack of agency in "were added." Warren erases the entire Populist Movement ! She also can't seem to get her head round the idea that workers didn't necessarily play by the existing ruies in order to create new ones. And:

Workers have a right to expect our government to work for them. To set the basic rules of the game. If this country is to have a strong middle class, then we need the policies that will make that possible. That's how shared prosperity has been built in the past, and that is our way forward now. Change won't be easy. But we don't get what we don't fight for. And I believe that America's workers are worth fighting for.

Now, on the one hand, this is great. I, too, believe that "America's workers are worth fighting for." What Warren seems to lack, at the visceral level, is the idea that workers should be (self-)empowered to do the fighting (as opposed to having the professional classes pick their fights for them). Here is Warren on unions:

Every worker should have the right to organize, period. Full-time, part-time, temp workers, gig workers, contract workers, you bet.

Very good. More:

Those who provide the labor should have the right to bargain as a group with whoever controls the terms of their work .

The idea that workers themselves should control the terms of their work seems to elude Warren. This erases, for example, co-ops. More:

Government is not the only advocate on behalf of workers.

"Not the only?" Like, there are lots of others? This seems a tendentious, not to say naive, view of the role of government. More:

It was workers [here we go], bargaining through their unions [and the qualification], who helped [helped?] introduce retirement benefits, sick pay, overtime, the weekend, and a long list of other benefits, for their members and for all workers across this country. Unions helped build America's middle class, and unions will help rebuild America's middle class.

Here, at least, Warren grants workers (partial) agency, but only through the institutional framework of unions . That distorts the history. Granted, "helped introduce" is doing a lot of work, and who they were "helping" isn't entirely clear, but the history is enormously complicated. (Here again, Warren needs to do the reading.) For example, the history of the weekend long predates unions . And "bargaining through their unions" isn't the half of it. Take, for example, the Haymarket Affair . From the Illinois Labor History Society:

To understand what happened at Haymarket, it is necessary to go back to the summer of 1884 when the Federation of Organized Trades and Labor Unions, the predecessor of the American Federation of Labor, called for May 1, 1886 to be the beginning of a nationwide movement for the eight-hour day. This wasn't a particularly radical idea since both Illinois workers and federal employees were supposed to have been covered by an eight-hour day law since 1867. The problem was that the federal government failed to enforce its own law, and in Illinois, employers forced workers to sign waivers of the law as condition of employment.

Fine, "rules." Which weren't being obeyed! More from the Illinois Labor History Society:

Monday, May 3, the peaceful scene turned violent when the Chicago police attacked and killed picketing workers at the McCormick Reaper Plant at Western and Blue Island Avenues. This attack by police provoked a protest meeting which was planned for Haymarket Square on the evening of Tuesday, May 4. Very few textbooks provide a thorough explanation of the events that led to Haymarket, nor do they mention that the pro-labor mayor of Chicago, Carter Harrison, gave permission for the meeting . Most speakers failed to appear . Instead of the expected 20,000 people, fewer than 2,500 attended . The Haymarket meeting was almost over and only about two hundred people remained when they were attacked by 176 policemen carrying Winchester repeater rifles. Fielden was speaking; even Lucy and Albert Parsons had left because it was beginning to rain. Then someone, unknown to this day, threw the first dynamite bomb ever used in peacetime history of the United States. The next day martial law was declared, not just in Chicago but throughout the nation. Anti-labor governments around the world used the Chicago incident to crush local union movements.

This is how workers "helped introduce" the eight-hour day.

Yes, America's workers are "worth fighting for." But they also fight for themselves , and are fought against! Warren's theory of change -- which seems to involve people of good will "at the table" -- cannot give an account of events like Haymarket or why, in the present day, it's Uber's drivers who are also the drivers of change, and not benevolent rulemakers. Warren's views on the social contract are in great contrast to Sanders' "Not me, us."

NOTES

[1] Warren is far stronger in areas where she has developed academic expertise than in areas where she has not.

[2] Google is Google, i.e., crapified, but if Warren has retracted or changed her views on Uber, I can't find it. She was receiving good press for this speech as late as August 2017 .

[3] Oddly, bankruptcy is where Warren made her academic bones. I'm frankly baffled at her lack of full-throated advocacy on this, especially before a friendly audience.

[4] Warren, by juxtaposition, suggests that Massachusetts' health insurance coverage causes it to be "the healthiest state in the nation." This post hoc fallacy ignores, for example, demographics and the social determinants of health .

[5] Warren focuses on health insurance, not health care. I'm nothing like an expert in the Massachusetts health insurance system. However, looking at this chart , I'm seeing all the usual techniques to deny access to care: Deductibles, co-pays, out-of-network costs, and (naturally) high-deductible plans. Health care should be free at the point of delivery. Why is that so hard to understand?


Burritonomics , January 20, 2019 at 5:16 pm

I quickly went over the (188 page!) report referenced in Warren's claim that "Massachusetts has the highest rate of health insurance coverage in the nation. We are the healthiest state in the nation". It should be noted I went in with the expressed purpose of finding something to be snarky about, and I found it.

One of the metrics under "core measures" of clinical care was Preventable Hospitalizations. As it states in the report itself: "Preventable hospitalizations reflect the efficiency of a population's use of primary care and the quality of the primary health care received Preventable hospitalizations are more common among people without health insurance and often occur because of failure to treat conditions early in an outpatient setting". Wow! With such bang up health insurance in MA, one would figure they would do great on this metric. Nope! MA ranks 37th in the country. Many more such examples can be found, I'm sure.

I have a real dislike of these "who's best" lists, regardless of topic. Rarely do they (the aggregated ratings) contain insight beyond that captured by the individual metrics.

lambert strether , January 20, 2019 at 5:24 pm

Massachusetts is #1 on mortality (though they have issues with opioids). They have median US age, so it's not the enormous Boston student population. So they're doing something right, I'm just not sold it's health insurance or, more to the point, health insurers. They do have more physicians (and psychiatrists) per capita.

Joe Well , January 20, 2019 at 8:52 pm

What is "mortality" in this case? I'm curious about this because people often casually say that US health outcomes are worse than in other countries by looking at life expectancy (which I guess is not the same as mortality), and that comparison is rarely done on a state by state basis in the US.

Massachusetts is roughly tied with the other top ten states in life expectancy, which are almost all "blue" states . Worldwide, life expectancy among highly developed countries is roughly similar, within a few years of each other . The US comes out towards the bottom (no. 31), but only by about 1-3 years.

Also amazed just now to see that Asian American and Latino life expectancy are so much higher than for white and black Americans. Does anyone know anything about that? I'm really stunned.

Usually, lower life expectancy for blacks is given as evidence of inequality, but the white-black gap (about 1-2 years) is tiny compared with the black-Latino and black-Asian gap, or for that matter, the white-Latino or white-Asian gap, which are more like 5-10 years. I'm really floored by that.

In general, looking at the numbers just now has shaken my assumptions about poor US life expectancy and also racial disparities and I'm wondering if I'm misinterpreting them.

Joe Well , January 20, 2019 at 9:10 pm

Wow, you learn something new every day.

Apparently there is something called the "Hispanic Health Paradox" that has been studied intensively for over 30 years . The biggest reason seems to be much lower rates of smoking. There also seems to be a filtering effect whereby healthier people migrate to the US. Anecdotally, I'd suggest much lower rates of alcohol and drug abuse, but the article doesn't mention that.

So, why Mass. has a relatively high life expectancy could in part be due to it having one of the earliest and most aggressive anti-smoking movements. I'm guessing historically high smoking rates (up to 50% of adults in the 1950s with huge second-hand exposure) could also account for poorer health outcomes today.

BoyDownTheLane , January 21, 2019 at 12:49 am

One of my favorite pictures (the one I have not yet taken) would have been an elevated shot of the intersection at Longwood and Brookline Avenues (379–385 Brookline Ave) at noon on a clear, sunny spring day to see the murmuration of medical staff running between appointments, lunch, rounds, etc.

The intersection is surrounded by arguably some of the finest medical institutions in the Western world (Beth Israel Deaconess, Dana-Farber, Brigham & Women's (where Atul Gawande, author of the book "Better" and the whole entire concept of positive deviance, once held court), Harvard Medical School itself with its etched-in-granite entrace to the Countway Library that reads "Ars Longa, Vita Brevis", and the Harvard School of Public Health.

The murmuration of white coats may be at that moment the greatest single concentrated density of medical excellence at one time. It is easy to scoff. I've been the recipient of bad medicine myself, but also far more high-quality, life-saving medicine. But the public health movement in Massachusetts has been around for a very long time and is supported by and engrained within governmental regulations, oversight and policy. Insurance plans covering most of the state ranked, typically and for years, #'s 1, 2, 3 and more. The Healthcare Effectiveness Data and Information Systems report out results that are painstakingly gathered, audited to improve performance. It is fair to say that a major part of the intersection between computing and medicine was born and is overseen across the river in Cambridge. Organizations that collect or audit data for health plans and providers are screened, trained and certified by NCQA ( https://www.ncqa.org/about-ncqa/ ).

In addition, there are national, regional and state associations devoted to quality improvement and toi improvement of access. The National Association of Community Health Centers (those clinics funded Federally to serve the under-served for free or on a sliding scale) "works in conjunction with state and regional primary care associations, health center controlled networks and other public and private sector organizations to expand health care access to all in need." There are CHC's dotted everywhere around the country (albeit not enough of them), and there is a state association in almost every state. No one can ever be turned away from a CHC, especially for lack of ability to pay; the Federal government underwrites their care.

nothing but the truth , January 20, 2019 at 5:29 pm

govts can call force us to call toilet paper a pound, but i doubt they can make it worth a pound of sterling silver – if they pretend that they can produce any amount.

Brooklin Bridge , January 20, 2019 at 5:58 pm

Warren's emphasis on the economic market for health "care?" (insurance companies making plenty of money ) and particularly her whole rant on the superlatives of Massachusetts insurance care (that means, care for insurance companies) , increasingly neglects health and people care as the primary concern of medicine and the people who practice it.

As an average Joe, meaning not part of the medical world, I have come across a surprising number of doctors in both social circumstances as well as health issues of my own and of my extended family, where doctors have complained about the ever worsening constraints imposed on them by insurance companies. I know at least three doctors who retired early because of it and one of them talks about it being a significant problem in keeping highly qualified doctors in general practice. From ever more ridiculously short visits, to constant refusal to cover such and such a drug, to all manner of schemes to improve patients health by overseeing and controlling what the doctor does to finding ways to monitor what the patient does; what he or she takes as medicine and exactly when and how often – cutting the doctor out of the loop completely. Improve the patient experience my *ss. It's horrible and it all comes down to ever new ways to reduce coverage – to make more money.

Perhaps I'm being a little unjust, but Warren seems fine with this "system" where the gate keepers make, "plenty of money," as long as people are going in and out of doctors' offices in countable droves as if on run-away conveyer belts. I should at least allow that many of her superlative claims are accurate (or somewhat accurate) and that there is fairly wide coverage in this state but nevertheless stress that our excellent medical facilities in Boston proper are due to historical reasons and NOT to RomneyCare.

deplorado , January 20, 2019 at 5:59 pm

Thank you Lambert, for your cogent and discerning analysis as always. I've long ago disabused myself of the notion that E. Warren is more than "lipstick" on the usual "pig", but it was good to have written support for that thesis and I will save it for my reference.

What worries me more though is Sanders's bill and why he wouldn't go all the way? Would you do an analysis of that please – will really appreciate it.

Thanks!

Joe Well , January 20, 2019 at 6:10 pm

The vast majority of Massachusetts health plan providers are nonprofit HMOs so I'm baffled by the idea that they are making tons of money since legally they are not supposed to.

The most obvious difference between Mass and the rest of the country is precisely the preponderance of nonprofit health plans (it's not commonly called health insurance here) and nonprofit hospitals. The idea of for-profit health plans and hospitals freaks me out.

It's worth noting that Mass health coverage seems to have gotten worse in recent years, though I don't know how much of that is due to Obamacare. High deductibles, coinsurance, confusing in-network requirements combined with poor documentation and even poorer customer service to tell you what is in-network and what is not. I just got a surprise $370 bill for a provider that supposedly was out of network even though I had checked extensively that they were in-network. That is the first time that has ever happened to me in Mass. Not to mention the confusing and unnerving notices I got the last few months saying I was in danger of losing coverage. A great big ball of Weberian beaureaucratic stress.

bob , January 20, 2019 at 8:04 pm

Non-profit health insurance Company – https://www.democratandchronicle.com/story/money/business/2014/04/25/former-excellus-ceo-package-total-m/8155853/ The final retirement package for former Excellus BlueCross BlueShield CEO David Klein likely will exceed -- by millions -- the $12.9 million the company reported to the state in March. $29.8 Million in retirement. Non-profit for who? It's a complete misnomer and a huge problem in the discourse of healthcare. Hospitals are usually non-profits too. They non-profitly charge you $80,000 for a few stitches and some aspirin.

somecallmetim , January 20, 2019 at 10:08 pm

Health Care Economist / Professor Uwe Reinhardt used to comment that in the current system non-profit hospitals (The Sisters of Mercy, with a token nun on their board, in his telling) were subject to the same forces as for profit hospitals.

He also said Massachusetts has the only adult health care system, and the other states are all adolescents.

johnnygl , January 20, 2019 at 9:10 pm

We've got for-profit hospitals Cerberus took the caritas network. The hospitals dominate this state. The rest of us are just living here.

johnnygl , January 20, 2019 at 9:15 pm

Special thanks to the catholic church for selling such an important institution to a monster that guards the gates of the underworld.

I bet it was to cover the costs of child predator priests.

Joe Well , January 20, 2019 at 10:20 pm

Wow, I'd missed that (moved out of state, then came back). Thanks for the update. It looks like the Catholic Church (former owner of Caritas) has further enhanced its legacy in Massachusetts. However, I believe it is still true that the hospital market in Mass. is dominated by nonprofits (albeit greedy nonprofits).

And yes, hospitals and hospital chains (e.g., Partners Healthcare, which is nonprofit) pose huge challenges to managing healthcare costs in Mass. as the numerous Boston Globe investigative series attest, by using their market power to raises prices.

My concern is when the market becomes dominated by for-profit actors, the profit-seeking, which is already bad with nonprofits, becomes even worse, especially in an ultra-expensive market like Greater Boston.

Brooklin Bridge , January 20, 2019 at 6:16 pm

I should add (if my earlier comment get's posted), it's even more surprising how many doctor's seem just fine with all the negative changes being brought about by insurance companies' intrusive quest for control and I don't mean just the ones who say nothing.

That is, some doctors seem to enjoy the vestiges of the glow of community respect and honor that once went with being a doctor all while doing almost nothing other than sheep herding patients through the office in good file while staff (not the good doctor) attend to making the visit digital and storing it away in some cloud.

Tomonthebeach , January 20, 2019 at 7:07 pm

I agree with Warren Mosler that Elizabeth Warren's apparent ignorance of MMT, much less mastery of it, makes here a lame candidate in my book. She needs to get woke pretty quickly or settle for some cabinet appointment.

Anarcissie , January 20, 2019 at 10:10 pm

Is MMT now Scripture?

ChrisAtRU , January 20, 2019 at 10:22 pm

It's more important than 'scripture' it's how sovereign fiat money actually works .

Joe Well , January 20, 2019 at 10:57 pm

You don't even need MMT. When asked how the federal government can pay for something, people can just answer, "the same way we pay for military and intelligence spending." Any politician who won't say at least this is deeply suspicious.

David in Santa Cruz , January 20, 2019 at 7:40 pm

In The Unwinding , George Packer quotes Elizabeth Warren as describing her political views thusly:

"I was a Republican because I thought that those were the people who best supported markets"

I'm glad that she's out there, I'm glad that she's talking, and we need an open and transparent nomination process, but Bernie Sanders remains the only (potential) nominee who comes close to representing my views. Good piece.

emorej a hong kong , January 20, 2019 at 7:50 pm

The transcript could easily have been a speech by Hillary (and even delivered to Goldman Sachs if Hillary had had the foresight to realize that every speech would become known to everybody in the Internet age -- before Russiagate was leveraged into Social media banning of anti-establishment speech).

The speech's date (May 19 2016), was two days after Bernie won the Oregon primary by 14%, and two days before Hillary won the Washington state primary by 5%.

Synoia , January 20, 2019 at 8:07 pm

It was going to be BS directly after this:

New America (board chair emeritus Eric Schmidt

The Eric Schmidt who took Google down the primrose part of spying on everybody. Warren is centrist.

Synoia , January 20, 2019 at 8:11 pm

It was going to be BE after this phrase

New America (board chair emeritus Eric Schmidt,

The Eric Schmidt who took Google doen the path of spying on everybody. He has nothing to offer by centrist rhetoric. It would be very interesting in how much In-Q-Tel invested in Google.

flora , January 20, 2019 at 8:39 pm

Thanks for this post.
And thanks for the reminder that the 8 hour workday and the 40 hour workweek were not 'given' to workers, they were won by workers.

Matthew G. Saroff , January 20, 2019 at 9:48 pm

I made an a similar observation on my blog .

Compare these two quotes on Pharma looting.

Warren:

Giant companies may hate my Affordable Drug Manufacturing bill – but I don't work for them. The American people deserve competitive markets and fair prices. By fixing the broken generic drug market, we can bring the cost of prescriptions down.

Sanders:

If the pharmaceutical industry will not end its greed, which is literally killing Americans, then we will end it for them.

This is a not an insignificant difference

Mike Barry , January 20, 2019 at 10:30 pm

The best is the enemy of the good.

Yves Smith , January 20, 2019 at 11:17 pm

Tell me what about Warren not understanding how federal taxes work, which is fundamental to formulating sound fiscal policy and spending plans, not being serious about fixing our health care system, or praising the predatory gig economy, is "good".

RepubAnon , January 20, 2019 at 11:32 pm

On a side note: self-employed workers pay more out-of-pocket into Social Security than W-2 employees. W-2 employees only pay half the Social Security tax – employers pay the other half via a "payroll tax."

The self-employed pay both the employee's half of Social Security, and also pay a "Self-Employment tax" (the employer's half of Social Security). The logic is that if you are both employee and employer, you should pay both halves.

Yves Smith , January 21, 2019 at 12:58 am

This is thread jacking, plus an economist would point out that the employer clearly is paying a net wage that reflects his awareness that he is paying the employer side of the FICA taxes.

Ape , January 21, 2019 at 12:31 am

Or lesser of two evils? There really needs to be a good discussion again about reform versus structural change without Chait-like pretensions. The question isn't just whether we'll get there in time, but whether reform even out runs reaction. Once you take out patriotic myth, it's not obvious whethervthe good in the long term is even worth bothering with.

Glen , January 21, 2019 at 12:47 am

Warren 2020 campaign is DOA. If you want Trump for another four years go with Warren 2020. Bernie would have won.

The Rev Kev , January 20, 2019 at 11:01 pm

I can't help but think that if you are talking about the "Next Social Contract", them you should put something in there that if you have children going hungry then something has gone wrong with your society. Not being snarky here as I believe that a fundamental purpose of society is to protect those in need. An earlier society talked about 'women and children first' and they were not too far off the mark here.

She was invited to talk about the gig economy but in reading her speech I was under the impression that she wants the Federal government to underwrite the costs of workers for corporations to ensure that maybe these workers have food to eat while working for these very same corporations. I suspect that this is the thinking behind letting Amazon workers go for Federal assistance for the sheer basics of life while Amazon makes off like bandits.

No. The way to go is to enforce corporations like this pay a living wage and not to have them count on the country to make up the difference. If they start to protest, then start to talk about looking over their accounts for any discrepancies to make them back off. That's how they got Al Capone you know. Not for being a gangster but for not paying his taxes while doing so. And do the same for mobs like Uber and Lyft and all the other corporations.

BoyDownTheLane , January 21, 2019 at 12:16 am

" Elizabeth Warren is Hillary Clinton reborn, and they're both unlikable, because they're both inauthentic scolds who suffer from hall monitor syndrome. They spent their entire lives breaking every rule they could find while awkwardly fantasizing about running every tiny detail of everyone else's lives ."

http://sultanknish.blogspot.com/2019/01/why-no-one-likes-elizabeth-warren.html

Left in Wisconsin , January 21, 2019 at 12:38 am

Sigh. Nail hit squarely on head. The one thing I will say to Warren's credit is that she has learned in some specific ways that the world isn't invariably the pure meritocracy that is so instinctively part of her world view. That said, it seems clear there will always be plenty that she is simply not capable of seeing, so she will always say and support things that are just wrong. She will not be leading the revolution.

[Jan 19, 2019] Three Bernie Sanders Bills to Arrest the Highway Robbery in the Prescription Drug Market

Jan 19, 2019 | economistsview.typepad.com

anne , January 15, 2019 at 05:59 PM

https://prospect.org/article/three-bernie-sanders-bills-arrest-highway-robbery-prescription-drug-market

January 14, 2019

Three Bernie Sanders Bills to Arrest the Highway Robbery in the Prescription Drug Market
Allowing foreign imports, authorizing Medicare bargaining, or setting prices at what other nations pay -- all good options
By DEAN BAKER

The prescription drug market in the United States is an incredible mess. From an economic standpoint, everything is wrong. Drugs that would sell for a few hundred dollars in a free market often sell for tens or even hundreds of thousands of dollars because we give their manufacturers patent monopolies. This leads to the sort of distortions and inefficiency that would be expected from tariffs as high as many thousands percent.

From a heath perspective the situation is no better. The huge markups give drug companies enormous incentive to misrepresent the safety and effectiveness of their drugs and to push them for uses where they may not be appropriate. This is a big part of the story of the opioid epidemic.

Cumulatively, it is a huge deal in both economics and health. We spent more than $430 billion (2.2 percent of GDP) on prescription drugs last year. These drugs likely would have cost less than $80 billion in a free market. The difference of $350 billion is almost five times the annual federal budget for food stamps. This is real money.

This is the backdrop for three bills proposed last week by Senator Bernie Sanders, along with Representatives Elijah Cummings and Ro Khanna, to address the high and rapidly rising cost of prescription drugs. The three measures provide alternative paths for reducing drug prices.

The first one, "The Prescription Drug Price Relief Act," would end the patent monopoly for any drug that sold for a price exceeding the median price in five other major countries: Canada, the United Kingdom, France, Germany, and Japan. This would allow large savings since drug prices in these countries are roughly half as much as in the United States. Drug companies would have a choice of either lowering their prices or losing their patent monopoly.

In the latter case, the competition is likely to push the price well below the levels in the five countries. While these nations do regulate drug prices, patent monopolies still let the companies charge a price that is far higher than the price that would exist in a competitive market with generic competition.

The second bill is "The Medicare Drug Price Negotiation Act." This bill would allow Medicare to negotiate collectively for the drugs purchased through Medicare prescription drug insurance. Since this program spends roughly $100 billion annually on drugs, it should have serious bargaining power.

Anyone designing a rational drug insurance program would have required negotiation when the program was created, but rational design was not necessarily the top priority at the time this program was enacted.

Anyone designing a rational drug insurance program would have required negotiation when the program was created, but rational design was not necessarily the top priority at the time this program was enacted. Representative Billy Tauzin, who headed the Energy and Commerce Committee, which structured the Medicare prescription drug legislation, resigned immediately after the bill was signed into law to become head of the pharmaceutical industry's trade association.

The third bill, "The Affordable and Safe Prescription Drug Importation Act," is also an effort to take advantage of the fact that drugs are so much cheaper in other countries than in the United States. This bill would allow people to freely import drugs from other wealthy countries that have safety standards that are comparable to those in the United States.

This bill both highlights the sharp differences in prices between the United States and other countries and calls out one of the big lies used to justify these differences. Allies of the drug industry often claim that we cannot count on getting safe drugs from other countries, implying that countries like Canada and Germany do not protect their populations from unsafe drugs.

This is, of course, absurd. The standards in these countries are every bit as high as in the United States. And, if we think the quality of imported drugs is a problem, we all should already be very worried because many of the drugs and ingredients in drugs sold in the United States are already imported, largely from China. So the idea that we can't be assured of the safety of imported drugs is simply an industry talking point, not a real concern.

Which of these paths for reducing drug costs is best? Importation is probably the most far-reaching, since it should quickly bring our prices down to the level of other wealthy countries. As a practical matter, however, progressives should back anything that moves the debate forward.

We really need to turn the industry on its head, paying for research upfront and then having drugs sold in a free market, like paper plates and shovels. It is absurd to pay for research that has already been done, at the point when people are suffering from serious conditions jeopardizing their health or their life.

No one thinks it makes sense to pay firefighters based on the value of their work when they come to our burning house with our families inside, yet this is essentially how we pay for drug research under the patent monopoly system. In fact, the story is even worse with drugs, since typically we have a third party payer (either an insurance company or the government) who we are trying to get pick up most of the tab.

These bills would not fully solve the problem, but each would be a big step in the right direction. Sanders, Cummings, and Khanna have done a great service in pushing them forward.

mulp -> anne... , January 16, 2019 at 04:33 PM
"No one thinks it makes sense to pay firefighters based on the value of their work ..."

We value fire fighters as worthless, by not paying most fire fighters in the US.

After all, requiring the people saving your life to be paid kills jobs, so we end up with unpaid life savvers.

We should appply the same principle to people providing life saving food, the people building the roads needed to deliver life savings, the people making the vehicles used by those providing life saving services.

In fact, no one should be paid to work! Thats free lunch economics!

Sarcastic, yes.

Dean Baker meantioned nothing about costs, which are always labor costs.

Look, Keynes argued that when there were unemployed workers, and capital is scarce, government should tax and spend to pay workers to build capital.

For drugs, paying unemployed researchers to build capital, eg, life saving drugs, then taxing the drugs produced to repay the cost of developing the drugs, with so many new drugs developed, the private capital in drug factories, etc will produce so many drugs that drug prices fall to total labor costs per unit, plus the drug tax.

We know there are unemployed drugresearchers because NIH always runs out of money to pay all thre recent collage grads seeking grants to fund their hoped for job as a researcher.

Plp -> mulp ... , January 18, 2019 at 01:41 PM
Mulp what about monopoly profits my friend

Research could rise and marketing cuts pay for it

Yes there's slack created
In marketing jobs and funding entertainment of course

Plp -> anne... , January 17, 2019 at 08:40 AM
Bernie and Liz are too valuable to waste running for
The Dem nom

Leave that for a clever weather vane
Like Harris and that jersey senator

The gal from the Bronx
is another Bill Bryan

She is the future

anne -> Plp... , January 18, 2019 at 09:21 AM
The gal from the Bronx
is another Bill Bryan

She is the future

[ Funny and right and especially clever. ]

Julio -> Plp... , January 18, 2019 at 09:21 AM
Agreed completely.
Warren, in particular, makes a great senator but I doubt would make a great president.
Christopher H. said in reply to Julio ... , January 18, 2019 at 10:01 AM
Disagree, unfortunately in the American system the President gets all the attention and can spread the message.

Either Bernie or Warren would be good. I'd much prefer Bernie.

Plp -> Christopher H.... , January 18, 2019 at 01:43 PM
No problem if they win the POTUS job

Still I'd prefer AOC

[Jan 13, 2019] Libertarian wet dreams and reality of the Us healthcare

Jan 13, 2019 | www.nytimes.com

JB Nashville, Tennessee Jan. 11

@Bill - So you're willing to gamble with your own health and the well-being of any family or loved ones you have and trust in some ambulance chaser against an armada of $3000 suits? Good luck with that.

While I'm often skeptical of our government, I have ZERO faith in any corporation to do right by me.

Their only mission is to make as much money as they can, and even paying out the occasional lawsuit is a reasonable cost of doing business. The only way a capitalist entity can be trusted is if a more powerful authority is looking over their shoulder. The FDA is one of many federal entities standing between us and an indifferent group of shareholders and CEOs.

[Jan 11, 2019] Health Insurer Greed or Desperation An Odd Data Point From Cigna naked capitalism

Notable quotes:
"... It was for the deductible the insurer did not pay – routine – AND for another thousand dollars, which was not. ..."
"... The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home. ..."
Jan 11, 2019 | www.nakedcapitalism.com

Health Insurer Greed or Desperation? An Odd Data Point From Cigna Posted on January 9, 2019 by Yves Smith I sometimes give personal Consumerist-type anecdotes about dodgy vendor behavior in case readers have had similar experiences.

Admittedly, health insurers being difficult about paying claims is so common that they fall in the realm of "dog bites man" stories. But the elements of my latest arm-wrestle with Cigna suggest that the insurer is so eager to maximize profit and burnish its financials that it is doing the equivalent of pulling up the sofa cushions to collect change.

I've had this plan a very long time, since the early 1990s. Cigna in theory has not changed the terms (to do so, it would have to notify me and New York State) save approved rate increases. In practice it has, by among other things a few years back requiring that claims be submitted within 120 days of service. That has allowed it to engage in a new form of mischief: simply not processing some claims. No doubt the hope is that consumers won't notice, or will notice too late to get duplicate documentation and resubmit before the 120 days are up.

Mind you, for well over 15 years, I never had a single claim go astray. Now it happens with sufficiently high frequency for it to be implausible that the US Postal Service is losing so many of my letters, when other envelopes virtually never go missing. So every time I submit a claim, I have taken to recording the details necessary to locate the items in Cigna's system, as well as the mailing date.

Last July, Cigna sent a letter about a "pharmacy claim". It was a remarkably content-free document, with no reference to dates of service or any clues to allow a customer to figure out what they might be referring to, particularly since I do not have a pharmacy plan. A "pharmacy plan" is when the doctor sends a scrip to the pharmacy on behalf of a patient, and the pharmacy bills the insurer, with the patient responsible for any co-pay. My plan covers prescription drugs, including ones I get overseas (I've submitted prescription drug claims from England and Australia). I pay for the drugs and I submit for reimbursement. And until the mysterious July letter, I never had any problem with them being paid (provided, of course, Cigna didn't try claiming it had never gotten the claim).

Fortunately, because I keep good records, I could see I had sent in a claim in late June for four dates of service for less than $400 worth of meds total. The only reason the amount was that high was three of the four items were 90 day supplies.

I called Cigna and got a rep who found the four items and confirmed they were in a payment limbo and ought to be paid.

When no check had arrived by September, I called again, had the agent say that there was not reason for the claim not to have been paid, and put it in for reprocessing.

On November 28, with still no payment, I insisted on speaking to a supervisor, which it took an ungodly amount of time to reach. I started making noise about external appeal to New York state (my plan is a New York state regulated plan). She confirmed like everyone else that it should have been paid, and said the check would go out in three to five days.

Two weeks later, nothing from Cigna.

I called again. I got an agent who said the payment is pending.

By this time, steam was pouring out of my ears. I asked again to speak to a supervisor. After a 30 minute wait, I was told one would call me back. I should have known from long experience with Cigna that promises to make calls or follow up are empty, as this proved to be.

I decided to have one last go on the phone before writing the state for an external appeal. I called over the weekend. The agent said that the payment was issued on January 3, but she saw only three of the four drugs in the scans of the claims. Mind you, this was the cheapest scrip, and a shortfall versus what I should have received of about $13 (assuming that check finally arrives). But this is what this incident says about Cigna:

1. Recall that on the first call, and if my recollection serves me right, on at least one of the later calls, I confirmed the dates of the claims. The one that disappeared was the most recent in the date range, making it almost certain that I cited it most if not all calls.

This strongly suggests that the original Cigna hope was that I would not follow up adequately on their bafflegab letter, and when I did, someone went and scrubbed my record to reduce the amount Cigna would have to lay out. This is such a small amount that it would seem hardly worth the effort .which further suggests that Cigna has this sort of records-doctoring highly enough routinized to be able to do it cheaply. 1

2. Cigna has supposedly initiated payment right after the new year. Even though Cigna ought to be on an accrual as opposed to a cash accounting basis, it's not hard to infer that they kicked the payment back into a new fiscal year to flatter some sort of metric. It might not even be a financial reporting metric but some other measure that senior management and/or analysts follow.

As we said at the outset, in terms of abuses, this is small beer. But that's the point. Corporate America has been institutionalizing penny-ante scams like the one Cigna ran on me, knowing in this era when class action suits are virtually dead, that they can grift with no fear of being held to account.

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

____

1 The last agent checked my records for the date of the gone-missing drug claim to see if it had somehow gotten separated from the other three and was being handled separately. She came up empty-handed. Recall that I now have a not-approved, not-noticed-as-required change to my contract of a 120 day submission limit, so disappearing that item so late in the game makes it impossible for me to resubmit that item.

Geo , January 9, 2019 at 4:09 am

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

Well said. You're much more thorough and persistent than I am. I'm their target dupe that won't notice such things and just accept that it was my fault when I do notice. Very insightful read. Thanks so much!

WestcoastDeplorable , January 9, 2019 at 3:17 pm

Sorry to read of your problems, but Insurance companies aren't the only category screwing with the details; I recently transferred a balance to U.S. Bank on one of those "zero interest for 12 month" deals. In about 2 months after the transfer, all the sudden I get a late notice from them, then realize I didn't receive a statement (which was about 10 days late). And they laid a $39 charge on the account, which I was able to get waived with a trip to my local bank. Little did I realize this "late pay" also resulted in nixing the "zero interest" deal, and they levied the full interest on the balance.
Needless to say, I transferred the balance elsewhere, but seems to me lots of companies are gaming the mailing of statements to pad their coffers.

campbeln , January 9, 2019 at 3:53 pm

I had a good one with Macy's we bought a ton of stuff for the new house back here in the US and got the 0% interest for 12 months on their credit card for the first purchase or some-such. What the lady at the counter did was to run 2 separate transactions on the card so the second, much smaller, transaction fell outside of the "first purchase" and incurred the minimum monthly interest charge. Over the course of the 12 months, I'd have been in a slight deficit thanks to these additional charges, so I paid the damned thing off in full and threw it in the drawer.

So Macy's went from having a part-time AmEx card user to one that never uses it all because they didn't want to uphold their own promo Picking up pennies in front of a steamroller

Barbara , January 9, 2019 at 5:55 pm

Some years ago, I got such a 0% offer from a bank which issued one of my credit cards. This one was for existing debt and lasted until the debt was paid off. I was happily paying off my debt in reasonable monthly installments. After I paid my 6th monthly installment, I got a letter from the bank saying that they needed to raise the interest rate and would appreciate if I would concede. They added that if I continued to insist on 0%, as was my right to do, my credit card would be discontinued on the last payment. I chose to continue the 0% deal and, as promised (the only promise they kept), my credit card was cancelled thereafter.

Fast forward several years, I regularly get credit card offers from said company. Needless to say, I don't think much of people (or businesses – corporations are people too!) who renege on deals. You can guess what is not in my wallet!

The Rev Kev , January 9, 2019 at 4:18 am

Excuse for for asking but just to clarify a point. When you send mail to Cigna and you say that you record the details, are you talking about certified mail and registered mail then? The reason that I ask is that by using the same in Oz, it has saved both my daughter and I individually over a thousand dollars each when the recipient tried at first tried to deny receiving what we sent until confronted with tracking numbers that can be checked online.

Arthur Dent , January 9, 2019 at 9:15 am

More and more I am going to tracking numbers with signature required for things that have any sort of value.

The joy of focusing on shareholder value is that all other stakeholders are subservient to it. Ultimately, the sheer greed of the corporations is likely to force the general population to demand a government-run single-payer system where at least they can vote the politicians out of office instead of having unaccountable executives making their lives miserable. The inability to repeal the Affordable Care Act was just the first shot across the bow.

Spent more time in Canada over the past few weeks. Everybody I spoke to up there is utterly baffled by what is going on in the US and is seriously wondering if the US is officially insane. They cannot understand why we continue to live down here. BTW – many of these people are white people over 50 with military backgrounds and little to no college in the demographic that would have been probably voting for Trump in the US.

Octopii , January 9, 2019 at 1:05 pm

Have considered moving but they don't want us up there.

Yves Smith Post author , January 9, 2019 at 9:44 am

It takes $3+ per envelope to send something certified and a half hour tax on my time to go to the post office.

And sending a letter certified does not prove what was in the letter. It's useless from an evidentiary standpoint. Cigna could claim the envelope had no claims in it, or that the claims were "unscannable" (another "dog ate my homework" they've tried now and again). It's useless in proving a submission.

monday1929 , January 9, 2019 at 4:22 pm

Yves, you might try video-taping the mailing process, including video showing the papers as legible etc as they are sealed in envelope and handed over postal counter and showing tracking numbers.
Include in the envelope a letter explaining you will post video on you-tube if they claim "unscannable" or that envelope was empty.
United Healthcare broke dozens of promises to "call back"- they never ONCE did so. Hopefully not to far off topic, I would like to keep NC updated on current complaint with NY Office of Professional Discipline regarding a dentist who possibly hid about 100 bad (as in semi-criminal) Yelp reviews by establishing a phony company name and shifting reviews there. So far, after one month not a peep from Port Chester regional office where referred to.

beth , January 9, 2019 at 7:35 pm

Alert to United Healthcare Medicare Supp. retirees. I'm sure the UH did this not just to me but to all of those who carelessly pay all bills sent to them. When I signed up for AARP United Healthcare insurance, the rep told me that he would have to accept a check for the first month and then had to put me on a ckg acct withdrawal plan. I had never done that before and didn't like the idea. It turned out that that saved me in the long run for two reasons. First they billed me for the first month after accepting my check. I did not pay it and by the time I received it they had already taken money out for the second month. I am sure there are many seniors who just paid the bill anyway. Slick trick & sick trick.
And then a year later I was finally diagnosed with my genetic disease after all these years. I began getting the only medicine specifically for this disease which since it is an orphan drug is expensive. They rejected the first bill from the provider and told them I was not a member of the plan. I was thrilled that I had had the money taken out of my acct. so they could not say the check was late.

Kradek , January 11, 2019 at 12:25 am

Why won't these companies let us email the claims? Cheaper for all, content and dates verifiable

run75441 , January 9, 2019 at 11:00 pm

Yves:

Green Card works in court and I have used it with Ocwen

flora , January 9, 2019 at 11:17 pm

By 'green card' do you mean the usps certified return receipt green card?

vlade , January 9, 2019 at 4:33 am

Hmm.. I haven't seen "the cheque will be issued" excuse for ages now, courtesy of pretty much all European payments being direct and settled on T+1 latest.

I guess having netflix and Facebook (the "great innovations" coming out of the US) is more important to a number of US residents than a working payments system like say the EU has.

mle detroit , January 9, 2019 at 10:12 am

I've been trying unsuccessfully to decode your first sentence. What is this payments system, where can a neophyte learn about it, does the UK use it, and what how Brexit affect it?

Kpl , January 9, 2019 at 4:36 am

When bad behaviour and fraud go unpunished this is what one should expect.

Disturbed Voter , January 9, 2019 at 5:27 am

Stick to your guns, and make them meet your business performance metrics!

Heath insurance is inherently un-profitable in the long run, unless service is denied.

oh , January 9, 2019 at 3:58 pm

Not really. Denial of claims is yet another way for them to pad their profits.

Louis Fyne , January 9, 2019 at 6:32 am

cigna bought express scripts and the deal closed in december.

it could be cost-cutting-induced incompetence. it could be intentional revenue padding. could be both.

and ya, compared to the daily/weekly neoliberal microaggressions, no wonder why after 3weeks a lot of people shrug when it comes to the government shutdown

Spring Texan , January 9, 2019 at 11:06 am

Love your phrase "neoliberal microaggressions." We need to start using that more!

Very descriptive.

rd , January 9, 2019 at 12:22 pm

This government shutdown is going to get very interesting as the Trump Administration tries to expand what are "essential services" requiring workers to come in without pay. So far it hasn't interfered with my travels because the TSA and ATC workers are all there working without pay. I believe tax refunds are going to be declared "essential" so those workers will be called back to process them without pay. This will likely be occurring in numerous other areas as the Administration gradually discovers that government workers actually do something.

Thad Allen had an interesting interview on NPR this morning as he discussed the Coast Guard working without pay: https://www.npr.org/2019/01/09/683501454/coast-guard-members-may-have-to-work-without-pay-during-shutdown

The GOP may have finally figured out how to pay for tax cuts: you still provide the services but you don't pay the workers!

Octopii , January 9, 2019 at 1:08 pm

Reminds one of the old Soviet saying, "They pretend to pay us and we pretend to work."

ambrit , January 9, 2019 at 1:10 pm

This dynamic is beginning to resemble the joke attributed to Lenin. "The Capitalists will sell us the rope with which we hang them."
I cannot think of a better way to energize a general strike than this.

Oh , January 9, 2019 at 4:02 pm

The TSA is just a pretend act anyway. It's all for show.

Larry , January 9, 2019 at 7:01 am

Perhaps the plan is to fatigue customers over small amounts to condition them to give up appeals over larger disputes.

Homard Mard Hankee Ospetsua , January 9, 2019 at 7:05 am

For most of the year 1982, I worked as a parlegal for a workmen's comp law firm representing petitioners (the sick or injured workers). Almost all of the cases we handled were from workers whose disability checks had stopped after six weeks. Always six weeks. That's the point at which the insurer would stop sending the checks and the worker would call us. Then, someone (like me) from the law firm would call the insurer. There would be one of a a stock set of about half a dozen responses, ranging from "my desk is so messy haha, but I know I saw that check in these papers somewhere" to "we don't have the proper medical documentation" (even though of course there needed to be medical documentation for them to send the first 6 weeks' worth of checks). After one or two phone calls from us, the checks would begin to flow again in a week or two (including checks for any week that the insurer had missed).

Oh, and 95% of these cases were from workers whose first language wasn't English.

The theory of the folks who'd been at this business for awhile was that, by having a built-in delay at the six-week mark, the insurers were making a little extra interest.

cnchal , January 9, 2019 at 7:17 am

> . . . in terms of abuses, this is small beer . . .

Tens of millions of small beers ends up being a gigantic vat of beer for Davos Man running Cigna. This is the result of Davos Man purchasing laws to prevent class action suits, which was paid for by stealing small beers from the peasants for decades.

I do pity the human capital at Cigna. Their worth to Davos Man is how well they steal small beers, the more they steal the higher in the organization they go, aspiring to be the next Davos Man.

Brenda Pawloski , January 9, 2019 at 8:33 am

If you are able to send your pharmacy claims online and keep an electronic copy, you can resubmit easier, faster and more often. I have done this with Cigna. I agree it is odd how they choose to ignore random claims, but it happens enough that it seems to be intentional.

BRUCE STONE , January 9, 2019 at 8:36 am

Have you tried sending the mailed correspondence by priority mail? Like Certified Mail–you get a tracking number– and documentation of delivery–but it's half the cost and my insurer will routinely refuse to accept certified mail to the claim's PO box number.
They can't refuse to participate in the priority mail tracking systems -- and it's as good in court as certified mail–although it does lack the signature credo from return receipt.

Also–my insurer routinely loses my docs and has a similar time limit on claims–but I have successfullly re-submitted based on documenting the previous sent item and the tracking data from USPS–most such systems require them to accept a resubmit when you can prove you sent it within the timeframe .

Yves Smith Post author , January 9, 2019 at 9:47 am

See the comment above. Won't help. Only proves I sent a letter in, not what was in the letter. They can say they got the earlier letter but the claim was not in it or was unscannable.

Questa Nota , January 9, 2019 at 8:54 am

Expecting reimbursement is a pre-existing condition and is not covered by the Plan for which you have eligibility. Refer to paragraph x.xx in section q.qq of user agreement #.##.

Yves Smith Post author , January 9, 2019 at 9:48 am

Not germane. Please don't offer irrelevant comments.

Kiwi , January 9, 2019 at 10:35 am

The comment was a joke

mle detroit , January 9, 2019 at 10:17 am

Good one, QN. Hope you didn't get scorched when you poked the Dragon.

RMO , January 9, 2019 at 4:39 pm

"You've chosen the 'never pay" plan option which clearly states (in this microdot that also serves as a period at the end of paragraph 4) that no claims you make will be honored. It's a good choice if you never get sick. Oh I hate to see a grown man cry Rev So get out of my office!" (adapted from the Pythons)

beth , January 9, 2019 at 7:40 pm

Do I sense a little hostility? Maybe you can be more explicit with what you are angry about.

Medical Quack , January 9, 2019 at 9:25 am

Well I gave a speech last year to a big doctors group about a lot of this and have written about it for years, it's called the Healthcare Algo Cartel. What folks can't see and don't want to believe is that there's tons of quants (called non traditional actuaries in healthcare) modeling policies and finding new areas every day where coverage for certain items can be "scored" to reduce the amount the insurer will pay.

I just don't know how long you all want to keep living in virtual perceptions and not realize this has been going on for years, just like the stock market, algos and their query results are running everything, and folks are too busy on Facebook or screaming at a box (Alexa) to take time out and learn up. Cigna is basically emulating United Healthcare and using the same models, but they don't own a PBM like United does or they don't own a bank like United does (an industrial bank). That bank by the way holds a lot of HSA money and United a couple years ago bought all the Wells Fargo HSA accounts, that's how they grow.

Nobody mentions an exit fine either for Cigna and Express Scripts. There's 5 years left for Cigna to be required to OptumRX as a PBM, contract signed with Catamaran, which OptumRX bought. Those folks with OptumRX as their PBM with Cigna have 5 more years before a switch to Express Scripts can be facilitated unless Cigna takes out another bond sale to pay it off.

People need to learn up and see what's going on, insurers are big data people and nobody seems to get that but just hang around long enough and more will come out about United Healthcare and what they and Apple are doing together, you already have United pimping Apple watches and all Apple employees are given an Optum Bank HSA account with one scratching the others back already.

Cigna by the way has Express Scripts hitting the big coupon savings route to compete, you can search that one up. Did you know that if you use a coupon to save money on your RX that that money can't be applied against a deductible? Time to learn up folks and see what the healthcare algos are doing, they're denying your care and access and there's more MBA quants on their way to be hired at insurers to model even more ways to profit by "scoring" consumers into oblivion, it's how you don't qualify done by queries and predictive models. The more complex they make it, the more insurers profit off of consumers not understanding the game and we don't have the ability to fight back (we don't have the algos and computer code).

Kris Alman , January 9, 2019 at 12:21 pm

The Cigna-Express Scripts merger is brilliant financial engineering to further consolidate insurance companies with PBMs in the fight between them and PhRMA over price gouging.

The coupons that you can get through Good Rx is a scheme of Express Scripts. https://www.biopharmadive.com/news/express-scripts-goodrx-roll-out-cost-savings-program/442197/

Now that Trump has signed bills lifting pharmacist 'gag clauses' on drug prices, the pharmacist can point you in the direction of drugs cheaper than your co-pays, which you pay-out-of-pocket and can't claim toward your deductible. What a win for Cigna/ExpressScripts!

Yves, I can't believe you have been so patient with Cigna! Complain to your insurance division. Though, I will add that while this may work at the individual level, it does nothing to create systemic changes.

JerryDenim , January 9, 2019 at 12:48 pm

Sorry to be so dense, but can you elucidate a bit more on "scoring" and how health insurance companies are using your personal data they've purloined or surreptitiously obtained to deny care? If you're not self-insured but receiving subsidized insurance through an employer plan are you still affected by "scoring"?

I would never knowingly register any health monitoring device with a health insurer or employer and I've always thought those who do are foolish, but recently I was considering buying an Apple Watch solely for the express purpose of being able to surf while being on call for my job. I believe there may be other waterproof, cellular-enabled wrist devices in the consumer space now besides Apple, but they all seem to be equipped with health monitoring sensors as well. I would never voluntarily register such a device with any programs in exchange for discounts, but it seems like linking a watch/wrist-phone to my cell phone account would be an iron identity shackle. I would really like a tiny robust cell phone reciever to screen calls while I'm in the water, which has the ability to increase my quality of life, but I don't want my heart rate and vitals logged and sold. I modified a song lyric a couple of decades ago to coin my own phrase; "Never mind what you're buying, it's what you're selling" – It becomes more true each passing year.

jfleni , January 9, 2019 at 9:31 am

RE: Health Insurer Greed or Desperation? An Odd Data Point From Cigna.

The "Nitty-gritty" A Scam wrapped in a Swindle, with a Fraud right on top!
Run -do not walk – to Medicare for ALL!

jefemt , January 9, 2019 at 9:58 am

Not fun to do the work, but imagine a few million Cigna clients at $13.00 a pop. Will pay for attorneys and accountants.

As to Priority Mail/ tracking/proof, why do we tolerate such a byzantine battle-prone system? Think of the man-hours Yves and countless others spend on running down this hors*#t. If she and others (doc offices/ care providers?) billed Cigna and others at a reasonable but market-based hourly rate for the collective man-hours spent on claims, Cigna et al would be out of business.

Its a level of complexity that is completely unnecessary. Our complacency, tolerance, and acceptance is pretty astounding. Must be the very real primacy of the threat and fear that personal health prompts. Immoral to lever off of this. Care versus insurance. Insuring a mortal being. Ridiculous premis only Wall Street could concoct. And we buy it because markets, capitalism, rugged individualism, American Exceptionalism.

Doc friends and family consistently state 35-40% of their costs, staff deals with billing, coding, reimbursement. There is huge savings to be gained in the process if we would go to a single payor system.

But you all know that- preaching to the choir.

I am still trying to figure out how to tie personal health choices, like diet and exercise, moderate alcohol use, etc.. and some incentivized skin-in-the game, some 'pain' disincentivises folks from over-using single payor and insisting on the highest dollar cost latest most expensive treatments -- how can this be institutionalized?

But , no need to reinvent the wheel- countless other nation-states have figured it out. For a nation of business-persons, we appear to be, as my old dad used to say, dumberthanwhaleshit

hunkerdown , January 9, 2019 at 12:04 pm

If they're overusing the system, what's the underlying reason? Probably loneliness or neurosis, either treatable on an outpatient basis as a mental/community health matter. If they demand heroic treatments or frivolous diagnostics , what's the underlying reason? Probably the consumer model of medicine and direct-to-patient marketing of interventions, also easily treatable (through restriction of advertising) and known to work well in other nation-states. If they eat crap, what's the underlying reason? The standard American diet is a consequence of national policy to grow grain instead of vegetables, which can be changed slowly and with effort as a public health hazard. If they don't exercise, what's the underlying reason? Built environments and lifestyles that are hostile to pedestrian traffic, which is not necessarily such an easy problem to solve due to the private interests and investments in the status quo, but whose opposing public interests would grow much stronger under a single-payer system.

Yet, all of these solutions, however difficult and world-changing they might be, are more effective over the long term and less resentment-inducing than having citizens pay to be individually scourged as a service in the name of individual incentive.

Yves Smith Post author , January 9, 2019 at 3:10 pm

The overwhelming majority of people do not elect to overconsume medical care.

People who don't exercise often don't have the time or money to do so (gym membership). Do not say "Anyone can run." Running on pavement is knee replacement futures. And there are people like me who could never jog even when young.

The ones that do fall into a few categories:

1. Ones with "lifestyle" diseases, like diabetes due to overweight/poor diet and smoking-related diseases. Problem is that these are typically the result of stress. Very hard to get off cigarettes and harder if you are subject to stress/use nicotine as a performance drug. Obesity significantly due to American portion sizes. too many refined carbs, and again, stress. And once people get fat, it is very hard for them to take and keep the weight off. I have managed to do so by virtue of seriously undereating for 40 years (<1200 calories/day, and that includes when I was exercising vigorously pretty much daily). Most people can't do that for social reasons. It is hard to be a meager eater when you are eating with other people.

2. People who are already have a problem and have been marketed to to demand tests and treatments. The classic version of this is doctors prescribing antibiotics to people with flus. The patients demand a treatment and the MD does not want to get in an argument. More extreme is patients not wanting to hear that there aren't any good options for what they have and shopping for an MD who will intervene anyhow. Another is all those new pricier drugs marketed on TV "Ask your doctor about..."

beth , January 9, 2019 at 8:15 pm

The best information about obesity is still the UCSF researcher Robert Lustig. He now has his own website but it not organized well to my taste and fails to keep the best long lectures there. Actually the best information in the shortest time is his first lecture that has been seen millions of times by geeks like me is "Sugar: The Bitter Truth" a one hour and 29 minute lecture he did in 2009. Youtube cuts it up and wants me to pay for it. But each time I have seen it has been on UCTV or UCSF. For those of us who want to understand the science this one is a must. There is good videos after that, but this is the foundational scientific information.

I can't give you a link because Google and the sugar industry makes it maddingly hard to find and moves it around.

flora , January 9, 2019 at 9:46 pm

It's a very good presentation. Thanks for the reminder. From UCTV:

https://www.uctv.tv/shows/Sugar-The-Bitter-Truth-16717

bob , January 9, 2019 at 3:21 pm

"I am still trying to figure out how to tie personal health choices some incentivized skin-in-the game "

You're trying to noeliberalize it. "How do we build in the need for 18 layers of very well paid bureaucrats who deal out spite, and lack of care, as part of their job descriptions?"

I can't imagine any more 'skin in the game' than all of the skin, and literally all of the person.

Do you ghouls even read what you write?

k. , January 9, 2019 at 9:59 am

As someone who managed a medical billing office in the 80s and 90s I can assure you that insurance companies losing claims is nothing new. That's why the advent of electronic billing to Medicare and Medicaid and BCBS and others was so wonderful. Finally, Medicare stopped "losing" all those claims we offices had to refile all of the time.

Sometimes it helped me to envision the office I was sending the paper claim to, imagining a constant turnover of new employees who didn't know what they were doing, or throwing away a stack of bills at the end of the day because they hadn't met their quota.

It's like borrowing "your" money longer, not paying what's owed in a contract.

EoH , January 9, 2019 at 10:38 am

Thanks for sharing.

This seems reminiscent of bank ATM fee scams. A dollar here, $2.50 there – systemwide – and soon you're talking about real money. It also matters whose budget the costs or income are shifted to, which is often a highly-competitive internal game. Same with the now ubiquitous and easily incurred penalty charges, which banks use to generate the outlandish returns they now consider their due.

Coincidentally, I was recently helping a friend with her latest medical bill. Always good sport if it's not your bill. It was "only" for about a thousand dollars. Her insurer paid the amount, minus her deductible.

The hospital system sent her a follow-up bill for the same service. It was for the deductible the insurer did not pay – routine – AND for another thousand dollars, which was not.

Here's the hospital's argument: It had billed the insurer and the patient only a thousand dollars. But the insurer considered bills for up to two thousand dollars for that service. Having, in effect, underbilled the insurer, the hospital added the difference between its first bill and the maximum amount the insurer would consider.

But the hospital did not bill the insurer for the higher amount, only the patient. That routine also happily avoided any reasonable and customary cap the insurer and hospital had agreed to.

The hospital does this routine systemically. Its "customer service" operators have a canned response for outraged patients: You'll pay it in the end and we'll dock your credit score in the bargain. Film at eleven.

Steven Hoel , January 9, 2019 at 10:39 am

I have found this letter (or to be used as script to be read over the phone) to be 100% effective so far. I suspect it gets kicked up to a supervisor who wants to get rid of the crazy customer:

"To: "Big Corporation"
Regarding Inv #

Hello,

You have issued your fourth notice. Please note that this is now my third notice to you of whom to bill. If I must spend more time on this issue, I will be billing out at $200 per hour in ½ hour increments. Sending a further notice without contacting "XYZ Healthshare" for payment will indicate acceptance of my terms.

This blood work was for my annual Physical. I am covered under "XYZ Healthshare" and they cover one physical per year.

Please submit above referenced invoice for payment to:

"XYZ Healthshare"
Payor ID:
P.O. Box 1234
Anytown USA 12345

Insured: John Doe
Policy # 123456789

It is not acceptable to simply send me another payment notice when you are not billing as I instructed. I will send my billable hours in return and submit a copy to my attorney.

Best Regards,

John Doe"

NotTimothyGeithner , January 9, 2019 at 10:44 am

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

Perfect.

jrs , January 9, 2019 at 12:56 pm

Of course Trump's misdeeds are becoming abuses much closer to home, having one's government closed becomes real impractical even on the day to day level.

Spring Texan , January 9, 2019 at 11:08 am

Wow, this makes me very happy I work for a self-insured employer which unfailingly pays bills in good faith. Awful.

California Bob , January 9, 2019 at 12:10 pm

I was with United Healthcare in the private sector for years, with good coverage and no serious issues (PPOs only). When I went on Medicare, I stayed with AARP-endorsed UHC; I figure the last thing UHC would want is a bunch of angry retirees with time on their hands. So far, so good.

Jimmie Q , January 9, 2019 at 5:40 pm

I don't know about that. I've not been able to login to the AARP/UHC website for 2 months.
They admit that there is a problem. After 2 months I'd say they are correct.
You'd think they would go back to the last working version of their log-in software.
What kind of testing was performed before inflicting this crap on their users. None, by the looks of it.
It's pretty obvious when you can't login. How stupid are these people ?

Oregoncharles , January 9, 2019 at 12:17 pm

Not medical, but a similar penny-ante scam that we encountered from a car rental, which I will name: it was Dollar/thrifty – they're the same company. Ironically, we were happy with their service, given the price, UNTIL we turned the car in at the Indianapolis airport. The agent claimed the system was down, so couldn't give me a receipt; foolishly, and feeling time-pressured, I walked away without one (don't do that).

The company first claimed the car had not been turned in, then discovered that it had been re-rented the next day, so charged us for an extra day. I refused to pay it, since an agent had agreed that our boarding passes from the airline proved when we'd turned it in. In fact I got the credit card company to reverse the extra amount (their service was exemplary). Attempts to clear it up on the phone led to hangups at their end, and ultimately they sent the $50 difference to collection. When I got a call, I started yelling about it being a fraudulent charge and making legal threats; never heard from them again – not worth it for such a small amount. I felt that principle was involved.

And now the oddity: Dollar/Thrifty belongs to Hertz, but we've had no trouble renting from Hertz. Go figure.

JerryDenim , January 9, 2019 at 1:21 pm

One scam I've seen Hertz attempt on me twice, was claiming a car wasn't returned completely full, like 1/16th shy of full, then they proceed to charge you for a full tank of gas (15, 20 gallons or whatever that means based on the vehicle) at some outrageous price like $9.00 a gallon. It's a scam that is always going to add up to over a hundred dollars. It's a quick, vicious one-time burn (sharp practice as Yves would say) they try to pull on customers they figure may never rent from them again anyway. Algos I'm sure. Always document, document, document with rental cars. Cell phone cameras are great in this regard. Photos of the odometer with gas gauge displayed work great for refuting such charges.

beth , January 9, 2019 at 8:32 pm

I was definitely scammed by Dollar/Thrifty. I have switched to using Enterprise but they sometimes don't have an airport location. So far so good. I usually take only one trip a year.

Oregoncharles , January 9, 2019 at 12:21 pm

Afterthought: Insurance is a service business, which would normally depend on providing reasonably good service – granted, in this case Yves is locked into an old contract, so they might be trying to get rid of her.

I wonder if this sort of behavior means they see the political handwriting on the wall, figure the business can't last much longer, and are trying to extract the last dime, because it IS the last?

EoH , January 9, 2019 at 3:13 pm

Standard business model. Nothing special.

I question whether insurance is any longer a service, at least for the customer. Health insurance used to be a business that offered a reasonable service, service tracking and payment processing for employers, who purchased the service for their employees as a form of deferred compensation, in exchange for a reasonable fee.

The model seems to have changed to one of open and notorious self-dealing. The intermediary has become a principal, and no fee and no level of profit is too great. The intermediary makes decisions that look to the lay person like practicing medicine – not seemingly in the interest of savings its employer customers money, but it making it for themselves. The model is a major reason for the extraordinary cost of medical care in the US.

Synoia , January 9, 2019 at 12:26 pm

Small claims court?

ambrit , January 9, 2019 at 12:57 pm

That would be a tax on her time, she has to physically show up in court for the 'trial', and money, as in, filing fees. A small claims judgement does not guarantee payment. That could take a second suit. (I had to go for a second filing to get my judgement paid.)
This is a systemic problem. The remedy in that elusive "perfect world" is to change the system.

AdamK , January 9, 2019 at 12:55 pm

"Corporate America has been institutionalizing penny-ante scams "

Don't get me started. 24 hour fitness sold membership for super sport facilities at a higher price promoting the deal that gives free towels to members while at the gym. 3 years after, towels are gone. Price was raised several times, and there is no difference between regular facility and super sport. No one complained. They simply got the news and adjusted. Saying something is not considered appropriate, so we continue to pay more and more and getting less and less.

ambrit , January 9, 2019 at 1:05 pm

Same dynamic used for Internet services, telecom services and cable services. Life is legally an "ethics free zone" today.
Reminds me of one of the more vulgar posters I once saw. A mid range shot of a woman's "private parts" with a 'tattoo' above the mons pubis saying; "Abandon all hope, ye who enter or exit here."

WheresOurTeddy , January 9, 2019 at 2:32 pm

seems germane:

"The political crisis we are facing is simple. American commerce, law, finance, and politics is organized around cheating people." – Matt Stoller

https://twitter.com/matthewstoller/status/893848256769171458

JerryDenim , January 9, 2019 at 1:10 pm

This story is strangely similar to the battles I used to wage years ago with Sallie Mae to pay down my student loan principal ahead of schedule. I would send checks that would never be cashed. If they ever were the amount would always be applied to interest and never principal. Tons of emails, phone calls and letters stretching out over months all about one check or another.

"Oh you sent the check to that address? No that's all wrong, try this one." "Oh, no, you have to write a letter stating you want the amount to be applied to principal. Oh, you did already? Oh, well send one to this department at this address instead and your next one should be be applied to principal."

Absent an aggressive regulator corporations can play infuriating games like this for years until the consumer gives up or lawyers up. Lawyering up is no guarantee of victory and doesn't make financial sense for small penny-ante grievances. Most people stuck dealing with hassles like these don't have the money to lawyer up anyway and corporations know it. I remember back in 1995 when my phone service was changed without my permission and I received an outrageous bill. I placed one phone call to the FCC that lasted a few minutes and I received a $250 credit and my phone service was free for the next year. I miss those days.

"The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home."

Absolutely. It's really tough for working class Americans to shed a tear for Central American border jumpers having a rough go of things with ICE when their own government refuses to protect them from thousands of small capitalist depredations that they are subjected to on a daily basis.

tongorad , January 9, 2019 at 1:11 pm

Corporate America has been institutionalizing penny-ante scams like the one Cigna ran on me
I received an errant charge when I chose to cancel my account with a phone-carrier giant. Lots of time on the phone speaking to different people, demanding to be sent an invoice/bill.
In the end, I just paid. I was losing sleep over it.
I have a feeling that these kinds of extractions are commonplace.
What a world

beth , January 9, 2019 at 8:41 pm

If we are discussing scams, I had an earthlink account for about a year when I noticed that rather than billing me monthly, they were billing me every 20 days and when I noticed it, they said they would refund my money at my request.

And what do you think happened?

M Morrissey , January 9, 2019 at 1:20 pm

File a complaint with your state insurance department. Most departments have dedicated staff who will follow up on such issues. If you one of many victims, it can lead to a "Targeted Market Conduct Examination" of the company.

Once that happens, the insurer will readily settle claims such as yours because besides fines, the impact of an examination damages their reputation. Also, if there is a pattern of misconduct, the complaint information is shared between the 50 states, who may also initiate targeted examinations. Don't get mad–get even.

monday1929 , January 9, 2019 at 6:06 pm

You are kidding, right?
And ."damage their reputation"- thank you, I needed a laugh.

JBird4049 , January 9, 2019 at 1:37 pm

The more people are in need of medical care the less likely they are to have the time, energy, or even money to maintain their records, read all their letters and emails, and write and call enough times to finally get their money. The sicker are the less likely you will get paid. Truly vulture capitalism.

Dan , January 9, 2019 at 1:57 pm

I tend to agree that these 'billing mistakes' are a conscious strategy on the part of insurers. For several years Kaiser (Northern California) would attempt to bill me $15 every time for routine physical visits (which my physician had requested!). Routine physicals, of course, are meant to be free under the ACA. Every time the receptionist would request payment in advance, I would decline an tell them that the appointment should be free. They then would proceed to bill me by mail, and I had to spend time calling them to resolve the issue. Unlike Yves' experience with Cigna, Kaiser customer service was always friendly and promptly resolved the 'error'.

Since we changed from a Covered California plan to a small business plan this practice appears to have stopped, at least for me. Nonetheless, this annual ritual was a ridiculous tax on my time, and I wonder how many people who were less informed/hostile to their insurer than I am have just paid these false and illegal fees up front. The consistency of this practice over a period of years makes it hard for me to believe that there is really error involved, as opposed to a subtle fraud by the insurer.

monday1929 , January 9, 2019 at 6:13 pm

It is never an "error", and it is always in their favor (proof it is not an error).
They target the sickest, least likely to fight back. There is an MBA somewhere who wrote an algorithm designed to screw the old and sick. My nightmare with United "healthcare" (why are they allowed to call themselves or imply they are healthcare providers?) was on behalf of someone else who never could have fought these scammers.

tiebie66 , January 9, 2019 at 3:31 pm

So, they legislate to permit disruption against you and not against them, but year after year – figuratively speaking – you send the same people back there. The system is beyond reform, is that not clear by now? Vote for anyone –except– a Democrat or Republican. It would create upheaval at first, like spring cleaning, but it is as necessary. If you are too timid to make changes, you will only get weaker and weaker until you are too weak to resist. Don your yellow jackets!

But on a different level – where does this originate? My sense is that it is a failure of education. The nation can neither read, nor write, nor think. This makes for easy victims. Do teachers really deserve better pay? Is teaching not a 'calling' rather than a career? Should teachers not do better? But perhaps the failure of education is also, in part, institutionalized?

Big Tap , January 9, 2019 at 4:55 pm

Speaking of insurance scams some involve a PPO type policy. More and more often I'm told at the time of service of a doctors visit to pay up front. With a PPO policy you usually don't know exactly what you owe till after the insurance company tells you what your co-pay is and then you're billed. When you pay up front bring overcharged intentially is the scam. Getting a refund of your own money can time consuming.

Pft , January 9, 2019 at 6:49 pm

Not only health insurance. Good luck if your house burns down and you want them to honor the contract in a timely fashion. They hold off until you accept less hoping you hate living in 2nd rate accomodations enough to cave. My sisters contract called for full replacement of all contents regardless of age. She paid a hefty premium for that. They held out for months offering less saying some of the contents were older and not worth the replacement cost which is what she wanted to avoid by paying the extra premium for the upgrade. Came to an agreement somewhere between but took 15 months before she could move back in.

EoH , January 9, 2019 at 7:37 pm

There is the basic problem that with almost every medical service, the customer does not know the price until the bill(s) show up in the mail. (Nor have they any training or experience that would enable them to choose alternative treatments or vendors.) Only later still does an insured customer find out what portion of that bill is her responsibility. And that's without errors and intentional mis-billing, which are common.

The usual conservative refrain that patients need more skin in the game studiously ignores that patients always have all their skin in the game, even though no one tells them the game or the rules until it's too late. It is an environment that could only make predatory behavior flourish.

Katherine , January 9, 2019 at 9:57 pm

This is one of the most unsettling posts I have read on NC since becoming hooked about 6 months ago.

cat sick , January 10, 2019 at 2:44 am

Live a healthy lifestyle and self insure

I am sure not dealing with insurance companies is a sure way to lower stress levels and therefore require much less healthcare.

As a fairly healthy 50 year old I find that even though I have access to a good free first world healthcare system (Singapore ), never using it and paying doctors direct for all my needs is the way to go and probably costs me 10% of what a US citizen might pay for an insurance policy.

When I am in the US and so many people you meet have "meds" that they take on a daily basis it leads me to believe that not only are the insurance companies in on the scam but also the doctors and drug companies plying people with drugs that in most cases probably make them worse off

The first $20 of care I would reccomend is to buy one copy each of "how not to die" and "the case against sugar" read these and then do all you can to avoid both insurance companies and doctors .

[Jan 09, 2019] $3.5 Trillion A Year- Is America's Health Care System The World's Largest Money-Making Scam- -

Jan 09, 2019 | www.zerohedge.com

Authored by Michael Snyder via The Economic Collapse blog,

If the U.S. health care system was a country, it would have the fifth largest GDP on the entire planet. At this point only the United States, China, Japan and Germany have a GDP that is larger than the 3.5 trillion dollar U.S. health care market. If that sounds obscene to you, that is because it is obscene. We should want people to be attracted to the health care industry because they truly want to help people that are suffering, but instead the primary reason why people are drawn to the health care industry these days is because of the giant mountains of money that are being made. Like so many other things in our society, the health care industry is all about the pursuit of the almighty dollar, and that is just wrong.

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In order to keep this giant money machine rolling, the health care industry has to do an enormous amount of marketing. If you can believe it, a study that was just published found that at least 30 billion dollars a year is spent on such marketing.

Hoping to earn its share of the $3.5 trillion health care market, the medical industry is pouring more money than ever into advertising its products -- from high-priced prescriptions to do-it-yourself genetic tests and unapproved stem cell treatments.

Spending on health care marketing nearly doubled from 1997 to 2016, soaring to at least $30 billion a year , according to a study published Tuesday in JAMA.

This marketing takes many different forms, but perhaps the most obnoxious are the television ads that are endlessly hawking various pharmaceutical drugs. If you watch much television, you certainly can't miss them. They always show vibrant, smiling, healthy people participating in various outdoor activities on bright, sunny days, and the inference is that if you want to be like those people you should take their drugs. And the phrase "ask your doctor" is usually near the end of every ad

The biggest increase in medical marketing over the past 20 years was in "direct-to-consumer" advertising, including the TV commercials that exhort viewers to "ask your doctor" about a particular drug. Spending on such ads jumped from $2.1 billion in 1997 to nearly $10 billion in 2016 , according to the study.

As a result of all those ads, millions of Americans rush out to their doctors to ask about drugs that they do not need for diseases that they do not have.

And on January 1st, dozens of pharmaceutical manufacturers hit Americans with another annual round of massive price increases.

But everyone will just keep taking those drugs, because that is what the doctors are telling them to do. But what most people never find out is that the pharmaceutical industry goes to great lengths to get those doctors to do what they want. According to NBC News , the big drug companies are constantly "showering them with free food, drinks and speaking fees, as well as paying for them to travel to conferences".

It is a legal form of bribery, and it works.

When you go to most doctors, they will only have two solutions to whatever problem you have – drugs or surgery.

And since nobody really likes to get cut open, and since drugs are usually the far less expensive choice, they are usually the preferred option.

Of course if doctors get off the path and start trying to get cute by proposing alternative solutions, they can get in big trouble really fast

Today's medical doctors are not allowed to give nutritional advice, or the American Medical Association will come shut them down , and even if they were, they don't know the right things to say, because they weren't educated that way in medical college. So instead, M.D.s just sling experimental, addictive drugs at symptoms of deeper rooted sicknesses, along with immune-system-destroying antibiotics and carcinogenic vaccines.

That's why any medicine that wrecks your health is easy to come by, just like junk food in vending machines. The money isn't made off the "vending" products, the money is made off the sick fools who are repeat offenders and keep going back to the well for more poison – it's called chronic sick care or symptom management. Fact: Prescription drugs are the fourth leading cause of death in America, even when "taken as directed."

Switching gears, let's talk about hospitals for a moment.

When you go to the hospital, it is often during a great time of need. If you are gravely ill or if an accident has happened and you think you might die, you aren't thinking about how much your medical care is going to cost. At that moment you just want help, and that is a perfect opportunity for predators to take advantage of you.

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Just consider the example of 24-year-old Nina Dang. She broke her arm while riding her bicycle in San Francisco, and so she went to the emergency room.

The hospital that Facebook CEO Mark Zuckerberg donated so much money to definitely fixed her arm, but later they broke her bank account when they hit her with a $24,000 bill

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50 . Premera Blue Cross, her health insurer, would only cover $3,830.79 of that -- an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay , which the hospital threatened to send to collections in mid-December.

Most Americans assume that if they have "good health insurance" that they are covered if something major happens.

But as Dang found out, you can still be hit with crippling hospital bills even if you have insurance.

Today, medical debt is the number one reason why Americans declare bankruptcy. Because of the way our system is set up, most families are just one major illness away from financial ruin.

And this kind of thing is not just happening in California. The median charge for a visit to the emergency room nationally is well over a thousand dollars , and you can be billed up to 30 dollars for a single pill of aspirin during a hospital stay.

Our health care system is deeply broken, and it has been designed to squeeze as much money out of all of us as it possibly can.

Unfortunately, we are stuck with this system for now. The health care industry is certainly not going to reform itself, and the gridlock in Washington is going to make a political solution impossible for the foreseeable future.


the_river_fish , 3 minutes ago link

Healthcare has displaced Retail as the largest employer in the United States

https://thistimeitisdifferent.com/healthcare-us-january-2019

Consuelo , 9 minutes ago link

The ghost of Ted Kennedy that keeps on giving...

He played an outsized role in the trashing of the doctor/patient relationship.

css1971 , 10 minutes ago link

Most big hospital ERs negotiate prices for care with major health insurance providers and are considered "in-network." Zuckerberg San Francisco General has not done that bargaining with private plans, making them "out-of-network." That leaves many insured patients footing big bills.

HMOs.

Constrain supply. Increase the price.

https://en.wikipedia.org/wiki/Health_Maintenance_Organization_Act_of_1973

That was the purpose of the 1973 HMO act. It was at this point, that US medical costs began to escalate far beyond the rest of the world.

https://pusz4frog.files.wordpress.com/2012/04/healthcare-costs-oecdchart_3.gif

LawsofPhysics , 10 minutes ago link

Considering the demographics of the country and the fact that fraud is the status quo now, this should not surprise anyone.

LawsofPhysics , 21 minutes ago link

That's a tough question considering we don't really know how much is flowing to the military industrial complex. My guess healthcare spending is in second place.

[Jan 08, 2019] Risk On Again - Distractions from the Real Problems and Issues

Jan 08, 2019 | jessescrossroadscafe.blogspot.com

Stocks and Precious Metals Charts - Risk On Again - Distractions from the Real Problems and Issues

"On April 3, Nina Dang, 24, found herself in a position like so many San Francisco bike riders -- on the pavement with a broken arm.

A bystander saw her fall and called an ambulance. She was semi-lucid for that ride, awake but unable to answer basic questions about where she lived. Paramedics took her to the emergency room at Zuckerberg San Francisco General Hospital, where doctors X-rayed her arm and took a CT scan of her brain and spine. She left with her arm in a splint, on pain medication, and with a recommendation to follow up with an orthopedist.

A few months later, Dang got a bill for $24,074.50. Premera Blue Cross, her health insurer, would only cover $3,830.79 of that -- an amount that it thought was fair for the services provided. That left Dang with $20,243.71 to pay, which the hospital threatened to send to collections in mid-December..."

Sarah Kliff, A $20,243 bike crash: Zuckerberg hospital's aggressive tactics leave patients with big bills

"Monopolies hurt the public and the republic alike; the job of policing that power must be taken seriously."

Elizabeth Warren

Within so many of the corporate dominant monopolies like Healthcare, Banking, Pharmaceuticals, some companies seem to be free to do just about whatever they wish in billing consumers.

Healthcare in the US is bordering on insane when it comes to billing practises and lack of practical recourse or common sense, with Big Pharma running a close second. But the Banks are not all that far behind.

I have met many, many dedicated professionals in the healthcare industry, but like most participants they are just being swept along because they have little practical recourse or power. To speak up is to be punished, and severely.

A simple law that states that when a patient is brought into a hospital emergency room for treatment, their private insurance and the treatments must be provided at the network rates in their insurance policy, or at the prevailing rate for a Medicare patient, whichever is lower. And any uncollectible services to be written off or compensated by government will be done at the Medicare rate and not at some ficitonal billing statement.

I believe that New York State has a law requiring ER and Hospital doctors to accept private insurance for patients as if they are in-network. This includes those 'consultations' which happen during a hospital stay by doctors who accept no insurance and who charge whatever they feel like charging for some service, of which provider or price the patient is never informed beforehand.

The real solution is of course universal healthcare, which has been implemented for years by every major developed nation but the US. This will not happen for the same reason that we are seeing no movement towards meaningful reform in Pharma or Banking. And you know exactly why, unless you have been living in a bubble or are willfully blind.

Stocks managed to extend their rally today despite some setbacks.

We will see what Trumpolini has to say about our 'crisis' at the southern border this evening, and the trade war, and probably whatever else crosses his mind. My only certainly is that it will not involve any meaningful reform in healthcare, finance, insurance, or pharmaceuticals.

Have a pleasant evening.

[Nov 26, 2018] >Revealed: faulty medical implants harm patients around world by Hilary Osborne , Hannah Devlin and Caelainn Barr

Notable quotes:
"... In the US, the Food and Drug Administration (FDA) has collected 5.4m "adverse event" reports over the past decade, some from manufacturers reporting problems in other parts of the world. ..."
"... Interviews with patients and doctors have revealed flaws in how the medical devices industry is regulated. ..."
Nov 25, 2018 | www.theguardian.com
The Implant Files investigation reveals damage caused by poor regulation and lax testing rules

Why we're examining the implants industry

Patients around the world are suffering pain and many have died as a result of faulty medical devices that have been allowed on to the market by a system dogged by poor regulation, lax rules on testing and a lack of transparency, an investigation has found.

Pacemakers, artificial hips, contraceptives and breast implants are among the devices that have caused injuries and resulted in patients having to undergo follow-up operations or in some cases losing their lives.

In some cases, the implants had not been tested in patients before being allowed on to the market.

In the UK alone, regulators received 62,000 "adverse incident" reports linked to medical devices between 2015 and 2018. A third of the incidents had serious repercussions for the patient, and 1,004 resulted in death.

In the US, the Food and Drug Administration (FDA) has collected 5.4m "adverse event" reports over the past decade, some from manufacturers reporting problems in other parts of the world.

These included 1.7m reports of injuries and almost 83,000 deaths. Nearly 500,000 mentioned an explant – surgery to remove a device.

The figures come from research by 252 journalists from 59 media organisations in 36 countries, which has uncovered a litany of problems in the global $400bn (£310bn) industry.

Examples of failure in the market include:

Replacement hips and vaginal mesh products sold to hospitals without any clinical trials. Patients relying on faulty pacemakers when manufacturers were aware of problems. Complications with hernia mesh that ruled one of Britain's top athletes out of competing for years. Regulators approving spinal disc replacements that later disintegrated and migrated in patients. Surgeons admitting they were unable to tell patients about the risks posed by implants because of a lack of central registers. Patients in Australia being given devices that the regulator has approved on the basis they have been approved in Europe.

The findings raise concerns about the level of scrutiny devices undergo before and after they go on the market, and whether regulators detect and act upon findings quickly enough.

Information about problems with devices is, in many countries, kept under wraps, making it difficult for patients to research procedures that have been recommended to them.

Interviews with patients and doctors have revealed flaws in how the medical devices industry is regulated.

Prof Derek Alderson, the president of the Royal College of Surgeons, said there had been enough incidents involving flawed devices to "underline the need for drastic regulatory changes", including the introduction of mandatory national registries for all implantable devices.

"In contrast to drugs, many surgical innovations are introduced without clinical trial data or centrally held evidence," he said. "This is a risk to patient safety and public confidence."

The Guardian and organisations including the BBC , Le Monde and Süddeutsche Zeitung, coordinated by the International Consortium of Investigative Journalists (ICIJ), have trawled through thousands of documents, many obtained through freedom of information (FoI) requests, to unearth some of the biggest problems.

Alongside interviews with patients and doctors, these have revealed flaws in the way the industry is regulated that are unlikely to be fixed by rules due to come into force in Europe.

Among the concerns raised by the Implant Files project are that manufacturers are in charge of testing their own products after faults have developed – and are allowed to shop around for approval to market their products, without declaring any refusals.

The Guardian has also heard about doctors who have close industry ties or seem eager to be early adopters of the latest devices to enhance their professional standing.

Plans for tougher EU rules have been watered down after industry lobbying, according to a huge trove of documents uncovered by the project.

[Oct 27, 2018] Surgery on a Sunny Afternoon Got Me Thinking About Healthcare

Notable quotes:
"... Millions young and old, caught up in the struggle for Healthcare and now there's a consensus. ..."
caucus99percent
span y divineorder on Sat, 10/27/2018 - 1:52pm Millions young and old, caught up in the struggle for Healthcare and now there's a consensus.

Yesterday we caught the bus downtown to the Dragon Room in the Santa Fe Plaza area for Happy Hour to meetup with friends we hadn't seen in a year. Heh. As happens with we seniors, part of the time was spent catching on health issues.

Our friend is facing knee replacement surgery with complications. Carpenter property manager by day, musician by night, he was worried about how things would turn out. But at least he had coverage through his wife's employment. Millions still don't have healthcare, and many who do, face denial of coverage and worse.

It clearly is a huge issue for some in the upcoming midterms.

Senior or no, perhaps you, too are worried about how things will turn out?.

Medicare Advantage vs. Medicare for All https://t.co/EFG1G4QKCS

-- Alice Marshall (@PrestoVivace) May 31, 2018

For those who followed the healthcare debacle during Empty Suit era it has been gratifying to see the coverage and movement toward single payer.

But there are still serious obstacles.

Dr. @awgaffney details the barriers to #SinglePayer reform: "Obstacle number one is the corporate opposition, obstacle number two is the potential that #MedicareForAll could be co-opted or sort of mutated into a lesser thing." https://t.co/E4xTSBPx2E via @businessinsider

-- PNHP (@PNHP) October 26, 2018

Here's another link for those who want to educate themselves on MA vs IMFA.
http://healthoverprofit.org/2018/03/27/medicare-advantage-vs-medicare-fo...

Over the last few decades, insurers participating in Medicare Advantage have schmoozed Congress into compensating them with more money per person than is allocated to traditional Medicare. Don McCanne of Physicians for a National Health Program writes:

"Each year the administration, whether Democratic or Republican, uses quirky arcane rules to ensure an adequate revenue buffer so that private insurers can compete favorably with the traditional Medicare program by offering lower premiums and cost sharing and expanded benefits Once a critical mass has enrolled in private plans, Congress will gradually reduce the relative value of the voucher-equivalent, reducing the government component of the funding of Medicare by shifting more costs to the Medicare beneficiaries."

We see this happening right now, with top leaders of Republican Party expressing a strong interest in cutting Medicare. In response, physician advocates argue that the private Medicare Advantage HMOs should be isolated as a source of wasteful government spending, and that benefits offered by these plans should be expanded into traditional Medicare. Physicians for a National Health Program (PNHP), the doctor-led think tank for single payer policymaking, has been putting forward a strong case against Medicare Advantage for some years.

PNHP points to a number of studies that show the Medicare Advantage HMOs cherry pick healthy patients and lemon drop expensive, unhealthy ones. This is done through narrow coverage networks and poor access to specialized care , driving patients with heavy medical burdens into traditional Medicare – where they can choose their own providers. A 2015 Brown University study showed that of Medicare Advantage patients who had long-term stays in nursing homes, 17% switched to traditional Medicare the next year. The report's lead author, Momotazur Rahman, told NPR news that there are incentives, including "steep cost-sharing as patients need more expensive care" and "limitations on expensive treatments",that because sick patients to drop out of Medicare Advantage plans. A 2017 Government Accountability Office (GAO) report found that of 126 Medicare Advantage plans, 35 plans saw disproportionally high numbers of sick enrollees dropping out into traditional Medicare.

In 2017, a Kaiser Family Foundation (KFF) study found one out of every three Americans enrolled in Medicare Advantage plans were given narrow physician networks. It concluded that plans offering broader networks tended to have much higher premiums than narrow-network plans. KFF also found that one out of every five plans do not include a regional academic medical center in their networks, and estimated that 40% of Medicare Advantage networks included top-quality cancer centers.

The Medicare Advantage insurers can also increase their profits by upcoding the severity of the diseases that their patients have. HMOs are paid per capita based on the number of patients they cover. The payments are also risk adjusted according to the severity of the illnesses of those covered: the more severely ill, the higher the compensation. So it is to the Medicare Advantage plans' advantage to upcode, to make patients seem sicker. Investigations by the Center for Public Integrityand the work of academics show that there is both direct and indirect evidence of massive upcoding in Medicare Advantage, costing the government and taxpayers tens of billions of dollars.

While Medicare Advantage is not an efficient or an equitable means of offering care to senior and disabled Americans, it's important to look into some of the benefits that satisfied patients (who tend to be healthy) are grateful for. All of these benefits would be offered (and enhanced) through a national health insurance system like National Improved Medicare for All (NIMA).

Sorry for leaving out the extensive hot links in the above quote.

So as before its a crapshoot that the Dems and their Repub buds won't screw this up for us.

My wife C99er jakkalbessie and I rode our pedal assist bikes down the Arroyo de Chamisa Urbano to the grocery store this morning, and it is one beautiful fall day here in
The City Different. Leaves are changing, there's a little snow up on the mountains east and west. Such a glorious day to be alive, and able to pedal around still!

I got to get my butt in gear and get ready for MOHS surgery. Spending too much time out in the sun, I guess.

Running through my mind are thoughts like " How much will I have to end up paying? Will my Medicare Advantage Employer group coverage try to deny it?"

What if I were like millions, with no coverage at all? My brother has a much larger problem on his face and no insurance what so fcking ever.

It's all but guaranteed that Trumpco will finally strangle ACA to death and soon. And then there's the worry about how corpadems can fck everything up.

What are people going to do? All the best to you and yours, good health to all.

Of course its not just we mouldy odies that care about this sheet.

AP-NORC/MTV Poll: Young people back single-payer health care https://t.co/pnBGhCq0Pq

-- Health Care For All (@HCASFV) October 26, 2018

Young Americans called health care a very important issue in deciding how to vote. Sixty-two percent of those who will be old enough to vote in the midterms rated it as such. That's the most who said the same of any issue in the poll, including... https://t.co/K2oMRAXPRz

-- Big Easy Magazine (@bigeasy_mag) October 27, 2018


More power to us all.

Wish me luck! Hoping to be in the 94% success rate for this surgery. Divineorder.

[Oct 25, 2018] Is Medicare for All the Answer to Sky-High Administrative Costs? by Lambert Strether

Oct 25, 2018 | www.nakedcapitalism.com

"Is Medicare for All the Answer to Sky-High Administrative Costs?" [New York Times].

The answer will surprise you! "Medicare's direct administrative costs are not only low, but they also have been falling over the years, as a percent of total program spending.

Yet the program's total administrative costs -- including those of the private plans -- have been rising. 'This reflects a shift toward more enrollment in private plans," Mr. [Kip] Sullivan said.

"The growth of those plans has raised, not lowered, overall Medicare administrative costs.'" • It is very gratifying to see a single payer stalwart like Kip Sullivan quoted as the authority he indeed is.

And, contrary to the headline, it does look like Medicare has a bad neoliberal infestation that needs to be dealth with. "Free at the point of delivery" is a good starting point, because that strikes a deathblow at the complex eligibility determination process so beloved by markets-first liberals.

[Mar 21, 2018] Big pharma racket: Bottom line, it's doctors and patients fault for not defending themselves against the ludicrously corrupt health insurance industry

Notable quotes:
"... instruction manual ..."
"... Bottom line, experts say, medical professionals should make the patient aware if they prescribe a high-priced medicine and explain why it's beneficial. Patients should play defense and ask their physicians about the cost of every new prescription. ..."
"... " experts say " ..."
"... medicine is less expensive if you pay the cash price and we don't run it through your health plan ..."
Mar 21, 2018 | www.nakedcapitalism.com

Enquiring Mind , March 20, 2018 at 9:17 am

Shame is a 20th century concept ill-suited to this modern post-tobacco settlement world. Where some saw a consumer victory after decades of warnings on packs by getting big tobacco to acknowledge risks, others saw methodology victory for the neo-liberal machine, and an instruction manual .

Like the Big C, cancer, that machine keeps rolling along. Now it is mainstream, to be emulated instead of castigated. At least that is what appears to have happened among those shame-free star pupils of Big Pharma and their fellow travelers in FIRE, aided and abetted on the Big Screen where deviancy got defined down so far it got erased. Political and economic trends ebb and flow, with some elements of populism appearing on the horizon. Greater awareness of the plight of one's fellow humans may help focus the mind.

RabidGandhi , March 20, 2018 at 6:16 am

Bottom line, experts say, medical professionals should make the patient aware if they prescribe a high-priced medicine and explain why it's beneficial. Patients should play defense and ask their physicians about the cost of every new prescription.

Bottom line, it's doctors and patients fault for not defending themselves against the ludicrously corrupt health insurance industry. Bottom line, medical professionals and patients have to spend their time and effort (increasingly dwindling, because markets) to try to avoid being charged a month's pay for a tube of ointment. Because, bottom line, changing the system is not an option, so keep banging your head against that wall!

notabanker , March 20, 2018 at 6:36 am

Yeah, try getting a straight answer on what this stuff will cost BEFORE you take possession, er , are treated. "$200" has turned into $1000 bills from a third party device company that magically turns to $0 after 3 months of emails and phone calls. I've walked out of hospitals after getting full disclosure of costs minutes before a procedure that was scheduled weeks in advance.

The neolib corruption numbness has to seep through the cartilage into the bones to call these practices anything but criminal.

oh , March 20, 2018 at 2:30 pm

There is really no excuse for the crooks in the medical (health care? nah!) industrial complex not to provide costs of any procedure or service ahead of time. I admire you for walking out minutes before the procedure and more people should do the same. I would do the same and have.

Amfortas the Hippie , March 20, 2018 at 4:15 pm

If there's no "Price Discovery", is it really a "Marketplace"?

towards the end of my six and a half year slog through the disability process(sic), I learned about Cuba. I got a price for a new hip pretty easily from them (around 10 grand, including a "bungalo on the beach with a private nurse for recovery")

so I called the nearest hospital, and asked what a new hip would cost me, cash money, walking in the door.

The person obviously didn't understand the question, and after some time of me waving my arms and trying to word the question in a form she would understand she said" oh insurance takes care of that and it depends on many factors"

"such as?" sez I

Her:" like what kind of replacement they use which is up to the surgeon and many things"

This went on and on, and I finally got her not nailed down at around 300 grand.

Then I asked her what medicare would pay for the same thing and she hung up on me. It ain't a "Market", it's a Racket.

(and, about the toenail fungus my grandmother would tell her to just pee on it .)

Bukko Boomeranger , March 20, 2018 at 7:06 am

By the "logic" of the guest post, bottom line is it's that baby's fault for not being strong enough to defend itself against the big kid who took its candy. It's the woman's fault for dressing that way before she was raped.

The victims should be blamed because they didn't play defence well enough against the criminals who write the rules of the system. I presume your comment is to flesh out the BS justification from the article, Gandhi, not to endorse it. Excuses like the one capping the guest post, instead of rabid outrage, are part of what allows the crimes to continue. I can see why so many Merkins want to burn the (family blog)er down, even though they wind up voting for Trump as a means of expressing that feeling.

HistoricalPerspective , March 20, 2018 at 11:32 am

" experts say "

Seriously, who are these 'experts'!?!? Between the 'experts' , who blame the victims, kick cans down the road and pass the bucks to the lay-people (no one is an expert in everything, i.e. everyone is ignorant about something at some point in their lives) they're suppose to be advising whenever 'expertise' is required, and the 'journalists' who give them a venue to spew their apocryphal twaddle in an attempt to portray themselves as 'experts' when their true intentions are to gaslight, obfuscate and divide common sense and decency. Throw in the politicians, crony capitalists and all the other puppet masters and you have the perfect storm so many Americans, like myself, finds themselves drowning in. Once upon a time expertise inferred wisdom. Those days are history.

jackiebass , March 20, 2018 at 6:31 am

I don't know if it works but I've been told that petroleum jelly will cure toenail fungus. it seems salves or topical medicines are usually expensive. I use a salve that I apply to the rash from my. Eczema. I have used it for years and the price is constantly increasing. When I started using it the cost was $50 per tube. The last tube I got cost $480. I was prescribed an inhaler for Bronchitis. It cost almost $500 and didn't seem to do much to relieve the symptoms. Fortunately my insurance payed for the medicine. It still makes me mad when I think about what was charged for these prescriptions.

divadab , March 20, 2018 at 8:00 am

There are much cheaper alternatives to inhalers for asthma or bronchitis. Buy a "Nebulizer" (we just bought a portable one for $50), which is a vaporiser, and get your doctor to prescribe "nebules" of albuterol sulphate and/or sodium chromalyn to load into the nebulizer. We get a prescription refill of nebules for $3.49 v. over $50 for a ventolin inhaler . And there is no propellant in the nebulizer which there is on an inhaler.

The greed and parasitism of the pharmaceutical cartel is criminal.

Arthur J , March 20, 2018 at 10:13 am

My gp told me to use Vick's VapoRub for my toenail fungus. I asked the pharmacist and she said it has about a 10% success rate, same as the petroleum jelly from which Vick's is made. There was some branded treatment, $40 for a 2ml bottle that she said worked maybe 15% of the time. Only been a few weeks, but so far I haven't seen much of a change.

Eudora Welty , March 20, 2018 at 12:32 pm

Yes, I used Vick's Vaporub on a toe fungus and it worked. I was told it wouldn't work.

home for wayward trout , March 20, 2018 at 1:00 pm

The People's Pharmacy has a lot of information on toenail fungus and also has an article recommending treatment with mentholatum.

I now go to their website before filling any prescription I'm given by a doctor.

RalphR , March 20, 2018 at 8:22 pm

I did (after trying other topical but non-prescription products) and it didn't initially.

But then I used it in conjunction with a lotion with a lot of hyaluronic acid in it. Hyaluronic acid is widely used in cosmetic products to increase penetration of the active ingredients into the skin.

Worked great.

Just by sure to apply any treatment to the cuticle, particularly at the root of the nail. That is where the fungus lives.

donw , March 20, 2018 at 12:42 pm

It is a fungus, so being outside in the sun wearing flip flops might kill it.

Marie Parham , March 20, 2018 at 6:42 am

Last summer I had toenail fungus and researched how to treat it. Soaked my feet is diluted vinegar a few days and scrubbed the area. Then I used https://www.cvs.com/drug/miconazole . It worked. Next time I have an annual checkup I will talk to my nurse practitioner. Web MD was a big help. https://www.webmd.com/skin-problems-and-treatments/guide/fungal-nail-infections-topic-overview#1

So was Mayo clinic

https://www.mayoclinic.org/diseases-conditions/nail-fungus/diagnosis-treatment/drc-20353300

I am not recommending websites replace physicians, but apparently it is necessary to always second guess the physicians.
My treatment cost less than $10.

Normal , March 20, 2018 at 6:42 am

How about requiring every provider to give a firm quotation on every product and service? Every other industry has to live with this constraint.

XXYY , March 20, 2018 at 10:22 am

I'm amazed this simple idea never gets traction. Car mechanics, e.g., are required by law to provide a written estimate before work begins; if something is found that will change the estimate, they have to get your OK. Car repairs are usually much cheaper than medical bills and are often equally or more opaque to diagnose.

Having doctors and medical offices provide you with an estimate after diagnosis but before treatment does not seem like it would be terribly hard. They (uniquely) have visibility into your insurance arrangements, their reimbursement rates, their costs, overhead, profit rates, and so on. Software for this purpose would make pretty short work of boiling this down to the out-of-pocket for the patient. The patient could then either OK it, negotiate other options, or decide to shop around. If the provider later tries to charge more, the patient would have something on paper to justify refusing it.

There's no reason patients should be treated like a bottomless bank account by the medical industry.

sharonsj , March 20, 2018 at 12:58 pm

Many doctors have no clue what things cost. I received a single shot of cortisone for an arthritic shoulder and was charged $200. When I complained to the health care system, I was told that, had I been insured, the cost to me would be $100 less. When I complained to my doctor, he had no idea about any of this.

P.S. I knew the owner of an herb farm who had foot fungus. She visited a podiatrist and was prescribed some expensive salve which didn't work. The woman then went out on her farm, gathered some herbs according to an old remedy, made her own salve and was cured.

oh , March 20, 2018 at 3:02 pm

I was told to get the shot for shoulder pain (was a bad idea from this quacK). The "doctor" had no idea what it would cost!! At any rate it cost me over a $100 even with Kaiser coverage and it did NOT help. It hurt a lot for a few days (in more ways than one). What a fraud this industry is.

I dread the day I'd have to go to the hospital where I it was such an emergency that I'd be at the mercy of this robber baron system

JTMcPhee , March 20, 2018 at 10:25 am

Had any car or truck repair work done lately? Or speaking of things automotive, have any of us had experiences with the sales machinery of car and truck dealers, new or used? Speaking of transparency in pricing, firm quotes and all that? As just one example of how The Machine actually works? Catch-22: "They can do anything to us they want that we can't keep them from doing." http://www.slate.com/articles/life/the_spectator/2011/08/seeing_catch22_twice.html

FluffytheObeseCat , March 20, 2018 at 11:19 am

Big ones twice in the past four years on the RAV4. 2 different shops, in different states. They both gave me firm, up front price quotes. One was wrong on the low side, and the owner called me with the real price and an apology before doing the work. Just like the law requires.

This kind of fair dealing and respect for the customer never happens in medical practices. The doctors rarely soil their highly educated minds with matters of cost; everyone else in the office has little authority, and the chubby young women who sit up front in scrubs do as little as possible for the captives they call patients.

nycTerrierist , March 20, 2018 at 3:07 pm

"This kind of fair dealing and respect for the customer never happens in medical practices. "

This! And stress over billing affects health!
it is stressful and aggravating that doctors can't/won't address cost at the point of service. This destroys patient's trust in the physician as well.
Therapeutic relationship is wrecked as well as health and personal finances.

Paul P , March 20, 2018 at 7:19 pm

This NYS law applies to services, not drugs. It's a start:

Emergency Medical Services and Surprise Bills Law – New York State
https://www.health.ny.gov/regulations/ bill /ems_and_surprise_bills_law_faq.htm
If they do not participate in a patient's health care plan, they must upon request from a patient inform the patient of the estimated amount they will bill absent unforeseen medical circumstances that may arise. Under subdivisions (3) and (4), physicians in private practice also must provide information regarding any other ..

anonymous , March 20, 2018 at 6:57 am

"We're talking about mild toenail fungus. The price tag is difficult to rationalize, experts ( and every breathing human ) said."

Eureka Springs , March 20, 2018 at 7:03 am

We're talking about mild toenail fungus. The price tag is difficult to rationalize, experts said.

What kind of "expert" tries to rationalize cost of prescription on severity, rather than, say, cost of making the product?

16,500 for the course of an eleven month treatment with 6 percent chance of working. Seems like a medical RX vacation almost anywhere else in the world would be prudent.

Enquiring Mind , March 20, 2018 at 9:07 am

What kind of expert, you ask?

Today's fast-paced, stimulating world in pharmaceutical revenue management and marketing needs H1-B visa assistance to hire the kind of expert that is not available in sufficient quantity or quality to allow efficient pursuit of medical excellence. In past years, such personnel were to be found only in select industries such as tobacco and other personal care products. Building the right team, with applicable key performance indicators and mission-critical elements, is too important to be left to chance so every avenue must be explored, every base touched. Consumer options are opened up in the free market of healthy competition for products rather than stifled under excess regulatory and legal layers.

That kind of expert. /s

Jon S , March 20, 2018 at 12:34 pm

I really enjoyed that!

sgt_doom , March 20, 2018 at 1:54 pm

Man oh man!!!!

Had a deja vu moment there -- thought I was back as an employee during a leveraged buyout by the typically sleazy PE firm of Baird Private Equity!!!!!

Lambert Strether , March 20, 2018 at 7:07 am

Sounds like Soloviev wasn't a "smart shopper"!

Miamijac , March 20, 2018 at 7:28 am

Teatree oil, anti fungal. >$3.00. They only have a license to practice.

Croatoan , March 20, 2018 at 8:17 am

Just be careful with the natural stuff

"The results of our laboratory studies confirm that pure lavender and tea tree oils can mimic the actions of estrogens and inhibit the effects of androgens ," said Korach. "This combinatorial activity makes them somewhat unique as endocrine disruptors."

https://www.nih.gov/news-events/news-releases/lavender-tea-tree-oils-may-cause-breast-growth-boys

Kevin , March 20, 2018 at 9:06 am

My wife is a massage therapist and dispenses oils occasionally. NEVER use straight oils – ALWAYS use a carrier oil in conjunction.

BTW – anyone else notice the toe fungus ad placed above the comments we're being watched!

oh , March 20, 2018 at 3:14 pm

Another myth propagated by the hand maidens to the Pharma industry.

cnchal , March 20, 2018 at 8:29 am

The title of the post is a bit misleading.

It should have been "Bill Of The Month: For Toenail Fungus, A $16,500 Prescription and less than 10% effective".

. . . She began swabbing it on the two toenails, as directed, having been told it would take about 11 months to treat the fungus .
– – – –
Unbeknownst to her, Kerydin, which it turned out costs nearly $1,500 per monthly refill . . .
– – – –
In its application for Food and Drug Administration approval granted in 2014, Anacor Pharmaceuticals highlighted that a yearlong treatment of Kerydin completely cured toe fungus in 6.5 percent of patients for one trial, and 9.1 percent of patients in another.

The post's title diminishes the scale of the scam by a factor of at least 100.

sgt_doom , March 20, 2018 at 1:55 pm

Very well articulated and thought out!

Props and kudos!!!

lyman alpha blob , March 20, 2018 at 3:52 pm

That last bit blew my mind. Why in the hell is the FDA approving anything as a treatment that can only be shown to cure what it's supposed to less than 10% of the time!?!? And we know how the approval process scam works – the companies only submit the best results in the first place and leave out the data the shows treatments to be less successful.

That being said, who would like to try out my new wonder drug? It cures absolutely everything that ails you at least 5% ot the time. I call it Plaisibeaux – the ingredients are French and they're a trade secret. Any FDA employess around who can fast track this one for me?

Joel , March 20, 2018 at 8:35 am

My simple stupid solution just avoid them entirely, the docs the tests the meds the hospitals. Advil is cheap and works for most of the pain. A couple of other basic meds for occasional random stuff that I buy when I travel outside the US. Try to work out a bit and eat more or less right. Except for easy obvious stuff I never met anyone that actually got better by going to a doctor. When its time to die I guess I will die.

Stillfeelinthebern , March 20, 2018 at 2:43 pm

X1000

Couldn't agree more.

oh , March 20, 2018 at 3:16 pm

+1

sierra7 , March 20, 2018 at 10:00 pm

In our healthcare system (and I guess totally), when you're healthy you're wealthy!

mark , March 20, 2018 at 8:35 am

It's really worse than the article suggests. Kerydin (tavaborole) isn't even all that effective. In one trial, "cure" was achieved in about 7% of cases and in other trials "completely or almost clear nail rates" were achieved in 15 – 30% of cases:

In clinical trials, tavaborole was more effective than the vehicle (ethyl acetate and propylene glycol) alone in curing onychomycosis. In two studies, fungal infection was eliminated using tavaborole in 6.5% of the cases vs. 0.5% using the vehicle alone, and 27.5% vs. 14.6% using the vehicle alone.

https://en.wikipedia.org/wiki/Tavaborole#Therapeutic_trials

For those interested, this is the original paper that the Wikipedia entry is based on:

https://www.sciencedirect.com/science/article/pii/S0190962215015121

Thomas Briggs , March 20, 2018 at 9:14 am

Last visit was a snake bite. Antivenom was about 60k. Pretty sure same can be had in Mexico for less than $1,000, maybe much less. That was 5 years ago. I refuse to participate any longer, & I have good insurance. I hope eating better, exercise, & homeopathic treatments can work for me. Have not seen a doctor since & won't unless taken unconscious.

oh , March 20, 2018 at 3:18 pm

Agree with you. Eat healthy foods, exercise, homeopathic or ayurvedic treatment when absolutely necessary. No need to go for their "free" physicals. Listen to your body.

Pat , March 20, 2018 at 9:19 am

So a physicians assistant diagnosed a fungus strictly on observation, calls in a prescription for an ineffective and more difficult to use but massively expensive prescription and it is the patient's fault.

Don't know about the rest of you, but I see at least three problems in that that have nothing to do with the patient OR even the obscene greed of the pharmaceutical industry but a whole lot with the Braun Dermotological Center.

XXYY , March 20, 2018 at 10:32 am

I have no proof, but my guess is that these medical centers have sweetheart deals with mail-order pharmacies for various overpriced drugs. We took my son to a dermatology place several times for acne treatment; they would commonly propose something I had never heard of and urge us to order from a particular mail-order pharmacy, often providing coupons. I saw no reason not to get it from our local pharmacy but they were strangely insistent on us doing it by mail.

One obvious problem with mail-order pharmacies is made clear in this piece: by the time you find out how much things cost, it's already a done deal. At a retail pharmacy, you can walk away without paying. This is obviously a feature of mail-order pharmacies, not a bug.

Kevin , March 20, 2018 at 11:02 am

The proliferation of specialty medical centers around the western Chicago suburbs has been amazing to witness – similar to the proliferation in the number of bank outlets prior to the crash

Katniss Everdeen , March 20, 2018 at 11:33 am

No kidding. How is prescribing a drug, even a cheap one, that's "effective" only 7% of the time even considered medical "treatment?"

And what in the world is that "statement" pictured above? It's flat out false. Is it somehow supposed to be official? Where did it come from?

"Total Rx cost" in January: $56.52???? No, it was $1,496.09–same as in February.

"You paid" (Patient paid?) in January: $56.52? No, the patient paid $1,439.57, "funded" through her HRA and shown with an asterisk at the bottom. $56.52 was apparently a drug company rebate / coupon.

About the only true thing in January was that the insurance paid $0.

The "You paid" in February was not, in fact paid by the patient, but by another drug company rebate / coupon. She was not even asked to write a check for the copay, an expense she would have expected.

The "Your Cost" of $620.43 at the top appears to be the sum of the two drug company coupons for January and February, although no time frame is specified. At this point, the patient had written NO checks, even for the copays.

As an aside, where is the $60 "Copay/Co-insurance for January?

The patient's actual "cost" over the two months would most accurately be represented as the sum of the two months' Rxs–about $3000–plus two $60 copays. "You Paid" should be what she actually paid, either out of pocket or through the HRA, and any fees or copays that were covered by drug company rebates should be clearly noted as CHARGED but ABROGATED.

I'd suggest that deliberately confusing and understating seemingly obvious terms such as "cost" and "paid"
deliberately obfuscates the situation in order to sell expensive drugs that people would balk at purchasing if they knew the true "cost."

And all of this is before figuring out, for a Medicare recipient, how all these worthless, expensive drugs, coupons and rebates propel the patient toward the "donut hole," an entirely different kettle of fish in which nobody pays for nuthin' except the patient.

Joel , March 20, 2018 at 4:45 pm

+1 These "statements" web pages or whatever are designed by either morons or sadistic fiends. Probably the same ones that design cell phone bills

anonymous , March 20, 2018 at 9:48 am

This reminds me of the time I was billed $300 for a foot splint by a podiatrist that my insurance refused to pay for. I could have bought a foot splint off Amazon for $30.

Always ask for prices for any treatments or medicines. I trust my dentist way more than any doctor I've been too.

vidimi , March 20, 2018 at 10:05 am

this stuff is free in france for anyone with a social security number

Bugs Bunny , March 20, 2018 at 10:46 am

Kerydin has not been approved by the European Medicines Agency. You shouldn't state things as fact unless you can back them up.

Jon S , March 20, 2018 at 12:40 pm

I'm sure he meant "medicine that fixes toe fungi" is free in France, not Kerydin. And of course Kerydin isn't approved in Europe, with a 7% efficacy rate, it's doesn't really have medicinal value. It would only be prescribed in the US.

crittermom , March 20, 2018 at 10:15 am

Stories such as this are infuriating.

I went to a Podiatrist a couple years ago for a different problem but mentioned I thought I had a toenail fungus, too.

The Dr confirmed that but instead of prescribing something he recommended coconut oil. He said it worked much better & faster than any pills he could prescribe & he was right.

I had a large jar of solid coconut oil (around $6) & applied it with a Q tip.
In very short time the fungus was gone.

A girlfriend had gone to her Dr who prescribed pills.
Her fungus returned within a few months.
Mine hasn't.

Lord Koos , March 20, 2018 at 1:08 pm

This is not surprising – before I read your post I was thinking, there is probably a simple home remedy for that condition. There are a lot of useful drugs out there, but there are probably just as many that are useless, ineffective, or that have dangerous side effects and unintended consequences. I took over-the-counter anti-allergy meds for my hay fever for years, only recently reading that they (Claritin, etc) are now implicated in the onset of Alzheimer's. Thanks a lot

JamesG , March 20, 2018 at 10:41 am

I caught a similar prescription with a high co-pay and refused to pick up the merch from the pharmacist.

I then treated my fungus with Lamisil an OTC product which works for me.

Steve Roberts , March 20, 2018 at 10:42 am

I was written a script for a tube of cream that supposedly cost nearly $3k. It's hard to know what the pharmacy benefit manager actually paid because they are pretty secretive about that sort of thing. Per a friend she estimated it at probably $50 which is still idiotic. It was an anti-itch cream and wasn't any better than a $2.50 tube of cortisone cream.

otis , March 20, 2018 at 11:22 am

For the love of Pete. Isopropyl alcohol costs $1.79. Cut your toenails then apply with q tip. No more nail fungus. One bottle = many years supply.

I'm amazed people will take pills to cure nail fungus. So Dumb.
$14.000 annual toe cream. Dumb dumb dumber.
Thanks for posting these absurd bills. It lays bare the financialized health care holocaust underway in the USA.

perpetualWAR , March 20, 2018 at 11:32 am

Toenail fungus? Get apple cider vinegar.
Why do people not first look at home remedies?
Apple cider vinegar clears that up in a snap.

Synoia , March 20, 2018 at 11:49 am

Fungus can be treated by soaking in a 25% solution of vinegar, twice a day for two weeks.

Change the pH, kill the fungus.

That was my prescription for a fungus on my foot, by my doctor. And it worked.

Fred , March 20, 2018 at 1:00 pm

I pay less for my medicines when I pay cash as the pharmacy gives me a discount. But, because Part D has a penalty for not enrolling, I use it for 5 of medicines and then pay cash for one of them and pay about $5 more per month. Not to mention my doctor offered to do my stints for half price if I paid for cash. The whole healthcare system is a mess.

Pogonip , March 20, 2018 at 1:16 pm

I don't know about other countries, but here in the U.S. you should always, always, always assume that in any transaction you engage in, the seller has been financialized and will actively try to squeeze more money out of you, the ideal being to take all your available money and give you nothing in return. Be wary.

There are plenty of honorable exceptions, like the honest doctors and the mechanics described above. Cherish those sellers, patronize them, spread the word of mouth, especially if you think capitalism is the best of all possible economic worlds. The rent-seekers, if they continue unchecked, will destroy capitalism, because it requires some minimum level of trust to work. The odds that the seller will provide a good product or service have to be at least better than even.

Anonymous , March 20, 2018 at 1:54 pm

Philia is a necessary casualty of identity politics. Society depends on the collective will of people to take actions that are not in their direct benefit because they know others will make them. The "Tragedy of the Commons" does not occur when philia is strong because people know they can trust others not to abuse common resources. Once people do not trust others to act for the greater good it is a race to the bottom. The problem with identity politics is that it creates distrust of others outside ones own identity group as 'others' who cannot be trusted.

jrs , March 20, 2018 at 3:51 pm

oh yes identity politics created that, as if there wasn't far stronger prejudice by dominant groups long before identity politics was even a glimmer in it's dad's eye.

CrosslakeJohn , March 20, 2018 at 3:12 pm

Ten years ago or so in Corte Madera California, I was very lucky to find a podiatrist who was doing research on toenail fungus. I had nine of ten toe nails involved, some since high school (so for decades). His protocol for this was
1) pulse dose of two Lamasil tablets at the start of treatment
2) OTC bottle of fungoid tincture (with little brush built into the cap) from drug store with half a Lamasil tablet dissolved in it
3) every morning in the shower, scrub the nail ends with a toothbrush and a chlorine powder cleaner like Comet
4) brush a small amount fungoid tincture onto nail ends after morning shower and at night before bed.
5) keep nails short with clean cut ends

As I recall, the Lamasil pulse dose kills the fungus in the nail bed right away, and the fungoid tincture wicks into the nail every time and carries the anti-fungal drug to the fungus residing within the nail. The chlorine cleaner acts as a dessicant and pH modifier.

Ultimately, he gave me the few necessary Lamasil tablets as free samples, and back then the fungoid tincture was maybe $4/bottle at walgreens.

The new nails grew in from the nail beds perfectly, and after many months I had perfect toe nails and ceased treating them. They have remained so ever since.
I have always wondered if this approach was ever published in a medical journal. No significant money to be made from it by the manufacturer of Lamasil, so it's hard to see who had an incentive to promote it.
Disclaimer: I am not a doctor and am not giving medical advice. Pursue at your own risk.
Thanks!!

rps , March 20, 2018 at 4:48 pm

Why your pharmacist can't tell you .
WASHINGTON -- As consumers face rapidly rising drug costs, states across the country are moving to block "gag clauses" that prohibit pharmacists from telling customers that they could save money by paying cash for prescription drugs rather than using their health insurance The pharmacist cannot volunteer the fact that a medicine is less expensive if you pay the cash price and we don't run it through your health plan ."

The White House Council of Economic Advisers said in a report this month that large pharmacy benefit managers "exercise undue market power" and generate "outsized profits for themselves."

P Fitzsimon , March 20, 2018 at 4:57 pm

I'm going to get in trouble for saying this but toenail fungus isn't exactly leprosy. I've had a case continuously for 40 years after damaging my toenails in an accident. About 20 years ago I went to a doctor to see what could be done to get rid of it. He said I can give you a prescription that may cure it . But would you rather risk your liver or take the fungus with you to the grave after a full and healthy life with the fungus. I dont know what it would have cost because I chose the fungus. If it had cost $1500 and he hadn't told me the cost I would have been most unhappy.

Bill Carson , March 20, 2018 at 6:09 pm

This is shameful and absurd. However, the article mentions that there are "pills" that can be prescribed to treat the toe fungus, but some people taking those pills (terbinafine aka lamisil) have developed severe liver damage leading to liver transplant or death.

How much does it cost to just remove the toenail?

Bill Carson , March 20, 2018 at 6:28 pm

Why does this prescription cost $1,650 per month and not $16,500? Or $165,000? Or $1,650,000? Who decided that $1,650 was reasonable and $1,650,000 wasn't?

Bill Carson , March 20, 2018 at 6:46 pm

Oops, I meant $1,500 per month. But it probably costs more now anyway.

And how do they make an ointment last only a month? I've got some ointments under my sink that are 30 years old.

Bill Carson , March 20, 2018 at 6:39 pm

I'm a lawyer. I took Contracts 25 years ago in law school, but I seem to remember that there are certain elements to a contract that have to be present before the parties can be bound. Let's see

1. Offer
2. Acceptance
3. Consideration
4. Mutuality

Now, it seems to me that Consideration can't just be left blank. It is a very rare (non-medical) contract indeed where the buyer says, "I want X, no matter what it costs."

If I stay at a hotel and they have a mini-fridge with various refreshments and snacks, and I take a Diet Coke and a Milky Way, they can't legally charge me $10,000 for that.

I don't know why this isn't considered defrauding the consumer. We should be able to sue the crap out of these companies.

mtnwoman , March 20, 2018 at 7:40 pm

Give the medical practitioners a break! So now they need to puruse the Wall St Journal daily to see what pirate has acquired what formerly cheap generic drup to monopolize it and raise the price 500%?

Yes, the price was outrageous. How is the practitioner supposed to know every patients health care coverage and what one particular insurance carrier will cover for what drug? What's $50 for one person is $1500 for another, depending on their insurance.

Our entire health care system sucks. The only people who like it are the Insurance and Pharma execs.

Tim , March 20, 2018 at 9:09 pm

I won't give a doctor a break that prescribes a non-essential medicine with a 6% success rate.

[Mar 17, 2018] How to negotiate directly with physicians and hospitals

That's a fantasy: "It is important to lock this agreement in, quickly, before my account is sold to a third-party collection agency, which is nowhere near as likely to accept such a deep discount" Many hospitals sells you to collection immediately.
Mostly this is a cheap self-promotion of a yet another snake oil salesmen... Some more tidbit still might be useful You are warned.
If you try to fight medical-industrial complex alone most of the time you will be crushed. As a minimum you need a legal help. Often you need insurance too: at the end it is cheaper to have insurance then to fight astronomic bills. But those bottom feeders still can get to you via balance billing. and in most case, when you stay in hospital they do get back to you with the additional biils. That's why you will need a lawyers to fight this.
The usual trick of this scammers is to get "out of the network" ambulance and bill you $5K or more. Even the transfer from one hospital to another via ambulance can cost you tons of money.
Unnecessary procedures is another important danger. Stents is one such danger, in case of suspicion for the heart attack. You can get several several of them even if do not need them as a courtesy of those greedy jerks ;-)
And they will never agree for Medicare rates. Forget about it.
Notable quotes:
"... As we have already learned, all healthcare services have been assigned a code by the AMA, a five digit CPT code. So, if you trip and fall off your patio, you might get a doctor's bill like the following table located in your handouts: ..."
"... You may receive other bills from several doctors such as anesthesiologists and radiologists, as well as laboratory services, therapists, and the ambulance company. The bills all look similar, and the strategy and tactics I am presenting, today, should work for each of them as well. ..."
"... The purpose of this overpricing by the medical providers is to force the insurance companies to the negotiating table. The insurance company is bringing a large volume of patients to the medical providers, the members in their network, so they are able to negotiate a lower discounted allowable fee from the medical providers. However, if the insurance carrier is not able to negotiate a contractual allowable fee schedule, then they will end up paying the higher billed charges of the out-of-network provider for the members that still end up being treated by that medical provider in emergencies when precertification is not required. ..."
"... Now, on to where you can find these prices. Well, if you have insurance, then after you receive medical care and the healthcare providers send their claims to the insurance carrier, you should receive from the payer an Explanation of Benefits (EOB), or you probably can go online and view an Electronic Remittance Advice (ERA). For every CPT code that the providers billed , you will see both a billed charge and allowable. ..."
"... Fortunately, as you will now learn, there is a much more simple and better way to be 100% certain of your diagnosis, diagnosis code, procedure, procedure code, and even the medications the physician will offer you, at least for elective conditions. Here it is. If it isn't an emergency, then make a doctor's appointment! ..."
"... Does this sound unlikely? Too good to be true? Then consider this: Medical providers are highly incentivized to give the patients they treated huge discounts. Why? Because they know that collecting money from patients foments malpractice litigation. They would rather have you pay them pennies, than have you sue them for millions. ..."
"... I recently had breakfast with a pharmacist friend of mine that has worked as a manager for Walgreens for more than a decade. mrs_horseman is probably smiling when she hears that I have a pharmacist friend, because she knows how I feel about most of the people in that industry. Nonetheless, I told him about this presentation I am making, and asked if he had any advice for negotiating directly with the pharmacies for medications. It turns out, he does, and I would have never guessed the tactic he described. ..."
Mar 17, 2018 | www.zerohedge.com

... ... ...

Approximately 63% of Americans have no emergency savings for things such as a $1,000 emergency room visit or a $500 car repair, according to a survey released Wednesday of 1,000 adults by personal finance website Bankrate.com, up slightly from 62% last year. Faced with an emergency, they say they would raise the money by reducing spending elsewhere (23%), borrowing from family and/or friends (15%) or using credit cards to bridge the gap (15%).

http://www.zerohedge.com/news/2016-01-07/sad-state-affairs-two-thirds-a

... ... ...

You are going to need five things, which I am going to give to you, today, free of charge!

  1. Some absolutely critical industry vocabulary
  2. A clear understanding of how healthcare is priced in the USA
  3. Insight into to actual pricing
  4. A proven negotiation strategy, including:
    • a. The point of contact
    • b. Foreknowledge of what prices medical providers will usually agree to
    • c. A sample offer and agreement
  5. The confidence to successfully negotiate

Unfortunately, I couldn't come up with a better way to impart to you an understanding of the industry lingo, other than these simple handouts. However, this information is so important for you to be able to understand any negotiation strategy that I simply must slog through each term with you now. Please, I ask that you hold your questions and comments until I get through the vocabulary. Many of the terms are cross-referenced, and will become more clear after we here them all.

... ... ..

To begin to understand how healthcare is priced, we are going to look at

  1. the doctor's bill given to a patient,
  2. the claim forms the doctor and hospital send to the insurance carrier, and
  3. ERAs that the insurance carrier then send back to the patient and the providers.

As we have already learned, all healthcare services have been assigned a code by the AMA, a five digit CPT code. So, if you trip and fall off your patio, you might get a doctor's bill like the following table located in your handouts:

On the hospital's bill you might see something like this:

It is important to understand that the amounts shown on both of these bills are un-discounted Billed Charges (Usual and Customary Fees). They are the highest price the provider might ever hope to receive for the service, also known as full retail, or MSRP. Don't panic when you get these bills, because as everyone knows, "Never pay retail."

You may receive other bills from several doctors such as anesthesiologists and radiologists, as well as laboratory services, therapists, and the ambulance company. The bills all look similar, and the strategy and tactics I am presenting, today, should work for each of them as well.

If you have insurance, the providers will send your carrier a claim with essentially the same data as is on the bill they will provide to you if you are not insured, or if you simply request a copy.

An important fact is that Federal Law, as a requirement for the medical provider's participation in Medicare, requires that a medical provider charge every patient the same amount for a given CPT item. What it does not require, however, is that a medical provider accept the same payment amount from every patient for a given CPT item. This allows insurance companies, government payers, and you to negotiate a discounted fee, known as a contracted allowable, and not be in violation of the law.

The purpose of this overpricing by the medical providers is to force the insurance companies to the negotiating table. The insurance company is bringing a large volume of patients to the medical providers, the members in their network, so they are able to negotiate a lower discounted allowable fee from the medical providers. However, if the insurance carrier is not able to negotiate a contractual allowable fee schedule, then they will end up paying the higher billed charges of the out-of-network provider for the members that still end up being treated by that medical provider in emergencies when precertification is not required.

This creates a tiered-pricing structure for medical services that looks very much like this table in your handouts:

At this point, if you are paying close attention, then it should start to dawn on you where I am leading you with this talk, which, after all, is titled: How to negotiate directly with physicians and hospitals.

Spoiler Alert: You are learning how to negotiate for Medicare rates, at worst, and Medicaid rates, at best. In our example, a bilateral elbow fracture patient in Texas received surgeon and hospital bills totaling $179,219. Medicare allows $30,542 and Medicaid $22,600, which means the government negotiated an 83% or 87.4% discount, respectively. You can too!

Before we move on to providing you with access to these fee schedules, and then a negotiation strategy, do you have any questions about how healthcare is priced in the USA?

Now, on to where you can find these prices. Well, if you have insurance, then after you receive medical care and the healthcare providers send their claims to the insurance carrier, you should receive from the payer an Explanation of Benefits (EOB), or you probably can go online and view an Electronic Remittance Advice (ERA). For every CPT code that the providers billed , you will see both a billed charge and allowable.

Quick show of hands: how many of you have received a medical bill, or an EOB, and threw it away because you could not understand it? That is intentional! They want you to be confused. However, after today, I doubt that you will ever do that again.

What if we do not have insurance, or we want to know the allowable, because we think this is important information to know so that we can negotiate before receiving healthcare? Think having a baby or elective surgery. Do not worry! The federal government provides us with the Medicare rates online, and I believe that each state provides its Medicaid fee schedules online.

You would soon discover, however, that it is much easier to determine the allowable for a physician service than a hospital service, for which you will likely need to look up the DRGs for the ICD codes and then try to cross-reference them with the IPPS Fee Schedule, at a minimum, or you may even need to look up and calculate conversion factors. It is not easy, again, intentionally so!

Regardless, we would first need the CPT codes for the services you are seeking from the physician, and probably the ICD codes, too, in order to price hospital services. You could try to guess at the diagnosis and the services you think the doctor is going to provide to you, and then try to use a search engine to determine the ICD codes and CPT codes, or buy a coding book.

"I know I need a hip replacement. My trainer at the gym told me so. I'll just Google, hip replacement ICD and CPT code."

Good luck with that! The odds of you guessing the correct diagnosis and appropriate procedures (without going to medical school) are incredibly slim, especially with the new ICD-10 diagnosis codes. Also, chances are good that your athletic trainer doesn't know what the hell she is talking about when it come to medicine, and in reality, you probably just need a new athletic trainer, and not a new hip.

Is your head spinning, yet? Good! Now, stop it, because you will see that we don't need to do any of that! It's all just a red herring designed to keep us confused and the health insurers in business and profitable. Sounds a lot like our banking system, no?

Fortunately, as you will now learn, there is a much more simple and better way to be 100% certain of your diagnosis, diagnosis code, procedure, procedure code, and even the medications the physician will offer you, at least for elective conditions. Here it is. If it isn't an emergency, then make a doctor's appointment!

You may be thinking, "Isn't that putting the cart before the horse? Don't we want to know the costs in order to negotiate the fees before the services are provided?" The surprising answer is, no! Why? Well, because we only need to negotiate the fee schedule, specifically, Medicare or Medicaid, and not the exact fee. This is very important. Think back to the tiered-pricing structure.

Eventually, we may want to know the actual (or sometimes estimated) allowable amounts in order to budget for elective procedures, but this occurs after, or at the time of the physician's office visit, when they can provide us with the ICD codes, CPT codes, and usually the allowable amount, too! Later, we may choose to audit the allowable amount they give us, to make sure it is correct, and we were not over charged, but this is seldom done, as most people still trust their doctor, and the discounts you will be receiving are so HUGE you may feel a little guilty. Also, I will tell you, the auditing process is very tedious, not to mention the appeal process.

Therefore, we are now going to start talking about a negotiating strategy before we even attempt to access any pricing data. Again, we first need to know the diagnoses and proposed treatments. So, the solution is to start with a simple negotiation with the physician's office, probably just for the cost for the initial office visit, at the very least, and maybe some expected diagnostic tests. This is best done over the telephone, is easier and more successful than you might think, and is analogous to finding a mechanic to, "just take a look," at your car and tell you what is wrong with it, and then getting an estimate to repair it. Just like we expect to pay a little bit for the mechanic to diagnose our car, we should expect to pay a little bit for the doctor to diagnose us. The funny thing is that my mechanic and Medicare both charge or allow about $100 for a diagnosis. This is not so funny if you are the surgeon that spent 13 more years in school than the auto mechanic with a high school diploma.

Here we go, step by step:

1) I usually prefer to skip the added expense of going to a GP or family practice intermediary just to get a referral to a specialist that can actually help, especially when I can determine what medical specialty is likely to be most helpful for by medical condition by visiting the website of the American Board of Medical Specialties. (Is your ignition system acting up, your suspension riding a little rough, need new tires, brakes squeaking, transmission grinding?)

http://www.abms.org/member-boards/specialty-subspecialty-certificates/

2) Use the links on abms.org to visit the appropriate specialty board's website, and then use their "find a physician" with the sub-specialty likely to be most helpful for the condition

3) Start calling the sub-specialty physician offices listed, tell them you are a prospective new patient, and ask to speak to the Business Office Manager. Ask him or her the following questions:

a) "Do you accept Medicare and/or Medicaid insurance?" If yes, then...

b) "Super! Do you accept cash payment at the time of service?" If yes, then...

c) "Great! Then, of course, you will accept as payment in full, the Medicaid allowable, but paid in cash by me to you, directly, at the time of service? Correct?" If yes, then (e). If no then (d).

d) "I guess I understand. Well, then surely you will at least accept as payment the Medi­care allowable, paid in cash by me to you, directly, at the time of service? If yes, then (e). If no then conclude the call, because you cannot fix stupid.

e) "Thank you! Can you please tell me what the estimated amount is for an office visit, using this fee schedule, so I can know how much money to bring, and please make a note on my account that we have negotiated a Single Case Agreement for me to pay these rates to you, in cash, at the time of service?

f) Tell him or her your specific reason for the visit (I am leaking red fluid on the floor of my garage) and that you want to be fully prepared for the visit. Ask what diagnostic tests, if any, are usually required for this type of problem, lab, X-ray, CT, MRI, ultrasound, etc., and which ones would probably need to be done outside the physician's clinic?

g) Make sure to get the BOM's name and contact information, and the appointment time and date.

After your office visit, if it turns out that you need a procedure such as day surgery at an Ambulatory Surgery Center (ASC), an inpatient admission at a hospital, a diagnostic test like an MRI or CT, or a series of treatments such as physical therapy, then you simply repeat the above negotiation, starting with the facility your physician recommends, and in the case of a hospital or ASC, always where he or she has privileges. ASC's allowable rates are always much lower than a hospital, so act accordingly. When telling the BOM that you are a prospective new patient, make sure to give the name of your physician. Instead of just making a note of any negotiated agreement in your account, the BOM and you should execute a written Single Case Agreement. It is usually a one-page agreement that looks something like this sample found in your handouts:

It should be obvious to you why, when possible, these negotiations should occur before treatment, which is more often than you might imagine. In general, elective conditions are negotiated in advance in this manner. Next, we are going to look at emergency conditions, which are more than likely negotiated after examination and treatment.

Before we do, are there any questions?

Ok, so I experience some kind of true medical emergency, where my life or limb is in jeopardy, like a heart attack. mrs_horseman puts me in an ambulance that rushes me to the Emergency Room at the hospital, and they run all kinds of tests, and give me some very expensive medications. Fortunately for me, a long enough timeline has not yet passed, my survival rate has not dropped to zero, and I don't even get to go to the cath lab or have emergency heart surgery. However, we do get several large medical bills from the hospital, ER doctor, ambulance, laboratory, and cardiologist. I either have no insurance, am self-insured, or I have a catastrophic insurance plan with a very high deductible that I am not likely to meet with this event, or this year. What do I do?

When I receive each bill, I immediately call each provider and get the name and address of the BOM. I then draft a Single Case Agreement Offer and Acceptance, and I offer to pay the estimated Medicaid allowable clearly labeled as such (by using the tiered-pricing structure I covered earlier) and expiring 10 days after it is received. I may also include some horseshit narrative about how I just received a small windfall, and was advised by my attorney to settle my hospital bill before I piss it away on fast women and slow horses, or worse, squander it. I send this to the BOM, Certified Mail-Return Receipt Requested , with my attorney copied on the bottom of the offer. The BOM may argue the accuracy of my Medicaid estimate, and make a counter offer with a more accurate Medicaid allowable, but the odds are very, very, high that he or she either agrees to the Medicaid allowable, or counters with something like a Medicare allowable. Either way, at this point I have successfully negotiated somewhere around an 83% - 87% discount on average, less for doctors, more for hospitals.

It is important to lock this agreement in, quickly, before my account is sold to a third-party collection agency, which is nowhere near as likely to accept such a deep discount, and far better than a healthcare provider at actually getting blood from a turnip. Medical providers are now turning their accounts over to collections as soon as 90 days from the date of service, which can mean that you are still being treated for this condition when this happens! Do not let this happen to you! Open the bills! Mail the offer! Maybe they say no, but that is not likely. On the other hand, the collections agencies are working very hard to get you on a payment plan for Billed Charges, with interest, for the rest of your life!

Does this sound unlikely? Too good to be true? Then consider this: Medical providers are highly incentivized to give the patients they treated huge discounts. Why? Because they know that collecting money from patients foments malpractice litigation. They would rather have you pay them pennies, than have you sue them for millions.

There it is. I said it. Think about that for a moment.

Now, considering the minimal risk of negotiating, and the large potential reward, do you now have the confidence to successfully negotiate directly with physicians and hospitals?

Before I spend just a few more minutes talking about pharmacies, and then finally some self-insurance goals, are there any questions or comments?

I recently had breakfast with a pharmacist friend of mine that has worked as a manager for Walgreens for more than a decade. mrs_horseman is probably smiling when she hears that I have a pharmacist friend, because she knows how I feel about most of the people in that industry. Nonetheless, I told him about this presentation I am making, and asked if he had any advice for negotiating directly with the pharmacies for medications. It turns out, he does, and I would have never guessed the tactic he described.

Are you ready? Coupons and free discount cards. He explained that if one simply goes online and searches for Walgreens coupons, it is usually possible to save between 5% and 60%. He specifically recommends Good Neighbor Pharmacy Prescription Savings Club.

http://www.mygnp.com/prescription-savings-club

He says that when you purchase medications, then you have 5 days to return to the same location Walgreens and bring a coupon for reimbursement of any savings. He says that if you are paying cash, then you must be sure to request a generic, if available. For long term meds, he explains that the drug manufacturer's web sites will often offer a free co-pay assistance card. If you have insurance, then you can present the free card from the manufacturer to the Walgreens pharmacy, and it will cover your co-pays. In closing, I want to talk just a bit about insurance and one of the situations where we would want to be able to negotiate directly with physicians, hospitals, and pharmacies.

As we have discussed, today, one of the primary benefits of having health insurance is to take advantage of the discounts negotiated by the insurance company or government. However, we just learned that providers are usually willing to accept similar discounted rates from cash pay patients.

The other big benefit of health insurance is to share with other people the risk of having to pay large bills that are the result of serious and unexpected injuries or illnesses. This is the traditional role of insurance. However, the costs and benefits of sharing risk are directly related to the health and healthcare consumption habits of all the members of the risk pool. As the post-vasectomy head of a healthy household, do I really want to be swimming in the Obamacare risk pool with millions of morbidly obese, perpetually pregnant, HIV infected drug abusers? No. It is too expensive!

What to do? Well, what do many smart employers in Texas do to save money with Worker's Compensation Insurance? They self-insure! They have money put away in case of an emergency. If they have an employee that is injured, then they negotiate directly with the healthcare providers, and pay deep discounts well below the statutory Worker's Compensation allowable, which we learned earlier is usually the highest allowable. They pay themselves a premium each month, which is effectively a forced savings plan. Sometimes, these companies may also purchase a relatively inexpensive health insurance plan called catastrophic, just in case a really big and expensive event occurs, like the whole oil refinery blows up and puts a few hundred employees in the hospital. However, if nothing happens, and the employees don't have any accidents, the company gets to keep most of the money, instead of giving it all to the insurance companies!

Hmmm. I wonder. Could I do that for my health insurance? Yes, and in fact mrs_horseman and I do exactly this. We have a high-deductible catastrophic health insurance plan and a $600 savings line item in our budget that we pay ourselves every month. We bet on ourselves to be healthy, unlike an HSA, where you bet on yourself to be unhealthy. This is true, and why we simply refuse to take the pre-tax bait of an HSA.

... ... ...

[Dec 05, 2017] A coalescence and consolidation of insurers effectively being single-payer, expensive private sector paying monopoly. This by-and-large parasitic industry consumes add 35-40% tot he costs feeding whose executives and employees do not contribute constructively to the CARE equation

Notable quotes:
"... Taking jefemt's thinking further, imagine the health insurance provider was not only monopolistic (owned the entire market), but was also a GSE (government sponsored enterprise). Now take it one more step and imagine it was an actual part of the government and not merely a GSE. ..."
"... I was thinking of this too as a reponse to Why Steve Bannon Wants You to Believe in the Deep State" [Politico]. "Like the Death Star, the American Deep State does not, of course, exist. " ..."
"... Indeed, I think of the insurance industry as being part of the deep state already. It seems that congress's preference is that this part of the deep state is outsourced. So that's it not a GSE, and not even a monopoly, but maintained as an oligopoly. And then, well hey whatever surplus it can hoover up is fair game. After all free-hand of the market and all that. [And heaven knows, we don't want to crowd that out.] ..."
"... The CIA has a long history of drug trafficking. The FBI traffics in blackmail. The NSA in network surveillance. DIA, special ops. NRO, satelite throughput. 11 more in the US of A and countless more globally. They all have opaque resources outside of regular channels. ..."
"... Great documentary about the 80's cocaine business in Miami called "Cocaine Cowboys." It's real life Scarface. Guess who the Feds sent to get a handle on the cocaine smuggling? See-eye-aye man George H.W. Bush. Coincidence? ..."
Mar 23, 2017 | www.nakedcapitalism.com
djrichard, March 22, 2017 at 5:35 pm

Just a bit of a thought experiment, building on some thinking from a comment yesterday by jefemt

Paradoxically, we appear to be seeing a coalescence and consolidation of insurers, we will end up being delightfully exceptional, again -- effectively being single-payer, private sector, paying a monopoly an add-on cost of 35-40% to a parasitic industry whose executives and employees do not contribute to the CARE equation.

Taking jefemt's thinking further, imagine the health insurance provider was not only monopolistic (owned the entire market), but was also a GSE (government sponsored enterprise). Now take it one more step and imagine it was an actual part of the government and not merely a GSE.

Conceivably, it wouldn't even have to live off appropriations from congress, assuming it was equally as extractive from the private sector as it is now (i.e. revenue model is the same). Talk about good living. Who knows, maybe they pocket their proceeds into some kind of surplus in Treasury dept.

But let's assume they had to give up on revenue models. [Afterall, it's easier to find partners in congress when you have an appropriations process that binds you to them.] Then they would be exposed. Somebody would get the bright idea that this agency doesn't need as much staffing since they are no longer revenue oriented. That indeed, they could have the same staffing profile as the agency responsible for medicare. Indeed they could be folded into medicare.

I was thinking of this too as a reponse to Why Steve Bannon Wants You to Believe in the Deep State" [Politico]. "Like the Death Star, the American Deep State does not, of course, exist. "

Indeed, I think of the insurance industry as being part of the deep state already. It seems that congress's preference is that this part of the deep state is outsourced. So that's it not a GSE, and not even a monopoly, but maintained as an oligopoly. And then, well hey whatever surplus it can hoover up is fair game. After all free-hand of the market and all that. [And heaven knows, we don't want to crowd that out.]

In contrast to other parts of the deep state that don't really have a revenue model. In which case, those parts need to be insourced by the Fed Gov.

human , March 22, 2017 at 7:46 pm

The CIA has a long history of drug trafficking. The FBI traffics in blackmail. The NSA in network surveillance. DIA, special ops. NRO, satelite throughput. 11 more in the US of A and countless more globally. They all have opaque resources outside of regular channels.

Ernesto Lyon , March 23, 2017 at 12:09 am

Great documentary about the 80's cocaine business in Miami called "Cocaine Cowboys." It's real life Scarface. Guess who the Feds sent to get a handle on the cocaine smuggling? See-eye-aye man George H.W. Bush. Coincidence?

[Nov 30, 2017] Healthcare Costs and Its Drivers Today by run75441

Notable quotes:
"... We no longer care for patients, but we care about what's going on. You see, most of us are employed by insurance companies to do preauthorization for drugs and medical procedures ..."
"... Now before you start on insurance companies and doctors; understand, this is not as free a market place as many would assume. ..."
"... In all of their political wisdom, Congress favors pharmaceutical companies over doctors, insurance companies, and the welfare of the constituents. ..."
"... Through legislation, Congress has made it impossible for insurance companies to negotiate pharmaceutical pricing in Medicare Part D insurance and also the ACA ..."
"... So we spend more for healthcare than any other country in the world; but, Americans do not get the care they need. There is a simple reason. Treatment decisions are not being driven based on a physician's knowledge or judgment. They are being driven by what payers are willing to pay for. ..."
Nov 25, 2017 | angrybearblog.com

I have been doing my typical reading on healthcare in the US and ran across several articles which seemingly come together at various points in the dialogue and are written by different authors. I decided to tie them together into a much wider and telling story.

An interesting point being was made by MedPage Today's Dr. Milton Packer on his blog, " people suffer and die because Payors (Healthcare Insurance) is cost effective ." He starts his discussion on the opiate epidemic in the US, opiates are being prescribed by doctors for pain relief and . . .

"Patients are becoming addicted to opiates after the initial 10 day prescription with one-fifth of patients still using opiates a year later. There is no need to prescribe opiates as other less addictive pain-relief formulations are available, which are not commonly prescribed." This raises the question of why?

Payers will not pay for the alternatives. The less-addictive opiates are more expensive and payers have declined to support them. Patients get addicted because prescribing for the lower cost and highly addictive opiates saves the payers money initially (me) .

September 17, 2017, the New York Time and ProPublica (independent, nonprofit investigative journalism organization) collaborated on an article concerning the opiod epidemic in the US.

At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications.

The reason given: Opioid drugs are generally cheap while safer alternatives are often more expensive.

While the pharmaceutical manufacturers, distributors , and doctors have come under scrutiny; insurance companies and the pharmacy benefit managers (CVS Caremark, Express Scripts and OptumRx) make the final decisions as to what is covered. It could be something as simple as a higher tier and deductible to block usage.

A little side trip here and a continuation of the above. A week or so ago, I ran across another MedPage Today article by Dr. Packer; " Who Actually Is Reviewing All Those Preauthorization Requests and How the System Works ." Dr. Packers was giving a talk on advances in medicine with regard to heart failures to a room of about 20 or so doctors who were retired.

Since many of them were no longer involved in active patient care, he wondered why they might want to hear a presentation on new advances in heart failure. Here was their answer:

Doctors: " We no longer care for patients, but we care about what's going on. You see, most of us are employed by insurance companies to do preauthorization for drugs and medical procedures ."

" Dr. Packer: I just gave a talk about new drugs for heart failure. Are you responsible for preauthorizing their use for individual patients? "

The answer; "Yes."

" So did I say anything today that was helpful? I talked about many new treatments. Did I say anything that you might use to inform your preauthorization responsibilities? "

"Oh, we've heard about those drugs before. We are asked to approve their use for patients all the time; but, we don't approve most of the requests. Nearly all of them are outside of the guidelines we are given."

" I just showed you evidence that these new drugs and devices make a real positive difference in people's lives. People who get them feel better and live longer. "

"Yes, you were very convincing. But the drugs are too expensive. So we typically reject requests, at least the first time. We figure that, if doctors are really serious, then they should be willing to make the request again and again."

" If the drugs will help people, how can you say no? "

"You see, if it weren't for us, the system would go broke. Every time we say yes, healthcare becomes more expensive, and that isn't a good thing. So when we say no, we are keeping the system in balance. Our job is to save our system of healthcare."

" But you are not saving our healthcare system. You are simply making money for the company that you work for. And patients aren't getting the drugs that they need. "

"You really don't understand, do you? If we approve expensive drugs, then the system goes broke. Then no one gets healthcare."

"Plus, if I approve too many expensive drugs, I won't get my bonus at the end of the month. So giving out too many approvals wouldn't be a smart thing for me to do. Would it?"

Now before you start on insurance companies and doctors; understand, this is not as free a market place as many would assume.

In all of their political wisdom, Congress favors pharmaceutical companies over doctors, insurance companies, and the welfare of the constituents.

Through legislation, Congress has made it impossible for insurance companies to negotiate pharmaceutical pricing in Medicare Part D insurance and also the ACA .

Furthermore with the consolidation happening in healthcare, negotiation by insurance companies with a consolidating and growing healthcare industry is becoming more and more difficult as the former does not have as great of leverage. You have read my argument calling out of Single Payor, Medicare-for-All, Public Option, etc. as the cure for today's healthcare issues and rising cost not being enough as the ACA and Part D were specifically blocked or the cost issue unaddressed in the legislation written by Congress. If these issues are not addressed from the very beginning, we will be fighting the same issues with rising costs a decade later with other programs.

At this point, I begin to disagree with Dr. Packers as he goes on to say:

" So we spend more for healthcare than any other country in the world; but, Americans do not get the care they need. There is a simple reason. Treatment decisions are not being driven based on a physician's knowledge or judgment. They are being driven by what payers are willing to pay for. "

It is true that patients may not get some of the healthcare they need at the time due to denial, which can be appealed to the ACA, and can be a tiring process. It could be approved, passed on to patients, resulting in higher premiums the following year, and the Part D Risk Corridor program pay for it if excessive for the present year. What Dr. Packers does not mention is the rising prices and cost of drugs being blamed by pharmaceutical company on R&D, tooling up to manufacture, etc. The counter argument is much of the R&D is funded by the US government through tax deductions and write-offs for pharmaceutical R&D and capital Overhead. Pharmaceutical profits are double digit at ~25% beating out hospital supplies and healthcare insurance, which is already limited in what can be charged back to the insured by the MLR. To blame insurance companies totally for the higher costs in healthcare is false. Furthermore, a doctor's decision do not always lead to less costly cures or practices.

Maggie Mahar of Health Beat Blog would take the subject of costs a step farther and state Medicare will approve anything the FDA approves for usage regardless of the quality of outcome when measured against older proven treatments. Notably the VA does limit its pharmacy and its care is rated higher than that of today's commercial, for-profit healthcare to which most citizens are exposed.

Dr. Donald Berwick, President Obama's proposed appointment for Medicare and who was in charge of Medicare and Medicaid for 17 months stated;

"20 to 30 percent of health spending is 'waste' that yields no benefit to patients, and that some of the needless spending is a result of onerous, archaic regulations enforced by Medicare and Medicaid.

He listed five reasons for what he described as the 'extremely high level of waste.' They are overtreatment of patients, the failure to coordinate care, the administrative complexity of the health care system, burdensome rules and fraud .

Much is done that does not help patients at all and many physicians know it."

That is the same Medicare/Medicaid being touted by many proponents today as an alternative.

Speaking of costs and pricing for pharmaceuticals, there have been recent incidents of skyrocketing costs on particular drugs. A short while ago, I wrote a post concerning the appointment of Alex Araz as the new HHS Secretary replacing Dr. Tom Price. Formerly, Alex Araz was the CEO of the pharmaceutical giant Eli Lilly & Co.'s U.S. division . He also served under George W. Bush administration as the HHS General Counsel and Deputy Secretary. During that stint, he received praise for his management competence with the HHS; although, he did not have a healthcare background prior to this position.

Here it gets interesting when examining what took place during his tenure with Eli Lilly. One of the leading costs identified in pharmaceuticals increases has been in the rising cost of diabetes medication.

"While the Tweeter-in-Chief, Trump tells us presidential campaign contributor Alex Azar will be a 'star' who will lower prescription prices,"

Public Citizen's Peter Maybarduk (Director) had this to say: " Eli Lilly is notorious for spiking prices of a century-old isolated hormone during Azar's tenure as president and vice president. Eli Lilly raised the price of Humalog by 345%, from $2,657.88 per year to $9,172.80 per year.

Maybe President Trump in appointing Alex Azar to be HHS Secretary should have asked the 6 million diabetic Americans whose insulin prices have more than tripled under Azar's watch at Eli Lilly."

This has nothing to do with R&D and has more to do with pharmaceutical companies controlling the market regardless of supply and throughput restricted manufacturing (capacity).

What I have tried to do is tie these articles together into one cohesive story of how the pharmaceutical industry, insurance, and healthcare can have an impact on healthcare costs. For those who are interested, my background does include working in the manufacture of hospital supplies and pharmaceuticals. Using various citations from these articles, I have tried to touch upon the impact of insurance companies, the healthcare industry, government intervention under the HHS, one particular Med in the market place, etc. Overall, what is going on in the marketplace.

Another article, I read the other day gets into the foundation of what is happening based upon a recently completed study by JAMA. Using this study, the Methods Man, Dr. Perry Wilson (MedPage Today) examines what is driving healthcare costs in his article Here's What's Really Driving Healthcare Costs using data from Factors Associated With Increases in US Health Care Spending, 1996-2013 and the US Disease Expenditure Project . Dr. Wilson breaks it down using three simple charts which I have consolidated to one.

Dr. Perry Wilson starts off making an overall point about the rising cost of healthcare from 1996 to 2013 and stating; "after accounting for inflation, healthcare expenditures increased $933.5 billion from 1996 to 2013."

Going on: "Healthcare expenditures in the US being high and rising rapidly is nothing new, but the study appearing in the Journal of the American Medical Association identifies the exact components of healthcare that are driving those soaring costs. The data from this study suggests traditional economic forces break down in the US healthcare market.

Different chronic diseases have different patterns of price increases. The biggest increase was seen in diabetes care, as you can see here, driven largely by the rising costs of pharmaceuticals."

The Chart breakdowns reveal the various impacts of healthcare costs moving from left to right and then downward:

• 50% of the increase in healthcare costs was simply due to higher prices.

• Inpatient care or Service Utilization (purple) went down from 1996 – 2013 as outpatient treatment increased; however, the price of the remaining inpatient care went up much more – increasing overall inpatient care spending by around $250 billion.

• Different Chronic Diseases have different patterns of price increases. The biggest increase was seen in diabetes care and driven largely by the rising prices of pharmaceuticals.

The takeaway drawn by Dr Perry Wilson: "Regardless of the disease, it is clear, the price of what we're buying – whether a drug, an ED visit, or a hospital stay – not the amount of what we're buying is the major driver of cost increases . Efforts to reduce the consumption of healthcare may not bend the cost curve as much as efforts to reduce its price."

You can not make an argument about the regulation of costs "not" being one of the dynamic components of a healthcare plan given the continuous unhindered industry driven rising cost of healthcare. Yet, every healthcare plan I have read fails to mention cost regulation specifically, provide remedy for it, and many assume a natural occurrence of control.

Tags: run75441 Comments (9) Digg Facebook Twitter Comments (9)

Longtooth , November 26, 2017 12:59 am

Run thanks for this, but in my opinion you're avoiding the central problem , though you briefly touched upon it without being more explicit:

"This has nothing to do with R&D and has more to do with pharmaceutical companies controlling the market regardless of supply and restricted manufacturing throughput. "

The market can't be controlled by the pharmaceutical companies unless the government lets them. So this is a government sourced and caused problem unless you believe laissez-fair is the gov'ts job to promote and endorse.

You can't blame the pharmaceutical companies for doing precisely what the gov't lets them do by law.. the pharmaceuticals company's owners are in this to be philanthropic are they?

What you are essentially not coming to grips with is that our government is not designed to be democratic but designed by it's concept to be a system to ingratiate those who pay the most to keep the gov't in power which is to say those that represent them are paid to do their bidding in other words a gov't controlled by the sources of wealth to maintain it. if it were anywhere near a democratic system, how could 1% control it?

Longtooth , November 26, 2017 1:08 am

Run, sorry I forgot that there's never been a democratic system from the Spartan through the Athenian to the present that hasn't been controlled by the wealth. There have only been moments brought about by extreme deprivation that have had to deal with that deprivation to avoid revolution.

When we want to fix U.S. healthcare costs and quality we know how to do it, but you have to fix the system of government we employ to do it. Address the source of the problem rather than effects of it.

Longtooth , November 26, 2017 1:36 am

Run, let me only add that I don't know how we can have a free market based and biased system of government and anything even approximating a democratic system at the same time. That is the actual dilemma since they are mutually exclusive.

If you think about how to "comprise" one with the other then you have to decide how such compromise is made and sustained (sustained being key word) and I can't see or find any evidence in U.S. history that suggests such compromise has ever worked to provide for the greater good on a sustained basis.

Perhaps its not even possible among human systems of civilized government .. but then why the charade as if it is? If the public wants to improve the healthcare system then why does it elect Presidents and representatives who don't want to improve it? If the public want's to improve the healthcare system why do Supreme Court interpret the Constitutional "law" to prevent it? Or if the 200+ year old constitutional law is so outdated as to be irrelevant than why doesn't the pubic demand to change it?

Or does the pubic want it's cake and eat it too? The public may be confused (I'm sure of this in fact) because they want simultaneously mutually exclusive conditions.

Denis Drew , November 26, 2017 9:29 am

Run, great major post.

Long, " I don't know how we can have a free market based and biased system of government and anything even approximating a democratic system "

No? Look at continental Europe -- look at across the board labor union density -- look at sector-wide labor agreements. Come to think look at our northern neighbor.

Mostly all other problems from health care to student debt to everything are just symptomatic of the same economic/political-union free pathology. Bernie and Eliz don't spend a lot of time looking abroad either -- or even looking at 1973 stateside.

Come a Dem Congress I think the best idea is:
Why Not Hold Union Representation Elections on a Regular Schedule?
Published November 1st, 2017 – Andrew Strom

https://onlabor.org/why-not-hold-union-representation-elections-on-a-regular-schedule/

This can be sold as taking a page from Repub govs (e.g., Walker) who force government employee unions to re-certify every year -- with majority of union members, not just those who vote, required to retain.

I'm playing with the idea of proposing (via spam mail*) re-certification for every union in the country every year -- oh, of course, that would include certification elections for every nonunion workplace: that's the Trojan Horse .

We really want to certify/recertify every three or five years (three at first while we are trying to build density -- maybe five later on). Once we organize enough we can write the rules any way we want. By proposing re-certification every year (from my spider hole in Chicago) maybe I can get union members dander up and thereby at least wake them up to the issue. Cab driver political drama.

(* I have about 2000 email addresses, journalists, union, academic, politicians -- in WA, OR, CA, NV -- that I like to hit with new ideas.)

run75441 , November 26, 2017 11:40 am

Denis:

You may want to look at this again. A portion of it was blocked due to an error in linking to an article on Pharma costs which was kind of important. I have another article coming out which will discuss Pharmaceutical companies pulling advertising from medical news sites and mags if they are critical of pharma. As I read each of these articles, I could see a similar thread in them.

in 2015, AARP broke ties with MetLife over LTC insurance which MetLife discontinued in 2011 (no new applications). No big deal except AARP never told its membership of the AARP sponsored insurance break with MetLife. AARP now has a new LTC insurer New York Life announced as of 2015 and no letter to its members holding MetLife policies. Those who had AARP sponsored MetLife are now left with MetLife who is requesting a 21.75% increase just for cost over 3 years in addition to the normal inflation factor which was ~10% for 2018. AARP refers all inquiries to MetLife even though documents from MetLife still has AARP logos on it. Another interesting post of companies and Organizations screwing people.

Longtooth , November 26, 2017 5:48 pm

Dennis,

FWIW I come from a long line of union activists, members, and in one case a major union leader in the western U.S. and California in particular -- Building & Construction Trades Council.

I've been and remain a hugely strong union supporter. However my uncle (the Western US major union leader) was a realist and well understood the nature of economics viz-a-viz unions and capital owners.

In a series of discussions while I resided with he and his wife during one summer college break, he made me understand those trade-offs, and what drove them. At the time the college educated workforce in the US was 10% (4 year or better degree). He said a major factor in union's was the level of the college educated workforce and he said in 1966, that if the rate of college degree growth reached the then unprecedented rate of ~ 0.5%/year than in a few decades 1/3rd of the workforce would have college degrees -- the upshot of which is that they would very unlikely be persuaded to join unions or create new ones. His prognosis in 1966 turns out to be pretty close to reality even though he had little historic information to go on., .. he was not a pie in sky type, but a practical and major proponent of the general working class an working poor.

He also told me in 1966 that if unions demanded too much of the capital owners profits, they would resort to capital invested in automated methods -- his primary example of which was the hift to lath & plaster skilled union members to wall board which required no skill per-se and that forced union wages for interior "plasterers" down as lower skill and more efficient "sheetrock" hangers too over.

He cited other examples of automation replacing skilled union labor and without elaborating it was an eye-opener for me to see that unions were on their way down He not only knew the economics of building and construction business and labor, but of mining and manufacturing.

This was all long before Reagan's anti-unionism push (which in reality was Reagan using what was already well underway as a means of pumping up is conservative credentials).

My uncle's wisest advice was that if unions demanded more than capital owners were able to profit, they would simply use their capital in other enterprises where profits were greater -- this included not only investing in automated methods in mfg'ing and the building and construction trades (remember "sheetrock") , but in foreign low wage labor regions where especially mfg'ed goods could be produced at lower costs IF(the big IF in 1966) transportation and import duties made it more profitable to do so. He cited Mexico as the primary source of low transport cost low wage labor at the time, and at that time import duties from the few mfg'ed goods produced in Mexio were excessive which was the only reason mfg'ing hadn't shifted to use Mexican labor in Mexico for production and also why mfg'ing was investing more and more capital in automation. BUT, he said sooner or later it would become clear that capital owners would push to chane US import policies from Mexican roduced goods and the this would reduce mfg'ing's need for U.S. labor, thus Union's would have far less leverage to take a share of capital profits.

So he was a few decades off in his estimates, but he was right in 1966.. My uncle was among those in the U.S. union leaders who all understood all this very well what they said in public was different that what they saw occurring and would continue to occur they just didn't know then the rate of occurrence -- the computer age hadn't started . semi-conductors were being invented and barely developed for example. China's opening up hadn't occurred yet either. Clinton's NAFTA was still far in the future.

Through al the years since 1966 I've watched the progression of what my Uncle told me during our discussions in the summer of 1966. take place, for precisely the reasons he (and other major union leaders) knew they would.

In hindsight what fails in the U.S. relative to Europe is Germany's constitutional protections of labor unions. which by osmosis transfers to the other major European nations just as U.S. union wages and benefits transferred by the same osmosis to non-union wages and benefits rising to keep pace.

Keep up the good fight, Dennis, but you're forgetting about the economic realities in the US and it's individualism worship and constitution that protects it. .

JackD , November 26, 2017 9:22 pm

Run, as you know, nothing substantive on controlling medical costs can possibly occur with Republicans in charge. With Democrats in charge, it's tough enough. Witness the ACA's development and the impact of the blue dogs.

JimH , November 27, 2017 10:28 am

JackD wrote "Run, as you know, nothing substantive on controlling medical costs can possibly occur with Republicans in charge."

I could not agree with you more.

The Republicans' implementation of Medicare Part D which forbids negotiation of drug prices was asinine. Where was their concern for the national deficits and debt?

On heath care President Obama was negotiating with the duplicitous. His opposition had only one concern, their oath to Grover Norquist.

Daniel Becker , November 27, 2017 5:22 pm

It's not just that pharma has some say on what gets published, but in the health literature world, the trend was to only publish positive results.

As you can imagine, this has left a major void in truly understanding what happens in the body when a treatment is applied. There is a push to change this. Additionally, there is the push toward the idea of "numbers to treat". That is, how many have to receive the treatment to create one positive results. Outcomes can look a lot more different when looking at numbers to treat.

[Nov 30, 2017] A comprehensive health care program for social services recipients can be provided for about 3-4% of the cost of services. Private medical insurance providers rake 20%. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets its just so damn easy to cheat and cheaters are never in short supply.

Nov 30, 2017 | marknesop.wordpress.com

Patient Observer , November 27, 2017 at 5:12 pm

Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.

[Nov 30, 2017] I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties.

Nov 30, 2017 | marknesop.wordpress.com

[email protected] , November 27, 2017 at 6:02 pm

I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.

[Nov 30, 2017] The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system)

Nov 30, 2017 | marknesop.wordpress.com

Ryan Ward , November 28, 2017 at 3:40 am

With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany

[Nov 30, 2017] The most interesting insight into healcare in the USA: The cost is shocking

Nov 30, 2017 | marknesop.wordpress.com

James lake , November 28, 2017 at 12:21 am

This is s very interesting insight into healcare in the USA. The cost is shocking.
I live in the UK and the healthcare system is paid for from taxation.
When it was established over 70 years ago it's
The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means.
It was the best thing in my view that government has ever done.
Good healthcare should be available to all and not dependent on peoples ability to pay.

However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.
Which many people do not mind.
-Elderly care was also privatised as it's the most expensive
-care for the disabled also is a issue for local councils
-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.
And yet still more and more taxation is needed for the NHS!
The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

Patient Observer , November 28, 2017 at 12:49 pm
The Albanian Kosovo Liberation Army harvested organs from captured Serb civilians and soldiers:

https://thebloodyellowhouse.wordpress.com/

In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.

Bold text emphasis added.

Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.

Per Wikipedia:

The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine into western Europe.[16]

A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.

On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.

So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist and genocidally inclined West.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.

[Nov 30, 2017] Looks like the rot in the US healthcare system is terminal

Nov 30, 2017 | marknesop.wordpress.com

kirill , November 27, 2017 at 8:38 pm

Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

[Nov 30, 2017] Looks like the rot in the US healthcare system is terminal

Nov 30, 2017 | marknesop.wordpress.com

kirill , November 27, 2017 at 8:38 pm

Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

[Nov 30, 2017] The most interesting insight into healcare in the USA: The cost is shocking

Nov 30, 2017 | marknesop.wordpress.com

James lake , November 28, 2017 at 12:21 am

This is s very interesting insight into healcare in the USA. The cost is shocking.
I live in the UK and the healthcare system is paid for from taxation.
When it was established over 70 years ago it's
The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means.
It was the best thing in my view that government has ever done.
Good healthcare should be available to all and not dependent on peoples ability to pay.

However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.
Which many people do not mind.
-Elderly care was also privatised as it's the most expensive
-care for the disabled also is a issue for local councils
-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.
And yet still more and more taxation is needed for the NHS!
The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

Patient Observer , November 28, 2017 at 12:49 pm
The Albanian Kosovo Liberation Army harvested organs from captured Serb civilians and soldiers:

https://thebloodyellowhouse.wordpress.com/

In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.

Bold text emphasis added.

Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.

Per Wikipedia:

The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine into western Europe.[16]

A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.

On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.

So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist and genocidally inclined West.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.

[Nov 30, 2017] The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system)

Nov 30, 2017 | marknesop.wordpress.com

Ryan Ward , November 28, 2017 at 3:40 am

With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany

[Nov 30, 2017] I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties.

Nov 30, 2017 | marknesop.wordpress.com

[email protected] , November 27, 2017 at 6:02 pm

I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.

[Nov 30, 2017] A comprehensive health care program for social services recipients can be provided for about 3-4% of the cost of services. Private medical insurance providers rake 20%. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

Nov 30, 2017 | marknesop.wordpress.com

Patient Observer , November 27, 2017 at 5:12 pm

Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.

[Nov 29, 2017] The Best Health Care You Can Afford by marknesop

Notable quotes:
"... "No, I mean I'm sorry that you've inherited such a miserable, collapsing Old Country. A place where rich Bankers own everything, where you've got to be grateful for a part-time job with no benefits and no retirement plan, where the most health insurance you can afford is being careful and hoping you don't get sick ..."
"... "Until fairly recently, every family had a cornucopia of favorite home remedies–plants and household items that could be prepared to treat minor medical emergencies, or to prevent a common ailment becoming something much more serious. Most households had someone with a little understanding of home cures, and when knowledge fell short, or more serious illness took hold, the family physician or village healer would be called in for a consultation, and a treatment would be agreed upon. In those days we took personal responsibility for our health–we took steps to prevent illness and were more aware of our bodies and of changes in them. And when illness struck, we frequently had the personal means to remedy it. More often than not, the treatment could be found in the garden or the larder. In the middle of the twentieth century we began to change our outlook. The advent of modern medicine, together with its many miracles, also led to a much greater dependency on our physicians and to an increasingly stretched healthcare system. The growth of the pharmaceutical industry has meant that there are indeed "cures" for most symptoms, and we have become accustomed to putting our health in the hands of someone else, and to purchasing products that make us feel good. Somewhere along the line we began to believe that technology was in some way superior to what was natural, and so we willingly gave up control of even minor health problems." ..."
"... The Complete Family Guide to Natural Home Remedies: Safe and Effective Treatments for Common Ailments ..."
"... "The vast wealth of the financial oligarchy, expressed in their ownership of massive corporations, must be seized and expropriated, while the complex technologies, supply chains, and advanced transportation systems must be integrated in an organized, planned manner to harness the anarchic force of the world economy and eliminate material scarcity. ..."
"... Interesting article. Looks like the rot in the US is terminal. ..."
"... This is s very interesting insight into healcare in the USA. The cost is shocking. I live in the UK and the healthcare system is paid for from taxation. When it was established over 70 years ago it's. The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means. It was the best thing in my view that government has ever done. Good healthcare should be available to all and not dependent on peoples ability to pay. ..."
"... Privatisation has meant profits for businesses, poor services to vulnerable groups. ..."
Nov 27, 2017 | marknesop.wordpress.com

"The art of medicine consists of amusing the patient while nature cures the disease."

"No, I mean I'm sorry that you've inherited such a miserable, collapsing Old Country. A place where rich Bankers own everything, where you've got to be grateful for a part-time job with no benefits and no retirement plan, where the most health insurance you can afford is being careful and hoping you don't get sick

Cory Doctorow; Homeland

"Until fairly recently, every family had a cornucopia of favorite home remedies–plants and household items that could be prepared to treat minor medical emergencies, or to prevent a common ailment becoming something much more serious. Most households had someone with a little understanding of home cures, and when knowledge fell short, or more serious illness took hold, the family physician or village healer would be called in for a consultation, and a treatment would be agreed upon. In those days we took personal responsibility for our health–we took steps to prevent illness and were more aware of our bodies and of changes in them. And when illness struck, we frequently had the personal means to remedy it. More often than not, the treatment could be found in the garden or the larder. In the middle of the twentieth century we began to change our outlook. The advent of modern medicine, together with its many miracles, also led to a much greater dependency on our physicians and to an increasingly stretched healthcare system. The growth of the pharmaceutical industry has meant that there are indeed "cures" for most symptoms, and we have become accustomed to putting our health in the hands of someone else, and to purchasing products that make us feel good. Somewhere along the line we began to believe that technology was in some way superior to what was natural, and so we willingly gave up control of even minor health problems."

Karen Sullivan; The Complete Family Guide to Natural Home Remedies: Safe and Effective Treatments for Common Ailments

No, I haven't abandoned Uncle Volodya, or shifted my focus to American administration; what follows is a guest post on the American healthcare system, by our friend UCG. As I've mentioned before – on the occasion of his previous guest post, in fact – he is an ethnic Russian living in the Golden State.

As an American in America, naturally his immediate concern is going to be healthcare in America; but there are lessons within for everyone. Don't get me wrong – doctors have done a tremendous amount of good, and medical researchers and many others from the world of medicine have made tremendous advances to which many of us owe their lives. Sadly, though, once a field goes commercial, the main focus of attention eventually becomes profit, and there are few endeavors in which the customer base will be so desperate. While there are obvious benefits to 'socialized medicine' such as Canada enjoys and American politicians scorn as 'Commie' – enough to earn the admiration of many – it results in such a backlog for major operations that those who don't like their chances of dying first, and have the money or can somehow get it, often flee to America, where you can get a good standard of medical care without running out of time waiting for it.

Without further ado, take it away, UCG!!

Healthcare in America

This article is my opinion. My hope is that others will do their own research on America's Healthcare Industry, because this is an issue that needs to be addressed, and for this article to be a mere starting point in this research. The reason for my citations is so that you, the reader, can verify them. Once again, this is my opinion. I write this in the first paragraph, so that I can avoid stating "in my opinion" before every sentence.

Let's start with Owen Davis who was charged $14,018 for going to a hospital because he sliced his hand, and they fixed it . A study published by Johns Hopkins showed that for $100 of ER treatment, some hospitals were charging patients up to $1,260 . A redditor claimed that :

I tore my ab wall a month ago and didn't think much of it until my pain kept worsening. I went to an immediate care facility to rule out a hernia (I had all the symptoms) and they told me to get to ER ASAP. I go to the ER and they give me a CT scan and one x-ray and say it's not a hernia and let me go. Fast forward to today and I got a bill for $9,200 and $3,900 of it is out of pocket. $9,200 for two tests???? No pain meds were administered; it was literally those two tests. What should I do to contest it? I will be calling tomorrow to demand an itemized bill, but is there anything else I should do in the meantime?

All of these took me a few minutes on Google to find, and another few minutes to post. The reason I chose that reddit, is because one of the readers offered an ingenious solution: Next time you hurt yourself – book a return ticket to NZ – go to accident and emergency, say you're a tourist and you hurt yourself surfing, pay nothing – fly home and pocket $8,000 in spare change. If that was me, I'd spend at least $2,000 on tourism in New Zealand. You guys have that system, so you clearly deserve the money! Anyone interested in a startup?

But I am not done with examples just yet. Shana Sweney described her experience in the emergency room : I delivered in 15 minutes. During that time, the anesthesiologist put a heart rate monitor on my finger and played on his phone. My bill for his services was $3,000. $200/minute. I talked to the insurance company about it – and since I ran my company's benefit plans, I got a little further than most people, but ultimately, that was what their contract with the hospital said so that's what they had to pay. Regardless of if he worked 15 minutes or 3 hours. Similarly, my twins were born prematurely and ended up in the NICU for 2 weeks. While the NICU was in-network for my insurance, for some mysterious reason, the neonatologists that attended the NICU were out of network. I think that bill was $16k and they stopped by to see each kid for an average of about 30 min/day.

Almost done with the examples, just please bear with me. How would you like a hospital billing you $83,046 for treating a scorpion sting , if a Mexican ER might have treated you for the same type of sting for $200? Perhaps being charged $546 for six liters of saltwater is more to your liking? $1,420 for two hours of babysitting ? $55,000 for an appendicitis operation ? $144,000 to deliver a perfectly healthy, albeit quite impatient baby? According to my interpretation of the sources linked, all of these actually happened. I encourage you to do your own research.

The World's Biggest Legalized Corruption (IMHO)

$984.157 billion. That's $984,157,000,000. That is how much money I believe the United States wastes on Healthcare. Not spends; wastes. As in money down the drain. The astute reader figured out that equates to five percent of America's 2016 GDP . Said reader is absolutely correct. How did I estimate such a gargantuan amount? According to the OECD data , in 2013 the United States spent 16.4 percent of its GDP on Healthcare; the two next biggest spenders, Switzerland and the Netherlands spent 11.1 percent. Even if one was to give the United States the benefit of doubt, and claim that the United States healthcare is just as efficient as that of Switzerland or the Netherlands – which is most likely not true according to an article from Business Insider , but even if it was – that meant that the United States wastes 5.3% of its GDP on healthcare. Wastes. I just want to make sure that the amount of this alleged legalized corruption, which will most likely reach a trillion dollars by 2020, is noted.

Let me place those funds into perspective: it's almost as much as the amount that the rest of the World spends on the military, combined . The SCO member states, including China, Russia, India, and Pakistan spent roughly $360 billion on the military . The wasted amount is equivalent to the GDP of Indonesia, and greater than the GDP of Turkey or Switzerland . In 2016, the US Federal Government spent $362 billion, or 36.8% of the wasted amount, to run all Federal Programs , including the Department of Education and NASA, with the exception of Social Security, Medicare/Medicaid, Veteran's Affairs, the military, and net interest on the US debt. All other Federal Programs were covered with the $362 billion. The US Federal Debt stands at $20.4 trillion , meaning that the debt can be paid off in 30 years, merely if the Healthcare Waste is eliminated.

But why stop there? The US Housing Crisis started partly because loans were allowed to be taken out without the 20% down payment. Could this funding, if applied directly to the housing market, stop the 2008 Great Recession? Absolutely, and all the Federal Government had to do was to gear these funds towards down payment on subprime mortgage loans to meet the 20 percent barrier. I can go on and on about what can be accomplished, like making collegiate attendance free, or at least very inexpensive, or drastically improving the quality of education, paying off the national debt, reinvesting into the economy, reinvigorating the rural sector, and so on, and so forth. A trillion dollars is a lot of money.

Lobbyists, the Media and the Waste

Any guess how much was spent on lobbying by the Healthcare, Insurance, Hospitals, Health Professionals, and HMOs? How about 10.5 billion dollars? I knew that was your guess! That's a lot of money, and that does not include "speaking fees", or when a politician who constantly made calls beneficial to the Healthcare Lobby gets $150,000 to speak in front of an audience after they retire from politics. Obama made a speech in front of Wall Street, netting $400,000 . And by pure coincidence, only one Wall Street Broker was jailed as a result of the scandal. That $10.5 billion is just a tip of the iceberg, because "speaking fees" are notoriously hard to track, and not included in said amount.

Obama genuinely tried to reform US Healthcare to the Swiss Model. He was going to let Wall Street slide, he was going to let Neocons conduct foreign policy, just please, let him have healthcare! First, the lobbyists laughed in his face. Second, they utilized the Blue Dog Coalition to block Obama's attempt at Healthcare Reform, until it was phenomenally nerfed, and we have the disaster that we have today. As a result, Obama's Legacy, Obamacare is having major issues, including the rise of racism.

Obamacare helped the poor, (mostly minorities,) at the expense of the middle class, (mostly whites,) thus transferring funding from whites to minorities. While the intent was not racial, it is being called out as racial by the mainstream media . This probably suits the lobbyists, because if the debate is about racism, one cannot have a genuine discussion about Healthcare Reform.

Racism strikes both ways. Samantha Bee came out with a "fuck you white people" message right after the election. Jon Stewart, without whom she probably wouldn't have her own show, pointed out that it was simply economics, like the healthcare insurance premium increase , that brought Donald Trump to power. Interestingly enough, James Carville made the same argument when Bill Clinton beat George Bush, but when Hillary Clinton lost, Carville was quick to blame Russia. These delusions on the Left are letting the Right mobilize stronger than ever before. And all of this takes away from the Healthcare Debate.

In an attempt to blame Trump's Election on white racism, rather than basic economics, numerous outlets simply fell flat. For instance, Eric Sasson writes : white men went 63 percent for Trump versus 31 percent for Clinton, and white women went 53-43 percent. Among college-educated whites, only 39 percent of men and 51 percent of women voted for Clinton What's more, these people hadn't suffered under Obama; they'd thrived. The kind of change Trump was espousing wasn't supposed to connect with this group.

Did this group thrive? The collegiate debt went from $600 billion to $1.4 trillion under Obama's Administration, while the health insurance increased from $13,000 to $18,000 per family . This is thriving? Was the author experimenting with medical marijuana when said article was written? Nevertheless, the parade of insanity continued, with Salon assuring us that it was blatant racism that gave us Trump . The Root, which also claimed that Russians attempted to hack election machines, pointed out that Russia exploited America's racism , and thus Trump won the election. Washington Post claimed that racism motivated white people more than authoritarianism . Comedian Bill Maher tried to sway the discussion back to economics, by pointing out that outrage over Pocahontas or Halloween should not stop the Democrats from working for the working man . Sadly, Maher and Stewart are in the minority, and instead of a Healthcare Debate, the US is now stuck in a debate over racism, which isn't even three-fifths as effective. Meanwhile the US continues to waste almost a trillion dollars on healthcare .

Who Benefits?

Let's start with the banks. Medical students graduate with an average of $416,216 in student debt . The average interest rate on said loan is seven percent. Roughly 20,055 students go through this program, per year . Presuming a twenty year loan, the banks are looking at about $7.185 billion in interest payments. It really is a small fraction of the cost. Prescription drug prices are another story. In 2014, Medicare spent $112 billion on medicine for the elderly . Oh la la! Cha-ching. I would not be surprised if at least half of that was wasted on drug price inflation. You know the health insurance companies? It's a great time to be one, since profits are booming – to the tune of $18 billion in projected revenue for 2017.

Of course the system itself is quite wasteful, with needless hours spent on paperwork, claim verification, contractual review, etc, etc, etc. Humana's revenue was $54.4 billion , Aetna's was $63.2 billion , Anthem's was $85 billion , Cigna's was $39.7 billion , and UnitedHealth's was $184.8 billion . Those are just the top five companies. None of them ia a mom-and-pop shop or small business store. Do any of these insurers support Obamacare? Even if they do, it is without much enthusiasm . They are leaving, and leaving quite quickly. Thirty-one percent of American counties will have just one healthcare insurer . Welcome to a monopoly that is artificially creating itself. And despite the waste, 28.2 million Americans remain uninsured . Mission accomplished!

Who else benefits? Those who hire illegal immigrants instead of American workers, since illegal immigrants cost the United States roughly $25 billion in Healthcare spending . Meanwhile those who hire them can avoid certain types of taxes and not have to cover their Healthcare; communism for the rich, capitalism for the rest of us. Of course that is just a rough estimate, since this spending is also quite hard to track.

The Future

The problem with changing Healthcare is that too many people have their hands in the proverbial pie. There is not a single lever of power that isn't affected by Healthcare, and most of the levers that are affected, benefit quite a bit. Insurance companies will fight to the death, because Universal Healthcare will be their death knell. Banks will defend it, because who doesn't want to make billions from student loans? Medical schools too – since it lets them charge higher and higher tuition. Pharmaceutical companies can use the increase in Healthcare expenditure to justify their own price hikes, even though a major reason for those price hikes is artificial patent based monopoly.

What is an artificial monopoly? In my opinion, it's when a patent is utilized to prevent competitors from manufacturing the same exact drug. In less than a decade, the price of Epi-Pen soared from $103.50 to $608.61. When asked the justify said increase, one of the reasons provided by the CEO was that the price went up because we were making investment; as I said, about $1 billion over the last decade that we invested in the product that we could reach physicians and educate legislatures. "Reaching" doctors and legislators; I wonder, how was said "education funding" spent? According to US News, a website that is extremely credible when it comes to internal decision making within the United States, drug companies have long courted doctors with gifts , from speaking and consulting fees to educational materials to food and drink. But while most doctors do not believe these gifts influence their decisions about which drugs to prescribe, a new study found the gifts actually can make a difference – something patient advocates have voiced concern about in the past. Do you feel educated? Would you feel more educated if I paid you a $150,000 consulting fee? What about $400,000? What? It's just consulting; no corruption here!

Everyone knows that this is going on. But there is not going to be change. Why not? The same reason that there was not change with Harvey Weinstein, until Taylor Swift came along. Remember how I said that almost everyone has their hands in the Healthcare Pie? It was not much different with Weinstein. Scott Rosenberg explained why it took so long for people to speak out against Harvey , and the reasons were numerous. First, Harvey gave many people their start in Hollywood, and treated all of his friends like royalty. That drastically increased their loyalty. Second, he ushered the Golden Age of the 1990s, with movies like Pulp Fiction, Shakespeare in Love, Clerks, Swingers, Scream, Good Will Hunting, English Patient, Life is Beautiful – the man could make phenomenal movies. Third, even if one was willing to go against his own friends, workers, mass media, and so on, there was no one to tell. There was no place to speak out. Fourth, some of the victims took hefty settlements.

That fourth reason enabled mass media to portray rape victims as gold diggers. Rape Culture is alive and well. In California, a Judge gave minimal sentencing to a convicted rapist , because he was afraid a harsher sentence would damage the rapist's mental psyche for life. Uh dude, from one Californian to another, he, uh, raped. His mental psyche is already damaged; for life. That's the kind of pressure that Rose McGowan had to deal with. She had a little kerfuffle with Amazon , and she thinks it was partially because of Harvey Weinstein. How many times had the word "socialism" been thrown around to describe Universal Healthcare? Switzerland has it – are they Socialist?

Enter Taylor Swift . In order to destroy allegations that women are filing sexual harassment claims as gold diggers, she sued her alleged sexual assaulter for a buck; one dollar. She won. Swift stated that the lawsuit was to serve as an example to other women who may resist publicly reliving similar outrageous and humiliating acts. On top of that, Weinstein was no longer as popular as he used to be, and an avenue to tell the story, an outlet was created. The additional prevalence of the internet caused the stories of Weinstein's sexual abuse to leak. Within a month, the giant fell.

Something similar is needed to change Healthcare in America. But until that comes along, racism will increase, the cost of Healthcare will rise, emergency room costs will most likely double every ten years, and the future remains bleak. As if that was not enough, more and more upper class Americans, (like yours truly,) are seeking treatment abroad. It cost me less money to lose five weeks of wages, spend three weeks partying in Eastern Europe, (Prague to be more specific,) after my two weeks of treatment, buy a roundtrip plane ticket, and stay in a five star, all-inclusive hotel, than the cost of the same treatment in the US. If anyone wants to utilize this as a startup – let me know!

Of course its effects on Healthcare will hurt, since it is a huge chunk of business that will be traveling across the Atlantic. But what can be done to stop it? One cannot stop Americans from traveling to other countries. One cannot force the poor to work for free. Perhaps this is the change that is needed to make those who benefit from the Healthcare Waste realize that this cannot continue. Perhaps not. What we do know, is that Obamacare insured the poor, at the expense of the middle class . And that is regarded as a failure in America.

Northern Star , November 27, 2017 at 3:12 pm
As for Obongo Care ??:

"In trying to show that he was successfully managing the Obamacare rollout, the president last week staged a high-profile White House meeting with private health insurance executives -- aka Obamacare's middlemen. The spectacle of a president begging these middlemen for help was a reminder that Obamacare did not limit the power of the insurance companies as a single-payer system would.
****The new law instead cemented the industry's profit-extracting role in the larger health system -- and it still leaves millions without insurance."*** (THAT is the Achille's lower torso of the ACA)

https://www.healthcare-now.org/blog/single-payer-healthcare-vs-obamacare/

https://www.dailykos.com/stories/2016/2/11/1483523/-Single-Payer-Healthcare-vs-The-Affordable-Care-Act-A-Simple-Comparison

ucgsblog , November 28, 2017 at 3:58 pm
Exactly! That's why I stated that they're now oligapolizing the market, and will slowly start to increase their insurance rates and profits once again.
Northern Star , November 27, 2017 at 3:23 pm
"Prince Harry..Do you take this American mulatto negress -aka raghead untermensch-as your lawfully wedded royal wife?*
http://www.newsweek.com/prince-harrys-worst-moments-meghan-markle-rogue-723177
https://www.sbs.com.au/guide/sites/sbs.com.au.guide/files/styles/body_image/public/nazi.jpg?itok=q1oxMi44&mtime=1503879842

Ummm Advice to Meghan .make sure the honeymoon motorcade stays clear of tunnels in Paris
or elsewhere!!!

Northern Star , November 27, 2017 at 3:52 pm
Appurtenant to many of the issues raised in Mark's post:

http://www.wsws.org/en/articles/2017/11/27/pers-n27.html

(Socialist or not..the WSWS writers continue to state that which NEEDS to be hammered home)

"The vast wealth of the financial oligarchy, expressed in their ownership of massive corporations, must be seized and expropriated, while the complex technologies, supply chains, and advanced transportation systems must be integrated in an organized, planned manner to harness the anarchic force of the world economy and eliminate material scarcity.

Amazon is a prime example. Its supply lines and delivery systems could distribute goods across the world, bringing water, food, and medicine from each producer according to his or her ability, to each consumer according to his or her need.

The massively sophisticated computational power used by the technology companies to censor and blacklist political opposition could instead be used for logistical analysis to conduct rescue and rebuilding missions in disaster zones like Houston and Puerto Rico. Drones used in the battlefield could be scrapped and rebuilt to distribute supplies for building schools, museums, libraries, and theaters, and for making Internet service available at no cost for the entire world.

The ruling class and all of the institutions of the political establishment stand inexorably in the way of efforts to expropriate their wealth. What is required is to mobilize the working class in a political struggle against the state and the socio-economic system on which it is based, through the fight for socialism.
Eric London "

Particularly for American Stooges:

Patient Observer , November 27, 2017 at 5:17 pm
Advanced technology is helpful but not essential for a humane and just society. Its what we believe and feel that matters. FWIW, I like socialism on a national/international level and individual accountability on a personal level.
saskydisc , November 27, 2017 at 4:04 pm
While general medical care is single payer in Canada, dental services are not. For major work on teeth, it is cheaper to fly to Mexico. The downside is for Mexicans -- such practices will drive the costs up in Mexico.
Patient Observer , November 27, 2017 at 5:12 pm
Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.
[email protected] , November 27, 2017 at 6:02 pm
I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.
kirill , November 27, 2017 at 8:38 pm
Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

Jen , November 27, 2017 at 11:15 pm
Thanks very much UCG, for your article. Very interesting reading for us Australians as the Federal Government eventually wants to shove us kicking and screaming into a US-style privatised healthcare insurance model.

Funnily enough I'm currently considering changing my private health insurer. I'm with Medibank Private at present but considering maybe going with a smaller non-profit health fund like Australian Unity or Phoenix Health Fund.

Fern , November 28, 2017 at 7:02 am
I was just about to post along the lines of "I don't know if Jen has experienced this in Australia but here in the UK ." so I'll finish the thought. In the UK, successive governments, not just Conservative ones, have been trying to dismantle the NHS and move us to the American system. It is pure ideology – no amount of the very abundant evidence of the inefficiencies of the US system, its waste etc makes any dint in the enthusiasm of those pressing for change.
ucgsblog , November 28, 2017 at 4:17 pm
Thank you Jen! My advice: don't let the Government cajole you into wasting your money on Corporate Greed. Share the article with your fellow Australians, if you must, but don't let our wasteful system be replicated. Interestingly enough, one of my friends, Lytburger, send me a meme right after Ukraine adopted America's Healthcare System, it said: "ISIS refused to take responsibility for Ukraine's Healthcare Reform!" I'd be happy to provide other data or answer questions about the Healthcare System here.

As for insurance, I'm not sure if Australia has the in-network and out-of-network rules. Does it? Whatever insurance you get, make sure that it has good coverage. If you own a home in the US, and you end up in a hospital's emergency room that's not covered by your insurance, the hospital can take your house under certain circumstances. Ironically, even the Government cannot. All of my real property is in various Trust Accounts, just in case, and I make sure that I have insurance where all major hospitals are in-network and that's the best I can do.

James lake , November 28, 2017 at 12:21 am
This is s very interesting insight into healcare in the USA. The cost is shocking. I live in the UK and the healthcare system is paid for from taxation. When it was established over 70 years ago it's. The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means. It was the best thing in my view that government has ever done. Good healthcare should be available to all and not dependent on peoples ability to pay.

However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.

Which many people do not mind.

-Elderly care was also privatised as it's the most expensive

-care for the disabled also is a issue for local councils

-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.

And yet still more and more taxation is needed for the NHS!

The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

Patient Observer , November 28, 2017 at 12:49 pm
The Albanian Kosovo Liberation Army harvested organs from captured Serb civilians and soldiers:

https://thebloodyellowhouse.wordpress.com/

In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.

Bold text emphasis added.

Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.

Per Wikipedia:

The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine into western Europe.[16]

A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.

On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.

So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist and genocidally inclined West.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.
Ryan Ward , November 28, 2017 at 3:40 am
With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany

[Nov 15, 2017] Alex Azar Can There Be Uglier Scenarios than the Revolving Door naked capitalism

Notable quotes:
"... By Lambert Strether ..."
"... So should Mr Azar be confirmed as Secretary of DHHS, the fox guarding the hen house appears to be a reasonable analogy. ..."
"... In this post, I'd like to add two additional factors to our consideration of Azar. The first: Democrat credentialism makes it hard for them to oppose Azar. The second: The real ..."
Nov 15, 2017 | www.nakedcapitalism.com

Alex Azar: Can There Be Uglier Scenarios than the Revolving Door? Posted on November 15, 2017 by Lambert Strether By Lambert Strether

Clearly, Alex Azar, nominated yesterday for the position of Secretary of Health and Human Services by the Trump Administration, exemplifies the case of the "revolving door," through which Flexians slither on their way to (or from) positions of public trust. Roy Poses ( cross-posted at NC ) wrote, when Azar was only Acting Secretary:

Last week we noted that Mr Trump famously promised to &#8220;drain the swamp&#8221; in Washington. Last week, despite his previous pledges to not appoint lobbyists to powerful positions, he appointed a lobbyist to be acting DHHS Secretary. This week he is apparently strongly considering Mr Alex Azar, a pharmaceutical executive to be permanent DHHS Secretary, even though the FDA, part of DHHS, has direct regulatory authority over the pharmaceutical industry, and many other DHHS policies strongly affect the pharmaceutical industry. (By the way, Mr Azar was also in charge of one lobbying effort.)

So should Mr Azar be confirmed as Secretary of DHHS, the fox guarding the hen house appears to be a reasonable analogy.

Moreover, several serious legal cases involving bad behavior by his company, and multiple other instances of apparently unethical behavior occurred on Mr Azar&#8217;s watch at Eli Lilly. So the fox might be not the most reputable member of the species.

So you know the drill&#8230;. The revolving door is a species of conflict of interest . Worse, some experts have suggested that the revolving door is in fact corruption. As we noted here , the experts from the distinguished European anti-corruption group U4 wrote ,

The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy , especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door from industry to the Trump administration once again suggests how the revolving door may enable certain of those with private vested interests to have excess influence, way beyond that of ordinary citizens, on how the government works, and that the country is still increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism.

Poses is, of course, correct. (Personally, I've contained my aghastitude on Azar, because I remember quite well how Liz Fowler transitioned from Wellpoint to being Max Baucus's chief of staff when ObamaCare was being drafted to a job in Big Pharma , and I remember quite well the deal with Big Pharma Obama cut, which eliminated the public option , not that the public option was anything other than a decreasingly gaudy "progressive" bauble in the first place.)

In this post, I'd like to add two additional factors to our consideration of Azar. The first: Democrat credentialism makes it hard for them to oppose Azar. The second: The real damage Azar could do is on the regulatory side.[1]

First, Democrat credentialism. Here is one effusive encomium on Azar. From USA Today, "Who is Alex Azar? Former drugmaker CEO and HHS official nominated to head agency" :

"I am glad to hear that you have worked hard, and brought fair-minded legal analysis to the department," Democratic Sen. Max Baucus said at Azar's last confirmation hearing.

And:

Andy Slavitt, who ran the Affordable Care Act and the Centers for Medicare & Medicaid Services during the Obama administration, said he has reason to hope Azar would be a good secretary.

"He is familiar with the high quality of the HHS staff, has real-world experience enough to be pragmatic, and will hopefully avoid repeating the mistakes of his predecessor," Slavitt said.

So, if Democrats are saying Azar is "fair-minded" and "pragmatic" -- and heaven forfend that the word "corruption"[2] even be mentioned -- how do they oppose him, even he's viscerally opposed to everything Democrats supposedly stand for? (Democrats do this with judicial nominations, too.) Azar may be a fox, alright, but the chickens he's supposedly guarding are all clucking about how impeccable his qualifications are!

Second, let's briefly look at Azar's bio. Let me excerpt salient detail from USA Today :

1. Azar clerked for Supreme Court Justice Antonin Scalia .

2. Azar went to work for his mentor, Ken Starr , who was heading the independent counsel investigation into Bill and Hillary Clinton's Whitewater land deal.

3. Azar had a significant role in another major political controversy when the outcome of the 2000 presidential election hinged on a recount in Florida . Azar was on the Bush team of lawyers whose side ultimately prevailed [3]

For any Democrat with a memory, that bio provokes one of those "You shall know them by the trail of the dead" moments. And then there's this:

When Leavitt replaced Thompson in 2005 and Azar became his deputy, Leavitt delegated a lot of the rule-making process to Azar.

So, a liberal Democrat might classify Azar as a smooth-talking reactionary thug with a terrible record and the most vile mentors imaginable, and on top of it all, he's an effective bureaucratic fixer. What could the Trump Administration possibly see in such a person? Former (Republican) HHS Secretary Mike Leavitt explains:

"Understanding the administrative rule process in the circumstance we're in today could be extraordinarily important because a lot of the change in the health care system, given the fact that they've not succeeded legislatively, could come administratively."

We outlined the administration strategy on health care in "Trump Adminstration Doubles Down on Efforts to Crapify the Entire Health Care System (Unless You're Rich, of Course)" . There are three prongs:

1) Administratively, send ObamaCare into a death spiral by sabotaging it

2) Legislatively, gut Medicaid as part of the "tax refom" package in Congress

3) Through executive order, eliminate "essential health benefits" through "association health plans"

As a sidebar, it's interesting to see that although this do-list is strategically and ideologically coherent -- basically, your ability to access health care will be directly dependent on your ability to pay -- it's institutionally incoherent, a bizarre contraption screwed together out of legislation, regulations, and an Executive order. Of course, this incoherence mirrors to Rube Goldberg structure of ObamaCare itself, itself a bizarre contraption, especially when compared to the simple, rugged, and proven single payer system. ( Everything Obama did with regulations and executive orders, Trump can undo, with new regulations and new executive orders . We might compare ObamaCare to a child born with no immune system, that could only have survived within the liberal bubble within which it was created; in the real world, it's not surprising that it's succumbing to opportunistic infections.[2])

On #1, The administration has, despite its best efforts, not achieved a controlled flight into terrain with ObamaCare; enrollment is up. On #2, the administration and its Congressional allies are still dickering with tax reform. And on #3 . That looks looks like a job for Alex Azar, since both essential health benefits and association health plans are significantly affected by regulation.

So, yes, there are worse scenarios than the revolving door; it's what you leave behind you as the door revolves that matters. It would be lovely if there were a good old-fashioned confirmation battle over Azar, but, as I've pointed out, the Democrats have tied their own hands. Ideally, the Democrats would junk the Rube Goldberg device that is ObamaCare, rendering all of Azar's regulatory expertise null and void, but that doesn't seem likely, given that they seem to be doing everything possible to avoid serious discussion of policy in 2018 and 2020.

NOTES

[1] I'm leaving aside what will no doubt be the 2018 or even 2020 issue of drug prices, since for me that's subsumed under the issue of single payer. If we look only at Azar's history in business, real price decreases seem unlikely. Business Insider :

Over the 10-year period when Azar was at Lilly, the price of insulin notched a three-fold increase. It wasn't just Lilly's insulin product, called Humalog. The price of a rival made by Novo Nordisk has also climbed, with the two rising in such lockstep that you can barely see both trend lines below.

The gains came despite the fact that the insulin, which as a medication has an almost-century-long history, hasn't really changed since it was first approved.

Nice business to be in, eh? Here's that chart:

It's almost like Lilly (Azar's firm) and Novo Nordisk are working together, isn't it?

[2] Anyhow, as of the 2016 Clinton campaign , the Democrat standard -- not that of Poses, nor mine -- is that if there's no quid pro quo, there's no corruption.

[3] And, curiously, "[HHS head Tommy] Thompson said HHS was in the eye of the storm after the 2001 terrorist attacks, and Azar had an important role in responding to the resulting public health challenges, as well as the subsequent anthrax attacks "

MedicalQuack , November 15, 2017 at 10:31 am

Oh please, stop quoting Andy Slavitt, the United Healthcare Ingenix algo man. That guy is the biggest crook that made his money early on with RX discounts with his company that he and Senator Warren's daughter, Amelia sold to United Healthcare. He's out there trying to do his own reputation restore routine. Go back to 2009 and read about the short paying of MDs by Ingenix, which is now Optum Insights, he was the CEO and remember it was just around 3 years ago or so he sat there quarterly with United CEO Hemsley at those quarterly meetings. Look him up, wants 40k to speak and he puts the perception out there he does this for free, not so.

diptherio , November 15, 2017 at 11:25 am

I think you're missing the context. Lambert is quoting him by way of showing that the sleazy establishment types are just fine with him. Thanks for the extra background on that particular swamp-dweller, though.

a different chris , November 15, 2017 at 2:01 pm

Not just the context, it's a quote in a quote. Does make me think Slavitt must be a real piece of work to send MQ so far off his rails

petal , November 15, 2017 at 12:52 pm

Alex Azar is a Dartmouth grad (Gov't & Economics '88) just like Jeff Immelt (Applied Math & Economics '78). So much damage to society from such a small department!

sgt_doom , November 15, 2017 at 1:21 pm

Nice one, petal !!!

Really, all I need to know about the Trumpster Administration:

From Rothschild to . . . .

https://en.wikipedia.org/wiki/Wilbur_Ross

Since 2014, Ross has been the vice-chairman of the board of Bank of Cyprus PCL, the largest bank in Cyprus.

He served under U.S. President Bill Clinton on the board of the U.S.-Russia Investment Fund. Later, under New York City Mayor Rudy Giuliani, Ross served as the Mayor's privatization advisor.

Jen , November 15, 2017 at 7:56 pm

Or from a "small liberal arts college" (which is a university in all but name, because alumni).

Tim Geitner ('82 – Goverment)
Hank Paulson ('68 – English)

jo6pac , November 15, 2017 at 2:13 pm

Well it's never ending game in the beltway and we serfs aren't in it.

https://consortiumnews.com/2017/11/15/trump-adds-to-washingtons-swamp/

Alfred , November 15, 2017 at 2:53 pm

I don't believe that the President's "swamp" ever consisted of crooked officials, lobbyists, and cronies I think it has always consisted of those regulators who tried sincerely to defend public interests.

It was in the sticky work of those good bureaucrats that the projects of capitalists and speculators bogged down. It is against their efforts that the pickup-driving cohort of Trump_vs_deep_state (with their Gadsden flag decals) relentlessly rails.

Trump has made much progress in draining the regulatory swamp (if indeed that is the right way to identify it), and no doubt will make considerably more as time wears on, leaving America high and dry. The kind of prevaricator Trump is may simply be the one who fails to define his terms.

Henry Moon Pie , November 15, 2017 at 4:13 pm

I think we've moved past the revolving door. We hear members of the United States Senate publicly voice their concerns about what will happen if they fail to do their employers' bidding (and I'm not talking about "the public" here). In the bureaucracy, political appointees keep accruing more and more power even as they make it clearer and clearer that they work for "the donors" and not the people. Nowhere is this more true than the locus through which passes most of the money: the Pentagon. The fact that these beribboned heroes are, in fact, setting war policy on their own makes the knowledge that they serve Raytheon and Exxon rather than Americans very, very troubling.

I suspect Azar's perception is that he is just moving from one post to another within the same company.

Watt4Bob , November 15, 2017 at 5:28 pm

Perfect cartoon over at Truthout

I'm amazed there is enough private security available on this planet to keep these guys safe.

Larry , November 15, 2017 at 8:01 pm

Big pharma indeed has so much defense from the supposed left. It combines their faith in technological progress, elite institutions, and tugs on the heart strings with technology that can save people from a fate of ill health or premature death. Of course, the aspect of the laws being written to line the pockets of corrupt executives is glossed over. While drug prices and medical costs spiral ever higher, our overall longevity and national health in the US declines. That speaks volumes about what Democrats really care about.

[Oct 27, 2017] Prime case of crapification in medicine is that many doctors bowled over by the drug companies

Notable quotes:
"... One thing this article doesn't distinguish between are hospital doctors and solo practitioners (i.e. family doctors, or occasionally doctors in small hospitals). There is a huge issue with doctors simply not keeping up with current research if they don't have the peer pressure and oversight that you would expect in a well run hospital. I was a victim of this as for years as a child I was repeatedly given antibiotics by my family doctor for 'chest infections'. In fact, I had asthma triggered by a cold air sensitivity, and was only diagnosed in my late teens (after I'd been carted to hospital after a school outdoors sport session). ..."
"... I've also heard numerous stories about terrible practices by specialists in small hospitals, who can become mini-emperors with nobody to contradict their professional opinions. This is one reason why all doctors will generally advise that the best place when you are ill is a large teaching hospital (definitely not a small private hospital). Bad diagnostic practice is much more likely to be stamped out in the biggest hospitals where there is greater peer oversight. ..."
"... Physicians aren't bots. There are different reasons people go into medicine, not all of them about "patient care" and altruism -- "unselfish regard for or devotion to the welfare of others behavior by not beneficial to or may be harmful to itself but that benefits others of its species." Sometimes quite the opposite, thanks to greed and pleasure-seeking and the burdens of "debt" assumed by so many "providers," or even rare psych phenomena like von Muchausen's by proxy ..."
"... Always, the smart kids in the room want to systematize and organize every kind of function, and in the neoliberal universe, reduce complexity to profit-generating, "management"-centric forms. Sometimes that application of rationalization is a good thing, it can help focus attention wisely and lead to those often undefined "good outcomes." ..."
"... Constant mechanization of medicine results in stuff like the ICD-10 classification thing, which is mostly about Big Data and payments. "Billable" medicine has been "reduced" to about 70,000 "diagnosis codes" and a whole lot of treatment and procedure codes, up from about 13,000 diagnosis codes in ICD-9. ..."
"... ICD-9 is widely considered to be based on outdated technology, with codes unable to reflect the use of new equipment. ICD-10 offers far more integration with modern technology, with an emphasis on devices that are actually being used for various procedures. The additional spaces available are partly designed to allow for new technology to be seamlessly integrated into codes, which means fewer concerns about the ability to accurately report information as time goes on. In Conclusion, ICD-10 is not a simple update to ICD-9. The structural changes throughout the entire coding system are very significant, and the increased level of complexity requires coders to be even more thoroughly trained than before. However, it is possible to prepare for the changes by remembering a few simple guidelines: ..."
"... Train early- The more familiar your staff are with ICD-10, the better. While currently scheduled to begin Oct. 1, 2014, beginning the training now is not a bad idea. ..."
"... Understand the ICD-10- The structural changes require a change in the way people think about coding, and understanding it will help to break current coding habits. Medical professionals used to reporting things a certain way so they can be coded may need to change what they say in order to work well with the new system. ..."
"... EBM is just another management buzz(kill)word, like "total quality management" and "zero defects" and "zero-based budgeting." All supported by proponents who rationalize and argue in the language of squishy "disciplines" like psychology and economics, using "specialized" lexicons that often are cloudy restatements of commonplaces in arcane terminologies, and the creation of intellectual artifacts that have tenuous or little relationship to the reality most "uneducated" observers perceive -- yes, sometimes incorrectly as more acute observations might show, but more often accurately than the modeling and force-fitting that "experts" soar off on. How many of the articles cited as authoritative on various points have anything other than presence in peer-reviewed land as proof of the claimed "findings" both of the original researchers and authors, or acuteness and accuracy of the proposition for which they are offered subsequently? And how much fraud and selectiveness (like medication trials that exclude likely non-responders to the therapies) and purblindness fills the vast swath of "published studies" ..."
"... I've personally experienced and seen lots of misdiagnoses and clinician blindness and tunnel vision, starting as a child ..."
"... And our favored subsequent family doctor, who mis-diagnosed my mother's fatal ovarian cancer (a common failing given vagueness of symptoms) for a year or more after her original office visit, as a gall bladder problem needing bile salts. (Said doctor, seeking alpha, had moved largely into "industrial medicine," doing workers comp and employment physicals -- a wonderfully nice guy, but clinical skills atrophy or lose focus or get too sharpened into narrow channels– totally understandable, given human nature -- channels that get reinforced by "economic" forces, stuff like HMOs and corporate bottom lines, and stuff like the vast and geometrically growing pile of "medical knowledge" of more or less validity, on and on. ..."
"... And "we" can hope that AI and EBM and the horrors wrought by the other false gods of "modern medical practice" like "Electronic Medical Records" don't intermediate and leverage their way into the care we mopes need and hope for. EBM from what I have seen can be a useful approach in some ways, but then Smith's Law of Crapification is as universal as Murphy's ..."
"... I think, what this article alludes to is that medicine is complex and not easily algorithmic ..."
"... The problem with the art of medicine, is that it takes time as it comes with experience. Much more experience that one can learn in medical school or residency. ..."
"... My suspicion is that those early in their careers would benefit from practicing a high level of guideline based medicine until they gain experience. ..."
"... Above, I speak of how to practice medicine without consideration of how to pay for it. Now when you start adding payments, reimbursements, and insurance claims, you add another level of complexity, bias, and incentive. It appears the free market insurance model is not working, as well as the fee for service model. Here the trick is to change the way medicine is reimbursed and incentivized. ..."
"... My point is that there are mandates and financial incentive for hospitals to pressure physicians into adhering to guidelines which are not universally good for patients or for cost of care ..."
Oct 27, 2017 | www.nakedcapitalism.com

el_tel , October 27, 2017 at 7:24 am

Interesting article and a couple of clarifications:

Psychologists have studied the accuracy of risk assessments made by statistical predictors and by clinicians, but they have not done similar studies of the accuracy of evaluations of patient preferences over health outcomes.

True but health economists have done so . And they got so scared by the results that some (Dolan) left the field to do something else. This particular example is that whilst the general population reckons "extreme pain" to be worse than "extreme depression/anxiety", those members of the population who'd experienced them both put them the other way round. Which has profound implications for the UK values assigned to health outcomes. Of course other countries might do things in different ways and this is NOT some veiled attack on what the US might do if single payer gets onto the playing field. It's merely adding to the warning in the paper about how to do it. Which leads to a second warning I'd make – averages. They conceal a lot.

Mental health is the archetypal example and, again, maybe the paper is right that something like maximin is warranted, given that "living by averages" means some groups automatically lose out. Just some thoughts, which hopefully are constructive this time round and expand on points made.

PlutoniumKun , October 27, 2017 at 8:19 am

One thing this article doesn't distinguish between are hospital doctors and solo practitioners (i.e. family doctors, or occasionally doctors in small hospitals). There is a huge issue with doctors simply not keeping up with current research if they don't have the peer pressure and oversight that you would expect in a well run hospital. I was a victim of this as for years as a child I was repeatedly given antibiotics by my family doctor for 'chest infections'. In fact, I had asthma triggered by a cold air sensitivity, and was only diagnosed in my late teens (after I'd been carted to hospital after a school outdoors sport session).

I talked much later to a family member who is a specialist in prescribing practice who said that this was by far the most common misdiagnosis/treatment and as late as the 1990's in the UK (where he did research on the subject), he found that 25% of GP's (family doctors) were not identifying asthma correctly. Very often, pharmacists are the only gatekeepers to identify bad prescribing practices.

I've also heard numerous stories about terrible practices by specialists in small hospitals, who can become mini-emperors with nobody to contradict their professional opinions. This is one reason why all doctors will generally advise that the best place when you are ill is a large teaching hospital (definitely not a small private hospital). Bad diagnostic practice is much more likely to be stamped out in the biggest hospitals where there is greater peer oversight.

JTMcPhee , October 27, 2017 at 10:04 am

I'd ask what the author assumes is the best model for doctor-patient interaction, what "patient care" means. To me it should be two or maybe more (including nurses and family members and other caregivers) people, ones with more knowledge of physiology and systems, others with more knowledge and experience of whatever the "presenting condition" happens to be, interacting to increase longevity, reduce pain, repair damaged structures, correct physiological malfunctions and problems with homeostatic functions and so forth, to maximize function, independence and comfort -- an incomplete definition of a very complex notion.

Physicians aren't bots. There are different reasons people go into medicine, not all of them about "patient care" and altruism -- "unselfish regard for or devotion to the welfare of others behavior by not beneficial to or may be harmful to itself but that benefits others of its species." Sometimes quite the opposite, thanks to greed and pleasure-seeking and the burdens of "debt" assumed by so many "providers," or even rare psych phenomena like von Muchausen's by proxy

Always, the smart kids in the room want to systematize and organize every kind of function, and in the neoliberal universe, reduce complexity to profit-generating, "management"-centric forms. Sometimes that application of rationalization is a good thing, it can help focus attention wisely and lead to those often undefined "good outcomes."

But there's almost an infinite number of ways humans can get injured, sickened and die. Human physiology is vastly complex. The interaction pathways are likewise near infinite. Medicine is an art of observation compounded over time, and a lot of the knowledge base (I personally hate that term) is just wrong, from a wide variety of causes including bias, sample size, things like referred pain, atypical "presentations," "normal variation" and so forth. When what to me is a semi-mystical interaction between practitioner and person works well, it is a thing of beauty and kindness. As with anything human-created and -mediated, too often the result is far worse -- most of us can insert one or more anecdotes here, on either extreme.

Constant mechanization of medicine results in stuff like the ICD-10 classification thing, which is mostly about Big Data and payments. "Billable" medicine has been "reduced" to about 70,000 "diagnosis codes" and a whole lot of treatment and procedure codes, up from about 13,000 diagnosis codes in ICD-9. It's a "whole new way of doing business:"

ICD-9 is widely considered to be based on outdated technology, with codes unable to reflect the use of new equipment. ICD-10 offers far more integration with modern technology, with an emphasis on devices that are actually being used for various procedures. The additional spaces available are partly designed to allow for new technology to be seamlessly integrated into codes, which means fewer concerns about the ability to accurately report information as time goes on. In Conclusion, ICD-10 is not a simple update to ICD-9. The structural changes throughout the entire coding system are very significant, and the increased level of complexity requires coders to be even more thoroughly trained than before. However, it is possible to prepare for the changes by remembering a few simple guidelines:

Train early- The more familiar your staff are with ICD-10, the better. While currently scheduled to begin Oct. 1, 2014, beginning the training now is not a bad idea.

Understand the ICD-10- The structural changes require a change in the way people think about coding, and understanding it will help to break current coding habits. Medical professionals used to reporting things a certain way so they can be coded may need to change what they say in order to work well with the new system.

EBM is just another management buzz(kill)word, like "total quality management" and "zero defects" and "zero-based budgeting." All supported by proponents who rationalize and argue in the language of squishy "disciplines" like psychology and economics, using "specialized" lexicons that often are cloudy restatements of commonplaces in arcane terminologies, and the creation of intellectual artifacts that have tenuous or little relationship to the reality most "uneducated" observers perceive -- yes, sometimes incorrectly as more acute observations might show, but more often accurately than the modeling and force-fitting that "experts" soar off on. How many of the articles cited as authoritative on various points have anything other than presence in peer-reviewed land as proof of the claimed "findings" both of the original researchers and authors, or acuteness and accuracy of the proposition for which they are offered subsequently? And how much fraud and selectiveness (like medication trials that exclude likely non-responders to the therapies) and purblindness fills the vast swath of "published studies"

I've personally experienced and seen lots of misdiagnoses and clinician blindness and tunnel vision, starting as a child when the family doctor, a partisan of allergies as the most common source of disease, and who patch-tested me and my sisters unmercifully, supposedly told my mom that my broken right forearm was the result of an allergy. And our favored subsequent family doctor, who mis-diagnosed my mother's fatal ovarian cancer (a common failing given vagueness of symptoms) for a year or more after her original office visit, as a gall bladder problem needing bile salts. (Said doctor, seeking alpha, had moved largely into "industrial medicine," doing workers comp and employment physicals -- a wonderfully nice guy, but clinical skills atrophy or lose focus or get too sharpened into narrow channels– totally understandable, given human nature -- channels that get reinforced by "economic" forces, stuff like HMOs and corporate bottom lines, and stuff like the vast and geometrically growing pile of "medical knowledge" of more or less validity, on and on.

These observations only touch on an enormously complex and painfully meaningful subject. Seems to me that the best "we" patients and patients-to-be can expect is that we connect with clinicians that still start from "Do no harm" and aspire to better the lives of we who seek and depend on their expertise -- a notably, and inevitably, ever smaller fraction of the available "knowledge base." And "we" can hope that AI and EBM and the horrors wrought by the other false gods of "modern medical practice" like "Electronic Medical Records" don't intermediate and leverage their way into the care we mopes need and hope for. EBM from what I have seen can be a useful approach in some ways, but then Smith's Law of Crapification is as universal as Murphy's

el_tel , October 27, 2017 at 10:15 am

Yeah I agree entirely . But more holistic approaches (judging medicine by overall quality of life) get into areas that have got a little Shall we say Controversial So I'm keeping my comments focused to stay within site guidelines.

cojo , October 27, 2017 at 12:08 pm

There are two reasons why patient care adhering to guidelines may differ from the care that clinicians provide:
Guideline developers may differ from clinicians in their ability to predict how decisions affect patient outcomes; or
Guideline developers and clinicians may differ in how they evaluate patient outcomes.

I think, what this article alludes to is that medicine is complex and not easily algorithmic. The concerns in medical decision making as noted by Yves and others is that if your data/knowledge you base your treatment choices on is outdated, or flat out wrong, you will be doing your patient's a disservice at best and harm at worse. In these situations evidence based medicine should be used as a guide. Where evidence based medicine runs into trouble, is two fold. One, when the guidelines are based on flawed evidence/data, and two, when they are no longer used as a guide, but as the law.

So in that case you may statistically help the population at large, based on the data at hand, but at the cost of doing preventable harm to a large cohort that could have been picked up by rational clinical decision making. This is where the "Art of Medicine" should theoretically be superior. The problem with the art of medicine, is that it takes time as it comes with experience. Much more experience that one can learn in medical school or residency.

My suspicion is that those early in their careers would benefit from practicing a high level of guideline based medicine until they gain experience.

With experience, the guidelines should still be understood but there is more flexibility to stray from the guidelines for individual patients based on patient preference and physician experience.

For those in the late stages of their careers, it is again important to understand and try to follow the guidelines so as to not become outdated in your practice knowledge.

At all three stages, one must understand the rational and methodology of the guidelines figure out which guidelines are to be used for most cases and which guidelines are just that, a guide.

Above, I speak of how to practice medicine without consideration of how to pay for it. Now when you start adding payments, reimbursements, and insurance claims, you add another level of complexity, bias, and incentive. It appears the free market insurance model is not working, as well as the fee for service model. Here the trick is to change the way medicine is reimbursed and incentivized.

Jason , October 27, 2017 at 12:14 pm

I am a practicing internal medicine hospitalist in a major US city. While in the past, there were large delays in physicians taking evidence-based practice and turning it into new habit and too much unwanted variation in clinical practice -- I feel like in the US, the pendulum is swinging too far the other way -- and in unintelligent ways, forcing clinicians into care protocols without regard for individual circumstance. Now there are clinical care guidelines from Medicare, the American Heart Association, the CDC, and others around major disease states (like stroke, heart failure, sepsis) that hospitals must follow for reimbursement -- yet the guidelines do not keep pace with current peer-reviewed evidence.

My point is that there are mandates and financial incentive for hospitals to pressure physicians into adhering to guidelines which are not universally good for patients or for cost of care (sepsis guidelines now are a good example of this). Often these expectations are negotiated by bureaucrats, not clinicians. The healthcare industry needs a better way of giving physicians real-time feedback about their clinical practice habits in relation to their peers -- - and having some common-sense expectations around unwanted variations in practice.

financial matters , October 27, 2017 at 12:50 pm

Hopefully you can get yourself on some committees dealing with these issues. Very important to have physician input.

Economics is definitely important, not only for improving the hospitals bottom line but for making medicine economically responsible generally.

Single payer, I think would be great but we still need to watch what we are paying for. No need for pharmaceutical companies to make outrageous profits.

One interesting area now is that many very expensive tests are becoming available for cancer testing. These need to be ordered responsibly and that takes physician, social and admin input. And at a deeper level needs to examine why the tests, drugs etc are so expensive.

el_tel , October 27, 2017 at 1:01 pm

Tranylcypromine – first generation antidepressant and still the gold standard for effectiveness (the "cheese effect" side effect has been overblown as numerous studies have more recently shown – I'm on it and can confirm this) costs the NHS over £1000 per month for me. It's been off patent for 50 years. However there is a monopoly supplier (price gouger). Why don't generic suppliers move in? Because the market is too small. Two generations of doctors have been taught that this class (MAOIs) are akin to leech therapy. Thus the assumption is that most people on them will be old and will die off. Scandalous, as any psychiatrist worth their salt will tell you (never mind the health economist like me).

el_tel , October 27, 2017 at 1:36 pm

Prime case of cr*pification in medicine if you ask me. Doctors bowled over by the drug companies selling SSRIs/SNRIs which let's not forget don't even work as the pharmacology says they should – they should show benefits at day 4/5 like MAOIs if their original pharmacological justification is paid attention to. Now does that mean they don't work? No I'm not saying that. But their method of action is clearly odd and not in line with the original pharmacological data and models.

Health economics 102 is derived demand – patients rely on doctors to enunciate their demand function. But when doctors have effectively undergone the medical equivalent of regulatory capture then Houston we have a problem.

financial matters , October 27, 2017 at 1:54 pm

Yes indeed. These pharmacologic profits can be perniciously spread around. It can be difficult to find a true patient advocate.

el_tel , October 27, 2017 at 2:17 pm

Thanks for the reply. The problem here is that patient advocacy requires systemic change: change in the medical curriculum along with a concerted effort to tell GPs about the new data on "old" drugs And they are already overburdened with stuff "coming at them from on high".

Plus even if (say) they learn the real data concerning MAOIs they still can't prescribe them straight off A psychiatrist must initiate it (then GP can carry on) And mental health services are close to breaking point. My local service is at critical levels. Austerity yet again .

Bill , October 27, 2017 at 1:48 pm

I was going to a physical therapist practice for spasticity and weakness and pain related to a pretty radical cervical laminectomy and progressive spine problems. I was a Medicare patient and they insisted on using the guidelines for rehabilitation after operation, even though my operation took place 12 years earlier. This consisted of exercises which only made my spasticity worse and aggravated my arthritis. What I needed was to have my chest and arms worked on to counteract the contraction of muscles caused by spasticity, which the therapist knew how to do. But she refused and told me that If I did not do the exercises, she would no longer treat me as I was violating the "guidelines", which did not apply to my circumstance. There was apparently nothing to allow treatment for chronic problems (except opiods, which I refused).

el_tel , October 27, 2017 at 2:00 pm

Sorry to hear that. I had reason to look at the UK guidelines on a range of conditions (from NICE). I was actually pleasantly surprised: although they do in many cases follow "stepped care" functions from medicine, there were a surprising number of "get outs" regarding if the patient cannot tolerate /has good reason to reject the official guidance. Patient preferences have begun to get recognised in the UK.

Of course whether austerity allows the doctors to *afford* differences is another sad story .

Bill , October 27, 2017 at 2:59 pm

I guess that what I need now is what amounts to palliative care (non-pharmaceutical). I find now that I have discovered high-CBD hemp (Otto II strain) which I can grow myself, I can actually slow down the progressive effects of my condition. Ironically, though I qualify for the medical marijuana card, I can't afford to buy from the dispensaries, and they mainly offer high THC strains anyway. I am lucky to have found a way to treat myself!

[Oct 25, 2017] Overtreatment in the United States Health Care System

American Family Physicians defines overtreatment as follows: "Treatment initiated when there is little or no reliable evidence of a clinically meaningful net benefit, where net benefit equals benefit minus harm. "
Over-treatment involves actual procedures performed on a patient, often surgically. Unnecessary cardiac stents is one example and is a real epidemic due to excessive green and pervert incentives.
Notable quotes:
"... By Lambert Strether of Corrente. ..."
"... Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn't need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments. ..."
"... The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of the company's cardiac stents into trusting patients in a single day: "Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei's home." Employees from St. Joseph's attended the feast. ..."
"... It's clear that one ..."
Oct 25, 2017 | www.nakedcapitalism.com

Posted on October 24, 2017 by Lambert Strether By Lambert Strether of Corrente.

Over the past, oh, decade or so I've been so consumed with the battle to get everybody into the heatlh care system -- "Everybody in, nobody out," as Quentin Young puts it -- that I haven't put much energy into thinking about the heatlh care itself. After all, just because a house is energy inefficient doesn't mean that it's OK to leave people out in the cold. Now that single payer is no longer "never, ever," but a program that could actually be achieved with (an enormous) level of effort, KHN's new series, "Treatment Overkill," which starts with Liz Szabo's "So Much Care It Hurts: Unneeded Scans, Therapy, Surgery Only Add To Patients' Ills," provides me with a change to broaden my scope a bit, with a survey post like this one.

So I'm going to look at two issues: (1) Is overtreatment a real problem? and (2) What are the causes of overtreatment? Spoilers: Yes, and it's complicated.

Confession time: I'm the sort of person who doesn't get the idea of deductibles at all; I can't understand why anyone would seek out medical treatment unless they were absolutely sure they needed it. And the reason I fear the health care system is, in fact, the prospect (painful) overtreatment; the dental clinic that was going to give me full anesthesia to remove a wisdom tooth; or my nightmare of "end of life care" hooked up to a machine in a nursing home in a room with a television I can't turn off.

Overtreatment Is Real Problem

Evidence for overtreatment[1] falls into two categories: Anecdotes, and studies and surveys. I'll look at anecdotes first.

"Anecdotes" isn't really a fair word, though; most of the stories are more about entire vertical markets (for example, stents, as we shall see). Szabo starts out with this example:

When Annie Dennison was diagnosed with breast cancer last year, she readily followed advice from her medical team, agreeing to harsh treatments in the hope of curing her disease.

"In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent six weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she said, because she had no idea there was another option.

Medical research published in The New England Journal of Medicine in 2010 -- six years before her diagnosis -- showed that a condensed, three-week radiation course works just as well as the longer regimen. A year later, the American Society for Radiation Oncology , which writes medical guidelines, endorsed the shorter course.

In 2013 , the society went further and specifically told doctors not to begin radiation on women like Dennison -- who was over 50, with a small cancer that hadn't spread -- without considering the shorter therapy.

"It's disturbing to think that I might have been overtreated," Dennison said. "I would like to make sure that other women and men know this is an option."

(Note, sadly, that Dennison immediately puts the onus on the consumer patient to be informed; an obvious tax on time, to be paid with the patient has the least time or energy to spare, instead of looking for the systemic solution she vaguely hints at with "would like to make sure." This impulse is a topic for another post.)

Nobel Prize Winner Bernard Lowns gives a second example in this interview (after demolishing "bed rest" for heart attack patients as "a form of medieval torture" as well):

[DR. LOWN]: At the Peter Bent Brigham Hospital [now Brigham and Women's Hospital in Boston] in 1960, I was asked to see a patient who was in her late 70s, demented, and had burns over 60 percent of her body. She had been smoking in bed. They asked me to consult about putting in a pacemaker, which she did not need. Furthermore, she was clearly dying, and implanting a pacemaker would only have increased her suffering without prolonging her life. I was mortified. I wrote a note urging against a pacemaker. It created quite a rumpus. If that were an isolated episode, it would be tragic. But that kind of thing happened daily.

Here is a third, and egregious example, from Health Beat :

Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn't need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments.

The Baltimore Sun broke Dr. Midei's story in January. In February the U.S. Senate Committee on Finance, which oversees Medicare and Medicaid, began investigating. Monday, the Finance Committee released a 1200-page report..

The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of the company's cardiac stents into trusting patients in a single day: "Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei's home." Employees from St. Joseph's attended the feast.

(It may seem that I'm stacking the deck on causality here, but I'm really not, although it would be foolish to deny that such cases exist.)

Note again that these examples all involve treatment : Radiation treatment, a pacemaker, and stents. We're not talking about ordering a few two many tests. ( The American Family Physican supplies numerous classes of overtreatment, not just anecdotes. See Table I.) Now to the studies and surveys.

"Overtreatment in the United States," by Heather Lyu, et al (from the Public Library of Science, and thus peer-reviewed) has induced a good deal of discusson since its publication in September 2017. From the Findings:

The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures.

Dear me. If one-fifth of all medical care is unnecessary, that does seem like rather a lot of stress and fear induced for no reason. And if one out of every ten treatments is unncessary, that's rather a lot of people going to Pain City because their number came up, and not for any medical reason. Those odds aren't quite as bad as Russian roulette, but they'e in the ballpark! I haven't (yet) been able to find figures on the costs of overtreatment, but there have been studies done on the costs of unnecessay care. Health Affairs :

Current estimates for unnecessary expenditures on overuse range from 10 to 30 percent of total health care spending. Even the lower estimate, from the Institute of Medicine , amounts to nearly $300 billion a year. No specialty is immune from practices that lead to overuse, as a recent spate of papers in medical journals can attest. In cardiology, even using criteria that are relatively permissive, an estimated 11 percent of stents are delivered to " inappropriate patients ." At some hospitals, that rate is closer to 20 percent.

(Note that the figure of 11% unnecessary stents jibes well with Lyu's figure of 11.1% of all procedures being unnecessary.)

I'm sure none of this is new to any medical professionals in the NC readership, but it was new to me, and may well be new to NC readers -- especially those who received treatments that they retrospectively, or just now, understood to be unnecessary.

The Causes of Overtreatment

It's clear that one cause for overtreatment is the profit motive. (I would speculate that individuals like Midei, the stent dude, are edge cases, and that the real causes are more subtle and systemic.) Quoting again from Lyu, et al. :

The top three cited reasons for overtreatment were "fear of malpractice" (84.7%), "patient pressure/request" (59.0%), and "difficulty accessing prior medical records" (38.2%) Seventy-one percent of respondents believed that physicians are more likely to perform unnecessary procedures when they profit from them. The interpolated median response for the percentage of physicians who perform unnecessary procedures with a profit motive was 16.7%; 28.1% of respondents believed that at least 30–45% of physicians do so (Fig 2). Respondents who were attending physicians with at least 10 years of experience (OR 1.89 (1.43–2.50) vs trainees) and specialists (OR 1.29 (1.06–1.57)) were more likely to believe that physicians perform unnecessary procedures when they profit from them Respondents' compensation method and hospital characteristics were not associated with differences in perceptions on the profit motive associated with unnecessary care.

So, the more experienced the doctor is, the more likely the doctor is to believe that profit drives unnecessary procedures. However, the profit motive imputed to individuals cannot be the sole driver (see "DICE: Nonclinical Causes of Overtreatment" for a model that includes "Economics" without being reductive) as this letter in the British Medical Journal shows :

As a person who follows the evolution of health care policy from the vantage point of the United States, I found BMJ's May 12 article on "Choosing Wisely in the UK" [see here ; CW is an "informed consumer" model] very interesting. The authors ascribe the phenomenon of medical overtreatment in the UK to a culture of "more is better" fostered by such factors as "defensive medicine," "patient pressures," "commercial conflicts of interest," "payment by activity," and the demands of "pay for performance."

Many critics of the American health care scene ascribe the problem of irrational overtreatment unsupported by available evidence in the U.S. to precisely the same causes, and argue that the key to rationalizing American medical practice lies in adoption of the UK's single payer, universal coverage health care system and the UK's system of civil justice. The fact that a Choosing Wisely program is necessary in the UK, and for most of the same underlying reasons as apply in the U.S., proves that the UK has not found the panacea to achieving rational medical practice and that emulation of the UK methods of health insurance, physician payment, and civil justice will not work as a panacea in the U.S. either.

So, sadly, single payer as such is unlikely to solve overtreatment (although I can't think of an advocate who ever said it would).

Conclusion

If there were one kind of doctor-patient relationship that I would like to see incentivized when single payer comes to pass, it's this one. Again Dr. Lown :

U.S. News: Problems with America's health care system are economic, but they are also human. What's been lost in modern medicine?

[DR. LOWN: In my view the lost art of listening is a quintessential failure of our health care system. I think that you cannot heal the health care system without restoring the art of listening and of compassion. You cannot ignore the patient as a human being. A doctor must be a good listener. A doctor must be cultured in order to understand where the patient lives, why he lives like that, and also realize that the leading cause of disease in the world is poverty.

Call me Polyanna, but I think if the health care system started treating patients like human beings, that a good deal of overtreatment would be avoided.

NOTES

[1] Overtreatment is not the same as overtesting, or overdiagnosis. Over-treatment involves actual procedures performed on a patient, often surgically. In other words, lots of pain and suffering imposed to no good purpose. (Szabo's article considers all three, but I am focusing only on overtreatment.) American Family Physicians defines overtreatment as follows: "Treatment initiated when there is little or no reliable evidence of a clinically meaningful net benefit, where net benefit equals benefit minus harm. "

taunger , October 24, 2017 at 1:41 pm

I worked as a disability advocate for years, which is a high volume practice. I read literally tens of thousands of medical records during that time. I can say, unequivocally, overtreatment is an issue.

Causes are far more difficult to deal with. The high cost of medical care is a reflection of the low quality of life many USAians are living. Listening is a good start, but far from the answer. Getting everyone in the system, so that more preventative medicine can work, avoiding patient demanded surgeries with low-probabilities of success would help as well. But even these two are just the tip of the iceberg.

In disability, chronic physical ailments mix with unemployment to form a deep pool of depressed individuals. Even with access to great healthcare (which few have), the advice to exercise, stretch, and eat healthy that would improve many conditions (spinal stenosis, other arthritis and orthopedic issues, obesity, heart disease) is worth very little. In a depressed state, changing long term habits into healthy ones is very difficult, and the prevalence of patients seeing a professional to make behavioral adjustments in concert with their disease treatment is few, not counting those that show up to the psychiatrist for medication regularly.

This is why single payer, jobs guarantee, and redistribution tax policy are necessary together.

Anon , October 24, 2017 at 2:28 pm

Excellent comment. The last sentence is a comprehensive statement of actions needed to heal us (U.S.)

Certainly, some will not respond to these actions, but many will and the attempt is magnanimous for a consciously sick nation.

Arizona Slim , October 24, 2017 at 2:03 pm

Experienced this a couple of years ago.

After a car wreck, both of my parents were hospitalized for a week. During that time, I got a lot of phone calls from the hospital, and many of them related to getting my permission for this, that, and the other test on my mother. Dad had Alzheimers, and, lucky for him, he evaded the endless tests. I guess the doctors figured that he wasn't going to live much longer, so what was the point? (He died nine months later.)

One of the phone calls really stood out. Mom was anemic, and the doctors wanted to do a colonoscopy to find out why. "Malnutrition!" I said. Loudly.

This had been a problem for years. Mom and Dad simply weren't eating enough. I'll get back to that point in a minute. But let me say that I refused the colonoscopy for my mother. In addition to being very invasive, I thought it was unnecessary.

Anyway, Mom got sent home and Dad was discharged to a nursing home. Once he was separated from my mother, he started eating like a horse. Gained 15 pounds in less than three months. Then he started losing weight and the nursing home sent him to hospice. In his case, that was the correct call.

Let's just say that my mother still has issues with food. Not a new problem. I remember it from my childhood. But she does have caregivers who insist on proper nutrition. And she complies.

Last time I spoke with Mom's doctor, he didn't say anything about anemia. Sounds like that's no longer a problem.

Rojo , October 24, 2017 at 2:04 pm

I think specialists are more likely to zero in on the "problem" -- the heart or lung or throat, while GP's are more likely to treat the whole person.

But GP's are often referral gateways to specialists.

Anon , October 24, 2017 at 2:47 pm

General Practice doctors are hugely important in the healthcare system. They are the traffic cops that direct patients to the appropriate specialist. They do most of the listening.

Nilavar, M. D. , October 24, 2017 at 4:58 pm

I think specialists are more likely to zero in on the "problem"

Call me skeptic after being a practioner of Medicine over 40 years! I was a GP before got trained as Diagnostic Radiologist after nearly 5 years of residency. I also worked as ER Physician in early years. I am also licensed to practice in Ontario(Canada) but practiced only in USA after the residency training!
A Diagnostic Radiologist is called ' a doctor's doctor" since the myriad of imaging exists to help the clinical diagnosis. I came across virtually all kind of specialists, medical and surgical kind! Ifound out to whom I wouldn't even send my 'dog' for treatment!

There are ethical and morally conscious docs, but they are in the minority!VERY FEW!

A specialist is like a HAMMER, s/he sees everything as if it is just problem of NAIL! Surgeon thinks through SCALPEL. Go to Pulmonologist, more likely you get bronchoscoped (needed or not), Gastroenterologist – gastro or colonoscopy, so on!

So buyer beware!

S.Nilavar. M.D.

Anonymous , October 24, 2017 at 2:07 pm

Imagine going to a restaurant where the waiter got to order for you.

"You want the steak? OK better start off with these two appetizers I think you'll like.
You'll need some wine too. There's a 1994 Cabernet that will pair great with this. I'll mark
that down. The cost? Oh don't worry about that, your dining insurance will cover it.
Now for dessert. They're all so good, I have picked out three for you. You don't need
to finish them. Now I'll just add in my customary 25% tip (I am highly trained) and we'll
call it a meal."

Vikas Saini , October 24, 2017 at 2:34 pm

As a regular lurker here, it's great to see you on this beat Lambert. We've been on this for awhile now at the Lown Institute. I refer you and the rest of the commentariat to a series we did in the Lancet which is here:

The Drivers paper is pertinent as a description of the ecosystem of bad care.

FYI it's a deep problem of modern medicine, part of the reductionism of the Flexner paradigm that needs to change. Over treatment exists in Canada and the UK as well as in an utterly profit driven system like the US.
Single Payer will be necessary but not sufficient for this problem. Monopsony will only go so far without a revolutionary shift in culture and consciousness.

oh , October 24, 2017 at 2:50 pm

If the patient is the one who controls the payment, things may improve. Right now with insurance, there is no one to one relationship between the patient and the health provider. Insurance companies stand between the patient and payment. Even in the case of single payer, if the patient is given incentives to get second opinions and refuse unnecessary treatment, things may work better.

Lyle , October 24, 2017 at 9:38 pm

Single payer is likley to require second and if need be third opinions for non emergency surgery. Most insurance pays for a second opinion if you want one (and would be a fool not to get) and if need be a third opinion if the first and second don't agree.

kb , October 24, 2017 at 3:03 pm

Kip Sullivan unequivocally disputes the "overtreatment" meme To the contrary, we are under treated in the US ..
Please read:
"The Health Care Mess: How we got into it and how we'll get out of it" by Kip Sullivan ..

hreikd , October 24, 2017 at 3:08 pm

Over treatment: My mom's story. From several years ago.

So I was the guardian for my very (VERY) demented mom whom we kept at home, at great cost but also great benefit to her. She had a basal cell tumor on her forehead. About the size of a nickel. She was 90 at the time. I live in one state, she the next state over about 2 hours away. She had full time help at home.

So one of my innumerable trips to help out and oversee, involved taking her to her md appointment at Brigham and Women's. She had a wonderful gerontologist, who referred me to a dermatologist affiliated with B &W. Her care giver took her a few weeks later and I got a call from the dermatologist, a young woman. Now I'm an old woman but a trained m.d. in Internal Medicine. I also knew (by then ) a great deal about dementia. And especially dementia in my particular mother.

So when the dermatologist called me she said "your mom needs a MOHS procedure". Well, a Mohs procedure is an 8 hour stop and go procedure. They keep cutting until the margins are clean. They cut, send the specimen to the lab, wait for the result and cut again. Patient is awake the whole time so there's no anesthesia risk, but 8 hours on a table for a woman with advanced Alzheimer's was not going to work. I told the dermatologist that there's no way my mom could tolerate that. The dermatologist got irate. Tried to scare me by saying, "the tumor could grow into her brain!". I said, "mom's 90, she'll be dead b/f the tumor goes anywhere!"

They were so intent on this procedure and challenged my right to speak on mom's behalf. so .. I had to fax PROOF of my guardianship for them to let me have the last say. I was pretty discharged. And complained bitterly to the referring doc when we saw him next . and he mentioned that my complaint wasn't the first.

Then I found out that the MOHS surgeons get a ton of money at the places they work, like $700,000.00 / year.

Nemo , October 24, 2017 at 3:57 pm

Thank you for sharing. It helps to know I am not alone in such experiences.

I often wonder how epidemic stories like yours are. I feel like I could write a whole book based on personal experiences along with those of family and friends. A person really has to educate oneself just to avoid being robbed blind or worse yet harmed, and you at least have the fortune of a medical education. To have to education oneself (trying to filter all the misleading 'marketing' information and quacks out there) on complex medical procedures on top of everything else is exasperating beyond words.

How long do we, and those we care about, have to continue suffering the indignities and malfeasance of a broken and corrupt (not worth using euphemisms to debate the issues at this point anymore) healthcare system?

McWoot , October 24, 2017 at 3:52 pm

I'd be surprised if a significant contributor to the "overtreatment" pie wasn't Pharma advertising

clarky90 , October 24, 2017 at 4:17 pm

The underlying premise of "modern medicine" is flawed. It dumber than Medieval bloodletting.

Allopathic medicine is brilliant for catastrophic events. In the case of paraplegic injuries, over the last 50 years, their survival rate, in the first two years after the injury, has increased dramatically. However their long term life expectancy is about the same as it was 50 years ago.

Trends in Life Expectancy After Spinal Cord Injury
"Results
Other factors being equal, over the last 3 decades there has been a 40% decline in mortality during the critical first 2 years after injury. However, the decline in mortality over time in the post–2-year period is small and not statistically significant ."

http://www.sciencedirect.com/science/article/pii/S0003999306004060

We are bamboozled by the "complexity" of the modern medicine model, BUT, "it" is stupidly simple. They define a "normal" range of numbers. This range is arbitrary and always changing. What is normal cholesterol? PSA? Blood sugar? ferritin? vitamin D?

Then they subject the patient to an array of blood tests, x rays, scans, urine tests

Then, the allopatic doctors use drugs or surgery in order to get your test numbers in the normal range.

Before you know it, the patient is on 15 drugs. They cannot sleep so they are prescribed sleeping pills. Then they are depressed, so anti-psychotics- Finally Oxycontin for the constant unbearable pain.

Allopathic care in NZ is cheap, readily available, but a death trap for the trusting (except for catastrophic events). USAians pays hundreds of thousands of dollars for misery and drug induced ill-health.

If cat poop (feces) were cheap and available in one place (NZ), but outrageously expensive and rationed in another (USA), it is still, basically, just cat shite.

VietnamVet , October 24, 2017 at 4:40 pm

The problem is for profit healthcare. The more tests and treatments, the higher the managers bonuses. There is no regulation except for the insurance companies who are only interested in their own bottom line. The patient is not in a position to rationally oversee their care by themselves. All that matters today is profits; no matter how they are achieved. That is why American life expectancy is decreasing. Besides giving everyone healthcare; a system of primary physicians, government oversight of hospitals and care facilities plus jail time for criminals are also needed.

kareninca , October 24, 2017 at 4:43 pm

I have relatives by marriage who live in southern Indiana near the Kentucky border. They are "respectable working class," and I guess they must have good health insurance. I have never known anyone to have so many surgeries. It is astounding. Cardiac surgeries and orthopedic surgeries, for the most part. The ones I have in mind are 58 and 62 years old; they have never smoked; they go to Mass every Sunday, they have been happily married since they were young and while they don't eat health food they don't eat every meal at McDonald's. But it is surgery after surgery after surgery. They never question the doctors; they never hesitate. And now, unfortunately, some consequences of the surgeries are coming due; the guy is in the hospital with infections both in his pacemaker and in his heart valve (they just replaced both; he'll probably be okay). No-one else I know has surgeries like this. I think it is a regional scam. It's true that my dad in CT has had a number of vascular surgeries, but he smoked for decades and the dire need for them has been very apparent.

Here in northern CA, I have a friend whose girlfriend's son went to the emergency room a number of years ago for a bad finger cut. He was told he needed amputation. Then they found out he had no insurance. He was told to use a salve, and in fact it worked fine. I also have a friend here in Silicon Valley who recently had digestive problems. The MRIs, CAT scans, lab tests and probings under sedation were endless. Finally she was told to stop eating acidic food.

nihil obstet , October 24, 2017 at 4:54 pm

Reducing the profit motive as much as possible is why I would prefer a National Health Service (call it VA for all). Insurance, even if it's single payer, is still open to fraud and overtreatment. Let's try to think of medical practitioners as professionals rather than entrepreneurs, and get them to think of themselves that way. I also see it as a possible way to reduce the very high premium given to specialists, so that more would go into primary care.

Nilavar, M. D. , October 24, 2017 at 5:09 pm

In modern Medical practice, PROCEDURALISTS ( Surgeons of all kind, Cardiologists, orthopods, Pulmonologists, gastro enterologists anfd of course, invasive and diagnostic Radiologists etc ) always get compensated more than the primary care providers!

There are more CPT codes to charge for specialists than the GPs or FPs

Medicine is business run by 3rd parties! Vested interests won't allow any challenges to status quo, just the banking system and the FIRE Economy!

Wade Riddick , October 24, 2017 at 4:59 pm

With all due respect, if the UK system has embraced, "commercial conflicts of interest," "payment by activity," and the demands of "pay for performance" then that means they have a substantial set of profit incentives already in place, rendering their medical system *more*, not *less*, similar to America's. They may have single payer but that just captures the monopoly rents by regulating the cartel/monopoly/utility or whatever you want to call the medical establisment (it's per se difficult to even talk about market competition when there's only one drug or treatment that will save a patient).

The unregulated private provision of public goods like medical care always leads to extortion for profit. If you privatize fire-fighting, entire cities will burn to the ground. If you privatize schools, you get ignorance. If you privatize prisons, you get kidnapping-for-profit and the highest incarceration rate in the civilized world.

If you privatize the military, you get endless war. Why would a for-profit business ever win a war? For that matter, why would they ever lose? The war's over and they'd be out of money. You think it's just a coincidence that in the age of corporate personhood (Citizens United) and unlimited bribery of public officials, you've had two of the longest, most expensive and least determinative conflicts in our history in Iraq and Afghanistan?

You think it's a coincidence that the more unregulated "markets" we through at medicine, the more expensive our medical care becomes and the sicker we all get?

Cures don't make money. Repeat customers do.

Show me a for-profit business that's in business to go out of business and I'll show you the perfect company for insuring against social hazards.

It's simple middle-manager fraud. Politicians love privatizing government because they get to pocket the public budget. When the marines or public school principals hand tax dollars back to politicians and their cronies, everybody goes to prison. Privatize it and then you can have the contractor or charter school give you "campaign donations" – no doubt celebrating your economic genius in the process. They can hire your spouse and cousins. The contractor can even bid up the real estate and then rent it back to themselves at exorbitant prices. There are a million ways to launder the money.

Why do you think there is no transparent public accounting on most of this stuff? The budget disappears into a black hole – which, incidentally, you'll discover the minute you're in a hospital, dealing with a pharmacy benefit manager (PBM) or health insurer. That was the true purpose of MERS – to make good mortgage information disappear so CDO purchasers would never know what was in the mystery meat.

This is the great unraveling of Progressive Era controls on public corruption.

If you pay a dotor for every surgical screw he installs, is it any surprise then that a diabetic winds up getting several in his spine he never needed?

This is also how we have set up the aluminum and copper markets, letting speculators buy and horde commodities to drive up the price. It's also how we run drug distribution under the PBMs. PBMs provide a kickback in the form of a "stocking fee" to pharmacies which would get people sent to prison in other industries. When derivatives traders are not end consumers or producers of a commodity, they bid up prices the same way. We actually give pharmacies a profit incentive to drive cheap, effective, public domain chemicals off the market in favor of expensive, privately patented medicines. Because they are expensive, they pay a greater kickback so the pharmacy has greater incentives to stock and push it.

When railroads charged both farmers and consumers shipping and receiving food, it bankrupted both sides of the transaction by creating incentives to reduce supply in the monopoly transportation network. Reducing rail capacity bid up transportation prices and saved the company on investment. That's how you raise profits: raise prices, lower expenses. They had no rival to compete. That's why these kickbacks were outlawed. Imagine if the post office made you buy a stamp for every letter you receive. Oh, wait. We have that with the end of net neutrality. The ISPs get paid both by the service supplier (e.g., Netflix) and by their "customer" (you and I).

You this same "rationing" take place now with drugs. Since legalizing PBM kickbacks, drug prices have soared and we've lived through some of the greatest drug shortages since the Soviet Union went bankrupt. Hundreds of chemotherapy patients per year have died because cartels control supply and they don't like patients getting cheap, efective, public domain treatments. Go look at the availability of methotrexate over the last ten years or your platinum-based compounds. No one tells you this. It's a blip on the back page of a newspaper (and pretty soon we won't even have those). Do you think TV "news" – making its profits off drug ads – will ever talk about this?

It's a new war of enclosure – and it's far more extensive than simply drug markets. The privatizers are confiscating clean air, potable water, healthy food, public education, public policing and a host of other "general welfare" functions of the government promised us in the preamble. It all traces back to the ideology of for-profit government – which, in technical political science terms, is called fascism – when businesses own and operate the government for private gain.

By the way, we don't need less testing in medicine. We need more. I don't know a single idiot in Silicon Valley who ever said we need less data collection. The simple fact is we need to test everything in a patient and compare everything we collect across thousands of diseases. The cost of sensors and DNA sequencing, imaging and protein detection – not to mention data processing – has been falling dramatically and yet "reformers" always stress "rationing" as the cure for health care prices. It's partly because we ration preventative medicine and diagnostics that we're in this situation.

Another great place to start would be separating diagnostics (evaluation) and treatment. Would you let the bank's chief loan officer also serve as the chief auditor? Yet we let the same doctor diagnose, treat and evaluate his own work.

As someone with serious chronic illness from these frauds, listen to me when I tell you we should be practicing medicine thousands of patients at a time with transparent public auditing and big data model building. Building my own private model of genetics from public research saved my life. Nobody does that for you in medicine. Nobody is paid anywhere in the system based on whether you get the cheapest, most effective and safest treatment; in fact, I've heard of people getting fired for exactly that.

nilavar, MD , October 24, 2017 at 5:37 pm

'By the way, we don't need less testing in medicine. We need more. '

ah?

No test is 100% accurate! Every test has a potential for a FALSE positive or FALSE negative result.

False + may lead to unnecessary more testing and probably unneeded surgery! False negative gives false sense of relief!

Every test has to stand alone for specificity, sensitivity and accuracy, by statistics!

Wade Riddick , October 24, 2017 at 7:48 pm

You've answered your own question. No single measurement, in isolation, is 100% accurate. That's why we need thousands.

We need a cheap gene array chip that measures 10,000 markers in the blood and we need a big data project to match those measurements against a baseline. We need cheap, safe whole body scans. We need measurements of what every cell is up to and how they deviate from the norm.

Nobody's very angry that cell phone cameras keep getting better, yet somehow we're always upset that doctors want plenty of tests. That camera is a sensor that measures our environment and the chip gets better and cheaper each year. We need the same attitude in medicine. But then cardiologists might get upset that an immuno-assay shows you're at risk for atherosclerosis. These guys still don't want to accept that clogged arteries are an immune system problem and the immune specialists don't want to accept that it mostly gets started in the gut. And the gut guys don't want to have anything to do with immunology or cardiology.

Round and round we go

Oregoncharles , October 24, 2017 at 5:09 pm

I'll have to read the post this evening, but I have something to add to the theme:

I was in a meeting where a prominent local single-payer advocate, an emergency room doctor, told us, passionately, that administrative costs were only half the problem,. or less. Overtreatment and overtesting were the bigger part. He blamed the doctors, but of course their billing practices are a big factor.

A big advantage of single-payer is that it creates an institution with the power and motive to change medical practice. Iatrogenic illness is a big factor; overtreatment can kill.

Mayo One , October 24, 2017 at 5:13 pm

My wife has some chronic health issues and is a regular visitor at–and occasional guest of– the Mayo Clinic, traditionally seen as the home of "integrated medicine" (i.e. the various specialties speak with each other). We count ourselves ridiculously, ridiculously fortunate to be able to so often and easily rely on the oft-named best hospital system in the world. That said, it's amazing to both of us, even there, how silo-ed medicine has become. This silo-ing HAS to create an inordinate amount of overtreatment. The generalists, however, are left far behind in the community practices, often not able to do much beyond prescribing antibiotics and making referrals. There is a LOT of need for more holistic thinking about the patient that modern western medicine has lost, likely inadvertently, as greater knowledge leads to the need for greater specialization. The gap of some type of "master generalist" (which would of course be another layer of expense in the healthcare system) is filled either by the patient (of patient's family) or left void. As a result, there's either a huge tax of time, stress, frustration spent searching internet chat boards and medical reference sites to understand topics because it seems like no single doctor "gets it", or a hugely inefficient and potentially quite harmful medical treatment experience as each specialty chips away at their corner of the patient. I'm not sure what the answer is, but if this is the experience of a frequent Mayo Clinic patient, I'd wager that the question posed is a pretty fundamental one to the entire practice of modern medicine.

PlutoniumKun , October 24, 2017 at 5:21 pm

I would add an extra 'over' to your list – overdiagnosis.

One of the the few bright spots in published stats for the US compared to other countries is an apparent higher survival rate from cancers. I mentioned this to a relative who is a medical specialist and he just laughed. 'its not surprising' he said 'since an amazing number of those treated in the US for cancer don't actually have cancer'. Quite simply, overuse of dubious 'tests' results in a huge number of false positives for cancer. This leads to 'successful' treatments. There are many tests in the US which are simply not permitted in countries with public systems because they produce far too many false positives to justify their use, either because the cancer doesn't exist, or it is not sufficiently malignant to justify treatment (apparently there are cancers that lie dormant without ever threatening life). I'm not aware, however, if this has ever been quantified, but its certainly true that there are many testing protocols commonly used in the US which are actively recommended against in most European health systems as they are considered not just a waste of money, but actively harmful.

A relative of mine who is a very highly regarded specialist in drug prescribing practice in Europe is currently doing a one year study on practice in the US (focusing on opiates, as it happens). He said that one of the initial findings is that there is a different culture around prescribing in the US to what he is familiar with. Quite simply, US doctors are not taught how to say 'no' to patients in a way which doesn't upset them or feeling they've been given a brush off.

Someone mentioned overuse of heart operations above. In Ireland, they developed what are called ' Sli na Slainte ' walks, which have spread worldwide. These were developed by the Irish Heart Association following complains that patients were asking for too many drugs and treatments, and not doing the simple thing which was shown to help in the aftermath of heart attacks – exercise. They are way marked walks of set distance – doctors simply prescribe the walk instead of drugs. They are hugely successful. But there is no money in it, so guess where they haven't been adopted?

*disclaimer* I should say I'm not a medical professional, but I do have an interest in the topic.

nilavar, MD , October 24, 2017 at 5:44 pm

'US doctors are not taught how to say 'no' to patients in a way which doesn't upset them or feeling they've been given a brush off.'

But there is always another doctor 'willing' to say YES! Shopping for 'yes' doctors is NOT usual! They are called 'DR. Feel good' ;-)

Remember, Medicine is a business in America!

Chris , October 24, 2017 at 5:44 pm

Thank you, PK. Very interesting, and follows from a thoughtful and insightful post from Lambert, but I guess it makes common sense to strengthen heart muscle and accelerate the body's natural ability to heal itself through exercise. Pity about the commonness of common sense though, but I digress.

We all know we can live longer and avoid or postpone chronic ailments by maintaining a healthy weight and doing some exercise, particularly cardio. And our arms and legs may look the same over our declining years, but if you don't use them, you will lose them, those muscles that is.

I post. that such an ideal is too far when you are time and money poor, constantly worried and depressed

Poverty and sickness and lower mortality – they're all linked to one another. Designed and baked into the dying system

JBird , October 24, 2017 at 6:54 pm

None or too little, or too much, and very occasionally just the right amount of medical care for the lucky few. What a mess.

I'll add that the elderly, and the poor's, opinions seem to be discounted by caretakers as if you are lucky enough to be old or unlucky enough to be destitute means you're soft in the head. So if a patient can understand and communicate what they want and realistically need they have to fight to be listened too.

Steve , October 24, 2017 at 7:25 pm

Four years ago my father who was 78 at the time began having difficulty eating. He had been diagnosed with parkinson's a couple years earlier but the meds he was on were acceptable and effective for him. He was a brilliant physicist. Well they did a colonoscopy and found tiny tumors. One couldn't be taken care of at the time and the process to his death began. No one knew how long the tumor had been there or at what speed it would grow but chemo and radiation were prescribed to make it easier to remove. This became a very long sad story which I will not go into detail on right now. The chemo made my Dad horribly sick. The radiation to pin point a tiny area less than the size of a quarter ended damaging all his organs. He died in pain on Thanksgiving morning 2 years ago. The radiation had done too much damage. When he asked questions about treatment he was shuffled to diffident doctors or just not answered. These were very high end NE Medical facilities. The reason he went in for digestive problems never were fixed. Had the tumors never been addressed he could very well be alive today. To date I have over 5 friends who have had a parent die not from the condition they sought help for but the radiation treatment.

mirjonray , October 24, 2017 at 8:09 pm

For me the problems start with the routine physicals which are "free" courtesy of Obamacare. The doctors run tests and find problems with this and that, and after ultrasounds and CT scans and little surgeries to get rid of benign little thingies, before you know it you've spent thousands of dollars (courtesy of high deductibles ) for basically nothing. This last time around my GP didn't like a few things in my lab results and I ended up with a specialist. He started off with "why are you here to see me today?" After questioning me for a little while about my (lack of) symptoms, I finally told him, "I never would have come here on my own if my doctor hadn't have sent me here."

cojo , October 24, 2017 at 9:04 pm

Dr. Lown is on to something:

[DR. LOWN: In my view the lost art of listening is a quintessential failure of our health care system. I think that you cannot heal the health care system without restoring the art of listening and of compassion. You cannot ignore the patient as a human being. A doctor must be a good listener. A doctor must be cultured in order to understand where the patient lives, why he lives like that, and also realize that the leading cause of disease in the world is poverty.

Medicine is becoming more dehumanizing. This is not only structural due to shorter patient visits, less face to face interaction, fewer family physicians treating the whole family, visiting the patient at their home, to see what their environment/neighborhood is like. It is also the way physicians practice medicine, treating patient's as mere data sets. I'm not trying to minimize data in medical decision making, but taken out of context from the human element, treating data may be misleading and may not be treating the patient's ills.

In my experience, when I see a patient coming in over and over for the same complaints, it is likley due to one of three main reasons. One, they are either being misdiagnosed and mistreated, two, they are seeking a special test or drug, or three, their symptoms are not due to an organic medical cause, but due to some sort of somatization secondary to life stressors. Trying to figure out which it is requires the clinician to listen to the patient and understand where they are coming from. Unfortunately, when a primary care physician only has 10 minutes per visit, it is much easier to order a battery of tests to not miss any important diagnoses, or to just capitulate to patient demands than to listen, and in many cases take the time to give the patient some much needed reassurance.

That being said, the patient is not always an innocent bystander in this. There are also many times that the clinician will pick up on the dynamics mentioned above, but reassurance will not satisfy the patient. The patient will demand more be done for a number of reasons. These are mostly anecdotal, such as I read an article and think I need such and such a test, or my friend/family member had this procedure done and I need it two. It sometimes takes me twice as long to explain to a patient why they don't need something done as it does as to why they do. This is a societal thing and this is linked to the problem of defensive medicine. I like to joke, that physicians always get sued for not ordering a test that may have been indicated, but rarely if ever get sued for over treating someone and then causing harm. Perhaps it has something to do with the ethos that it's better to do something and look like you're trying that to do nothing, even though that may be the best course for the patient.

In the end, I think physicians need to be better trained to listen, remember the mantra of "first do no harm", and treat each patient as if they were their close family member. The incentive structure in medicine has to also change, including the way physicians are reimbursed, as well as the way information and clinical data is sourced and distributed to avoid excess industry bias. And finally, patient's have to understand that more is not necessarily better, they or their relative do not have a god given right to every experimental, and outrageously expensive treatment available if it does not apply to them clinically and if the chances of it prolonging life are minimal.

GERMO , October 24, 2017 at 9:27 pm

Overtreatment can't possibly be as big a problem as undertreatment, at least certainly not in the world of crappy insurance or subsidized care our experience was definitely a solid reluctance to order expensive tests or to consider that the problem might be complicated and costly. Which it turned out to be, and the eventual surgery was scheduled as late as possible, as a last resort, and we had to insist on more thorough testing to get a proper diagnosis. They just wanted to save money. The tumor grew all the while this organization was hoping it was something minor. I don't want to hear about overtreatment, thanks -- it seems to always get distorted into blaming the patients for greedily consuming too much healthcare!

[Jun 28, 2017] Prescription Drug Spending is Consuming a Bigger Share of Wages

Notable quotes:
"... The three percent of annual wage income lost to higher drug spending over the past 40 years makes a big difference to working individuals and families. This increase in annual spending averages out to roughly $2,400 per household. CMS projections, combined with projections on wage income growth from the Congressional Budget Office, suggest that spending on prescription drugs will increase further through 2025. This ratio is expected to exceed five percent by 2024. ..."
Jun 28, 2017 | economistsview.typepad.com

anne

, June 27, 2017 at 05:19 PM
http://cepr.net/blogs/cepr-blog/prescription-drug-spending-is-consuming-a-bigger-share-of-wages

June 27, 2017

Prescription Drug Spending is Consuming a Bigger Share of Wages
By Brian Dew and Dean Baker

Prescription drugs are a large and growing share of national income. While it is generally recognized that drugs are expensive, many people are unaware of how large a share of their income goes to paying for drugs because much of it goes through third party payers, specifically insurance companies and the government.

The Centers for Medicare & Medicaid Services (CMS) produce projections of national expenditures on prescription drugs through 2025, along with historical estimates dating back to 1960. As shown below, prescription drug spending from 1960 to 1980 was equivalent to about one percent of total wage and salary income. In the years leading up to the passage of the Bayh-Dole act in 1980, wage income was rising faster than spending on prescription drugs. As a result, the share of wages spent on prescription drugs was actually falling, reaching a low in 1979 of 0.86%.

[Graph]

However, after 1980, prescription drug spending rose rapidly relative to wage income. The ratio of drug spending to wages rose each year from 1980 to 2007. In 2007 wage growth finally outpaced drug expenditures, with the ratio again increasing in the Great Recession. By 2010, prescription drug spending had climbed above four percent of wage income.

The three percent of annual wage income lost to higher drug spending over the past 40 years makes a big difference to working individuals and families. This increase in annual spending averages out to roughly $2,400 per household. CMS projections, combined with projections on wage income growth from the Congressional Budget Office, suggest that spending on prescription drugs will increase further through 2025. This ratio is expected to exceed five percent by 2024.

While an aging population has been a factor increasing spending on drugs, demographics alone cannot explain the sharp increase in prescription drug spending. Inflation-adjusted prescription drug spending per household has increased more than eightfold since 1980, far outpacing any demographic trend surrounding age. The share of people over age 65 in the population has increased from 9.2% in 1960 to 14.8% in 2015. This can at most explain a small part of the increase in spending on drugs over this period.

[Graph]

It is important to recognize that the high cost of drugs is the result of a conscious policy decision to give drug companies monopolies in the form of patents and other forms of exclusive marketing rights. Without these protections drugs would almost invariably be cheap, likely costing on average less than one fifth as much as they do now. Even worse, the perverse incentives resulting from patent monopolies distort the research process and can lead drug companies to misrepresent evidence on the safety and effectiveness of their drugs.

[Jun 22, 2017] Playing Games with Drugs at the Wall Street Journal

Jun 22, 2017 | economistsview.typepad.com

anne , June 21, 2017 at 05:02 AM

http://cepr.net/blogs/beat-the-press/playing-games-with-drugs-at-the-wall-street-journal

June 20, 2017

Playing Games with Drugs at the Wall Street Journal

A column * in the Wall Street Journal by Dana P. Goldman and Darius N. Lakdawalla presents a case for high drug prices by making an analogy to the salaries of major league baseball players. They ask what would happen if the average pay of major league players was cut from $4 million to $2 million. They hypothesize that the current crew of major leaguers would continue to play, but that young people might instead opt for different careers, leaving us with a less talented group of baseball players. Their analogy to the drug market is that we would see fewer drugs developed, and therefore we would end up worse off as a result of paying less for drugs.

This analogy is useful because it is a great way to demonstrate some serious wrong-headed thinking. It also leads those of us who had the privilege of seeing players like Bob Gibson, Sandy Koufax, Henry Aaron, and Willie Mays in their primes to wonder if there somehow would have been better players 50 years ago if the pay back then was at current levels.

But the issue is not just how much we should for developing drugs, but how we should pay. Suppose that we paid fire fighters at the point where they came to the fire. They would assess the situation and make an offer to put out the fire and save the lives of those who are endangered. We could haggle if we want. Sometimes we might get the price down a bit and in some occasions a competing crew of firefighters may show up and offer some competition. Most of us would probably pay whatever the firefighters asked to rescue our family members.

This could lead to a situation where firefighters are very highly paid, since at least the ones who came to rich neighborhoods could count on payouts in the millions or even tens of millions of dollars. Suppose someone suggested that we were paying too much for firefighters' services and argued that there we could drastically reduce what we pay for a service we all recognize as tremendously important. Well, Goldman and Lakdawalla would undoubtedly respond with a Wall Street Journal column telling us that fewer people will want to be firefighters.

But this is really beside the point. Just about everyone agrees that it does not make sense to be determining firefighters' pay when they show up at the fire. We pay them a fixed salary. While they sit around waiting most of the time, occasionally they provide an incredibly valuable service saving valuable properties from destruction or even more importantly saving lives.

No one thinks that firefighters get ripped off because they don't walk away millions of dollars when they save an endangered family. They get paid their salary (which we can argue whether too high or too low) for work that we recognize as dangerous, but which will occasionally result in enormous benefits to society.

In the case of developing drugs, we are now largely in the situation of paying the firefighters when they show up at the burning house. As a result of historical accident, we rely on a relic of the medieval guild system, government granted patent monopolies, to finance most research into developing new drugs. These monopolies allow drug companies to charge prices that are several thousand percent ** above the free market price.

This leads to all the corruption and distortion that one would expect from a trade tariff of 1000 or even 10,000 percent. These markups lead drug companies to expend vast resources marketing their drugs. They also frequently misrepresent the safety and effectiveness of their drugs to maximize sales. They make payoffs to doctors, politicians, and academics to enlist them in their sales efforts. And, they use the legal system to harass potential competitors, often filing frivolous suits to dissuade generic competitors.

This system also leads to a large amount of wasted research spending. This is in part because competitors will try to innovate around a patent to share in the patent rents. In a world of patent monopolies it is generally desirable to have competing drugs, however if the first drug was selling at its free market price, it is unlikely that it would make sense to spend large amounts researching the development of a second, third, and fourth drug for a condition for which an effective treatment already exists, rather than researching drugs for conditions for which no effective treatment exists.

Patent monopolies also encourage secrecy in research, as drug companies disclose as little information as possible so that they prevent competitors from benefiting from their research. This also slows the research process.

The obvious alternative would upfront funding, just like firefighters are paid a fixed salary for their work. Under this system a condition of the funding would be that all the research findings are posted on the web as quickly as practical to maximize the ability of the scientific community to benefit. We already do this to some extent with the $32 billion a year that goes to the National Institutes of Health, although this amount would likely have to be doubled or even tripled to make up for the research currently supported by government granted patent monopolies. (I outline a system for this in my book "Rigged: How Globalization and the Rules of the Modern Economy Have Been Structured to Make the Rich Richer" *** - it's free.)

Anyhow, it would be good if we could be having a debate about how we finance drug research rather than just telling silly stories about baseball players salaries. Bernie Sanders, Elizabeth Warren, Al Franken, Sherrod Brown and thirteen other senators have already introduced a bill that would have the government pick up the tab on some clinical trials and then putting the rights to successful drugs in the public domain so they can be sold at generic prices. The bill also has a patent buyout fund that would accomplish the same goal.

It is absurd that we charge people hundreds of thousands of dollars for life-saving drugs that cost a few hundred dollars to produce. Too bad the Wall Street Journal has so little creativity that it cannot even imagine an alternative to a grossly antiquated institution when it comes to financing prescription drug development.

* https://www.wsj.com/articles/take-me-out-to-the-pill-game-1497913367

** http://www.thebodypro.com/content/78658/1000-fold-mark-up-for-drug-prices-in-high-income-c.html

*** https://deanbaker.net/images/stories/documents/Rigged.pdf

-- Dean Baker

[Jun 21, 2017] Neoliberalism and opioids abuse

Jun 21, 2017 | economistsview.typepad.com

libezkova, June 21, 2017 at 07:25 PM

Over 33K people in US died of opiates overdoses in 2015 according to the Centers for Disease Control and Prevention.

Not only unemployed abuse opioids, but more and more college students and recent graduates are abusing the opioids as well, according to a survey of 1200 college aged adults commissioned the same year by Christie foundation.

Federal law does not require colleges to report drug death unless they are deemed criminal. But fatal overdoses have been rising at schools nationwide underscoring and horrifying reality of for administrators: in addition to binge drinking and marijuana, they have another crisis firmly entrenched on campus.

Now losing 30K people in one year is like small scale civil war (like the one they have in Ukraine) and in a way it is: war of wealthy and medical industrial complex against those in difficult circumstances, with dreams crashed and, especially, unemployed.

https://www.usnews.com/news/news/articles/2016-06-14/opioids-linked-with-deaths-other-than-overdoses-study-says

== quote ==

CHICAGO (AP) - Accidental overdoses aren't the only deadly risk from using powerful prescription painkillers - the drugs may also contribute to heart-related deaths and other fatalities, new research suggests.

Among more than 45,000 patients in the study, those using opioid painkillers had a 64 percent higher risk of dying within six months of starting treatment compared to patients taking other prescription pain medicine. Unintentional overdoses accounted for about 18 percent of the deaths among opioid users, versus 8 percent of the other patients.

"As bad as people think the problem of opioid use is, it's probably worse," said Wayne Ray, the lead author and a health policy professor at Vanderbilt University's medical school. "They should be a last resort and particular care should be exercised for patients who are at cardiovascular risk."

His caution echoes recent advice from the Centers for Disease Control and Prevention, trying to stem the nation's opioid epidemic. The problem includes abuse of street drugs like heroin and overuse of prescription opioids such as hydrocodone, codeine and morphine.

The drugs can slow breathing and can worsen disrupted breathing that occurs with sleep apnea, potentially leading to irregular heartbeats, heart attacks or sudden death, the study authors said.

In 2014, there were more than 14,000 fatal overdoses linked with the painkillers in the U.S. The study suggests even more have died from causes linked with the drugs, and bolster evidence in previous research linking them with heart problems.

The study involved more than 45,000 adult Medicaid patients in Tennessee from 1999 to 2012. They were prescribed drugs for chronic pain not caused by cancer but from other ailments including persistent backaches and arthritis.

Half received long-acting opioids including controlled-release oxycodone, methadone and fentanyl skin patches. Fentanyl has been implicated in the April death of Prince, although whether the singer was using a fentanyl patch, pills or other form of the drug hasn't been publicly revealed.

Long-acting opioids remain in the body longer. The study authors noted that the body's prolonged exposure to the drugs may increase risks for toxic reactions.

The remaining study patients had prescriptions for non-opioid drugs sometimes used to treat nerve pain, including gabapentin; or certain antidepressants also used for pain.

There were 185 deaths among opioid users, versus 87 among other patients. The researchers calculated that for every 145 patients on an opioid drug, there was one excess death versus deaths among those on other painkillers.

The two groups were similar in age, medical conditions, risks for heart problems and other characteristics that could have contributed to the outcomes.

The results were published Tuesday in the Journal of the American Medical Association .

The study involved only Medicaid patients, who include low-income and disabled adults and who are among groups disproportionately affected by opioid abuse.

Ray noted that the study excluded the sickest patients and those with any evidence of drug abuse. He said similar results would likely be found in other groups.

Dr. Chad Brummett, director of pain research at the University of Michigan Health System, said the study highlights risks from the drugs in a novel way and underscores why their use should be limited.

[May 31, 2017] End the Greedy Silence Dissident Voice

Notable quotes:
"... Unstoppable The Emerging Left Right Alliance to Dismantle the Corporate State (2014), among many other books, and a four-time candidate for US President. Read other articles by Ralph , or visit Ralph's website . ..."
"... This article was posted on Tuesday, May 30th, 2017 at 5:18pm and is filed under Capitalism , Health/Medical , Pharmaceuticals . ..."
May 31, 2017 | dissidentvoice.org
End the Greedy Silence

Enough Already

by Ralph Nader / May 30th, 2017

It is time Americans rise up against the corruption, inefficiency, and cruelty of our healthcare system and tell its corporate captors and Congress – Enough Already!

For decades other countries have guaranteed universal health insurance for all their people, at lower costs and better outcomes (President Truman proposed it 72 years ago in the US). When are we going to break out of this taxpayer-subsidized prison built by the giant insurance companies, drug goliaths and monopolizing hospital chains?

How long is Uncle Sucker going to pay through the nose for gouging drug prices, patient-denying health insurance companies and all the brutal fine print rules in consumer contracts whose trap doors are maddening tens of millions of Americans?

Deductibles, exclusions, waivers, co-pays, corporate immunities from injured patients, disqualifying changes in patients' status and just plain stonewalling are just some examples of this cruel madness.

Not to mention the endless electronic bills with their inscrutable codes and unchallengeable charges – that is if you can get anyone on the phone to answer your questions. Billing fraud and abuses alone cost us up to $330 billion a year!

Why do we put up with "pay or die" drug prices? Why do we tolerate our fellow Americans dying in the tens of thousands each year because they cannot afford health insurance to get diagnosed and treated in time?

Do we know that the profiteering drug companies regularly are given a slew of handouts, including huge tax breaks, free drugs developed by our National Institutes of Health, and few restraints on their high pressure sales of dangerous and addictive drugs (eg opioids) or, together with their corporate middlemen, return the favor by charging Americans the highest prices in the world? Other countries put limits on such blatant greed and exploitation.

Groping for ever more profits, the big drug companies offshore production to less regulated labs in China and India, which amount to 60% of the drugs we buy and 80% of the active ingredients in all medicines sold in the US. Unpatriotic in the extreme!

Compounding these inhumane practices is a supine Congress, with few exceptions like Rep. Lloyd Doggett (D, TX), and state legislatures, misusing the power we entrusted to them. These legislators see large pharmaceutical companies as honey pots for campaign cash that work as hush money paid by hordes of drug industry lobbyists. So craven was the majority in Congress in 2003 that, when the drug benefits bill was passed, it prohibited Medicare from negotiating volume discounts for this lucrative corporate sales bonanza (Past Congresses authorized the Pentagon and Veterans Administration to bargain and they get lower prices as a result).

Despite the fact that these healthcare challenges have been dealt with more humanely and economically by other Western countries in the world, Americans are consistently told to tolerate an aggravating status quo. Scores of books, articles and television exposés highlight all the ways we're pushed around, denied, excluded, harmed, overcharged and deceived, yet so many of these authors still maintain that our system of health insurance/healthcare can't be replaced with a much better one? So these writers continue to advise us how to duck, slide and swivel our escape from a few of these commercials chains and scams.

In all the fine articles written to help consumers navigate Obamacare, Medicare, and private health plans, the authors trap themselves in this vast corporate cul-de-sac by never mentioning the way out.

That way is Single Payer or Full Medicare for all, everybody in, nobody out, with free choice of doctors and hospitals – at far lower costs, mortality and morbidity. These narrow reformers can't escape their "it ain't going to happen here" syndrome.

Really? Don't they know that the public has long viewed Single Payer favorably (including a majority of doctors and nurses), even without political leaders standing up for it or mass media reporting this proven safe path.

The surrender to corporate tyranny infects the 113 members of the House of Representatives who have co-signed HR 676 to create full Medicare for all. They signed, but then gave in to a silent resignation by not fighting for it in Congress and back home.

When the companies and their apologists argue for a "free market" approach to healthcare, you can retort – what free market? Half the money coming to these companies is from the federal, state and local governments. Taxpayers also pay tens of billions of dollars for much of the discovery and testing of drugs. Tax breaks and loopholes in patent laws block generic drugs and distort the free market.

Drug patents are by definition monopolies. Concentration by mergers and acquisitions of hospitals, clinics and physician practices (note dwindling independent cardiology practices) raise serious anti-trust issues. Fine print contract peonage takes away the consumers' freedom of contract, as do the daily buy and sell equations, so often rendered by third parties for patients. Corporate billing and other crimes are endemic. What free market?

Each of you can help the Single Payer movement build momentum. Ask your members of Congress in writing if they support HR 676 and, if not, demand their appearance in person at a town meeting arranged by people like you to answer why. If they refuse, peacefully picket their local offices.

Ask the newspapers, radio and television stations, including the culpable public radio and public television, when are they going to cover the basic full Medicare reform supported by tens of millions of their listeners and viewers?

Finally, go to the website SinglePayerAction.org to find out what other people are doing and what more you can do with your friends and co-workers.

One percent of you, together with popular backing, can make it happen, through a persistent civic hobby. Remember, you only have to turn around less than 450 members of Congress.

Enough Already?

Ralph Nader is a leading consumer advocate, the author of Unstoppable The Emerging Left Right Alliance to Dismantle the Corporate State (2014), among many other books, and a four-time candidate for US President. Read other articles by Ralph , or visit Ralph's website .

This article was posted on Tuesday, May 30th, 2017 at 5:18pm and is filed under Capitalism , Health/Medical , Pharmaceuticals .

[May 29, 2017] As long as there is no countervailing force, financialization of healthcare will continue unabated

May 29, 2017 | economistsview.typepad.com

Health care -- skyrocketing cost of (USA only).

Financialization of health care makes Goldman-Sachs look like amateurs. Just read Suskind's Confidence Men -- now reading Rosenthal's American Sickness.

First hundred pages I thought her medicine was the exact same story as his Wall Street -- but hundreds more pages of her story goes on. The most unimaginable book I've read in a decade (decades?).

Single payer Medicare has none little to slow medical financialization. You can pick any health system you want from any country you like.

As long as there is no countervailing force, financialization will continue unabated. Repeat: 6% labor union density equates to 20/10 blood pressure -- starves every healthy process.

[May 05, 2017] William Binney - The Government is Profiling You (The NSA is Spying on You)

Very interesting discussion of how the project of mass surveillance of internet traffic started and what were the major challenges. that's probably where the idea of collecting "envelopes" and correlating them to create social network. Similar to what was done in civil War.
The idea to prevent corruption of medical establishment to prevent Medicare fraud is very interesting.
Notable quotes:
"... I suspect that it's hopelessly unlikely for honest people to complete the Police Academy; somewhere early on the good cops are weeded out and cannot complete training unless they compromise their integrity. ..."
"... 500 Years of History Shows that Mass Spying Is Always Aimed at Crushing Dissent It's Never to Protect Us From Bad Guys No matter which government conducts mass surveillance, they also do it to crush dissent, and then give a false rationale for why they're doing it. ..."
"... People are so worried about NSA don't be fooled that private companies are doing the same thing. ..."
"... In communism the people learned quick they were being watched. The reaction was not to go to protest. ..."
"... Just not be productive and work the system and not listen to their crap. this is all that was required to bring them down. watching people, arresting does not do shit for their cause ..."
Apr 20, 2017 | www.youtube.com
Chad 2 years ago

"People who believe in these rights very much are forced into compromising their integrity"

I suspect that it's hopelessly unlikely for honest people to complete the Police Academy; somewhere early on the good cops are weeded out and cannot complete training unless they compromise their integrity.

Agent76 1 year ago (edited)
January 9, 2014

500 Years of History Shows that Mass Spying Is Always Aimed at Crushing Dissent It's Never to Protect Us From Bad Guys No matter which government conducts mass surveillance, they also do it to crush dissent, and then give a false rationale for why they're doing it.

http://www.washingtonsblog.com/2014/01/government-spying-citizens-always-focuses-crushing-dissent-keeping-us-safe.html

Homa Monfared 7 months ago

I am wondering how much damage your spying did to the Foreign Countries, I am wondering how you changed regimes around the world, how many refugees you helped to create around the world.

Don Kantner, 2 weeks ago

People are so worried about NSA don't be fooled that private companies are doing the same thing. Plus, the truth is if the NSA wasn't watching any fool with a computer could potentially cause an worldwide economic crisis.

Bettor in Vegas 1 year ago

In communism the people learned quick they were being watched. The reaction was not to go to protest.

Just not be productive and work the system and not listen to their crap. this is all that was required to bring them down. watching people, arresting does not do shit for their cause......

[Apr 06, 2017] The country will spend over $440 billion this year for drugs that would likely sell for less than $80 billion in a free market.

Apr 06, 2017 | economistsview.typepad.com
anne , April 06, 2017 at 05:31 AM
http://cepr.net/blogs/beat-the-press/robert-atkinson-pushes-pro-rich-protectionist-agenda-in-the-washington-post

April 6, 2017

Robert Atkinson Pushes Pro-Rich Protectionist Agenda in the Washington Post

The Washington Post is always open to plans for taking money from ordinary workers and giving it to the rich. For this reason it was not surprising to see a piece * by Robert Atkinson, the head of the industry funded Information Technology and Innovation Foundation, advocating for more protectionism in the form of stronger and longer patent and copyright monopolies.

These monopolies, legacies from the medieval guild system, can raise the price of the protected items by one or two orders of magnitudes making them equivalent to tariffs of several hundred or several thousand percent. They are especially important in the case of prescription drugs.

Life-saving drugs that would sell for $200 or $300 in a free market can sell for tens or even hundreds of thousands of dollars due to patent protection. The country will spend over $440 billion this year for drugs that would likely sell for less than $80 billion in a free market. The strengthening of these protections is an important cause of the upward redistribution of the last four decades. The difference comes to more than $2,700 a year for an average family. (This is discussed in "Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer," ** where I also lay out alternative mechanisms for financing innovation and creative work.)

Atkinson makes this argument in the context of the U.S. relationship with China. He also is explicitly prepared to have ordinary workers pay the price for this protectionism. He warns that not following his recommendation for a new approach to dealing with China, including forcing them to impose more protection for U.S. patents and copyrights, would lead to a lower valued dollar.

Of course a lower valued dollar will make U.S. goods and services more competitive internationally. That would mean a smaller trade deficit as we sell more manufactured goods elsewhere in the world and buy fewer imported goods in the United States. This could increase manufacturing employment by 1-2 million, putting upward pressure on the wages of non-college educated workers.

In short, not following Atkinson's path is likely to mean more money for less-educated workers, less money for the rich, and more overall growth, as the economy benefits from the lessening of protectionist barriers.

* https://www.washingtonpost.com/opinions/global-opinions/how-trump-can-stop-china-from-eating-our-lunch/2017/04/05/b83e4460-1953-11e7-bcc2-7d1a0973e7b2_story.html

** http://deanbaker.net/images/stories/documents/Rigged.pdf

-- Dean Baker

[Apr 06, 2017] Health Care Renewal Not Going to Take it Anymore - Doctors in the Pacific Northwest Unionize, Begin Collective Bargaining with Hospital Systems

Apr 06, 2017 | hcrenewal.blogspot.com
Managerialist Tactics: Outsourcing

The NYT article opened with

in the spring of 2014, when the administration announced it would seek bids to outsource its 36 hospitalists , the hospital doctors who supervise patients' care, to a management company that would become their employer.

The outsourcing of hospitalists became relatively common in the last decade, driven by a combination of factors. There is the obvious hunger for efficiency gains. But there is also growing pressure on hospitals to measure quality and keep people healthy after they are discharged. This can be a complicated data collection and management challenge that many hospitals, especially smaller ones, are not set up for and that some outsourcing companies excel in.

Outsourcing is a now familiar entry in the managerialists' playbook. It is seen more in manufacturing than in health care. Although touted as improving economic "efficiency," it also may reduce the accountability of the managers of the organization that does the outsourcing.

Pursuit of Economic Efficiency

In this case,

Outsourced hospitalists tend to make as much or more money than those that hospitals employ directly, typically in excess of $200,000 a year. But the catch is that their compensation is often tied more directly to the number of patients they see in a day - which the hospitalists at Sacred Heart worried could be as many as 18 or 20, versus the 15 that they and many other hospitalists contend should be the maximum.

It was the idea that they could end up seeing more patients that prompted outrage among the hospitalists at Sacred Heart, which has two facilities in the area, with a total of nearly 450 beds. 'We're doctors, we're professionals,' Dr. [Rajeev] Alexander said. 'Giving me a bonus for seeing two more patients - I'm not sure I should be doing that. It's not safe .' (A hospital representative said patient safety was 'inviolate.')


A constant theme of managerialism, and the neoliberalism that underlies it, is economic efficiency. The usual narrative is that efficiency means providing better goods and services at lower costs. Instead, managerialism and neliberalism may mean decontenting goods and services so as to lower costs to the organizations providing them, but not necessarily providing more value to consumers. In health care terms, managerialism and neliberalism may lead to less accessible, more mediocre health care that increase revenue to the organizations providing it, as implied by the physicians' comments above. Making the US the most commercialized, managerialist run, and arguably neoliberal health care system among the developed countries has not led to lower costs, better access, or better health care quality.


The backstory for the outsourcing emphasizes that managerialism, and the resulting economic efficiency was indeed the goal of PeaceHealth...

In 2012, Sacred Heart's parent, PeaceHealth, a nonprofit health care system, installed an executive named John Hill to adapt its Oregon hospitals to the latest trends in health care . Mr. Hill, in an effort to rein in the budget and improve the efficiency of a hospital that administrators said was lagging in key respects, including how long the typical patient stayed, eventually concluded that the hospitalists at Sacred Heart should be outsourced.

Centralization of Control

Furthermore,

The hospitalists also chafe at the way the administration has tried to centralize decisions they used to make for themselves. This might include hiring fellow doctors or the order in which they see patients on any day. They also complain of being loaded down with administrative tasks.

'We're trained to be leaders, but they treat us like assembly line workers ,' said Dr. Brittany Ellison, a hospitalist in the group. 'You need that time with the patient,...'


A major feature of managerialism is the concentration of power within (generic) management. To quote Komesaroff(1),

In the workplace, the authority of management is intensified, and behaviour that previously might have been regarded as bullying becomes accepted good practice. The autonomous discretion of the professional is undermined, and cuts in staff and increases in caseload occur without democratic consultation of staff. Loyal long-term staff are dismissed and often humiliated, and rigorous monitoring of the performance of the remaining employees focuses on narrowly defined criteria relating to attainment of financial targets, efficiency and effectiveness.

We're Only In It for the Money

Also, the negotiations that started once the PeaceHealth physicians formed their union demonstrated a central tenet of managerialism

Even starker than the divide over these questions are the differences in worldview represented on opposite sides of the table. During a bargaining session last fall, the administration proposed increasing the number of shifts a year. Hospitalists now earn about $223,000 a year for 173 shifts and are paid extra for working more. The hospital offered $260,000 for a mandatory 182 shifts, and up to $20,000 in bonus pay for hitting certain medical performance targets. The hospitalists work seven days on and seven days off, so this would have effectively eliminated any time off for sick days or vacation.

When the doctors pointed this out, the administration responded that if they missed a few days, it would make sure they got extra days to hit the required number of shifts for full pay.

The hospitalists assured the administration negotiators that their concern had nothing to do with money - that none of this had ever been about money. They preferred to work less and make less to avoid burnout, which was bad for them and worse for patients. At which point the administration responded that money was always the issue , according to several people in the room. (The hospital declined to comment.)

Suddenly it dawned on the doctors why they had failed to break through, Dr. Alexander said. 'Imagine Mr. Burns,' the cartoonishly evil capitalist from 'The Simpsons,' 'sitting across the table,' he said. 'There's no way we can say, 'This isn't what we're talking about. We're not trying to get the bonus.''


Again, managerialism is based on neoliberalism, and neoliberal view is that the market rules. The market is the arbiter of success, and money is the only outcome that matters. As Komesaroff put it(1),

The particular system of beliefs and practices defining the roles and powers of managers in our present context is what is referred to as managerialism. This is defined by two basic tenets: (i) that all social organisations must conform to a single structure; and (ii) that the sole regulatory principle is the market .

Mission-Hostile Management

Never mind that the centrality of money seems entirely inconsistent with the stated mission of PeaceHealth ,

We carry on the healing mission of Jesus Christ by promoting personal and community health, relieving pain and suffering, and treating each person in a loving and caring way.

Ostensibly, this is accompanied by core values, such as,

Stewardship We choose to serve the community and hold ourselves accountable to exercise ethical and responsible stewardship in the allocation and utilization of human, financial, and environmental resources. and,

Social Justice
We build and evaluate the structures of our organization and those of society to promote the just distribution of health care resources.


We have frequently discussed how leadership of contemporary health care organizations often seem to act contrary to the organizations' stated mission, that is, mission-hostile management .

Value Extraction

Finally, while managerialism is ostensibly concerned with economic efficiency, whose efficiency matters. When managers address physicians' efficiency, they seem to look at amount of work done divided by the cost to the hospital of paying physicians. However, they never seem to look at their own costs, the costs of management, as being a negative.

The PeaceHealth 2014 form 990 , the latest available, states that the then CEO, Mr Alan Yordy (whose highest academic degree was an MBA, according to his LinkedIn page ) had total compensation in 2013 of $1,366,742, and 11 other managers had total compensation greater than $250,000, with 9 having total compensation greater than $500,000. Those figures should be compared to the highest compensation offered the hospitalists, a maximum of $280,000 for 182 shifts a year, eliminating all vacation and sick leave. So if it is all about the money, the managers are making the most of it.

We have discussed ad nauseum the ridiculous compensation of the leaders of health care organization, even non-profit organizations. Value extraction by top management has become a central feature of the US and global economy (look here ).

The NYT article did not discuss whether the upset hospitalists knew about their bosses' compensation. I suspect they did.

Forming a Functioning Union at the University of Washington

The media coverage of the UW housestaff unionization was less detailed. It does appear, though, that a stimulus was the pursuit of economic efficiency by UW management through squeezing the pay of housestaff, as described in the December article in the Seattle Times . In it the house staff said,

they account for about one-fifth of King County's doctors and they want higher pay, new child-care benefits and free parking. Some UW residents and fellows earn so little that they qualify for welfare programs like Temporary Assistance for Needy Families and the Seattle City Light Utility Discount Program, according to the UWHA [University of Washington Housestaff Association.]

Another article in early January, 2016 in the Seattle Times added,

The association has proposed that residents and fellows earn at least the same salary as the UW's lowest-paid physician assistants . Because the doctors in training work very long hours, they sometimes earn less than Seattle's minimum hourly wage , the UWHA has said.

The council members, in their letter to Cauce, called the situation shocking. And based on information from the UWHA, they wrote that some residents and fellows qualify for welfare programs like Temporary Assistance for Needy Families (TANF).


The Seattle articles noted that the UW housestaff may earn from just over $53,000 to just under $70,000 a year. Keep in mind, however, that under current rules, house staff may work up to 80 hours a week. So $53,000 for someone working those hours translates into $13.25/ hour, under what many people now claim is the living wage. That could be considered exploitation of workers with doctoral degrees working in often highly stressful situations where lives may be on the line. Whether there were issues other than money (and the respect it implies) involved at UW was not apparent based on the minimal press coverage.

[Apr 05, 2017] Health Care Renewal managerialism

Apr 05, 2017 | hcrenewal.blogspot.com
John Stossel Discovers Health Care Dysfunction, Blames it on "Socialists" - Like Maurice Greenberg (AIG), John Thain (Merrill Lynch), Sanford Weill (Citigroup), and David H Koch? We have been ranting for a while about the dysfunctionality of the US health care system. Unfortunately, many people only realize how bad things are when they become patients, when they have bigger things to worry about than complaining. Furthermore, even if they complain, many patients may not feel they understand enough about what has gone wrong to suggest solutions.

Bad Customer Service at New York Presbyterian

This may not apply when media pundits, especially those with strong ideological views, become patients. So this week Fox News commentator and well known libertarian John Stossel disclosed his new illness, and vented his opinions about his hospital stay . Mr Stossel unfortunately developed lung cancer, although he was optimistic about his prognosis: "My doctors tell me my growth was caught early and I'll be fine. Soon I will barely notice that a fifth of my lung is gone."

However, he was not happy about his hospital's customer service:

But as a consumer reporter, I have to say, the hospital's customer service stinks . Doctors keep me waiting for hours, and no one bothers to call or email to say, 'I'm running late.' Few doctors give out their email address. Patients can't communicate using modern technology.

I get X-rays, EKG tests, echocardiograms, blood tests. Are all needed? I doubt it. But no one discusses that with me or mentions the cost .

Also,
I fill out long medical history forms by hand and, in the next office, do it again . Same wording: name, address, insurance, etc.
And,
In the intensive care unit, night after night, machines beep, but often no one responds . Nurses say things like 'old machines,' 'bad batteries,' 'we know it's not an emergency.'
Finally,
Some of my nurses were great -- concerned about my comfort and stress -- but other hospital workers were indifferent .
Unfortunately, long wait times, poor communications, excess paperwork, and misapplied technology are all too familiar problems to those in the health care system.

Moreover, this all was happening at one of the most highly rated US hospitals,

After all, I'm at New York-Presbyterian Hospital. U.S. News & World Report ranked it No. 1 in New York .
Were "Socialist Bureaucracies" Responsible?

Mr Stossel had his own ideas about the causes of these problems.

Customer service is sclerotic because hospitals are largely socialist bureaucracies. Instead of answering to consumers, which forces businesses to be nimble, hospitals report to government, lawyers and insurance companies.

Whenever there's a mistake, politicians impose new rules: the Health Insurance Portability and Accountability Act paperwork, patient rights regulations, new layers of bureaucracy...

Also,

Leftists say the solution to such problems is government health care. But did they not notice what happened at Veterans Affairs? Bureaucrats let veterans die, waiting for care. When the scandal was exposed, they didn't stop. USA Today reports that the abuse continues. Sometimes the VA's suicide hotline goes to voicemail.

Patients will have a better experience only when more of us spend our own money for care. That's what makes markets work.

A "Socialist Bureaucracy" with a VIP Penthouse?

I am sorry to hear Mr Stossel has lung cancer, and hope that his prognosis is indeed good. I am a bit surprised that a media celebrity who became a patient found big issues with "customer service" at such a prestigious hospital. After all, many big hospitals have programs to give special treatment to VIPs (for example, see these posts from 2007 and 2011 ).

In particular, back in 2012 we posted about the contrast between the VIP services specifically at New York - Presbyterian Hospital and how poor patients are treated there. Then we quoted from a 21 January, 2012 article from the New York Times focused on the ritzy comforts now provided for wealthy (but perhaps not very sick) patients at the renowned New York Presbyterian/ Weill Cornell Hospital. It opened,

The feverish patient had spent hours in a crowded emergency room. When she opened her eyes in her Manhattan hospital room last winter, she recalled later, she wondered if she could be hallucinating: 'This is like the Four Seasons - where am I?'

The bed linens were by Frette, Italian purveyors of high-thread-count sheets to popes and princes. The bathroom gleamed with polished marble . Huge windows displayed panoramic East River views. And in the hush of her $2,400 suite, a man in a black vest and tie proffered an elaborate menu and told her, 'I'll be your butler.'

It was Greenberg 14 South, the elite wing on the new penthouse floor of NewYork-Presbyterian/Weill Cornell hospital . Pampering and décor to rival a grand hotel, if not a Downton Abbey, have long been the hallmark of such 'amenities units,' often hidden behind closed doors at New York's premier hospitals. But the phenomenon is escalating here and around the country, health care design specialists say, part of an international competition for wealthy patients willing to pay extra, even as the federal government cuts back hospital reimbursement in pursuit of a more universal and affordable American medical system.

Additional amenities include:

A waterfall, a grand piano and the image of a giant orchid grace the soaring ninth floor atrium....
Also,
the visitors' lounge seems to hang over the East River in a glass prow and Ciao Bella gelato is available on demand....
An architect who specializes in designing such luxury facilities for hospitals noted:
'These kinds of patients, they're paying cash - they're the best kind of patient to have,' she added. 'Theoretically, it trickles down.'
It appears that someone failed to book Mr Stossel into the penthouse. Instead, he found out what service was like for the masses.

Perhaps this was why Mr Stossel railed at the "socialist bureaucracies" he perceived as running New York - Presbyterian Hospital. However, calling the hospital management "socialist" seems - not to put too fine a point on it - wrong.

A "Socialist Bureaucracy" Paying Millions to its CEOs?

First of all, New York Presbyterian is hardly a government agency. It is a private, non-profit corporation. Every year as such it files a form 990 with the dread US Internal Revenue Service. (The latest publicly available version is from 2013, here.) Obviously, US government agencies do not file with the IRS.

In fact, the New York Presbyterian system seems about as far from a federal government agency as one can imagine.

First, its top managers are paid like for-profit corporate executives. In 2014, we posted about the humongous compensation given to its previous, long-serving CEO, Dr Herbert Pardes, who received multi-million dollar compensation every year through his 2011 retirement, and then continued to receive several million a year from the system in his retirement. His successor, current CEO Dr Steven Corwin, received $3.6 million in 2012. (More recent compensation figures are not yet available.)

A "Socialist Bureaucracy" Dominated by Managers, with Stewardship by Top Financial Executives, and one of the Koch Brothers?

The current leadership of New York Presbyterian is dominated by businesspeople, not physicians, nurses, or other health care professionals. Only 10 of 33 listed senior leaders are health care professionals. The rest have administrative/ management or legal backgrounds and training. Many appear to be generic managers , that is, people with background and experience primarily in administration or management, but not in medicine, health care, public health, etc.

The hospital system's board of trustees was and is filled with some of the top business executives in the US, including some finance executives who have been cited as responsible for the global financial collapse/ great recession.

For example, we wrote about Mr Dick Fuld, a trustee until recently. Mr Fuld was the CEO who presided over the bankruptcy of Lehman Brothers, which heralded the beginning of the great financial crisis/ great recession of 2008 onward. Mr Fuld seemed to lack the sort of compassionate approach one might expect from someone charged with the stewardship of a big hospital system. He had once publicly said about those who sold Lehman Brother stock short: "what I really want to do is I want to reach in, rip out their heart, and eat it before they die ."

[Mar 23, 2017] A "good start" at the expence of sick people for Collectly a new medical debt collection startuo -- they now collect twise larger share of debt then before. The founder is a former CEO of a debt collection agency and collected over $100 million before

Notable quotes:
"... our intelligent algorithm using state of the art innovative techniques of automation innovation disruption innovation disruption automatically sends orders to police and judges to prepare and serve pay or stay warrants, making sure your debtor goes to jail for their crime! ..."
Mar 23, 2017 | www.nakedcapitalism.com

"All 51 startups that debuted at Y Combinator W17 Demo Day 2" [ TechCrunch ] ( day one ). This is a good one:

Collectly helps doctors collect 2x's more debt than they have before. It's a business with $280 billion sent to debt but the debt collectors only collect on average up to 20%. The founder is a former CEO of a debt collection agency and collected over $100 million before

The acerbic Pinboard comments:
D Pinboard * Follow

@Pinboard

YC so far: surreptitious recording of phone calls, bus tickets for
the starving, debt collection, go live in a box, cow collars,
chatbots

11:41 PM-21 Mar 2017

He's not wrong. (And any time you encounter an online company with a cute name that's also an adverb, like collectly , run a mile, because it's a startup that wants to harm you. Kidding! I think .)

cocomaan , March 22, 2017 at 4:03 pm

Collectly is some really depressing stuff. Wow. More from their website.

3. Transparent collection
Our intelligent software automatically reaches out to customers that didn't pay in time, so you will never need to manually chase them again. And you can see every action on every case.

Totaly fair.

Totaly fair? I had to read it twice. Is that a typo? Or does it mean something?

Next up: our intelligent algorithm using state of the art innovative techniques of automation innovation disruption innovation disruption automatically sends orders to police and judges to prepare and serve pay or stay warrants, making sure your debtor goes to jail for their crime!

Edit: Weird, this went in the wrong place. Oh well.

[Mar 22, 2017] The Men Who Stole the World

Notable quotes:
"... History will look back at us with the same wonder that we look back on the mad excesses of certain nations founded in devotion to extreme, almost other-worldly, ideologies of the last century. ..."
"... Apparently the slashing of health benefits for the unfortunate is not severe enough in the proposed Trump/Ryan plan. Our GOP house neo-liberals are enthusiastic to unleash the wonders of the cure-all deregulated market on the American public, again. Like a dog returns to its vomit. ..."
Mar 22, 2017 | jessescrossroadscafe.blogspot.com
"The problem of the last three decades is not the 'vicissitudes of the marketplace,' but rather deliberate actions by the government to redistribute income from the rest of us to the one percent. This pattern of government action shows up in all areas of government policy."

Dean Baker

"When the modern corporation acquires power over markets, power in the community, power over the state and power over belief, it is a political instrument, different in degree but not in kind from the state itself. To hold otherwise - to deny the political character of the modern corporation - is not merely to avoid the reality.

It is to disguise the reality. The victims of that disguise are those we instruct in error."

John Kenneth Galbraith

And unfortunately the working class victims of that disguise are going to be receiving the consequences of their folly, and then some.

Secure in their monopolies and key positions with regard to reform and the law, the corporations are further acquiring access to the protections of the rights of individuals as well, it appears, at least according to Citizens United .

Maybe our leaders and their self-proclaimed technocrats will finally do the right thing. I personally doubt it, except that if they do it will probably be by accident.

More likely, the right thing will eventually come about the old-fashioned way- under the duress of a crisis, and the growing protests of the much neglected and long suffering.

History will look back at us with the same wonder that we look back on the mad excesses of certain nations founded in devotion to extreme, almost other-worldly, ideologies of the last century.

... ... ...

Apparently the slashing of health benefits for the unfortunate is not severe enough in the proposed Trump/Ryan plan. Our GOP house neo-liberals are enthusiastic to unleash the wonders of the cure-all deregulated market on the American public, again. Like a dog returns to its vomit.

Better if they start breaking up corporate health monopolies and embrace real reform at the sources of the soaring costs. The US pays far, far too much for drugs and healthcare, and deregulating the markets is not the solution. We do have the example of the rest of the developed world for what to do about this. It is called 'single payer.'

But players keep on playing. And politicians and their enablers in the professions will not see what their big money donors do not wish them to see. And that is one of their few bipartisan efforts.

Might one suggest that our political animals stop trying to do all the reforming and cost controls bottom up, while applying the stimulus top down? That approach they have been flogging to no avail for about thirty years is a recipe for a dying middle class.

Here is a short video from the Bernie Sanders WV town hall that shows The Face of American Desperation. By the way, the governor of West Virginia is a Democrat. He wasn't there.

...

[Mar 17, 2017] The Affordable Care Act came nowhere close to universal healthcare insurance coverage:

Mar 17, 2017 | economistsview.typepad.com
anne -> Fred C. Dobbs... March 16, 2017 at 06:41 AM , 2017 at 06:41 AM
The Affordable Care Act came nowhere close to universal healthcare insurance coverage:

https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf

September 13, 2016

People Without Health Insurance Coverage, 2007-2015

(Thousands without insurance for entire year)

2007 ( 44,088)
2008 ( 44,780)
2009 ( 48,985) Obama

2010 ( 49,951) (Affordable Care Act)
2011 ( 48,613)
2012 ( 47,951)
2013 ( 41,795)
2014 ( 32,968)

2015 ( 28,966)

anne -> Fred C. Dobbs... , March 16, 2017 at 07:26 AM
https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf

September 13, 2016

People Without Health Insurance Coverage, 2007-2015

(Percent without insurance for entire year)

2007 ( 14.7)
2008 ( 14.9)
2009 ( 16.1) Obama

2010 ( 16.3) (Affordable Care Act)
2011 ( 15.7)
2012 ( 15.4)
2013 ( 13.3)
2014 ( 10.4)

2015 ( 9.1)

[Mar 17, 2017] The difficulties that many families have paying for cancer treatments. The piece points out that even middle income families with good insurance may still face co-payments of tens of thousands of dollars a year

Mar 17, 2017 | economistsview.typepad.com
anne : March 16, 2017 at 06:19 AM

, 2017 at 06:19 AM
http://cepr.net/blogs/beat-the-press/government-granted-patent-monopolies-cause-people-to-skip-cancer-treatments

March 16, 2017

Government Granted Patent Monopolies Cause People to Skip Cancer Treatments

National Public Radio had an interesting segment * on the difficulties that many families have paying for cancer treatments. The piece points out that even middle income families with good insurance may still face co-payments of tens of thousands of dollars a year.

One item not mentioned in this piece is that the reason the prices of new cancer drugs is high is that the government grants companies patent monopolies. This is done as a way to finance research. In almost all cases these drugs would be available for less than a thousand dollars ** for a year's treatment if the drugs were sold in a free market.

While it is necessary to pay for research, there are more modern and efficient mechanisms than patent monopolies (see "Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer" *** ).

* http://www.npr.org/sections/health-shots/2017/03/15/520110742/as-drug-costs-soar-people-delay-or-skip-cancer-treatments

** http://www.thebodypro.com/content/78658/1000-fold-mark-up-for-drug-prices-in-high-income-c.html

*** http://deanbaker.net/images/stories/documents/Rigged.pdf

-- Dean Baker

anne -> anne... , March 16, 2017 at 06:20 AM
http://deanbaker.net/images/stories/documents/Rigged.pdf

October, 2016

Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer
By Dean Baker

The Old Technology and Inequality Scam: The Story of Patents and Copyrights

One of the amazing lines often repeated by people in policy debates is that, as a result of technology, we are seeing income redistributed from people who work for a living to the people who own the technology. While the redistribution part of the story may be mostly true, the problem is that the technology does not determine who "owns" the technology. The people who write the laws determine who owns the technology.

Specifically, patents and copyrights give their holders monopolies on technology or creative work for their duration. If we are concerned that money is going from ordinary workers to people who hold patents and copyrights, then one policy we may want to consider is shortening and weakening these monopolies. But policy has gone sharply in the opposite direction over the last four decades, as a wide variety of measures have been put into law that make these protections longer and stronger. Thus, the redistribution from people who work to people who own the technology should not be surprising - that was the purpose of the policy.

If stronger rules on patents and copyrights produced economic dividends in the form of more innovation and more creative output, then this upward redistribution might be justified. But the evidence doesn't indicate there has been any noticeable growth dividend associated with this upward redistribution. In fact, stronger patent protection seems to be associated with slower growth.

Before directly considering the case, it is worth thinking for a minute about what the world might look like if we had alternative mechanisms to patents and copyrights, so that the items now subject to these monopolies could be sold in a free market just like paper cups and shovels.

The biggest impact would be in prescription drugs. The breakthrough drugs for cancer, hepatitis C, and other diseases, which now sell for tens or hundreds of thousands of dollars annually, would instead sell for a few hundred dollars. No one would have to struggle to get their insurer to pay for drugs or scrape together the money from friends and family. Almost every drug would be well within an affordable price range for a middle-class family, and covering the cost for poorer families could be easily managed by governments and aid agencies.

The same would be the case with various medical tests and treatments. Doctors would not have to struggle with a decision about whether to prescribe an expensive scan, which might be the best way to detect a cancerous growth or other health issue, or to rely on cheaper but less reliable technology. In the absence of patent protection even the most cutting edge scans would be reasonably priced.

Health care is not the only area that would be transformed by a free market in technology and creative work. Imagine that all the textbooks needed by college students could be downloaded at no cost over the web and printed out for the price of the paper. Suppose that a vast amount of new books, recorded music, and movies was freely available on the web.

People or companies who create and innovate deserve to be compensated, but there is little reason to believe that the current system of patent and copyright monopolies is the best way to support their work. It's not surprising that the people who benefit from the current system are reluctant to have the efficiency of patents and copyrights become a topic for public debate, but those who are serious about inequality have no choice. These forms of property claims have been important drivers of inequality in the last four decades.

The explicit assumption behind the steps over the last four decades to increase the strength and duration of patent and copyright protection is that the higher prices resulting from increased protection will be more than offset by an increased incentive for innovation and creative work. Patent and copyright protection should be understood as being like very large tariffs. These protections can often the raise the price of protected items by several multiples of the free market price, making them comparable to tariffs of several hundred or even several thousand percent. The resulting economic distortions are comparable to what they would be if we imposed tariffs of this magnitude.

The justification for granting these monopoly protections is that the increased innovation and creative work that is produced as a result of these incentives exceeds the economic costs from patent and copyright monopolies. However, there is remarkably little evidence to support this assumption. While the cost of patent and copyright protection in higher prices is apparent, even if not well-measured, there is little evidence of a substantial payoff in the form of a more rapid pace of innovation or more and better creative work....

Tom aka Rusty said in reply to anne... , -1
I'm trying to imagine why anyone would write a 900 page textbook, plus add-ons (test bank, solutions manual) and then give it away.

I have refused to co-author several times because the work is agonizing, the revisions never ending, and only a few texts make anyone rich.

[Mar 14, 2017] No wonder the unemployed increasingly kill themselves, or others. The whole economy tells them, indirectly but unmistakably, that their human value does not exist.

Mar 14, 2017 | economistsview.typepad.com
Noni Mausa : March 13, 2017 at 04:13 PM

What the wealthy right wing has decided in the past 40 years is that they don't need citizens. At least, not as many citizens as are actually citizens. What they are comfortable with is a large population of free range people, like the longhorn cattle of the old west, who care for themselves as best they can, and are convenient to be used when the "ranchers" want them.

Of course, this is their approach to foreign workers, also, but for the purpose of maintaining a domestic society within which the domestic rich can comfortably live, only native born Americans really suit.

With the development of high productivity production, farming, and hands-off war technology the need for a large number of citizens is reduced. The wealthy can sit in their towers and arrange the world as suits them, and use the rest of the world as a "farm team" to supply skills and labour as needed.

Proof of this is the fact that they talk about the economy's need for certain skills, training, services and so on, but never about the inherent value of citizens independent of their utility to someone else.

No wonder the unemployed increasingly kill themselves, or others. The whole economy tells them, indirectly but unmistakably, that their human value does not exist. ken melvin : , March 13, 2017 at 04:48 PM

Can someone get me from $300 billion tax cut for the rich to getting the markets work for health care?
ken melvin : , March 13, 2017 at 04:54 PM
It isn't about 'markets', never is. It is about extraction of as much profit as possible using whatever means necessary. This is what the CEOs of insurance companies get payed to do. Insurance policies they don't pay out, the ones Ryan is referring to, are as good as any for scoring.
libezkova : , March 13, 2017 at 07:09 PM
"It isn't about 'markets', never is. It is about extraction of as much profit as possible using whatever means necessary. This is what the CEOs of insurance companies get payed to do."

What surprises me most in this discussion is how Obamacare suddenly changed from a dismal and expensive failure enriching private insurers to a "good deal".

Lesseevilism in action ;-)

ilsm : , March 13, 2017 at 01:41 PM
When the PPACA band-aid is pulled off the US health care mess the gusher will be blamed on "the Russians running the White House".

Cuba does better than the US despite being economically sanctioned for 55 years. Distribution of artificially scarce health care resources is utterly broken. This failed market is financed by a mix of 'for profit' insurance and medicare (which sublets a big part to 'for profit' insurance).

Coverage!!! PPACA added taxpayers' money to finance a bigger failed market. It did nothing to address the market fail!

Single payer would not address the market failure. Single payer would put the government financing most of the failed market.

Democrats have put band-aids on severe bleeds since Truman made the cold war more important than Americans.

At least we know what Trump stands for!

jeff fisher said in reply to ilsm... , March 13, 2017 at 01:58 PM
Cuba is the shining example of how doing the first 20% of healthcare well for everyone gets you 80% of the benefit cheap.

The US is the shining example of how refusing to do the first 20% of healthcare well for everyone only gets you 80% of the benefit no matter how much you spend.

jonny bakho : , March 13, 2017 at 12:09 PM
Mark's very nice argument does nothing to address The Official Trump Counter Argument:

[Shorter version: Obamacare is doomed, going to blow up. Any replacement is therefore better than Obamacare; Facts seldom win arguments against beliefs]

"During a listening session on healthcare at the White House on Monday, President Donald Trump said Republicans "are putting themselves in a very bad position by repealing Obamacare."

Trump said that his administration is "committed to repealing and replacing" Obamacare and that the House Obamacare replacement will lead to more choice at a lower cost. He further stated, "[T]he press is making Obamacare look so good all, of a sudden. I'm watching the news. It looks so good. They're showing these reports about this one gets so much, and this one gets so much. First of all, it covers very few people, and it's imploding. And '17 will be the worst year. And I said it once; I'll say it again: because Obama's gone."

He continued, "And the Republicans, frankly, are putting themselves in a very bad position - I tell this to Tom Price all the time - by repealing Obamacare. Because people aren't gonna see the truly devastating effects of Obamacare. They're not gonna see the devastation. In '17 and '18 and '19, it'll be gone by then. It'll - whether we do it or not, it'll be imploded off the map."

He added, "So, the press is making it look so wonderful, so that if we end it, everyone's going to say, 'Oh, remember how great Obamacare used to be? Remember how wonderful it used to be? It was so great.' It's a little bit like President Obama. When he left, people liked him. When he was here, people didn't like him so much. That's the way life goes. That's human nature."

Trump further stated that while letting Obamacare collapse on its own was the best thing to do politically, it wasn't the right thing to do for the country.

http://www.breitbart.com/video/2017/03/13/trump-republicans-putting-bad-position-repealing-obamacare/

[Mar 07, 2017] Americans' Challenges with Health Care Costs

Notable quotes:
"... Three in ten (29 percent) Americans report problems paying medical bills, and these problems come with real consequences for some. For example, among those reporting problems paying medical bills, seven in ten (73 percent) report cutting back spending on food, clothing, or basic household items. ..."
"... Challenges affording care also result in some Americans saying they have delayed or skipped care due to costs in the past year, including 27 percent who say they have put off or postponed getting health care they needed, 23 percent who say they have skipped a recommended medical test or treatment, and 21 percent who say they have not filled a prescription for a medicine. ..."
Mar 07, 2017 | economistsview.typepad.com
anne : March 06, 2017 at 11:40 AM , 2017 at 11:40 AM
http://kff.org/health-costs/poll-finding/data-note-americans-challenges-with-health-care-costs/

March 2, 2017

Americans' Challenges with Health Care Costs
By Bianca DiJulio, Ashley Kirzinger, Bryan Wu, and Mollyann Brodie

As lawmakers debate the future of the country's health care system and outline plans to repeal and replace the Affordable Care Act, much of the current debate surrounds how to change or eliminate the health insurance marketplaces developed under the ACA where individuals eligible for financial assistance could compare plans and purchase insurance. While this is an important source of coverage for some, the vast majority of Americans with insurance have coverage from other sources, such as an employer, Medicaid or Medicare, and the public's top priority for lawmakers is reducing what Americans pay for health care. Two recent Kaiser Health Tracking Polls take stock of the public's current experience with and worries about health care costs, including their ability to afford premiums and deductibles. For the most part, the majority of the public does not have difficulty paying for care, but significant minorities do, and even more worry about their ability to afford care in the future. Some of the key findings include:

Four in ten (43 percent) adults with health insurance say they have difficulty affording their deductible, and roughly a third say they have trouble affording their premiums and other cost sharing; all shares have increased since 2015.

Three in ten (29 percent) Americans report problems paying medical bills, and these problems come with real consequences for some. For example, among those reporting problems paying medical bills, seven in ten (73 percent) report cutting back spending on food, clothing, or basic household items.

Challenges affording care also result in some Americans saying they have delayed or skipped care due to costs in the past year, including 27 percent who say they have put off or postponed getting health care they needed, 23 percent who say they have skipped a recommended medical test or treatment, and 21 percent who say they have not filled a prescription for a medicine.

Even for those who may not have had difficulty affording care or paying medical bills, there is still a widespread worry about being able to afford needed health care services, with half of the public expressing worry about this.

Health care-related worries and problems paying for care are particularly prevalent among the uninsured, individuals with lower incomes, and those in poorer health; but women and members of racial minority groups are also more likely than their peers to report these issues....

Peter K. -> anne... , March 06, 2017 at 11:48 AM
"For example, among those reporting problems paying medical bills, seven in ten (73 percent) report cutting back spending on food, clothing, or basic household items."

That's what the neoliberals like our dear trolls kthomas and PGL want.

They're in the pocket of the lobbyists.

[Mar 07, 2017] Uncertainty and the Welfare Economics of Medical Care

Mar 07, 2017 | economistsview.typepad.com
anne -> anne... March 06, 2017 at 05:11 PM , 2017 at 05:11 PM
https://web.stanford.edu/~jay/health_class/Readings/Lecture01/arrow.pdf

December, 1963

Uncertainty and the Welfare Economics of Medical Care
By KENNETH J. ARROW

I. Introduction: Scope and Method

This paper is an exploratory and tentative study of the specific differentia of medical care as the object of normative economics. It is contended here, on the basis of comparison of obvious characteristics of the medical-care industry with the norms of welfare economics, that the special economic problems of medical care can be explained as adaptations to the existence of uncertainty in the incidence of disease and in the efficacy of treatment.

It should be noted that the subject is the medical-care industry, not health. The causal factors in health are many, and the provision of medical care is only one. Particularly at low levels of income, other commodities such as nutrition, shelter, clothing, and sanitation may be much more significant. It is the complex of services that center about the physician, private and group practice, hospitals, and public health, which I propose to discuss.

The focus of discussion will be on the way the operation of the medical-care industry and the efficacy with which it satisfies the needs of society differ from a norm, if at all. The "norm" that the economist usually uses for the purposes of such comparisons is the operation of a competitive model, that is, the flows of services that would be offered and purchased and the prices that would be paid for them if each individual in the market offered or purchased services at the going prices as if his decisions had no influence over them, and the going prices were such that the amounts of services which were available equalled the total amounts which other individuals were willing to purchase, with no imposed restrictions on supply or demand.

The interest in the competitive model stems partly from its presumed descriptive power and partly from its implications for economic efficiency. In particular, we can state the following well-known proposition (First Optimality Theorem)....

a

[Mar 07, 2017] Notes on US healthdoesntcare

Mar 07, 2017 | economistsview.typepad.com
libezkova : March 06, 2017 at 08:41 PM

The problems with US Healthdoesn'tcare started around 1980.

What we observe now (completely broken and corrupt to the core system) is the result of long term term slow deterioration.

Now the US Healthdoesn'tcare in many cases represent the completely opposite practice to healthcare -- health racket.

And they even created their specialized firms that help to extract maximum dollars for private providers.

An interesting example of how pervert the USA healthcare system became in the USA under neoliberalism is proliferation of private ambulance services which are technically are always "out of network" and after providing services (often non-essential and equal to the ride to ER, but mostly unavoidable as soon as 911 service or traffic police is involved, especially for those who are in this situation for the first time ) they bill an outrageous amount to lemmings who do not know how to fight the system.

Average private ambulance bill is probably around $5K in the USA. And that if this was just a ride to ER.

If you have insurance it will pay around the same as Medicare and your bill will be around ~$3.5K

This so called differential billing in now outlawed in a couple of states (CA, partially NY), but still is legal in most other states.

This industry also creates specialized collector agencies that deal almost exclusively with collecting ambulance bills like Revenue Guard - Ambulance Billing & Financial Management ( https://www.revenue-guard.com/). And look who is at the helm of this wonder of neoliberal health industry (pretty profitable -- currently bills over 120 million in revenue annually taking in probably lion share of that) -- James J. Loures, President & CEO

James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region.

Is not neoliberalism wonderful social system ?

So when somebody is taking about destruction of the US health care system by Trump one needs to understand that there is not much left to destruct. Most of the heavy lifting was done by previous administrations.

Including Obama with his coward method of betrayal of his voters and serving medical industrial complex.

Trump is bad, but to claim that because of that Obama was good is silly. He was just a perfect example of neoliberal "bait and switch" politician.

B.T. : , March 06, 2017 at 07:51 PM
So it's like the ACA?

Or it's terrible?

Make up your minds neoliberals. Since you didn't want single payer.

libezkova -> B.T.... , March 06, 2017 at 09:12 PM
It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. ( http://khn.org/morning-breakout/health-care-billing-errors/ )

"thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones."

Private medical industry and insurance are symbiotic in their desire to milk patients out of their money in the most efficient way possible.

And while those "death panel" decisions are very difficult indeed, fraud is rampant and they are very successful in over-billing patients.

This symbiosis is very similar in nature to what we observe with body shops and car insurance.

[Mar 06, 2017] Something about the meaning of life under neoliberalism

Notable quotes:
"... Probably the most telling example on neoliberal transformation is transformation of healthcare. ..."
"... Mulligan's research shows how "market values come to displace competing notions of what is "good" or "right" in health care" (Mulligan 2010:308–309). She argues that quality in health care is not only a technical matter for evaluating the performance of systems, but, more importantly, it is a particular epistemology, a specific way of knowing. ..."
"... Managing for-profit health care systems successfully requires innovative mechanisms of population control (Abadía-Barrero et al. 2011), including people's acceptance of market principles. ..."
"... In this historical context, what is crucial is the understanding of the relationship between techniques of governance and the production of social inequality (i.e., an ideological domination reflected in people's support for political practices that are antithetical to their interests). ..."
"... James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region. ..."
Mar 03, 2017 | economistsview.typepad.com
libezkova : March 03, 2017 at 03:51 PM
Something about the "meaning of life" under neoliberalism

Probably the most telling example on neoliberal transformation is transformation of healthcare.

http://onlinelibrary.wiley.com/doi/10.1111/maq.12161/full

== quote ==

Several anthropologists have written about how "market ideology and corporate structures are shaping medicine and health care delivery" (Horton et al. 2014; Lamphere 2005; Rylko-Bauer and Farmer 2002:476).

Mulligan's research shows how "market values come to displace competing notions of what is "good" or "right" in health care" (Mulligan 2010:308–309). She argues that quality in health care is not only a technical matter for evaluating the performance of systems, but, more importantly, it is a particular epistemology, a specific way of knowing.

The information that is produced in technical public health policy terms, and, I would add, in technical legal terms, is "a knowledge-making practice that creates information about the health care system and for managing the system in new ways" (Mulligan 2010:309).

Managing for-profit health care systems successfully requires innovative mechanisms of population control (Abadía-Barrero et al. 2011), including people's acceptance of market principles.

In this historical context, what is crucial is the understanding of the relationship between techniques of governance and the production of social inequality (i.e., an ideological domination reflected in people's support for political practices that are antithetical to their interests).

According to Fassin (2009), Foucault's undeveloped concept of a Politics of Life can illuminate how in regulating populations and normalizing societies, moral ideas about the meaning of life and about how life is valued are enforced.

An understanding of moral definitions of human life must take into account how history becomes embodied, which then illuminates the political tensions that support differential values by which life is organized, represented, and responded to, for example through public policy (Fassin 2007).

== end of quote ==

See also

https://www.youtube.com/watch?v=TsoZeg6CDRY

An interesting example of how pervert the healthcare system became in the USA under neoliberalism is proliferation of private ambulance services which are technically always "out of network" and after providing services (often non-essential) bill outrageous amount to lemmings who do not know how to fight the system. Average private ambulance bill is probably around $5K in the USA. If you have insurance your bill will be around ~$3.5K

This so called differential billing in now outlawed in a couple of states, but still is legal in most states.

This industry also creates specialized collector agencies that deal almost exclusively with collecting ambulance bills like Revenue Guard - Ambulance Billing & Financial Management ( https://www.revenue-guard.com/)

== quote ==

Revenue Guard Executive Team

James J. Loures, President & CEO
James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region. After merging MultiCare with the publicly traded Rural-Metro in 2001, James then founded Revenue-Guard in 2004. The company has grown to be a premier provider of EMS revenue cycle and management services in the hospital marketplace, and currently bills over 120 million in revenue annually for their clients. James studied economics at Rutgers University .

Steven J. Loures, Co-Founder and Chief Operations Officer
Steven Loures has 30 years of experience in the Emergency Medical Services / Mobile Health Services field and is considered an expert in revenue cycle, compliance and improving ambulance service operating margins. His real-world revenue cycle knowledge combined with 20 years of managing ambulance operations uniquely differentiates himself with a comprehensive industry perspective. His leadership has provided client confidence to initiate targeted change knowing his proven track record. He is the point of contact for all new and existing clients.

Prior to his current role Steven was the New Jersey Division General Manager of Rural Metro Ambulance. Rural Metro is a large nationwide provider of Emergency Medical Services. He was responsible for oversight of 350 employees, 6 operating locations in three states including New Jersey, Pennsylvania and New York City. Additionally, Steven's responsibilities included all budgets, revenue cycle management, billing compliance, and Sarbanes Oxley financial controls.

Prior to Rural Metro Steven was a Commercial Lear Jet Pilot. The operation provided nationwide long distance critical care air ambulance services. Steven graduated from Embry-Riddle Aeronautical University, Daytona Beach Florida with his Federal Aviation Administration Commercial, Multi-Engine, and Instrument ratings. Early in his career path Steven was a certified NJ paramedic at age 21 and one of the youngest certified paramedics in New Jersey.

Stephanie Dall, Vice President of Finance
Stephanie joined Revenue-Guard in 2005 and is responsible for Finance, Administration, Compliance and client reporting. She has 20 years experience in finance and administration with Rural-Metro Inc. the leading EMS provider in the nation. Stephanie develops budgets and establish performance metrics for Revenue-Guard. Stephanie has a bachelors degree in accounting from Rutgers University.

Jennifer Aldana, Vice President of Revenue Cycle
Jennifer joined Revenue-Guard in 2007 to manage and run the billing services division. She manages a staff of 60 billing specialist processing over $120M in ambulance claims annually. Jennifer is a former revenue cycle manager at Rural-Metro The country's largest EMS service based in Scottsdale, Arizona. She handles all system customizations, ePCR integration and client support services. Jen studied at Pace University in New York City.

[Mar 03, 2017] U.S. Medical Coding System

Notable quotes:
"... Successful medical coders learn and follow coding guidelines and use them to their benefit. Often if a claim is denied incorrectly, medical coders and billers use coding guidelines as a way to appeal the denial and get the claim paid. ..."
"... Each diagnosis code has to be coded to the highest level of specificity , so the insurance company knows exactly what the patient's diagnosis was. ..."
"... I've helpfully underlined places where an "unusual opportunity for profit" might be spotted and amplified; after all, it's not the coder's job to set policy in borderline cases; that's for management. ..."
"... A pair of transposed digits in a medical identification number was the difference between insurance coverage for Mike Dziedzic and the seemingly never-ending hounding for payment by the hospitals that cared for his dying wife. The astute eye of a medical billing advocate who Dziedzic hired for help caught the innocuous mistake - the sole reason his insurance company had refused to pay more than $100,000 in claims that had piled up and why collectors were now at his doorstep. ..."
"... Had it remained unnoticed - as often happens to patients faced with daunting medical debt - Dziedzic said, he most surely would have lost his Rifle home, his way of life and had little choice but to live in bankruptcy. ..."
"... thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones. They did so despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising. ..."
"... More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that. ..."
"... The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software. ..."
"... eight of 10 bills its members have audited from hospitals and health care providers contain errors. ..."
"... It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. ..."
"... Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent. ..."
"... Most services don't get paid based on ICD, they get paid based on HCPCs/CPTs (healthcare procedure codes) which is what is shown in the nerdwallet image. Also revenue codes will be used for facility services (such as the room charge in image). ..."
"... ICD-Diaganosis codes just tell you what conditions the provider diagnosed you with. ICD-Procedure codes are sometimes used for payments but usually only on inpatient claims. ..."
Mar 03, 2017 | www.nakedcapitalism.com
From my review of Akerlof and Shiller's Phishing for Phools , November 25, 2015 :

As businesspeople choose what line of business to undertake - as well as where they expand, or contract, their existing business - they (like customers approaching checkout) pick off the best opportunities. This too creates an equilibrium. Any opportunities for unusual profits are quickly taken off the table, leading to a situation where such opportunities are hard to find. This principle, with the concept of equilibrium it entails, lies at the heart of economics.

The principle also applies to phishing for phools. That means that if we have some weakness or other - some way in which we can be phished for fools for more than the usual profit - in the phishing equilibrium someone will take advantage of it . Among all those business persons figuratively arriving at the checkout counter, looking around, and deciding where to spend their investment dollars, some will look to see if there are unusual profits from phishing us for phools. And if they see such an opportunity for profit, that will (again figuratively) be the "checkout lane" they choose.

And economies will have a "phishing equilibrium," in which every chance for profit more than the ordinary will be taken up.

We might summarize Akerlof and Shiller as "If a system enables fraud, fraud will happen," or, in stronger form, "If a system enables fraud, fraud will already have happened."[1] And as we shall see, plenty of "opportunities for unusual profits" exist in medical coding.

... ... ...

Here is the medical coding process, from the coders perspective, as described by MB-Guide, a site for aspiring medical coders :

Successful medical coders learn and follow coding guidelines and use them to their benefit. Often if a claim is denied incorrectly, medical coders and billers use coding guidelines as a way to appeal the denial and get the claim paid.

Hmm. "Their" benefit. Here are the guidelines:

I've helpfully underlined places where an "unusual opportunity for profit" might be spotted and amplified; after all, it's not the coder's job to set policy in borderline cases; that's for management. The Denver Post gives a horrific example:

Miscoding Fictions, frauds found to abound in medical bills

A pair of transposed digits in a medical identification number was the difference between insurance coverage for Mike Dziedzic and the seemingly never-ending hounding for payment by the hospitals that cared for his dying wife. The astute eye of a medical billing advocate who Dziedzic hired for help caught the innocuous mistake - the sole reason his insurance company had refused to pay more than $100,000 in claims that had piled up and why collectors were now at his doorstep.

Had it remained unnoticed - as often happens to patients faced with daunting medical debt - Dziedzic said, he most surely would have lost his Rifle home, his way of life and had little choice but to live in bankruptcy.

Finally, there's "upcoding," and if you are reminded of "upselling" you are exactly right. The Center for Public Integrity :

But the Center's analysis of Medicare claims from 2001 through 2010 shows that over time, thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones. They did so despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising.

More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that.

The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software.

Now, I'll be the first to admit that I can't quantify the impedance mismatches, the miscoding, and the upcoding. Regardless, medical coding is the key dataflow in the healthcare system :

"Roughly $250 billion is moving through those codes," [says Steve Parente, professor of finance at the Carlson School of Management at the University of Minnesota]. On top of that, about 80% of medical bills contain errors, according to Christie Hudson, vice president of Medical Billing Advocates of America, making already-expensive bills higher. Today's complex medical-billing system, guided by hundreds of pages of procedure codes, allows fraud, abuse and human error to go undetected, Hudson says. "Until the fraud is detected in these bills the cost of health care is just going to increase. It's not accidental. We've been fighting these overcharges they continue to happen and we continue to get them removed from bills." These errors, which are hard to detect because medical bills are written in a mysterious code, can result in overcharges that run from a few dollars to tens of thousands.

That "mysterious code" is (now) ICD-10, and it's the mystery plus the profit motive that creates the phishing equilibrium. Kaiser Health News quotes the Denver Post :

Experts say there are tens of thousands more like Dziedzic across the country with strangling medical debts.

Medical Billing Advocates of America, a trade group in Salem, Va., says that eight of 10 bills its members have audited from hospitals and health care providers contain errors.

It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. Some say new reform laws will only make things worse." Others say that errors occur largely because of "the complexity of deciphering bills and claims weighted down by complex codes."

Even if the "trade group" is talking it's book, it's still quite a book . NBC :

Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent.

Gee, I wonder if the errors are randomly distributed?

Neoliberal "Consumer"-Driven Solutions

My guts have started to gripe, so I won't go into detail about how you too, the citizen , can learn medical billing codes if you want to dispute your bill. See this cheery post from NerdWallet on "How to Read Your Medical Bill :

Once you have the itemized medical bill for your care, you're ready to analyze it for mistakes and overcharges.

Your medical bill is going to be chock-full of codes and words you may not understand, so the first step is gathering resources that will translate them into plain English.

Ivy , March 2, 2017 at 2:29 pm

One useful adjunct to the coding discussion concerns other billing details such as meds. There is wide variability in prices charged, and when you see $160 for a single pill (e.g., Hexabrix) or $26 for a single Tylenol, then something is not right. Of course, that does not include any allocation for nurses, pharmacy or other potential costs, since those are rolled into other line items to decipher. When hospital billing reps are asked about the reasonability and basis of their charges, they spout the canned line about being in line with their local competitors.

Why not have some program with mutual insurance companies, removing in theory some of the profit that is driving the typical health care insurers?

TheBellTolling , March 2, 2017 at 2:31 pm

Most services don't get paid based on ICD, they get paid based on HCPCs/CPTs (healthcare procedure codes) which is what is shown in the nerdwallet image. Also revenue codes will be used for facility services (such as the room charge in image).

ICD-Diaganosis codes just tell you what conditions the provider diagnosed you with. ICD-Procedure codes are sometimes used for payments but usually only on inpatient claims.

_________________________________

Additionaly, coding also affects "risk adjustment" in Medicare Advantage and ACA payments and this form of payment does use ICD codes. They use the codes on the claims to determine how "sick"(has conditions that will cost more) each member is and give insurers more or less money based on the average risk scores of their members. Since it relies on coding this system is also subject to gaming.

In Medicare Advantage this is done relative to non-Medicare Advantage population, so if the MA plans are upcoding they get more money from Federal government. In 2010 CMS was given the ability to use some adjustment factors to MA payments to address the issue but I don't really know how effective it is.

In ACA this is done relative to all the other insurers in the individual/small group market(so all the money is changing hands between the insurers). More established plans generally do better since they have more data on members from before ACA to make sure they get coded in addition to resources they probably built from Medicare Advantage. This ends up disadvantaging smaller and newer plans like co-ops.
_____________

[Mar 03, 2017] How to Read Your Medical Bill

Notable quotes:
"... That is not the bill you want. To know what you're actually being charged for, you'll want to call the clinic or hospital and ask for the complete, itemized bill for all services you received, with codes. It is your right to know what you're being charged for, but you will probably have to call and request the detailed charges. The body of that bill should look more like this: ..."
NerdWallet
Clerical errors are more likely than you might think, says Gross, who has seen small mistakes in names and addresses result in huge billing complications. Before you move on, make sure your name, address, insurance information and dates of care are correct on the top of the bill.

header

When you receive inpatient or outpatient care, the first statement you'll receive is most likely a summary bill. Often, but not always, health care providers will send only a summary of charges with a final charge at the end. The body of the bill has a few generic categories and no codes, looking something like this:

summarybill

That is not the bill you want. To know what you're actually being charged for, you'll want to call the clinic or hospital and ask for the complete, itemized bill for all services you received, with codes. It is your right to know what you're being charged for, but you will probably have to call and request the detailed charges. The body of that bill should look more like this:

detailed

Once you have the itemized medical bill for your care, you're ready to analyze it for mistakes and overcharges.

Next, know what the codes are for

Before we get into the nuts and bolts of reading your medical bill, it's worth noting that there's more than one type of code that may be listed on your bill.

svccode

HCPCS Level I, or CPT Codes, are universal, used by all providers in the U.S. and consist of five digits that identify procedures or tests. Often, they are listed as service codes.

svccode2

HCPCS Level II Codes identify supplies or products used during your visit. These codes often start with a letter, rather than a number, but are also referred to as service codes.

[Feb 27, 2017] Why Markets Can't Cure Healthcare

Feb 27, 2017 | economistsview.typepad.com
anne -> anne... February 26, 2017 at 02:07 PM , 2017 at 02:07 PM
http://krugman.blogs.nytimes.com/2009/07/25/why-markets-cant-cure-healthcare/

July 25, 2009

Why Markets Can't Cure Healthcare
By Paul Krugman

Judging both from comments on this blog and from some of my mail, a significant number of Americans believe that the answer to our health care problems - indeed, the only answer - is to rely on the free market. Quite a few seem to believe that this view reflects the lessons of economic theory.

Not so. One of the most influential economic papers of the postwar era was Kenneth Arrow's "Uncertainty and the Welfare Economics of Health Care," * which demonstrated - decisively, I and many others believe - that health care can't be marketed like bread or TVs. Let me offer my own version of Arrow's argument.

There are two strongly distinctive aspects of health care. One is that you don't know when or whether you'll need care - but if you do, the care can be extremely expensive. The big bucks are in triple coronary bypass surgery, not routine visits to the doctor's office; and very, very few people can afford to pay major medical costs out of pocket.

This tells you right away that health care can't be sold like bread. It must be largely paid for by some kind of insurance. And this in turn means that someone other than the patient ends up making decisions about what to buy. Consumer choice is nonsense when it comes to health care. And you can't just trust insurance companies either - they're not in business for their health, or yours.

This problem is made worse by the fact that actually paying for your health care is a loss from an insurers' point of view - they actually refer to it as "medical costs." This means both that insurers try to deny as many claims as possible, and that they try to avoid covering people who are actually likely to need care. Both of these strategies use a lot of resources, which is why private insurance has much higher administrative costs than single-payer systems. And since there's a widespread sense that our fellow citizens should get the care we need - not everyone agrees, but most do - this means that private insurance basically spends a lot of money on socially destructive activities.

The second thing about health care is that it's complicated, and you can't rely on experience or comparison shopping. ("I hear they've got a real deal on stents over at St. Mary's!") That's why doctors are supposed to follow an ethical code, why we expect more from them than from bakers or grocery store owners.

You could rely on a health maintenance organization to make the hard choices and do the cost management, and to some extent we do. But HMOs have been highly limited in their ability to achieve cost-effectiveness because people don't trust them - they're profit-making institutions, and your treatment is their cost.

Between those two factors, health care just doesn't work as a standard market story.

All of this doesn't necessarily mean that socialized medicine, or even single-payer, is the only way to go. There are a number of successful healthcare systems, at least as measured by pretty good care much cheaper than here, and they are quite different from each other. There are, however, no examples of successful health care based on the principles of the free market, for one simple reason: in health care, the free market just doesn't work. And people who say that the market is the answer are flying in the face of both theory and overwhelming evidence.

* https://web.stanford.edu/~jay/health_class/Readings/Lecture01/arrow.pdf

anne -> anne... , February 26, 2017 at 02:44 PM
Correcting again and continuing:

Though Krugman always praises the work of Arrow on healthcare markets, Krugman never seems much been influenced by the work.

Though praising Arrow on healthcare markets, Krugman seemingly has spent no time on or possibly has dismissed research affirming Arrow and has not supported the sorts of healthcare insurance systems that would follow from accepting the work of Arrow:

https://promarket.org/there-is-regulatory-capture-but-it-is-by-no-means-complete/
/
March 15, 2016

"There Is Regulatory Capture, But It Is By No Means Complete"
By Asher Schechter

Kenneth J. Arrow, one of the most influential economists of the 20th century, reflects on the benefits of a single payer health care system, the role of government and regulatory capture.

Mr. Bill : , February 26, 2017 at 03:32 PM
So Anne, what your saying is that "health care" is a monopolistic industry that makes more money by restricting care and charging more ? Allowing people that can't afford to live, too die?

Well. yes, I agree with your presumed hypothesis, and I admire your boldness for stepping out in front of this moving freight train, risking your beloved tenure.

To me ? Thanks for asking.

I think that the 3 % administrative costs of the existing single payer system are more pareto optimal than the 25 % that the monopolists' extract. What do I know. This is America. Dumb is not an option.

anne : , February 26, 2017 at 06:33 PM
Turning again to Kenneth Arrow and healthcare markets, assuming that Arrow was correct for all these years, and subsequent research repeatedly has confirmed Arrow, then a typical American market-based healthcare insurance system is going to prove unworkable. Why then has the work of Arrow which is at least superficially so broadly praised by economists not been more influential in forming policy?
libezkova -> anne... , February 26, 2017 at 07:12 PM
"It is difficult to get a man to understand something, when his salary depends on his not understanding it."

― Upton Sinclair, I, Candidate for Governor: And How I Got Licked

[Feb 26, 2017] Clowbacks to benefits manager is like crack cocaine

This is racket. Plain and simple.
Notable quotes:
"... Pusey's contracts with drug-benefit managers at his Medicap Pharmacy in Olyphant, Pennsylvania, bar him from volunteering the fact that for many cheap, generic medicines, co-pays sometimes are more expensive than if patients simply pay out of pocket and bypass insurance. The extra money -- what the industry calls a clawback -- ends up with the benefit companies. Pusey tells customers only if they ask. ..."
"... "Some of them get fired up," he said. "Some of them get angry at the whole system. Some of them don't even believe that what we're telling them is accurate." ..."
"... Clawbacks, which can be as little as $2 a prescription or as much as $30, may boost profits by hundreds of millions for benefit managers and have prompted at least 16 lawsuits since October. The legal cases as well dozens of receipts obtained by Bloomberg and interviews with more than a dozen pharmacists and industry consultants show the growing importance of the clawbacks. ..."
"... The cases arrive at a critical juncture in the quarter-century debate over how to make health care more affordable in America. President Donald Trump is promising to lower drug costs, saying the government should get better prices and the pharmaceutical industry is "getting away with murder." The Pharmaceutical Care Management Association, a benefits-manager trade group, says it expects greater scrutiny over its role in the price of medicine and wants to make its case "vocally and effectively." ..."
"... Suits have been filed against insurers UnitedHealth Group Inc., which owns manager OptumRx; Cigna Corp., which contracts with that manager; and Humana Inc., which runs its own. Among the accusations are defrauding patients through racketeering, breach of contract and violating insurance laws. ..."
"... Benefit managers are obscure but influential middlemen. They process prescriptions for insurers and large employers that back their own plans, determine which drugs are covered and negotiate with manufacturers on one end and pharmacies on the other. They have said their work keeps prices low, in part by pitting rival drugmakers against one other to get better deals. ..."
"... The clawbacks work like this: A patient goes to a pharmacy and pays a co-pay amount -- perhaps $10 -- agreed to by the pharmacy benefits manager, or PBM, and the insurers who hire it. The pharmacist gets reimbursed for the price of the drug, say $2, and possibly a small profit. Then the benefits manager "claws back" the remainder. Most patients never realize there's a cheaper cash price. ..."
Feb 26, 2017 | economistsview.typepad.com
im1dc: February 24, 2017 at 05:26 PM
Real World Economics

"You're Overpaying for Drugs and Your Pharmacist Can't Tell You"

https://www.bloomberg.com/news/articles/2017-02-24/sworn-to-secrecy-drugstores-stay-silent-as-customers-overpay

"You're Overpaying for Drugs and Your Pharmacist Can't Tell You"

by Jared S Hopkins...February 24, 2017...9:52 AM EST

> Gag clauses stop pharmacists from pointing out a cheaper way

> Cigna, UnitedHealth and Humana face at least 16 lawsuits

"Eric Pusey has to bite his tongue when customers at his pharmacy cough up co-payments far higher than the cost of their low-cost generic drugs, thinking their insurance is getting them a good deal.

Pusey's contracts with drug-benefit managers at his Medicap Pharmacy in Olyphant, Pennsylvania, bar him from volunteering the fact that for many cheap, generic medicines, co-pays sometimes are more expensive than if patients simply pay out of pocket and bypass insurance. The extra money -- what the industry calls a clawback -- ends up with the benefit companies. Pusey tells customers only if they ask.

"Some of them get fired up," he said. "Some of them get angry at the whole system. Some of them don't even believe that what we're telling them is accurate."

Graphic

Clawbacks, which can be as little as $2 a prescription or as much as $30, may boost profits by hundreds of millions for benefit managers and have prompted at least 16 lawsuits since October. The legal cases as well dozens of receipts obtained by Bloomberg and interviews with more than a dozen pharmacists and industry consultants show the growing importance of the clawbacks.

"It's like crack cocaine," said Susan Hayes, a consultant with Pharmacy Outcomes Specialists in Lake Zurich, Illinois. "They just can't get enough."

The cases arrive at a critical juncture in the quarter-century debate over how to make health care more affordable in America. President Donald Trump is promising to lower drug costs, saying the government should get better prices and the pharmaceutical industry is "getting away with murder." The Pharmaceutical Care Management Association, a benefits-manager trade group, says it expects greater scrutiny over its role in the price of medicine and wants to make its case "vocally and effectively."

Racketeering Accusations

Suits have been filed against insurers UnitedHealth Group Inc., which owns manager OptumRx; Cigna Corp., which contracts with that manager; and Humana Inc., which runs its own. Among the accusations are defrauding patients through racketeering, breach of contract and violating insurance laws.

"Pharmacies should always charge our members the lowest amount outlined under their plan when filling prescriptions," UnitedHealthcare spokesman Matthew Wiggin said in a statement. "We believe these lawsuits are without merit and will vigorously defend ourselves."

Mark Mathis, a Humana spokesman, declined to comment. Matt Asensio, a Cigna spokesman, said the company doesn't comment on litigation.

"Patients should not have to pay more than a network drugstore's submitted charges to the health plan," Charles Cote, a spokesman for the Pharmaceutical Care Management Association, said in a statement.

Read more: Escalating U.S. drug prices -- a QuickTake explainer

Benefit managers are obscure but influential middlemen. They process prescriptions for insurers and large employers that back their own plans, determine which drugs are covered and negotiate with manufacturers on one end and pharmacies on the other. They have said their work keeps prices low, in part by pitting rival drugmakers against one other to get better deals.

The clawbacks work like this: A patient goes to a pharmacy and pays a co-pay amount -- perhaps $10 -- agreed to by the pharmacy benefits manager, or PBM, and the insurers who hire it. The pharmacist gets reimbursed for the price of the drug, say $2, and possibly a small profit. Then the benefits manager "claws back" the remainder. Most patients never realize there's a cheaper cash price.

"There's this whole industry that most people don't know about," said Connecticut lawyer Craig Raabe, who represents people accusing the companies of defrauding them. "The customers see that they go in, they are paying a $10 co-pay for amoxicillin, having no idea that the PBM and the pharmacy have agreed that the actual cost is less than a dollar, and they're still paying the $10 co-pay."

On Feb. 10, a customer at an Ohio pharmacy paid a $15 co-pay for 15 milligrams of generic stomach medicine pantoprazole that the pharmacist bought for $2.05, according to receipts obtained by Bloomberg. The pharmacist was repaid $7.22, giving him a profit of $5.17. The remaining $7.78 went back to the benefits manager.
Opaque Market

Clawbacks are possible because benefit managers take advantage of an opaque market, said Hayes, the Illinois consultant. Only they know who pays what.

In interviews, some pharmacists estimate clawbacks happen in 10 percent of their transactions. A survey by the more than 22,000-member National Community Pharmacists Association found 83 percent of 640 independent pharmacists had at least 10 a month.

"I've got three drugstores, so I see a lot of it," David Spence, a Houston pharmacist, said in an interview. "We look at it as theft -- another way for the PBMs to steal."

Lawsuits began in October in multiple states, and some have since been consolidated. Most cite an investigation by New Orleans television station Fox 8, which featured interviews with Louisiana pharmacists whose faces and voices were obscured.
Tight Restrictions

Many plans require pharmacies to collect payment when prescriptions are filled and prohibit them from waiving or reducing the amount. They can't even tell their customers about the clawbacks, according to the suits. Contracts obtained by Bloomberg prohibit pharmacists from publicly criticizing benefit managers or suggesting customers obtain the medication cheaper by paying out of pocket.

Pharmacists who contract with OptumRx in 2017 could be terminated for "actions detrimental to the provider network," doing anything that "disparages" it or trying to "steer" customers to other coverage or discounted plans, according to an agreement obtained by Bloomberg.

"They're usually take-it-or-leave-it contracts," said Mel Brodsky, who just retired as chief executive officer of Pennsylvania's Keystone Pharmacy Purchasing Alliance, which buys drugs on behalf of independent pharmacies.

OptumRx is among the three largest benefit managers that combine to process 80 percent of the prescriptions in the U.S. The other two, Express Scripts Holding Co. and CVS Caremark, haven't been accused of clawbacks. CVS doesn't use them, it said in a statement. Express Scripts is so opposed that it explains the practice on its website and promises customers will pay the lowest price available.
Potential Death Blow

Pharmacies fear getting removed from reimbursement networks, a potential death blow in smaller communities. But some pharmacists jump at opportunities to inform customers who question their co-pay amounts.

"Most don't understand," said Spence, who owns two pharmacies in Houston. "If their co-pay is high, then they care."

States are responding. Last year, Louisiana began allowing pharmacists to tell customers how to get the cheapest price for drugs, trumping contract gag clauses. In 2015, Arkansas prohibited benefit managers and pharmacies from charging customers more than the pharmacy will be paid.

"The consumers don't know what's going on," said Steve Nelson, a pharmacist in Okeechobee, Florida. "We try to educate them with regards to what goes into a prescription, OK? You've got to kind of tip-toe around things."

ilsm -> im1dc... , February 24, 2017 at 07:08 PM
pharma to USG

like drug cartel in Mexico

except no briefcases

im1dc -> ilsm... , February 24, 2017 at 07:47 PM
That's a valid observation.

[Feb 19, 2017] As Democrats stare down eight years of policies being wiped out within months, but those policies did virtually nothing for their electoral success at any level.

Notable quotes:
"... This point has been made before on Obamacare, but the tendency behind it, the tendency to muddle and mask benefits, has become endemic to center-left politics. Either Democrats complicate their initiatives enough to be inscrutable to anyone who doesn't love reading hours of explainers on public policy, or else they don't take credit for the few simple policies they do enact. Let's run through a few examples. ..."
"... missed the point the big winner is FIRE. ACA should have been everyone in medicare, and have medicare run Part B not FIRE. Obamcare is welfare for FIRE, who sabotage it with huge deductibles and raging rises in premium.. ..."
Feb 19, 2017 | economistsview.typepad.com
Peter K. -> Chris G ... , February 18, 2017 at 07:35 AM
via J.W. Mason (lots of F-bombs!):

http://democracyjournal.org/arguments/keep-it-simple-and-take-credit/

Keep It Simple and Take Credit

BY JACK MESERVE
FROM FEBRUARY 3, 2017, 5:42 PM

As Democrats stare down eight years of policies being wiped out within months, it's worth looking at why those policies did virtually nothing for their electoral success at any level. And, in the interest of supporting a united front between liberals and socialists, let me start this off with a rather long quote from Matt Christman of Chapo Trap House, on why Obamacare failed to gain more popularity:

There are parts to it that are unambiguously good - like, Medicaid expansion is good, and why? Because there's no f!@#ing strings attached. You don't have to go to a goddamned website and become a f@!#ing hacker to try to figure out how to pick the right plan, they just tell you "you're covered now." And that's it! That's all it ever should have been and that is why - [Jonathan Chait] is bemoaning why it's a political failure? Because modern neoliberal, left-neoliberal policy is all about making this shit invisible to people so that they don't know what they're getting out of it.

And as Rick Perlstein has talked about a lot, that's one of the reasons that Democrats end up f!@#$ing themselves over. The reason they held Congress for 40 years after enacting Social Security is because Social Security was right in your f!@ing face. They could say to you, "you didn't used to have money when you were old, now you do. Thank Democrats." And they f!@#ing did. Now it's, "you didn't used to be able to log on to a website and negotiate between 15 different providers to pick a platinum or gold or zinc plan and apply a f!@#$ing formula for a subsidy that's gonna change depending on your income so you might end up having to retroactively owe money or have a higher premium." Holy shit, thank you so much.

This point has been made before on Obamacare, but the tendency behind it, the tendency to muddle and mask benefits, has become endemic to center-left politics. Either Democrats complicate their initiatives enough to be inscrutable to anyone who doesn't love reading hours of explainers on public policy, or else they don't take credit for the few simple policies they do enact. Let's run through a few examples.

...

ilsm -> Peter K.... , February 18, 2017 at 12:47 PM
missed the point the big winner is FIRE. ACA should have been everyone in medicare, and have medicare run Part B not FIRE. Obamcare is welfare for FIRE, who sabotage it with huge deductibles and raging rises in premium..

[Jan 23, 2017] Consumer Guide to Health Care - Coping with Medical Bills and Debt Wisconsin Department of Health Services

Notable quotes:
"... Record the names and phone numbers of the people you are dealing with. ..."
"... Document the date, time, and results of your phone calls. ..."
"... Pay something - even a small amount - on each bill each month as a gesture of good faith. ..."
"... Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. ..."
"... Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately. ..."
"... Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt ..."
Jan 23, 2017 | dhs.wisconsin.gov
Unless you have successfully challenged your bill, you are responsible for paying all of your medical bills. If you cannot pay, here are some things to consider.
  1. Try to negotiate a payment plan. Your hospital or provider may be willing to accept smaller monthly payments. Keep in mind that your payments generally need to be reasonable and you must keep up with your payments. In its advice to parents of chronically ill children (link is external) , the American Academy of Family Physicians recommends the following:
    • Notify the appropriate offices quickly.
    • Keep in touch with your creditors.
    • Record the names and phone numbers of the people you are dealing with.
    • Document the date, time, and results of your phone calls.
    • Pay something - even a small amount - on each bill each month as a gesture of good faith.
  2. Get information on charity care in Wisconsin hospitals.
  3. Apply for Wisconsin Medicaid or BadgerCare Plus . If you are eligible, Medicaid may pay for some of your existing medical bills. Wisconsin Medicaid coverage can begin as early as the first day of the month, three months before the month you apply, if you would have been eligible in those months, so apply as soon as possible.
  4. Go for credit counseling. Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. Make sure you are working with a credit counseling service (also known as an adjustment service agency) that is licensed by the Wisconsin Department of Financial Institutions.
  5. Be creative about finding help from outside sources. Charitable foundations, civic organizations and churches and community groups might be able to help. The Patient Pal (link is external) (PDF, 197 KB) from the Patient Advocate Foundation (link is external) includes some fundraising ideas for those with high medical bills.
  6. Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately.
  7. Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt for two reasons:
    • The interest rates on your credit card will add significantly to your total payment.
    • Transferring medical debt to a credit card may affect your eligibility for Medicaid. Some medical costs can be deducted from gross income to determine your Medicaid eligibility. Medical debt on a credit card may no longer qualify as medical debt.
Dealing with collection agencies

If your hospital or other health care provider has turned your bill over to a collection agency, you are protected against harassment by the Fair Debt Collection Practices Act (FDCPA).

If you have questions about your rights or the conduct of a collection agency, contact the Department of Financial Institutions at (608) 264-7969, or 1-800-452-3328 (in Wisconsin only).

Bankruptcy The decision to file for bankruptcy should be last resort. More (PDF, 129 KB) information on how bankruptcy works and the different types (link is external) is available from the Wisconsin Department of Agriculture, Trade and Consumer Protection.

Legal help

If you find that you need legal help to deal with your medical debt, the Wisconsin State Bar Association's website provides general information on finding a lawyer (link is external) and information on finding a lawyer if you have a low income (link is external) .

The Legal Services Corporation (link is external) , a private, non-profit corporation established by Congress, provides a list of Wisconsin local legal aid programs (link is external) from its website.

[Jan 23, 2017] Medical Debt Collections –Unexpected Health Problems Costs

Jan 23, 2017 | www.debt.org

Medical debt collectors must abide by specific regulations, as set forth by the Fair Debt Collection Practices Act . Collectors cannot harass or lie to debtors, or perform any other practices deemed unfair.

[Jan 23, 2017] Medical Debt Collection

You can get a free Kindle version of "Debt Collection Answers" ebook on Amazon here .
Notable quotes:
"... We have heard from consumers who first hear about a medical bill from a collection agency. There is no federal law that protects you from this type of situation. ..."
Jan 23, 2017 | www.debtcollectionanswers.com
Having even a small medical debt reported as past due or in collections can seriously damage your credit history, you may be tempted to pay just to protect your credit.

Some medical providers may even try to pressure you into paying your debt owe by refusing to provide you (or one of your family members) with additional medical care until you do. Some of them may even refuse you future care while you are paying off your debt through an installment plan! Others may have a policy that as long as you owe them money, you must pay up-front for all future medical services they provide to you.

Warning: Aggressive medical providers can be a special problem for seniors living on fixed incomes when their spouses have been hospitalized or have accumulated a large outstanding bill with one or more of their doctors.


When Can I Be Sent to Collections On a Medical Bill?

If at all possible, you want to keep a medical bill out of collections. Once it is turned over to a collection agency, it will likely appear on your credit reports as a collection account and damage your credit rating.

Your medical debt may be turned over to collections:

How can you protect yourself from medical debt collection? Don't ignore medical bills. Talk to the medical provider. Get everything in writing, or follow up in writing yourself

... ... ...

If You Have Insurance and Your Insurer Refuses to Pay All or a Portion of Your Medical Bills

It's not unusual for health insurers to deny coverage for medical care. If that happens to you and you believe that the care should be covered, or if your insurer pays some but not all of your medical bill and you believe it should cover the entire bill, here's what we recommend:

[Jan 23, 2017] In debt and afraid: dealing with debt collectors

Notable quotes:
"... The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service. ..."
"... Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you. ..."
"... Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney. ..."
"... Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die! ..."
"... Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. ..."
"... Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death ..."
Jan 23, 2017 | finance.yahoo.com
Sarah Skidmore Sell, AP Personal Finance Writer

It's a scary place to be - in debt and afraid.

A new Consumer Financial Protection Bureau report found that more than one in four consumers felt threatened when contacted by debt collectors. The first-ever national survey of consumer experiences with debt collectors found consumers often faced calls that came too often, at odd hours and contained warnings of jail time and other threats. Some were contacted for debts they didn't owe. And many said when they asked the collector to stop contacting them, the request was ignored.

CFPB Director Rich Cordray said the report casts a "troubling light" on the industry, and that the bureau is working to stop abuses. But what are your rights when facing off with a debt collector?

A few things to know:

YOU ARE NOT ALONE

The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service.

The Federal Trade Commission, which enforces the Fair Debt Collection Practices Act, also said debt collectors generate more complaints to its offices than any other industry. While many debt collectors are careful to comply with consumer protection laws, some engage in illegal practices.

YOU ARE PROTECTED

The Fair Debt Collection Practices Act provides protection for those being pursued for personal debts, such as money owed on a credit card account, an auto loan or a mortgage. It doesn't cover debts incurred to run a business.

YOU HAVE RIGHTS

Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you.

They may not contact you at inconvenient times or places, such as early in the morning or late at night. And they may not contact you at work if they're told not to.

Debt collectors may not harass, oppress, or abuse you, according to the FTC. That includes threats of violence or using obscene language. Federal law also limits the number of calls a debt collector can place.

Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney.

YOU CAN TAKE ACTION

Report any problems you have with a debt collector to your state Attorney General's office, the Federal Trade Commission and the Consumer Financial Protection Bureau. Many states have their own debt collection laws that vary from federal law, so contact your attorney general's office for help.

Gary G

They are debt collectors the lowest form of bottom feeding #$%$ on the planet.step one, NEVER tell them any personal information whatsoever.step two, get a phone number and case number so you can call them back.step three call them from a phone that can record the conversation (theres an app for that)step three, call them when you are really ready to talk to them Inform them the call is being recorded. let them know clearly what forms of contact are and are not acceptable.step four, get the pertinent information about the debt including the debtor any account numbers and any settlement offers they have. Still NEVER give away any personal information. once you have all the information you need end the call, if at any time during the call you feel you are being harassed or intimidated inform them it is not acceptable (remember you are recording the conversation) and terminate the call. call back later.Now you are in control and can make informed decisions.If at some point you want/need to work out a settlement NEVER finalize anything on the phone, GET IT IN WRITING. NEVER, agree to give them your credit card or banking information under any circumstances!!!once you make an arrangement keep the printed document with the arrangement on file for the rest of your life.

Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die!

steven

Based on personal experience, the worst debt collectors are of the medical variety. Two years of a fatal ovarian cancer case overwhelmed not only my finances, but jeopardized my mental health as well. The only thing that kept me going was the necessity of showing up for work, and the support of coworkers and (may I say this?) my managers as well.

Mark

Consumer Financial Protection Bureau will be gutted under the GOP agenda. So the next time some cable company, Wall Street bank, or some other huge corporation screws you over, you'll have no recourse and you'll be on your own.

pfk

I find tgheses stories and the ads on TV (If you owe $1000 to IRS..., If you have more than $5,00 credit card debt, Reduce $50,00 debt to $5000..., etc) to e morally contemptible. If you cannot afford something do not buy it; if you have a job, pay your IRS taxes, etc. I'm tired paying extra for everything I buy or do for these people who spend and expect someone else (me) to pay.

a

hogwash! To scare off a junk debt buyer attorney all you need to do is make one call to your attorney. Many of you collectors "start fake lawsuits" to coerce debtors to pay. With no filing numbers, court stamps, etc... Once the debtor's attorney files a 'notice of appearance' and asks for a real lawsuit/trial, what happens? The creditor never files the lawsuit. Why? Because the junk debt buyer has to PROVE IT. The JDB creditor has no original contract signed to prove the debt exists, no chain of assignment/invoice to show they have standing to sue (own the debt) nor the account statements to verify what is owed. They are hoping at best for default judgements.

Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. You see Junk Debt Buyers buy debt with no contract signed by debtors, have no invoice they even own this particular debt in detail and no account statements to verify correct amount owed.

So debtors, beware, pay the few hundred dollars to your attorney to ask for a lawsuit and notice of appearance and see how fast that debt collector disappears. 99% of junk debt buyers/creditors buy unwarranted debt and CAN NOT PROVE IT IN COURT. There is a disclaimer on the debt stating there is no contract, invoice that it is sold nor account statements offered.

Just sue these junk debt buyers and they go away. If they sell the debt to another JDB again sue again and they drop the debt again. Resold debt has even less chance of winning in court because even less proof is available every time it is sold.

But DO NOT AVOID the fake lawsuit. If you do the creditor gets the default judgement and will garnish wages, lien your house, and will win. Now if the original creditor files the lawsuit you will most likely lose and owe (they have all the proof in their records). So in this case make a settlement offer of lump sum repay or payments you can afford.

Call me scum or whatever but I have used this strategy and it works. After a few decades of paying usurious interest rates I have some cash finally coming back; and no need to file bankruptcy. After 7 years it drops off your credit report and credit score goes way up. Make it anywhere to 4-7 years (depending on your state law timeframe) and the statute of limitations kicks in and money not legally owed any longer. Just do not make any payments on it to renew statute of limitations. No problems! Hell I gambled the money away anyway, how was I suppose to get it back -Ha, Ha. Joke was on the JDB in my case!

Gregory

Very poor article. Take it from some one who was being threatened for some one else's debt. A certified letter to the debt collector explaining you do not owe the debt means that once they receive the letter they can no longer contact you.

Violation of that law carries a 10,000 dollar fine. If the amount is in dispute the same tactic works, except they can contact you with the proof of what you owe. A lot times this involves too much work and they do not pursue it. So if they do not pursue it once the Statute of Limitations is over the debt can no longer be collected.

The limit varies by State Law and amount. Finally be aware that uncollected debts are often sold and the new "owner" of the debt may try to collect on it. Again a certified letter stops them as you have proof of notification that the debt is not owed. I hope this helps the victims out there.

Chub

Buying debt has become a large industry that attracts a lot of crooks. Companies buy debt for as little as a dime on the dollar! The original lender benefits because they are getting a little something out of a debt that they have no hope of collecting. The buyer of the debt benefits because the potential profit is very

Many of the people buying debt aren't your traditional debt collection agency. They are many times just an individual with a cell phone who could bend the rules because they can change their name and location as easy as you can report their activity. Many times you are just dealing with thugs with cellphones. If you owe them, don't be afraid to offer a lesser amount because they had bought the debt so cheap that they may still make a pretty good profit.

Chief_blamestormer

Realize that some debtors never borrowed a dime. It could be the result of a civil judgement. If you think all civil judgements are fair, then have a look at the cases in your local courthouse, or serve a couple rounds of jury duty.

W, 19 hours ago

Industry? There's nothing industrious about. Bill collectors are mostly thugs who can't get real jobs so they have to leverage their values off other people's misery. Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death , which is similar to a developing country, not a developed superpower.

[Jan 16, 2017] Trump said he will target pharmaceutical companies over drug prices and demand that they negotiate directly with Medicaid and Medicare.

Jan 16, 2017 | economistsview.typepad.com

pgl -> Fred C. Dobbs... , January 16, 2017 at 05:57 AM

If Trump is serious about what he said - expect a real battle with Speaker Ryan.
DeDude -> pgl... , January 16, 2017 at 06:57 AM
That may be exactly what Trump is counting on. Trump is a classic bully, he gets back at people (to make an example and reduce future "resistance"). It would be very difficult for the GOP to fight with Trump publicly in the first year. Question is what his specifics are. He may even be able to get bipartisan support and split the GOP, the way Bush did with his prescription drug plan for seniors.
reason -> DeDude... , January 16, 2017 at 07:35 AM
Trump doesn't do details. Details are for little people.
libezkova -> DeDude... , January 16, 2017 at 07:44 AM
Crushing Speaker Ryan is not bulling per se. This is a great service for the country.

He is definitely out of touch with reality.

Peter K. -> Fred C. Dobbs... , January 16, 2017 at 05:55 AM
"We're going to have insurance for everybody," Mr. Trump said. "There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us."

In the interview, Mr. Trump provided no details about how his plan would work or what it would cost. He spoke in the same generalities that he used to describe his health care goals during the campaign - that it would be "great health care" that left people "beautifully covered."

Single payer!

ilsm -> Peter K.... , January 16, 2017 at 06:10 AM
Trump would have to sell it, but in the past he has praised European style single payer, but said it would be a hard sell in the US.

If Nixon could go to China.

MLK would observe "if US can pay to gut the world, it can afford a little for the home front".

Peter K. -> ilsm... , January 16, 2017 at 06:52 AM
"Beautifully covered."

Can't wait!

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 06:00 AM
The GOP's strategy for Obamacare? Repeal and run.
http://www.bostonglobe.com/opinion/2017/01/15/gop-strategy-for-aca-repeal-and-run/aCcjrJWQDjx4r4aRxkMCaL/story.html?event=event25 via @BostonGlobe
Elizabeth Warren - January 15, 2017

For eight years, Republicans in Congress have complained about health care in America, heaping most of the blame on President Obama. Meanwhile, they've hung out on the sidelines making doomsday predictions and cheering every stumble, but refusing to lift a finger to actually improve our health care system.

The GOP is about to control the White House, Senate, and House. So what's the first thing on their agenda? Are they working to bring down premiums and deductibles? Are they making fixes to expand the network of doctors and the number of plans people can choose from? Nope. The number one priority for congressional Republicans is repealing the Affordable Care Act and breaking up our health care system while offering zero solutions.

Their strategy? Repeal and run.

Many Massachusetts families are watching this play out, worried about what will happen - including thousands from across the Commonwealth that I joined at Faneuil Hall on Sunday to rally in support of the ACA. Hospitals and insurers are watching too, concerned that repealing the ACA will create chaos in the health insurance market and send costs spiraling out of control.

They are right to worry. Massachusetts has worked for years to provide high-quality, affordable health care for everyone. But there's no magic wand we can wave to simply snap back to our old system if congressional Republicans decide to rip up the Affordable Care Act and run away.

Health care reform in Massachusetts wasn't partisan. Democrats, Republicans, business leaders, hospitals, insurers, doctors, and consumers all came together behind a commitment that every single person in our Commonwealth deserves access to affordable, high-quality care. When Republican Governor Mitt Romney signed Massachusetts health reform into law in 2006, our state took huge strides toward offering universal health care coverage and financial security to millions of Bay State residents.

That law was a major step forward. Today, more than 97 percent of Bay Staters are covered - the highest rate of any state in the country.

But Massachusetts still has a lot to lose if the ACA is repealed. One big reason for our state's health care success is that we took advantage of the new opportunities offered under the ACA. In addition to making care more accessible and efficient, our state expanded Medicaid, using federal funds to help even more people. And we combined federal and state dollars to help reduce the cost of insurance on the Health Connector.

When the ACA passed, Massachusetts already had in place some of the best consumer protections in the nation. But the ACA still made a big difference. It strengthened protections for people in Massachusetts with pre-existing conditions, allowed for free preventive care visits, and - for the first time in our state - banned setting lifetime caps on benefits.

If the ACA is repealed, our health care system would hang in the balance. Half a million people in the Commonwealth would risk losing their coverage. People who now have an iron-clad guarantee that they can't be turned away due to their pre-existing conditions or discriminated against because of their gender could lose that security. Preventive health care, community health centers, and rural hospitals could lose crucial support. In short, the Massachusetts health care law is a big achievement and a national model, but it also depends on the ACA and a strong partnership with the federal government.

If the cost-sharing subsidies provided by the ACA are slashed to zero, Massachusetts will have a tough time keeping down the cost of plans on the Health Connector. The state can't make funds appear out of thin air to help families on the Medicaid expansion if Republicans yank away support. And our ability to address the opioid crisis will be severely hampered if people lose access to health insurance or if the federal funding provided through the Medicaid waiver disappears. Even in states with strong health care systems - states like Massachusetts - the ACA is critical.

The current system isn't perfect - not by a long shot. There are important steps Congress could take to lower deductibles and premiums, to expand the network of doctors people can see on their plans, and to increase the stability and predictability of the market. We should be working together to make health care better all across the country, just like we've tried to do here in Massachusetts.

This doesn't need to be a partisan fight. But if congressional Republicans continue to pursue repeal of the ACA with nothing more than vague assurances that they might - someday - think up a replacement plan, the millions of Americans who believe in guaranteeing people's access to affordable health care will fight back every step of the way.

Repeal and run is for cowards.

pgl -> Fred C. Dobbs... , January 16, 2017 at 06:00 AM
"Providing health insurance to everyone in the country is likely to be very costly, a fact that could diminish support from fiscal conservatives."

Herein lies the real issue. Of course we could reduce these costs by ending the doctor cartel, ending the oligopoly power of the health insurance giants, and pushing back on Big Pharma. Alas, Speaker Ryan is not interested in any of these things.

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 06:01 AM
Rand Paul says he's drafting
a measure to replace Obamacare http://www.bostonglobe.com/news/politics/2017/01/15/rand-paul-says-drafting-measure-replace-obamacare/y6wMEPKjbi1oEkj9TkekSO/story.html?event=event25 via @BostonGlobe
Miles Weiss - Bloomberg - January 15, 2017

Republican Senator Rand Paul said he's drafting legislation for a health-care insurance plan that could replace Obamacare, including a provision to ''legalize'' the sale of inexpensive insurance policies that provide abbreviated coverage.

''That means getting rid of the Obamacare mandates on what you can buy,'' Paul said in an interview on CNN's ''State of the Union'' on Sunday. Obamacare, which Republicans are moving to repeal, requires insurers to cover a number of procedures -- such as preventive care and pregnancy -- that Paul said drives up the cost.

The Kentucky Republican said he'll propose helping people pay for medical bills through tax credits and health savings accounts, which allow users to set aside money tax-free to pay for medical expenses. His bill would allow individuals and small businesses to form associations when buying insurance, giving them more leverage, he said.

''There's no reason why someone with four employees shouldn't be able to join with hundreds and hundreds of other businesses'' to negotiate better prices, Paul said. Becoming part of larger pools would help small companies secure coverage ''that guarantees the issue of the insurance even if you get sick.'' ...

Paul said his legislation is meant to address concern among Democrats and some Republicans that ending Obamacare would also end health-care coverage for many of the 20 million people who acquired insurance under the law. While Republicans move ahead with their plans to eradicate Obamacare, they have yet to outline an alternative.

''It's incredibly important that we do replacement on the same day as we do repeal,'' Paul said on CNN. ''Our goal,'' he added, is to ''give access to the most amount of people at the least amount of cost.''

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 07:28 AM
(I urge that Dr Paul's plan include
guv'mint-supplied snake bite kits
for all. That could save a bundle.)

[Jan 15, 2017] Doctors in the United States get paid on average more than $250,000 a year

Jan 15, 2017 | economistsview.typepad.com
libezkova -> anne... , January 14, 2017 at 10:45 PM
"Doctors in the United States get paid on average more than $250,000 a year,"

I am sure that this is a right estimate. Certain specialties probably yes (dentists, cardiologist, gastroenterologists, neurosurgeons, etc), but family doctors, probably no.

[Jan 15, 2017] The Congressional defeat, insured by Democrats, of the proposal by Bernie Sanders to allow the import of drugs from Canada to lower drug prices in the United States

Jan 15, 2017 | economistsview.typepad.com
JohnH -> anne... , January 14, 2017 at 08:00 AM
The Congressional defeat, insured by Democrats, of the proposal by Bernie Sanders to allow the import of drugs from Canada to lower drug prices in the United States.
'
This is only the beginning of Democrats' appeasement of Trump and Republicans...it will be stunning to watch how much damage Republicans can do during Trump's first 90 days with only a slim majority in the Senate. During the first 90 days under Obama, who had a true electoral mandate and big majorities in both houses, Democrats basically sat on their hands, blaming Republicans for their unwillingness to do much for the American people.
Observer -> anne... , January 14, 2017 at 08:50 AM
So if we matched Canada, we'd see a 30% decrease, of a segment which comprises 10% of health care spending, or 3% overall decrease.

"PwC's Health Research Institute projects the 2017 medical cost trend to be the same as the current year – a 6.5% growth rate."

So reaching Canadian spending levels would counter ~ 6 months of health care cost increases. Reaching OECD levels buys you another couple of months.

Put another way, reaching OECD levels for drug spending closes 10% of the US-OECD spending gap.

Not nothing, but "fixing" drug prices seems more like an emotional (i.e. political) talking point than a real silver bullet for health care costs.

http://www.pwc.com/us/en/health-industries/health-research-institute/behind-the-numbers.html

pgl -> Observer... , January 14, 2017 at 11:17 AM
Ever noticed that marketing costs are 30% of revenue? This is a by product of the monopoly power in this sector. Dean Baker has often noted we could have the government do the R&D and then have real competition in manufacturing.
libezkova -> Observer... , January 14, 2017 at 10:40 PM
Don't be a lobbyist for Big Farma.

You forgot that those researchers often produce useless or even dangerous drags, which are inferior to existing. Looks as scams practiced with hypertension drugs.

This rat race for blockbuster drugs is the same as corruption in financial industry.

http://www.alternet.org/story/148907/15_dangerous_drugs_big_pharma_shoves_down_our_throats

pgl -> anne... , January 14, 2017 at 11:16 AM
Actually the industry profile is very relevant but goes in a different direction - if US firms were compelled to charge market (not monopoly) prices, we would better compete with foreign firms.
pgl -> Observer... , January 14, 2017 at 11:14 AM
Any excuse to charge sky high prices for drugs that don't cost that much to manufacture? If these monopoly profits were not so high, we would buy more drugs and employ more people.
Observer -> pgl... , January 14, 2017 at 12:57 PM
Do you think we would really buy materially more drugs if prices were lower? Particularly enough more, at those (30-50%?) lower prices, to generate the funds to employ more people?

(If that actually generated at much or more funds, it would seem like the pharma companies, seeking to make as much money as possible, would have already set prices at that lower per unit level.)

In any case, that seems like a LOT more drugs.

Perhaps Anne has data on the number of scripts per person in the US vs OECD.

pgl -> Observer... , January 14, 2017 at 01:06 PM
There are lots of poor people who don't take drugs because they can't afford them. This will become especially true if the Republican repeal Obamacare.
anne -> Observer... , January 14, 2017 at 09:05 AM
The point of course is wildly exploiting ordinary people in need of healthcare in every possible way, or a reflection of what we have come to. Returning now to the market...

[Jan 14, 2017] Insurance overhead runs are probably the best argument for single payer

Jan 14, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , -1
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

[Jan 13, 2017] What was at stake why Cory Booker joined Senate Republicans to kill a measure to import cheaper medicine

Jan 13, 2017 | economistsview.typepad.com
anne -> Observer... , January 13, 2017 at 07:39 AM
https://twitter.com/lhfang/status/819677587408568320

Lee Fang ‏@lhfang

What was at stake & why Cory Booker joined Senate Republicans to kill a measure to import cheaper medicine:

https://theintercept.com/2017/01/12/cory-booker-joins-senate-republicans-to-kill-measure-to-import-cheaper-medicine-from-canada/

BERNIE SANDERS INTRODUCED a very simple symbolic amendment Wednesday night, urging the federal government to allow Americans to purchase pharmaceutical drugs from Canada, where they are considerably cheaper.

2:49 PM - 12 Jan 2017

Peter K. -> anne... , January 13, 2017 at 09:33 AM
Cory Booker, another progressive neoliberal....
pgl -> Observer... , January 13, 2017 at 09:37 AM
Very good. On health insurance, they get 20% gross margins. I have argued many times we can cut this to 10%.

[Jan 13, 2017] Reducing the cost of healthcare

Jan 13, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , January 13, 2017 at 07:12 AM
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

anne -> Observer... , January 13, 2017 at 07:37 AM
https://www.nytimes.com/2017/01/12/us/politics/health-care-congress-vote-a-rama.html

January 12, 2017

Senate Takes Major Step Toward Repealing Health Care Law
By THOMAS KAPLAN and ROBERT PEAR

In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes....

[Jan 12, 2017] Cory Booker understands that a candidate cannot expect the Democratic nomination if he/she goes against the interests of BigPharma.

Jan 12, 2017 | www.nakedcapitalism.com
Benedict@Large , January 12, 2017 at 2:53 pm

Cory Booker understands that a candidate cannot expect the Democratic nomination if he/she goes against the interests of BigPharma.

RUKidding , January 12, 2017 at 3:26 pm

After spending day time hours publically going after Jeff Sessions (good), Booker uses the cover of darkness to reveal who he really works for.

Here's a clue: it isn't any of the 99%, whether in NJ or elsewhere.

Talk's cheap, but money walks – eh, Booker?

EndOfTheWorld , January 12, 2017 at 3:40 pm

Somewhere I saw that Bernie praised Trump taking on Big Pharma.

curlydan , January 12, 2017 at 3:33 pm

'specially if you're from Jersey. Kind of like Biden, Delaware, and credit cards. The strings on the puppets are awfully tight.

[Jan 12, 2017] Almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill

Jan 12, 2017 | www.nakedcapitalism.com
Class Warfare

"In a report from Bankrate.com, the firm found that almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill" [ 247 Wall Street ]. "While Millennials may be looked down on by older demographics, they are the most equipped generation to pay for an unexpected expense using their savings. It was found that 47% of those within the ages of 18 to 29 responded that they would use their savings to cover such a burden, up from 33% in 2014." I'd argue that's not virtue, but a rational response to the neoliberal destruction of universal benefits and government services generally.

Knifecatcher , January 12, 2017 at 2:12 pm

Re: Bankrate story – is there such thing as a $1k ER bill anymore? We paid nearly $3k for our unexpected trip, which involved 15 minutes with the doc, no tests or scans, and only a single dose of Childrens' Tylenol for consumables. (5 year old tried to poke his eye out with a stick and failed – but only just).

And of course our crapified insurance hadn't hit the deductible so we had to pay the whole bill out of pocket.

Vatch , January 12, 2017 at 2:31 pm

I'm lucky - I only have a $150 deductible, which is what I paid when I needed five stitches in my hand last year. The total bill was "only" about $1250, probably because I never saw an actual doctor. A nurse practitioner sewed me up. The explanation of benefits from the insurance company later showed that they only paid the hospital about one third of the billed price. I'm sorry that you had to pay the whole thing; I guess the insurance companies only enforce their standard payable fees when it's their money on the line.

optimader , January 12, 2017 at 2:58 pm

The kids I grew up with, that would have been crazy-glue/packaging-tape unless a finger articulation was compromised

http://morethanjustsurviving.com/stitches-bandages-or-super-glue/

btw..Animal bites should be left open and bandaged and treated w/ antibiotic so they heal from the inside out..

I remember in my misspent college youth an idiot scuba diver in Honduras (feeding a moray eel cheese wiz out of a can, guess what happened when she ran out?) who came to my friend's dad (a surgeon) insisting he sew her up.
He only bandaged her with butterfly bandages and gave her some kick-ass antibiotics. She was sure she was being undeserved (w/ gratis treatment) because he refused to sew her up, potentially trapping an infection.

ian , January 12, 2017 at 2:43 pm

I had a similar experience: 3 stitches on my sons finger. Treated by nurse (no doc), sutures and lidocaine was $1800. It got me wondering about how anyone could hope to reform health care when the accounting is so completely out of whack with reality.

[Jan 12, 2017] 200PM Water Cooler 1-12-2017 naked capitalism

Jan 12, 2017 | www.nakedcapitalism.com
Class Warfare

"Hierarchies aren't natural phenomena within the human race. Outside of parenting, human beings aren't born with the inclination to be ruled, controlled, 'managed,' and 'supervised' by other human beings" [ The Hampton Institute ]. Hierarchies are artificial constructs designed to serve a purpose. They are a necessity within any society that boasts high degrees of wealth and power inequities. They are a necessity for maintaining these inequities and ensuring they are not challenged from below."

"In a report from Bankrate.com, the firm found that almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill" [ 247 Wall Street ]. "While Millennials may be looked down on by older demographics, they are the most equipped generation to pay for an unexpected expense using their savings. It was found that 47% of those within the ages of 18 to 29 responded that they would use their savings to cover such a burden, up from 33% in 2014." I'd argue that's not virtue, but a rational response to the neoliberal destruction of universal benefits and government services generally.

"[A] good deal of [Wallace] Stevens's poetic output conveyed a feeling of sehnsucht ("inconsolable longing"). For example, in 'Sad Strains of a Gay Waltz,' Stevens writes of American southerners (although the words just as easily apply to their author) as 'voices crying without knowing for what, / Except to be happy, without knowing how.' The object of Stevens's inconsolable longing changed over time. In his early professional days, when he first moved to New York City, it was his hometown of Reading, Pa. Writing to his future wife, Elsie, Stevens lamented that he 'lost a world' when he left there" [ The American Conservative ].

Knifecatcher , January 12, 2017 at 2:12 pm

Re: Bankrate story – is there such thing as a $1k ER bill anymore? We paid nearly $3k for our unexpected trip, which involved 15 minutes with the doc, no tests or scans, and only a single dose of Childrens' Tylenol for consumables. (5 year old tried to poke his eye out with a stick and failed – but only just).

And of course our crapified insurance hadn't hit the deductible so we had to pay the whole bill out of pocket.

Vatch , January 12, 2017 at 2:31 pm

I'm lucky - I only have a $150 deductible, which is what I paid when I needed five stitches in my hand last year. The total bill was "only" about $1250, probably because I never saw an actual doctor. A nurse practitioner sewed me up. The explanation of benefits from the insurance company later showed that they only paid the hospital about one third of the billed price. I'm sorry that you had to pay the whole thing; I guess the insurance companies only enforce their standard payable fees when it's their money on the line.

optimader , January 12, 2017 at 2:58 pm

The kids I grew up with, that would have been crazy-glue/packaging-tape unless a finger articulation was compromised

http://morethanjustsurviving.com/stitches-bandages-or-super-glue/

btw..Animal bites should be left open and bandaged and treated w/ antibiotic so they heal from the inside out..

I remember in my misspent college youth an idiot scuba diver in Honduras (feeding a moray eel cheese wiz out of a can, guess what happened when she ran out?) who came to my friend's dad (a surgeon) insisting he sew her up.
He only bandaged her with butterfly bandages and gave her some kick-ass antibiotics. She was sure she was being undeserved (w/ gratis treatment) because he refused to sew her up, potentially trapping an infection.

ian , January 12, 2017 at 2:43 pm

I had a similar experience: 3 stitches on my sons finger. Treated by nurse (no doc), sutures and lidocaine was $1800. It got me wondering about how anyone could hope to reform health care when the accounting is so completely out of whack with reality.

[Jan 11, 2017] the DEPRAVED nature of the American "Health Kare" system

Jan 11, 2017 | www.nakedcapitalism.com
clarky90 , January 10, 2017 at 6:12 pm

For me, often it is the "small crimes" that exemplify the DEPRAVED nature of the American "Health Kare" system. (See the right hand panel of The Last Judgment Bosch triptych) https://en.wikipedia.org/wiki/The_Last_Judgment_(Bosch_triptych)

US drugmaker charges 200 times UK price for common worm pill

A US drugmaker has put a price tag of more than $800 on a pinworm treatment - 200 times more expensive than the equivalent medicine on British pharmacy shelves, in the latest example of "price gouging" in the world's largest healthcare market.
Impax Laboratories (Bastards!) started selling mebendazole this year at an average wholesale price of $442 per pill, according to figures seen by the Financial Times, which were checked with several US pharmacy chains including Walgreens and CVS.

Most cases of pinworm, a parasitic infection also known as threadworm, require two pills, meaning a course of treatment costs about $884. The drug is available prescription-only in the US but can be bought over the counter in the UK, where Boots, a British chemist chain, charges £6.99 for a pack of four pills, or £1.75 each.

The pinworm parasite, which is common in children, affects 200m people a year worldwide and up to 40m in the US. It is recommended that family members are treated for the highly contagious infection at the same time, meaning a household of five's treatment costs more than $4,400.

https://www.ft.com/content/f0080fe4-c3ad-11e6-9bca-2b93a6856354

"Mebendazole came into use in 1971, after it was developed in Belgium.[4] It is included in the WHO Model List of Essential Medicines, the most important medications needed in a basic health system .[5] Mebendazole is available as a generic medication.[6] The wholesale cost in the developing world is between 0.004 and 0.04 USD per dose .[7] In the United States a single dose is about 884.00 USD as of 2016.[8]

https://en.wikipedia.org/wiki/Mebendazole

[Jan 02, 2017] U.S. Healthcare Is A Global Outlier (And Not In A Good Way)

Jan 02, 2017 | www.zerohedge.com

Historically, the United States has spent more money than any other country on healthcare.

In the late 1990s, for example, the U.S. spent roughly 13% of GDP on healthcare, compared to about a 9.5% average for all high income countries.

However, as Visual Capitalist's Jeff Desjardins notes, in recent years, the difference has become more stark . Last year, as Obamacare continued to roll out, costs in the U.S. reached an all-time high of 17.5% of GDP . That's over $3 trillion spent on healthcare annually, and the rate of spending is expected accelerate over the next decade .

HIGH COSTS, HIGH BENEFIT?

With all that money being poured into healthcare, surely the U.S. must be getting better care in contrast to other high income countries.

At least, that's what one would think.

Today's chart comes to us from economist Max Roser (h/t @NinjaEconomics ) and it shows the extreme divergence of the U.S. healthcare system using two simple stats: life expectancy vs. health expenditures per capita.

Courtesy of: Visual Capitalist

THE DIVERGENCE OF U.S. HEALTHCARE

As you can see, Americans are spending more money – but they are not receiving results using the most basic metric of life expectancy. The divergence starts just before 1980, and it widens all the way to 2014.

It's worth noting that the 2015 statistics are not plotted on this chart. However, given that healthcare spend was 17.5% of GDP in 2015, the divergence is likely to continue to widen. U.S. spending is now closing in on $10,000 per person.

Perhaps the most concerning revelation from this data?

Not only is U.S. healthcare spending wildly inefficient, but it's also relatively ineffective. It would be one thing to spend more money and get the same results, but according to the above data that is not true. In fact, Americans on average will have shorter lives people in other high income countries.

Life expectancy in the U.S. has nearly flatlined, and it hasn't yet crossed the 80 year threshold. Meanwhile, Chileans, Greeks, and Israelis are all outliving their American counterparts for a fraction of the associated costs. buckstopshere , Jan 1, 2017 10:02 PM

A shorter life expectancy makes Social Security look more solvent.

Cooking the books.

junction buckstopshere , Jan 1, 2017 10:08 PM
The chart shows that Monsanto and the New World Order are succeeding, that more glyphosate herbicide in the food, more toxic chemtrails and more unneccessary operations are having the desired effect, to cull the American population. Helped immeasurably by the cocaine and heroin flown into the USA by the Bush Crime Cartel on Air Force cargo planes.
cheka junction , Jan 1, 2017 10:10 PM
nyc runs US health care. that tells one all he needs to know.
Pinch Dog Will Hunt , Jan 2, 2017 12:58 AM
Republitards and Freedumb-lovers need to watch Michael Moore's movie about this called "Sicko"

https://www.youtube.com/watch?v=thkBLpRwdSM

You need MORE socialism, not less.

Tards.

Chief Wonder Bread balolalo , Jan 1, 2017 10:42 PM
Australia, Norway, Switzerland, Germany, South Korea, Japan, Italy, U.S.

Which of these countries is not like any of the others? Haha. Multiculturalism is such a fantastic deal. Some "cultures" just don't make good lifestyle decisions such as thinking that grape drank and swisher sweets are healthful choices.

philipat cheka , Jan 1, 2017 10:35 PM
It is, of course, in part a "Lifestyle" issue but the US system is grossly inefficient because there are adverse incentives built in (Adverse selection etc.). The US still uses a "Fee for service" model which has never been able to control costs anywhere in the world. On top of that, high pharmaceutical prices in the US account for up to 90% of total Big Pharma profits ane Medical Malpractise insurance not only directly adds large costs but indirectly forces the use of an unnecessary number of tests and the use of the newest drugs etc. Without any sensible controls at any point in the system it will only continue to get further out of control, as ACA has illustrated.
Ballin D philipat , Jan 1, 2017 10:41 PM
What's the alternative to "fee for service?" Seems pretty standard to charge for services rendered.
philipat Ballin D , Jan 1, 2017 11:47 PM
Except that more services = more fees = higher costs. Hence multiple tests, multiple procedures and multiple drugs = higher costs and higher fees = inefficiency bias and higher still costs. Physicians are human and the Healthcare providers have become experts at maximising costs to breaking point. There are many alternative models within which to control costs through negotiated standard procedures and fixed costs for each procedure and drug formularies (including the use of generic drugs) etc. Single payer is used by much of the developed world where the supplier agrees to supply at a negotiated price or doesn't get to participate, which focuses their attention nicely. The benefits of scale, in whatever system is used, should result in lower prices but don't in the US where USG is already the largest single provider of healthcare (Medicare/Medicaid etc).
Canoe Driver philipat , Jan 2, 2017 12:36 AM
A lot of people, certainly not just doctors, are making a lot of money from this dysfunctional medical system. That is the difference no one is talking about. The money is not disappearing down a rabbit hole. It is being pocketed by thousands of multi-millionaires. It is a profit-based system. Medicine is the one field where Capitalism has no hope of efficiency. Why? Because the demand is infinite and inelastic. A recipe for the financial rape of millions.
dogsandhoney2 junction , Jan 2, 2017 12:43 AM
yeah,
and it also shows the effect of a
30% increase in psychological stress since 1980.
stress = ^stress hormones = stressed immune system =
anxiety/depression/cardiovascular disease/hyper inflammatory response/etc..

all to be treated by those in the stressed-out health care system,
usually with hyper-cost pharmaceuticals.

it's well past due date for the u.s. to become civilized by starting
single payer medical plans.

health insurance corporations = the terror.

sinbad2 heresy101 , Jan 1, 2017 10:48 PM
I wouldn't count on it.

Private healthcare and insurance is very profitable 2 of the 3 trillion the US spends on healthcare would go to shareholders and management of healthcare companies.

Mr Trump is a businessman and a realist. The media would be calling him a commie if he tried to fix it.

sinbad2 , Jan 1, 2017 10:38 PM
Americans would not have it any other way.

The countries that have the most cost effective healthcare, are countries that provide government run health insurance.

Americans would never tolerate claiming helthcare costs back from a Government run health providor, like in Australia, or waisting taxpayers money building hospitals.

Americans have to pay for their belief that private for profit health insurance is cheaper and better than government provided insurance.

Xena fobe sinbad2 , Jan 1, 2017 11:41 PM
Americans would accept single payer. But insurance companies would not.
TheEndIsNear I Write Code , Jan 2, 2017 12:05 AM
250,000 deaths in 2015 were due to medical error, the third leading cause of death in the U.S.
http://www.hopkinsmedicine.org/news/media/releases/study_suggests_medica...

38,300 people were killed on U.S. roads in 2015.
http://www.newsweek.com/2015-brought-biggest-us-traffic-death-increase-5...

33,636 deaths due to "Injury by firearms" of which only 11,208 were homicides, 21,175 were self inflicted suicides, and the remainder were due to accidental/negligent discharge of a firearm or "undetermined intent".
https://en.wikipedia.org/wiki/Gun_violence_in_the_United_States

brooklinite8 , Jan 1, 2017 11:07 PM
When I was visiting India I saw few women administer a baby birth basically in few minutes with bare hands, water, oil and some sarees. Here in the US I believe the bill comes around 5-10k at the least. Did we ever ask the question as to why do we need insurance to afford health care? Did we ever ask how has it become so out of control? Why has healthcare become such a big business? Where are the morals of humanity?

In USA the welfare of the state takes precedence to the welfare of the people. Human beings are valued at no different rate in USA than India. Welcome to the Land of the Free, Home of the Brave. Good Old USA. We are outliers and Everything we do should be an outlier. If not we will revisit and make sure it becomes an outlier. Lol

Canoe Driver brooklinite8 , Jan 2, 2017 12:57 AM
The total cost per childbirth in the US is said to be $50-65k. This figure is so outrageous that it is impossible to correlate it with the cost of providing the services. It is simply a bunch of profiteers taking their cut. And the profit can be several hundred percent of the underlying cost, precisely because the "customer" has no choice at all. Capitalism, which works well in many contexts, fails miserably in medicine. Demand is infinite and inelastic in the medical field.
hairball48 , Jan 1, 2017 11:15 PM
A shitty diet of sugar laden, high carbohydrate fast food products is what contributes to most Americans' shorter life spans, not "poor health care".

Health care is expensive because it's run by a de facto "health care mafia". I worked in the technical field of health care for 28 years. Excessive regulation is but just one reason health care is so expensive in the USA. Barriers to entry are another. Try to establish a medical school. See how long it takes. Fewer docs, the higher the price of docs. ECO 101. Don't look for a change anytime soon.

hairball

Miffed Microbio... hairball48 , Jan 2, 2017 12:14 AM
When I was an intern for clinical microbiology they gave us $300/month as a stipend. Today an internship costs $24k. This is on top of the 4 years degree. Plus the mechanization of the lab is continuing every year to the point there will be fewer jobs in the future. Hate to say it but my field is fucked. Much of my time is spent meeting regulatory compliance and it gets worse every year.

Miffed

tyberious , Jan 1, 2017 11:52 PM
Me, 20 years in Healthcare BS, MSPH, , started in reference labs, then trauma center, biotech and now in healthcare insurance quality improvement (Medicare). 1st of all the money is in the government, we all know that!

But my main response to the article is that the America sheep are being sheared! The assault starts at birth with 21 vaccines by adulthood( infant mortality), hormones in the food (preteen secondary sex characteristics)(breast cancer)(prostate cancer) , HFC (diabetes, heart diseases, and other complications) GMO's, glycophosphates, glutens, and the multitude of useless pharmaceuticals.

My point is Americans are being poisoned, not so much intentionally, but through fascist business models.

So recap: Chronic preventable illnesses, extensive bureaucracy, poor food choices (# 1 in my book), and a government that cares zero fucks about you!

chosen , Jan 2, 2017 12:18 AM
Doctors are way overpaid. Hospitals charge ridiculous prices that have no relation to reality. Insurance companies screw us even more.

The US medical system is worse than the university system. Both are scams whose main goal is to make the providers more and more money, and the users poorer and poorer. It is sick.

Canoe Driver chosen , Jan 2, 2017 1:12 AM
Basically, you are right. The idea is that the price is all the funds the "customer" has in the world, every time there is significant illness. This is because the demand for healthcare is essentially infinite and inelastic. If you want to live, pay us everything you have, then declare bankruptcy. That is what happens naturally in a for-profit medical system.

[Dec 30, 2016] Payment for Emergency Ambulance Services.

Dec 30, 2016 | dfs.ny.gov
The Office of General Counsel issued the following opinion on June 7, 2006, representing the position of the New York State Insurance Department.

Payment for Emergency Ambulance Services.

Re: Payment for Emergency Ambulance Services.

Questions Presented:

1. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or health maintenance organization ("HMO") has made partial payment of a bill?

2. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or health maintenance organization has denied payment entirely?

Conclusions:

1. Pursuant to N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006), the ambulance company may not bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or HMO has made partial payment of a bill under an insurance contract that provides major medical or similar comprehensive-type coverage. However, if such a contract is not involved, these provisions do not apply and there is no prohibition in the Insurance Law against the ambulance company billing the patient directly for the balance of the bill.

2. Yes. The ambulance company may bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or HMO has denied payment entirely, subject to the remedies available to the patient.

Facts:

This inquiry is general in nature.

Analysis:

N. Y. Ins. Law § 4303 (McKinney Supp. 2006) applies to non-profit health plans and HMO's. Although HMO's are primarily regulated by the New York Health Department, their subscriber contracts are regulated by the Insurance Department as if they were subscriber contracts of non-profit health insurers. See N.Y. Public Health Law § 4406(1) (McKinney 2002).

N.Y. Ins. Law § 4303(aa) (McKinney Supp. 2006) provides, in relevant part, as follows:

(aa)(1) Every contract issued by a hospital service company or health service corporation which provides major medical or similar comprehensive-type coverage shall include coverage for prehospital emergency medical services for the treatment of an emergency condition when such services are provided by an ambulance service issued a certificate to operate pursuant to section three thousand five of the public health law.

(2) Payment by an insurer pursuant to this section shall be payment in full for the services provided. An ambulance service reimbursed pursuant to this section shall not charge or seek any reimbursement from, or have any recourse against an insured for the services provided pursuant to this subsection, except for the collection of copayments, coinsurance or deductibles for which the insured is responsible for under the terms of the policy.

(3) An insurer shall provide reimbursement for those services prescribed by this section at rates negotiated between the insurer and the provider of such services. In the absence of agreed upon rates, an insurer shall pay for such services at the usual and customary charge, which shall not be excessive or unreasonable.

(4) The provisions of this subsection shall have no application to transfers of patients between hospitals or health care facilities by an ambulance service as described in paragraph one of this subsection. . . .

N.Y. Ins. Law § 3221(l)(15) (McKinney Supp. 2006), which applies to group or blanket accident and health insurance policies issued by commercial insurers and N.Y. Ins. Law § 3216(h)(24) (McKinney Supp. 2006), which applies to individual accident and health insurance policies issued by commercial insurers contain identical provisions.

In accordance with the above, if the insurance contract provides major medical or similar comprehensive-type coverage, it must include coverage for prehospital emergency medical services for the treatment of an emergency condition when such services are provided by an ambulance service issued a certificate to operate pursuant to section three thousand five of the public health law. The insurer must provide coverage for emergency ambulance services based upon the rates negotiated between the insurer and the provider of such services. If no participating provider contract exists, the insurer must pay for the services at the usual and customary charge, which shall not be excessive or unreasonable.

Once the insurer makes payment at the usual and customary charge, the provider must accept such payment as payment in full. The provider may not bill the patient directly for emergency ambulance services for the balance of a bill, except for the collection of copayments, coinsurance or deductibles that the insured is responsible for under the terms of the insurance contract.

Please note that N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006) are applicable only to insurance contracts that provide major medical or similar comprehensive-type coverage. Thus, if such a contract is not involved, these provisions do not apply and there is no prohibition in the Insurance Law against the ambulance company billing the insured directly. In addition, these provisions do not address a situation in which a New York authorized insurer or HMO has denied payment entirely for emergency ambulance services (i.e. where the insurer or HMO states that coverage was not in effect or that treatment was not medically necessary). In such cases, the ambulance company may bill the patient directly, subject to the remedies available to the patient.

If the ambulance company or patient disputes a payment made by the insurer or HMO as not constituting the usual and customary charge or disputes the fact that no payment was made, the ambulance company or patient may raise the issue with the insurer or HMO and/or file a complaint with the Department's Consumer Services Bureau.

Lastly, the New York Attorney General's Office has conducted an investigation on balance billing by ambulance companies. For further information, the inquirer was directed to contact the Attorney General's Office at (518)474-7330 or access their web site which is located at http://www.oag.state.ny.us.

This opinion does not provide an analysis of the No-Fault Insurance Law, which would result in a different analysis and conclusion, since the inquirer already had OGC Opinions on this subject. 1 Please note also that this opinion is limited to an interpretation of the New York Insurance Law. No opinion is rendered on any other laws.

For further information you may contact Associate Attorney Pascale Jean-Baptiste at the New York City Office.


1 See OGC Opinion No. 03-02-18, dated Feb. 18, 2003 and OGC Opinion No. 03-04-36, dated April 30, 2003; see also OGC Opinion No. 05-05-29, dated May 28, 2005.

[Dec 30, 2016] 20 things to know about balance billing

Notable quotes:
"... Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research . ..."
"... Balance billing complaints are up 1,000 percent in Texas . ..."
"... The rise in balance billing is partially attributable to a lack of network transparency with patients. ..."
"... The New York Times ..."
"... Kaiser Health News ..."
"... In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J., a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare rates - the physician balance billed the patient for an additional $10,635. ..."
"... Montana Public Radio ..."
"... Sunshine State News ..."
"... The New York Times ..."
"... The New York Times ..."
Dec 30, 2016 | www.beckershospitalreview.com

Patients, caught in the financial crosshairs, often feel powerless to negotiate costs. Consumer advocacy groups and federal and state legislators are turning their attention to balance billing practices this year with renewed vigor, forcing payers and providers to find other ways to settle financial disagreements.

Here are 20 things to know about balance billing.

1. Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research . In 2015, a nationwide study from Consumers Union found nearly one third of privately insured Americans received an unanticipated bill when their health plan paid less than expected for medical services within the past two years.

2. Balance billing complaints are up 1,000 percent in Texas . According to the Texas Department of Insurance , balance billing complaints rose from 112 in 2012 to 1,334 in 2015, an increase of 1,000 percent.

3. Lack of provider, network transparency. The rise in balance billing is partially attributable to a lack of network transparency with patients. In many cases patients are unaware they have received out-of-network care until they receive a balance bill in the mail. Nearly 70 percent of individuals with unaffordable out-of-network medical bills did not know the healthcare provider was not in their plan's network at the time of care, according to a survey conducted by Kaiser Family Foundation and The New York Times .

4. Emergency room services to blame, in part. A Health Services Research survey found in 2011, 68 percent of inpatient involuntary contact with out-of-network physicians was related to emergency care. These kinds of unanticipated medical bills may arise when a hospital participates in an insurer's network but its employed emergency physicians do not. For example, more than half of the hospitals in some Texas insurers' networks did not have a single physician on staff covered by the insurer, according to a 2015 study from the Centers for Public Policy Priorities in Austin.

5. Balance billing and contracted physicians. Many hospitals use physician outsourcing firms for anesthesiologists, emergency physicians, pathologists and radiologists, or will bring in an outside assistant surgeon to help with procedures. In many cases, these physicians do not participate in the same network as the hospital, unbeknownst to the patient. When physician groups and insurers are unable to resolve reimbursement disputes, patients can be served with much higher out-of-network charges. In Texas, for example, the specialty services most likely to submit balance bills are anesthesiologists, lab services, surgery and radiology, reports the Texas Department of Insurance .

6. Payers will fight out-of-network physicians with lower reimbursement rates. Last year, health insurance giant UnitedHealthcare said it would scale back how much it pays out-of-network physicians who practice at in-network hospitals, accusing physicians of demanding excessively high reimbursement levels, according to Kaiser Health News . During a billing dispute with out-of-network Bayonne (N.J.) Medical Center, the insurer accused the hospital of charging out-of-network rates 10 to 12 times higher for a medical service than area hospitals participating in United'snetwork. If a payer refuses to match physician reimbursement rates, the financial burden is passed on to the patient. In the aforementioned dispute between Bayonne and UnitedHealthcare, the patient was balance billed $1,170 for a total of five stitches.

7. Insurers are narrowing networks in an effort to reduce costs. As insurance companies have narrowed provider networks to keep premiums down, the number of patients who inadvertently received out-of-network care has jumped at hospitals, particularly with regard to contracted physicians.

8. Payers have sued providers for 'excessive' out-of-network fees. Aetna has sued a half dozen out-of-network physicians in recent years, alleging gross over charging for medical services. In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J., a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare rates - the physician balance billed the patient for an additional $10,635.

9. Balance billing can occur even when a payer adjusts out-of-network emergency bills to in-network rates for patients. A patient recently accused Duke University Medical Center in Durham, N.C., of balance billing his account for an out-of-network rate after the patient submitted in-network payment rates to Blue Cross Blue Shield. Owing to the medical emergency of his situation, Matthew Aitken said he received an in-network rate from Blue Cross Blue Shield of North Carolina. However, Mr. Aitken alleged Duke proceeded to charge him for the remainder of the bill at the higher out-of-network rate, resulting in a bill nearly double that of Mr. Aitken's out-of-pocket limit.

10. Air ambulance billing disputes, complaints on the rise. In rural areas of the U.S. the high price for life-saving air ambulance flights has grabbed media attention as rural residents, faced with excessive balance billing, have turned to state and federal auditors for intervention. Those in rural areas often must rely on air ambulance flights in life-or-death situations in lieu of feasible ground transportation. Reimbursement rate disputes between payers and medical air transport companies have strapped patients with devastating medical bills. When Amy Thomson's newborn daughter was in heart failure, Ms. Thomson had to use an air ambulance service in rural Montana for transport to a more capable facility. At the time her insurance company, PacificSource, did not have an in-network air ambulance company near her family, reports Montana Public Radio . Ms. Thomson received a $43,000 balance bill from Airlift Northwest after PacificSource contributed a policy cap of $13,000.

11. Provider-based billing practices. Consumers have been increasingly vocal about surprise medical bills derived from provider-based billing practices. Provider-based billing allows a healthcare organization to bill patients for physician care in addition to a service charge for the patient's use of hospital facilities and equipment. In some cases, a patient may be responsible for the service bill if their insurance declines to pay or if the patient has a high deductible health plan. Large hospitals like Cleveland Clinic have faced increased scrutiny for provider-based billing practices. After paying a $30 copayment for in-network care with a Cleveland Clinic chiropractor, Julie Beinhardt reported receiving a balance bill of $3,000 for provider-based service fees her insurance plan refused to cover.

12. President Barack Obama signed legislation against provider-based billing. Last year, President Obama signed legislation outlawing provider-based billing at off-campus outpatient facilities. The legislation does not apply to existing outpatient centers that already engage in the practice, however.

13. The president's 2017 budget proposal includes a provision to eliminate surprise medical bills. Although details are minimal, the president's 2017 budget proposal includes a provision to eliminate balance billing privately insured patients. The administration would address the issue by requiring physicians who regularly provide services in hospitals to accept in-network rates for service reimbursement, even if they aren't in the insurer's network.

14. About a quarter of U.S. states have laws that protect consumers from out-of-network medical bills incurred by emergency care. According to a study from Kaiser Family Foundation , 24 states have implemented laws that restrict providers from balance billing in emergency care situations, including California, Delaware, New Jersey, New York and Pennsylvania, among others.

15. More states are proposing independent dispute resolution between payers and providers in balance billing cases. Independent dispute resolution establishes a legal space in which providers and health insurers can settle disagreements regarding balance billing without involving the patient. The states of Illinois and New Yorkhave arbitration methods in place, and Florida , Washington and Pennsylvania are currently considering a similar resolution methods.

16. New York has some of the strongest consumer protection laws. Under New York law , consumers are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services. Patients can complete an assignment of benefits form that absolves them of financial responsibility and allows the provider to pursue payment from the health plan in balance billing disputes.

17. Florida state legislature is currently embroiled in a fight to pass balance billing laws. Legislation to outlaw balance billing in Florida has continued to creep through the state legislature since last fall. Introduced in both the house and senate, the bills have sparked conflicting and outspoken opinions from patients, payers, hospitals and physicians. Hospitals have largely denounced the bill, blaming balance billing disputes on payers that demand allegedly unsustainable reimbursement rates, reports Sunshine State News .

18. The "End Surprise Billing Act". Federal lawmakers are making moves to outlaw balance billing nationally. Co-sponsored by 25 lawmakers, the End Surprise Billing Act would protect patients from balance billing who went to in-network facilities for emergency services, reports Consumerist . In non-emergency cases, it would require providers to notify patients within 24 hours if an out-of-network specialist will be involved in an episode of care.

19. Consumers don't know how to navigate the legal waters. According to a Consumer Union report, 57 percent of patients who encountered balance billing from contracted physicians within the last two years paid in full because they didn't know their rights to fight the bills. An overwhelming majority (87 percent) did not know which agency or department in their state government is tasked with handling complaints about health insurance. "So many times, people just give up [in surprise billing disputes]," Elisabeth Benjamin, vice president of health initiatives with Community Service Society of New York, told NPR .

20. The New York Times dedicated a series to consumer encounters with surprise healthcare bills. Elisabeth Rosenthal's series in The New York Times entitled Paying Til it Hurts examined the personal and financial implications of excessive, unexpected medical costs on Americans, their families and their healthcare consumption. Ms. Rosenthal's installments often feature individuals with unaffordable balance bills like Peter Drier , who was served a $117,000 balance bill for an out-of-network physician's assistant he never knew was present during surgery.

[Dec 26, 2016] Are Psychiatric Medications Hurting More Patients Than They Help?

Notable quotes:
"... Scientific American ..."
Dec 26, 2016 | science.slashdot.org
(scientificamerican.com) 431

Posted by EditorDavid on Sunday December 18, 2016 @01:34PM from the depressing-anti-depressant-news dept.

An anonymous reader quotes Scientific American 's Cross-Check blog :

Two new posts on this website have me contemplating, once again, the terrible possibility that psychiatry is hurting more people than it helps. Reporter Sarah G. Miller notes in "1 in 6 Americans Takes a Psychiatric Drug" that prescriptions for mental illness keep surging. As of 2013, almost 17 percent of Americans were taking at least one psychiatric drug , up from 10 percent in 2011, according to a new study. "Antidepressants were the most common type of psychiatric drug in the survey, with 12 percent of adults reporting that they filled prescriptions for these drugs..."

This increase in medications must be boosting our mental health, right? Wrong. In "Is Mental Health Declining in the U.S.?," Edmund S. Higgins, professor of psychiatry at the Medical University of South Carolina, acknowledges the "inconvenient truth" that Americans' mental health has, according to some measures, deteriorated ...

It's all more evidence of something their blogger wrote in 2012. "American psychiatry, in collusion with the pharmaceutical industry, may be perpetrating the biggest case of iatrogenesis -- harmful medical treatment -- in history ."

[Dec 26, 2016] 5 Ways to Lower Your Medical Bills Personal Finance

Notable quotes:
"... "One should know what the cost of the procedure is, and that is something that is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing beforehand there were going to be these six different types of providers . . . sending me bills." ..."
Nov 29, 2007 | US News

Insurance companies aren't the only ones who can negotiate a lower price -- you can, too. Here's how.

By U.S. News & World Report

Sanjiv Luthra of Los Altos, Calif., suffered from the pain and fatigue of rapid-onset arthritis so severe that he couldn't walk 10 feet until he underwent double knee-replacement surgery in 2006. Now, two years later, he can walk and run, but he still suffers the fallout from another ailment: medical bills.

Six hours in an operating room, two knee replacements, medications and a five-day hospital stay added up to a bill of $80,000, Luthra estimates. That's not counting bills for an anesthesiologist, physical therapy, additional medicines and special exercise equipment to help him recover.

"One should know what the cost of the procedure is, and that is something that is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing beforehand there were going to be these six different types of providers . . . sending me bills."

Luthra's insurance company was able to negotiate with the hospital so that it paid about $20,000, and he parted with about $5,000, including expenses outside the hospital.

But individual patients can haggle for lower medical bills, too. Here are tips on how to go about it.

Work up the courage to ask. It's not just insurance companies that can negotiate.

"The typical insurer gets about a 60% discount," says Gerard Anderson, the director of the Johns Hopkins Center for Hospital Finance and Management. "If you go into the hospital and ask the chief financial officer , you may get a 30% discount, but you have to ask for it. It's totally up to the discretion of the CFO how much they or the person in the billing office are willing to give you."

Although it's common to negotiate with a real-estate agent or car salesperson you probably never will see again, it's much more difficult to negotiate with a doctor you trust to make you well and to provide continuing care for your family. Only 31% of Americans have tried to negotiate the price of medical bills, a survey by Consumer Reports National Research Center indicated. But of those who tried, 93% have been successful at least once, and more than a third saved more than $100.

Explore low-cost treatments. Many doctors incurred large loans to finance medical school and probably understand the need to get a fair price as well as you do.

But even though almost 80% of physicians will prescribe a generic medication over a brand-name drug to save patients money, far fewer consider patient costs when recommending diagnostic tests (51%) or choosing between hospitalization and outpatient treatment (40%), according to a survey of physicians by the Center for Health System Change and the University of Chicago

If money is an issue, you need to ask your doctor if cheaper, medically sound options are available. The trick is to keep it friendly and ask nicely. For minor health ailments such as ear infections and pinkeye, drugstore clinics list reasonable prices upfront, with no negotiating required.

Find the correct person. Although they are heavily involved in treatment decisions, doctors may not be directly involved in other billing issues, so you need to find a person with the ability to adjust your bill.

"I would suggest the consumer go to the office manager," says Timothy Cahill, a health-care consultant in Louisville, Ky., who has negotiated hospital bills on behalf of patients. The office manager should be able to direct you to the person in charge of billing.

Offer cash payments. This could be a mutually beneficial solution for you and the medical establishment.

"Paying cash is worth a lot to a doctor in terms of time and trouble, and it is a lot less complex for the hospital to deal with," says Shankar Srinivasan. He is a co-founder and the chief technology officer of Vimo.com, a company that uses public records to figure out what prices insurers negotiate with hospitals. Cash, he says, saves hospitals the trouble of negotiating financing terms, paying credit card transaction fees and sending collection agencies after patients who fail to pay.

Scrutinize the bill and your insurance. If you don't have the cash to pay a large medical bill, you need to educate yourself about what your insurance should cover and try to negotiate a discount off the sticker price.

"As a consumer, just like a detective, you have to really understand the specifics of your insurance benefit plan, take the initiative of setting up conference calls (including yourself, the hospital and your insurance company) proactively, and you have to document everything," says Luthra, who is chief operating officer of the health-care-consulting company Benu. "You don't just pay the bill as is."

This article was reported and written by Emily Brandon for U.S. News & World Report.

[Dec 26, 2016] How to avoid and handle surprise medical bills

Notable quotes:
"... The average balance billed to patients was $622.55 , though the study reported bills as high as $19,603.30. But, ERs are not the only source of surprise bills. ..."
"... Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the case may be out of network, and follow up with a surprise bill. ..."
"... If you have a serious medical emergency, your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense for high surprise bills. But, even if you visit an in-network ER, you have little control over the choice of doctor: By definition, you are facing an emergency, and must take whoever is available. ..."
"... Check with your state insurance regulator to see if your state has any consumer protections against surprise bills. ..."
"... At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills - either for out-of-network ER situations alone or for additional types of surprise bills. ..."
"... If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted rate. ..."
"... If the provider is out of network, do some research on an independent website, such as fairhealthconsumer.org , to estimate what the procedure typically costs in your locality. ..."
"... If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely. ..."
thehill.com
Surprise bills are never a welcome surprise. Typically, they arrive after you arranged care from a doctor and a hospital that were both in your health plan's network, but then you were unexpectedly treated by one or more other providers who, unbeknownst to you, were outside that network.

When these out-of-network providers send you a bill for their services, you may have to pay the full amount out of pocket or, if your health plan covers out-of-network care, to pay the balance of the bill that your insurance fails to cover. And the balance bill generally requires you to pay more than the out-of-pocket amount you would have owed if you had been treated by an in-network provider.

Emergency rooms are one of the most common locations where healthcare results in surprise bills.

As detailed recently in an article by two Yale scholars in the New England Journal of Medicine, in more than one in five cases nationwide, ER visits to an in-network facility involved out-of-network physicians. The average balance billed to patients was $622.55, though the study reported bills as high as $19,603.30. But, ERs are not the only source of surprise bills.

Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the case may be out of network, and follow up with a surprise bill.

Several states have already enacted laws to protect consumers against surprise bills, although some of the statutes protect patients only in the case of balance bills for out-of-network ER services for a serious medical emergency. Currently, the issue is being discussed in a number of statehouses. In the meantime, here are steps you can take to protect yourself from such surprises.

Prevent surprise bills

The best defense against a surprise bill is prevention. If you have a serious medical emergency, your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense for high surprise bills. But, even if you visit an in-network ER, you have little control over the choice of doctor: By definition, you are facing an emergency, and must take whoever is available.

However, for a planned surgery or other procedure, you probably have time to speak up. Make sure that your doctor and hospital are in your plan's network. Check with them and with your plan. Ask your physician and your hospital in advance if they can arrange to have only in-network providers treat you.

Some hospitals may have no in-network specialist for care you might require. Find out if another hospital in your area can provide all your necessary services on an in-network basis. In some areas, there may be no in-network specialists available of the type you need. In that case, inform your plan that its network lacks necessary services and find out if the terms of the plan or state law provide you protection from large balance bills in such circumstances.

Always refer to your plan by its exact official name. Often insurers have multiple plans with similar names but different networks. If you use the wrong plan name when inquiring about a plan's network, you may get a wrong and costly answer. Make your inquiries and requests in writing so you have documentation. Ask for the names of the providers who will be involved in your care, and check with your insurer and with the providers themselves to see if they are all in your plan's network.

Check if your state protects consumers

If you do get a surprise bill, take action. Check with your state insurance regulator to see if your state has any consumer protections against surprise bills. Many states have laws that require HMOs to protect consumers from surprise bills, especially with respect to necessary ER services. Fewer states have similar protections for other types of health plans, such as PPOs and EPOs.

At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills - either for out-of-network ER situations alone or for additional types of surprise bills. Generally, these laws provide that the consumer is required to pay only the amount he or she would owe for the services if provided in-network. States have different mechanisms for settling the balance, but they generally involve the insurer and the provider, not the patient.

If your state does not provide protection

If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted rate.

If the provider is out of network, do some research on an independent website, such as fairhealthconsumer.org, to estimate what the procedure typically costs in your locality. If your plan's reimbursement is based on an amount that is less than the typical charge, you can use this information to ask the plan to pay the provider on the basis of at least the typical rate. If the out-of-network provider's charge is higher than the typical rate, you might be able to negotiate with the provider to reduce your costs. You can try to persuade the provider to reduce the charge, or to discount an excessive balance bill, by showing the provider that his or her charge is above the typical market rate.

If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely.

Robin Gelburd, JD, is the president of FAIR Health, a national, independent nonprofit with the mission of bringing transparency to healthcare costs and insurance reimbursement. FAIR Health oversees the nation's largest repository of private healthcare claims data, comprising over 21 billion billed medical and dental charges that reflect the claims experience of over 150 million privately insured Americans. Follow on twitter @FAIRHealth

[Dec 25, 2016] How to Fight Back Against Outrageous E.R. Bills

Two excellent resources-Healthcare Blue Book and FAIR Health-can give you estimates of how much health care services should cost in your area. Plus, your insurer's website may also provide a tool that will allow you to compare costs.
Notable quotes:
"... But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says. ..."
"... "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says. ..."
"... "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money." ..."
"... This piece is by Drew Anne Scarantino ..."
www.thefiscaltimes.com

It's no secret that hospital bills in the U.S.-especially ones from the E.R.-can often hit astronomical proportions.

According to a recent cost study conducted by researchers at Stanford University, the University of Minnesota, the University of California, San Francisco and the Ecologic Institute, the median charge for an emergency room trip in the U.S. comes in at $1,233. But where it really gets interesting is when you look at the specific reasons for those E.R. visits: The researchers found that the treatment price for a headache could range from $15 to a whopping $17,797. As for a sprained ankle, it could set someone back a paltry $4 or up to $24,110!

So what gives with these wildly fluctuating price points?

For starters, most emergency room prices are inflated based on the rates at which insurance companies will reimburse the hospital on a patient's behalf. That's why a single aspirin can cost $30 per pill in the E.R., which is more than six times the price for a bottle of them at the drug store.

On the flip side, patients will often contact the hospital or surgeon's billing office to ask for a cost reduction, further adding to the inconsistency in pricing. It's a practice that often works in a patient's favor, says billing advocacy specialist Sharon Salters of Medical Cost Advocatea professional medical bill negotiation service.

And then there's also the fact that most hospitals offer discounts to self-paying individuals-especially if there's a risk that they might not pay at all.

So to help shed some light on the complexities of hospital medical billing for the average consumer, we asked three people to share their craziest emergency room stories, the even crazier bills that followed-and the steps they took to remedy them.

... ... ...

The Emergency: Head Injury
The Bill: $9,000

A few months ago, Amanda Harris, 27, of Morristown, N.J., fainted at work, hitting her head in the process. Due to liability concerns, her production company required Harris to take an ambulance to the emergency room, despite her refusal. "I didn't even have a cut on my head, just a slight bump. No headache, no nausea, no confusion, nothing," she says.

Harris waited for over an hour in the E.R. before her husband told the nurse that they were leaving. Minutes later, a doctor spoke to Harris for under a minute, confirming that she was fine to go. "He didn't do any tests-no light in my eyes, no blood pressure," says Harris. "I left thinking I wouldn't even get a bill."

But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says.

RELATED: Hospital Costs Explode: Between $127 and $151 Billion

What This Patient Did: Harris called her insurer and fought the bill. Luckily, her insurance covered all but a $3,000 deductible-but she was too exhausted to push for more. "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says.

What the Expert Says: Even though Harris didn't want to take an ambulance, Salters says that her company's suggestion was well-advised. "However, she should consider working with her employer to file the claim with her company's worker's compensation carrier," says Salters. "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money."

How You Can Avoid Outrageous E.R. Bills (Really!)

When it comes to a trip to the E.R., the reality is that there's usually no time to shop around and compare prices in advance. But if you do some research before an emergency happens, you could potentially keep costs significantly down.

The negotiation can seem like a lot of extra work, but the payoff can be tens of thousands of dollars in savings shaved off a potentially outrageous E.R. bill.

This piece is by Drew Anne Scarantino.

[Nov 23, 2016] 7 Tips For Fighting And Paying A Big Hospital Bill by Caroline Mayer

Notable quotes:
"... Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation. ..."
"... don't hesitate to appeal its decisions. You'd be surprised how often carriers overturn their earlier rejections. ..."
Sep 17, 2013 | www.forbes.com

Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at once.

You may also be able to successfully bargain down the particular dollar amounts you've been charged.

Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital, you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less than the initial rate quoted - the figure charged to uninsured patients.

Go online to check the rates other local hospitals charge for the procedure you had. Then, if you find your bill was way out of line, use this data as ammunition to try to get your fees lowered. You can get this type of information at such sites as Clear Health Costs, Healthcare Blue Book and FAIR Health.

Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation.

2. Vigilantly review the bills. "It's very common for hospital bills to contain errors and overcharges, so make sure you've actually received the services they said you did," Detweiler says.

Candice Butcher, vice president of Medical Billing Advocates of America, says if you're discharged in the morning (as most patients are), protest if you're socked with a full daily-room rate for the date you left the hospital.

And if you brought your medications with you, make sure you weren't charged for them by the hospital. "This frequently happens," Butcher says.

Also, dispute any additional fees on the bill for routine supplies, like gowns, gloves or sheets. These items should be factored into the hospital daily-room charge, because, Butcher says, they are "considered the cost of doing business."

3. Challenge your health insurer's decisions, when warranted. Keep track of any hospital bills the company rejects on grounds that the procedure or drug isn't covered by your policy. If you believe the insurer should be paying more, don't hesitate to appeal its decisions. You'd be surprised how often carriers overturn their earlier rejections.

4. Negotiate bills once you know how much you'll have to pay out of pocket. If you just want extra time to send the money, Dale says, "it is relatively easy to speak with hospital or clinic business office staff to arrange a payment plan."

Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at once.

You may also be able to successfully bargain down the particular dollar amounts you've been charged.

Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital, you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less than the initial rate quoted - the figure charged to uninsured patients.

Go online to check the rates other local hospitals charge for the procedure you had. Then, if you find your bill was way out of line, use this data as ammunition to try to get your fees lowered. You can get this type of information at such sites as Clear Health Costs, Healthcare Blue Book and FAIR Health.

Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation.

5. Consider hiring a pro. Since hospital bills are hairy, messy beasts, it may be worth your while to bring in a patient- or medical-billing advocate (Detweiler recommends the advocacy firm Copatient.com, which charges 30% of what it saves you) or an attorney. "It's like hiring a CPA to do your taxes," Dale says.

Be sure you won't be required to pay this expert any fees upfront. Patient advocates typically charge 20 to 30% of your savings; some put a cap on their fees. Karis' firm, for example, charges no more than $3,000. Attorneys often charge 30% of the savings they achieve.

... ... ...

Caroline Mayer is a consumer reporter who spent 25 years working for The Washington Post. Follow her on Twitter TWTR -0.69% @consumermayer.

[Nov 22, 2016] Negotiating can cut hundreds off your medical bills

Notable quotes:
"... There are also companies who claim they have a network of physicians throughout the state who offer medical services for 50 percent off or more. ..."
13 WTHR Indianapolis
But you can fight back against skyrocketing medical costs.

"I've heard discounts up in the area of 30 percent sometimes, which can be pretty significant," said Cathryn Perron, director of program development with Consumer Credit Counseling.

She says it's possible to negotiate down your medical bills - everything from ambulance rides to surgery. She says you can also bargain with your dentist, the lab that does your blood tests, the eye doctor - even the company that makes you prescription medication.

"Each company has a specific number you can call to fill out an application and many times, you'll get a discount, or you'll get the product free through the drug companies, if you qualify financially," Perron said.

All you have to do, with or without insurance, is make a call. Each case is handled differently. In most cases, everyone wants to pay the bill, but they're afraid to contact their doctor or hospital. They'll work with you to make sure the cost is paid.

So how do you pay less?

There are a number of options:

Charity care - Bills are forgiven, based on your income and expenses, but you'll have to fill out hardship paperwork.

"You'll most likely have to provide proof of income, they'll ask about your monthly living expenses and your other bills that you have to pay every month," said Perron.

Sholar called Indianapolis EMS.

"He says, 'Sir, you got to pay for the ambulance, all the stuff in the ambulance, the two people who drive the ambulance. That's just the way it is'," he said.

But he didn't give up.

"This bill says $1,300. She said, 'Yeah, that sounds about right.' I said, 'Let me talk to a supervisor'," Sholar said. "The supervisor's name is John. John wasn't too happy."

Mike put on the pressure and the bill was reduced by $532. The wounds to his buttocks are healed, but the other injury he got that night, on his thumb, is a constant reminder of the cost of healthcare.

"I don't need no X-rays, I don't need no other stuff. Just give me the stitches and I still haven't received a bill for that," he said.

But he's ready to negotiate and he says, in the future, he'll also weigh the costs before calling 911.

"I would have put a rag over it and got a ride here," he said.

Tips to Negotiate Your Medical Costs

Consumer Credit Counseling and Apprisen offer tips to get your medical bills reduced:

First and foremost be informed. Understand what type of medical insurance coverage you have and what your co-pays or financial responsibilities are. Some insurance companies have contracts with certain medical providers to offer a discount if you receive treatment from a "preferred provider." We encourage individuals to meet with their Human Resource department or contact their insurance company to speak with a representative about their coverage and benefits prior to receiving medical treatment. This could reduce your financial responsibility significantly.

Apprisen recommends for you to review your itemized statement from your medical provider. If you feel there are discrepancies or charges in question, contact your medical provider to meet with their Patient Account Specialist to discuss your questions or discrepancies. Communication is a vital part of resolving your issues. Simply ignoring communication from your medical provider will not resolve the issue and could potentially lead to a negative impact on your credit rating if resolution is not reached.

Whether you have insurance or not, you are encouraged to contact your medical provider prior to treatment (if possible) to discuss costs associated with your treatment and to work out the possibility of negotiating those costs down. Many medical providers will consider giving discounts to individuals who are willing to pay the balance in full upon services rendered or within a short period of time after receiving treatment. If you find yourself in a position where you are not able to pay the balance in full, consider negotiating with your medical provider for a monthly repayment plan interest free. You are encourage to analyze your personal budget to insure you are able to make the financial commitment to your medical provider. Negotiating your medical bill then failing to follow through with the financial payment arrangement could negate your hard effort to reduce your medical bill.

If you are uninsured, you are encouraged to meet with a Patient Account Specialist or a "decision maker" to see if you qualify for any financial hardship programs. Most hardship programs require you to provide evidence of your financial situation and the award is based on financial need. Be prepared to give a full budget disclosure in order to be considered for the hardship program.

Apprisen's mission is "To help people improve their financial well-being through counseling, community outreach and financial education."

You can call Apprisen at 1-800-355-2227 or visit apprisen.com.

There are also companies who claim they have a network of physicians throughout the state who offer medical services for 50 percent off or more. You can find out more about those companies at objectivedx.com.

[Nov 22, 2016] Hiring a Guide to the Medical Bill Maze by Lewis Braham

Notable quotes:
"... As part of her husband's benefits package, Isaac had access to a medical billing assistance company called Health Advocate . It negotiated with the physician's health-care group to reduce her bill to $7,000. ..."
Apr 29, 2013 | Bloomberg

When Annrose Isaac's twins were born prematurely, she thought her insurer would cover their stay in the neonatal intensive care unit. "The hospital was in our network, but it turned out the physician in the NICU who saw our daughters didn't participate with our insurer," says the Westwood (New Jersey)-based financial planner. "All of a sudden we were getting bills for over $30,000."

As part of her husband's benefits package, Isaac had access to a medical billing assistance company called Health Advocate. It negotiated with the physician's health-care group to reduce her bill to $7,000.

More than 60 percent of all U.S. personal bankruptcies are linked to illness and unpaid medical bills, according to a 2009 Harvard University study, even though 78 percent of those filing for bankruptcy because of illness have some form of health insurance. So hiring a medical billing advocate can be an essential part of the cure to financial ills.

Yet finding the right advocate can be tough, and those in the direst situations can ill afford the typical $75- to $130-an-hour rate. "This business is painfully slow-growing," says Becky Stephenson, co-president of the Alliance of Claims Assistance Professionals (ACAP), an advocate trade group. "There are a lot of people with problems but not a lot of people willing to pay you to help them." Despite long experience, Stephenson herself has trouble making a good living purely from advocacy, so she supplements her income by serving as an expert witness in medical lawsuits.

Employees working at sizable companies may already have access to a health advocate. Just over half of U.S. companies with more than 500 employees offer it as a benefit, according to Steven Noeldner, a senior consultant for Mercer's Total Health Management practice. Many employees don't know the benefit exists, he says, and the services generally aren't as customized as those of an independent billing advocate.

Credential Check

Unlike with more established professions such as accounting or law, there is no standard credential to look for when seeking a qualified advocate. At the most basic level you should ask if an advocate has certifications in medical bill coding from either the American Academy of Professional Coders or the American Health Information Management Association.

Many people with those designations aren't advocates, however, working instead for hospitals or insurers. And understanding the codes is only half the battle. Because of the complexity of our health-care system, you'll need someone who specializes in your specific kind of billing problem.

A good place to start is Claims.org, ACAP's website. It lets you search for experienced advocates by state. In a case like Isaac's, you'd need someone who specializes in hospital bills. Other advocates specialize in Medicare appeals, long-term care insurance, workers' compensation and insurance for special needs children.

Privacy Issues

The best way to find the right specialist is to ask the advocate for a resume and references. This can be tricky, because laws about disclosing private medical information are so strict that some advocates have difficulty providing references. In order to do so, their clients must agree to discuss their medical history.

Stephenson specializes in hospital bill audits. She studies itemized bills line by line, identifies padding and mistakes and negotiates lower rates. Prior to starting her Austin (Texas)-based advocacy firm VersaClaim in 2002, she ran an organization that helped doctors affiliated with hospitals set up their practices. That included all aspects of hospital billing.

A registered nurse for 12 years, Stephenson has an intimate knowledge of medical terminology and hospital procedures. "I ask questions like, Are there dosages of medications that are not compatible with my medical experience in real life?" she says. "Do the charges look realistic, or is there an $85 Tylenol?"

Location Matters

Another important factor to consider is an advocate's location. State laws vary in how they regulate insurers and hospitals. For Katalin Goencz, an advocate in Stamford, Connecticut, location is often irrelevant because she specializes in Medicare appeals: "The rules for Medicare are federal and pretty much universal, so the client's location doesn't really matter."

For a patient negotiating a lower bill directly with a local hospital or private insurer, having an advocate who knows the specific state regulations helps. State rules for advocates can also vary dramatically. Florida has some of the strictest. "Due to the large senior population in our state, we have a strong urge to make sure our people adjusting medical claims are licensed, competent and held to a high standard," says Matthew Guy, a spokesman for Florida's Division of Agent and Agency Services, which licenses and regulates advocates.

The state's Public Adjuster license for advocates requires licensees to be fingerprinted, have a criminal background check and hold a $50,000 surety bond. "If there's any wrongdoing by the adjuster, we can take the bond amount and use that towards restitution for the consumer," Guy says. Adjusters must pass an exam and take 24 hours of continuing education classes every two years.

Contingency Basis

A handful of advocates will work on contingency if they think you have a negotiable claim. Most will impose strict conditions to ensure they get paid if they win. "When I started my practice, I did everything on contingency but learned very quickly that a lot of consumers who want you to take their case on contingency in the end don't want to pay you," says Sheri Samotin, a billing advocate at Life Bridge Solutions in Naples, Florida.

Now Samotin requires a credit-card authorization up front for an amount sufficient to cover what her estimated contingency fee will be if her work succeeds. If the client doesn't pay within 10 days of a settlement being reached, she charges the card. Her fee is 35 percent of the client's medical bill savings.

Samotin is unusual in the advocacy world as she is more of a generalist, taking on all kinds of medical billing problems, including those of the uninsured. She has 25 years of experience in the health-care industry, so she has the knowledge to handle different kinds of problems, Samotin says. For a monthly $285 fee she will manage her clients' entire billing life -- a common need for seniors who have lost their capacity or desire to manage daily finances.

Instead of being a member of ACAP, Samotin is a member of the American Association of Daily Money Managers, a trade group for generalists. Only a handful of the AADMM's 700-plus members have the skills to also handle medical billing advocacy, Samotin says. Nor does she expect rapid growth in the field.

"Because this is a disorganized profession, people entering the field have to be entrepreneurs," she says. "They have to hang out their shingle and go out and get clients. In my experience, the majority of people who are good medical analysts and advocates are not necessarily good business getters."

So until the profession matures, finding a good advocate will remain difficult, no matter how vital the service is.

(Lewis Braham is a freelance writer based in Pittsburgh.)

To contact the editor responsible for this story: Suzanne Woolley at [email protected]

[Apr 05, 2013] How to handle medical bill problems by Lisa Zamosky

Notable quotes:
"... Most states have laws saying that patients are entitled to an itemized medical bill that details what services and supplies are included in their charges. ..."
"... In 2006, California passed a law to prevent hospitals from collecting more money from uninsured patients than what Medicare or other public programs would pay for the same service. ..."
"... "Once a patient contacts the hospital and shows evidence of their financial situation, state law requires us to offer a discount based on Medicare rates," says Jan Emerson-Shea, vice president of external affairs for the California Hospital Assn. ..."
"... All communications with a provider should be in writing, experts say. Insist that your account be placed on hold until the dispute is resolved to avoid having the bill sent to collections. ..."
"... If you meet with resistance, don't waste time by calling back the customer service line or billing department. Go straight to the top. ..."
"... filing a complaint with your state's department of insurance. ..."
Apr 05, 2013 | http://articles.latimes.com/2013/apr/05

For those with confusing or huge hospital bills, experts advise knowing rights, getting written explanations, turning to the right places for help and filing complaints if necessary.

When Keith Yaskin and his wife, Loren, rushed their 2-year-old son to the hospital with a dangerous infection in his neck, they weren't thinking about how much his care would cost. After his three-day inpatient stay with nonstop intravenous antibiotics, they were hit with $8,900 in charges.

But the toughest lesson for the Scottsdale, Ariz., couple came a month or so later when they began to sort out the hospital bills. Their insurance policy had a $10,000 deductible. So they scrutinized every item, made some calls and had a few surprises.

When, for instance, they asked a medical group they had never heard of why it was charging them $839.25, they said they got no clear answers, just threats if they failed to pay.

After 21/2 months of calls and a complaint to their state attorney general, the Yaskins finally learned that a pediatrician affiliated with the group had treated their son in the hospital. The medical group eventually cut the bill in half.

None of this surprises Pat Palmer, the founder of Medical Billing Advocates of America. "We get feedback from consumers saying that providers are telling them 'We can't give you an itemized statement' or 'You should have asked for it before you left the hospital.'"

The idea is to discourage patients from asking for the details behind the charges, she said.

Experts offer a range of suggestions for dealing with medical billing problems.

Know your rights. Most states have laws saying that patients are entitled to an itemized medical bill that details what services and supplies are included in their charges.

"You can't be billed if they can't tell you what they are charging for," Palmer says.

Contact the billing department at either the hospital or medical group where you received services, she said. Let them know that you want an itemized bill, and tell them you are aware of your legal right to have it.

Also, a few states have laws limiting how much hospitals can charge patients who pay for care on their own. In 2006, California passed a law to prevent hospitals from collecting more money from uninsured patients than what Medicare or other public programs would pay for the same service.

"Once a patient contacts the hospital and shows evidence of their financial situation, state law requires us to offer a discount based on Medicare rates," says Jan Emerson-Shea, vice president of external affairs for the California Hospital Assn.

Get explanations in writing and take protests to the top. All communications with a provider should be in writing, experts say. Insist that your account be placed on hold until the dispute is resolved to avoid having the bill sent to collections.

If you meet with resistance, don't waste time by calling back the customer service line or billing department. Go straight to the top.

Address a certified letter to the chief executive or chief financial officer of the hospital or medical group explaining that you have tried to resolve billing issues but have hit a brick wall. "The CEO and CFO will take it very seriously," Palmer says.

Get help from your insurer. In the Yaskins' case, both the hospital and the medical group were in their insurer's network and had contracts to provide services at a negotiated discount.

"If you are in network - and this is one of the good reasons to stay in network - you can go to your insurer for help. It has a responsibility to some degree to what happens between you and a contracted physician," says Susan Pisano, spokeswoman for the trade group America's Health Insurance Plans.

Also, ask to make sure you're getting the rate your insurer has negotiated with in-network providers, says Lynn Quincy, senior health policy analyst for Consumers Union, the policy arm of Consumer Reports. Insurers often pass claims through without processing them at the reduced rate. Ask your insurer to re-process the claim if the discount wasn't applied.

Seek help and file complaints. If your bill is large or you're having a hard time making headway, patient advocates can help sort things out. For either a flat fee or a share of the money you save, organizations such as Medical Billing Advocates of America (www.billadvocates.com) and Health Proponent (www.healthproponent.com) can help you fight charges or lower your bill.

If you're being stonewalled by your healthcare provider, and your insurer hasn't helped, Quincy of Consumers Union suggests filing a complaint with your state's department of insurance. In California, patients with HMO coverage can file a complaint with the California Department of Managed Health Care by calling (888) 466-2219 or visiting healthhelp.ca.gov. Californians with PPO coverage should try the Department of Insurance at (800) 927-HELP (4357) or visit http://www.insurance.ca.gov. If your provider isn't contracted with your insurer, your state's attorney general's office is a place to turn for help.

The Yaskins ultimately enlisted the services of an advocate to help them sort through all their billing questions.

[Oct 12, 2009] The Audacity of Greed How Private Health Insurers Just Blew Their Cover

Robert Reich's Blog

The health-insurance industry has finally revealed itself for what it is.

Background: The industry hates the idea that's emerged from the Senate Finance Committee of lowering penalties on younger and healthier people who don't buy insurance. Relying on an analysis by PricewaterhouseCoopers, insurers say this means new enrollees will be older and less healthy -- which will drive up costs. And, says the industry, these costs will be passed on to consumers in the form of higher premiums. Proposed taxes on high-priced "Cadillac" policies will also be passed on to consumers. As a result, premiums will rise faster and higher than the government projects.

It's an eleventh-hour bombshell.

But the bomb went off under the insurers. The only reason these costs can be passed on to consumers in the form of higher premiums is because there's not enough competition among private insurers to force them to absorb the costs by becoming more efficient. Get it? Health insurers have just made the best argument yet about why a public insurance option is necessary.

Right now they run their markets and set their prices, and pass on any increased costs directly to consumers. That's what they're threatening to do if the legislation attempts to squeeze, even slightly, the colossal profits they plan to make off of thirty million new paying customers.

They want every penny of those profits. They demand every cent. And if the government dares raise their costs a tad higher than they expected when they first signed on to support the bill, they'll pass those costs on to consumers in the form of higher premiums. They can carry out their threat only because they have unaccountable, untrammeled market power.

But they've now hoisted themselves on their own insured petard. They've exposed themselves. If they had to compete with a public insurance plan, they couldn't get away with this threat. They couldn't pass on the extra costs. They'd have to compete with a public insurance option that forced them to give consumers the best deals possible.

Now's the time for Congress and the White House to say to the insurance industry: You want to play hardball? Okay. We'll play it, too. You didn't want a public insurance option. That was one of your conditions for supporting the bill. You wanted gigantic profits from having thirty million new paying customers and the market to yourself. The Senate Finance Committee and the White House agreed because they wanted your support and were afraid of the negative ads and hurricane of opposition you could finance. But you're even greedier than we imagined. And now you've demonstrated that greed to the American people. They don't want to turn over even more of their hard-earned money to you. So, insurance companies, we've got news for you. We're going to make sure Americans have the freedom to choose a public insurance option that's cheaper and better, and you're going to have to work hard to keep them your customers.

Unconscionable Math

July 28, 2009 by Taunter

The House hearings on rescission – the retroactive cancellation of individual health insurance policies – were over a month ago, but after its initial run through Daily Kos it seems to have waited a bit before popping up on Baseline and Slate. James Kwak at Baseline described the practice as rare, affecting only 0.5% of the population. The faint light bulb above my head began to flicker: could that be true…that's not rare – that is amazingly common.

It is. In fact, from Don Hamm's (CEO of Assurant) prepared testimony, with the company logo nicely on the front of it in the original:

Rescission is rare. It affects less than one-half of one percent of people we cover. Yet, it is one of many protections supporting the affordability and viability of individual health insurance in the United States under our current system.

What tangled webs we weave…

To understand why 0.5% of the people Assurant covers is a lot of people – a jarring, terrifying, probably criminal lot – you need to understand a little bit of math. You need to understand just enough math to understand what Don and his legal team are not telling you. You need to understand conditional probability. And the folks at Assurant are counting on the fact that you don't.

A typical job interview question for aspiring finance folks is the Monty Hall Question. As typically phrased, you go on a game show and are asked to pick one of three doors. Behind two of the doors are goats. Behind one is a shiny new car. You pick a door. The host ceremoniously opens a door that you did not pick, and behind it is a goat. He turns to you while the audience giggles at the goat. Do you want to change your pick?

As I have pointed out on the Idea Locker comments, this typical phrasing is a bit unfair. If you haven't seen the show, you might think the choice of what door the host opened was random, unrelated to the door you picked. Since there is no correlation, you don't see why you should change your pick. If someone asked you to call the third of three coin tosses in a row, you wouldn't change your pick if the first two were heads, would you?

But the nuance of the game is that the door is not random. The door that is opened will always meet two conditions:

You had a 1/3 chance of being right in your initial pick. That means there was a 2/3 chance the car was behind "not your pick". Well, if you change your pick now, you cover the entire "not your pick" set – you have seen one of the two doors, know that it's empty, and now have the payoff from the other. You should change your pick.

Here's the health care nuance (2005 HHS report based on 2002 data):

Bar graph shows percent of total expenditure by percent of population: Top 1% (greater than or equal to $35,543), 22%; Top 5% (greater than or equal to $11,487), 49%; Top 10% (greater than or equal to $6,444), 64%; Top 20% (greater than or equal to $3,219), 80%; Top 50% (greater than or equal to $664), 97%; Bottom 50% (less than $664), 3%.

Half of the insured population uses virtually no health care at all. The 80th percentile uses only $3,000 (2002 dollars, adjust a bit up for today). You have to hit the 95th percentile to get anywhere interesting, and even there you have only $11,487 in costs. It's the 99th percentile, the people with over $35,000 of medical costs, who represent fully 22% of the entire nation's medical costs. These people have chronic, expensive conditions. They are, to use a technical term, sick.

An individual adult insurance plan is roughly $7,000 (varies dramatically by age and somewhat by sex and location).

It should be fairly clear that the people who do not file insurance claims do not face rescission. The insurance companies will happily deposit their checks. Indeed, even for someone in the 95th percentile, it doesn't make a lot of sense for the insurance company to take the nuclear option of blowing up the policy. $11,487 in claims is less than two years' premium; less than one if the individual has family coverage in the $12,000 price range. But that top one percent, the folks responsible for more than $35,000 of costs – sometimes far, far more – well there, ladies and gentlemen, is where the money comes in. Once an insurance company knows that Sally has breast cancer, it has already seen the goat; it knows it wants nothing to do with Sally.

If the top 5% is the absolute largest population for whom rescission would make sense, the probability of having your policy cancelled given that you have filed a claim is fully 10% (0.5% rescission/5.0% of the population). If you take the LA Times estimate that $300mm was saved by abrogating 20,000 policies in California ($15,000/policy), you are somewhere in the 15% zone, depending on the convexity of the top section of population. If, as I suspect, rescission is targeted toward the truly bankrupting cases – the top 1%, the folks with over $35,000 of annual claims who could never be profitable for the carrier – then the probability of having your policy torn up given a massively expensive condition is pushing 50%. One in two. You have three times better odds playing Russian Roulette.

People lie on their insurance forms, of course, and that is a serious problem. But let's not forget that the very nature of the forms is designed to create inaccuracies, and it doesn't matter in the slightest how minor the error may be once the company comes looking to get out of its policy. Back to Don Hamm:

I mentioned a story in my comment on the Baseline article, and it's a favorite of mine, so I'll repeat it here: Years ago I was walking a casino floor with a casino executive. It was an incredibly detailed tour, and we got to talking about pretty much everything that came to mind about crowds and gaming. Now, a clever observer might notice that even the tolerant people of Nevada will not allow alcohol in vending machines – wouldn't want the little ones to be able to get a Bud Light without a human being verifying their ID. But there we were in the middle of acres of blinking lights, with absolutely no one making sure that underage kids weren't walking up to a slot machine. Indeed, they don't card for the table games.

The executive told me you are free to play if you are underage, you just aren't free to win. You can sit down and pump your money into the slots, and if you look presentable you can drop some chips on blackjack or craps. However, if you should happen to start winning, the pit boss or security team will come over and check your ID. The house edge is 100%.

Conditional probability is tough for the human brain. We tend to think of things as either completely correlated (once the market tanked, McCain had to lose) or completely uncorrelated (coin tosses). To a certain extent, we make the calculations in everyday speech: when someone says that pancreatic cancer is exceptionally lethal, he doesn't mean that it is likely to kill an enormous number of people; he means it will kill an enormous percentage of the people who contract pancreatic cancer. Get a bit more tangential and even very smart people with Nobel Prizes miss things; one of the reasons Long Term Capital Management melted down was that once they started sustaining heavy losses, people bet against LTCM's other holdings – LTCM itself was the correlation. Low frequency, high severity events are also difficult for us to process – look at how much we invest fighting air piracy versus the sacrifices we are unwilling to make on drunk driving or domestic firearm violence.

Put them together and the guys with the actuaries working for them have a nearly insurmountable advantage. I tend to think of traditional banking and traditional insurance as mirror images: when you take out a mortgage, you get a lump sum and make a series of payments; when you get life insurance, you make a series of payments and get a lump sum. Health insurance is somewhat similar to life insurance, except the payout happens sometime during the payment stream instead of at the end.

When a person intentionally defaults on consumer credit, he is called a "ruthless defaulter" and the system, to the extent that it operates with any sort of efficiency, is designed to try to flush him out of the credit market in the future. Society can tolerate taking the risk of inadvertent defaults – the people who through some sort of misfortune are unable to make good their promised payments. The folks who do it on purpose…do it enough and the FBI might step in.

The insurance industry has a bit of a historical difference, in that pretty much everything in health insurance is similar to a liar loan. I tell the company if I have been sick, just like stating an income on a mortgage application. For a host of administrative and medical privacy reasons, the insurance industry has not historically wanted a comprehensive inventory of medical records before taking a client. Few people could probably deliver such a record even with the best of intentions. There is a problem with liar loans, and it was well described by Tanta (Calculated Risk's late writing partner) here:

Well, with Number 1 [a liar loan that has gone bad], it's "clearly" the borrower's fault. He or she lied, and we can pursue a deficiency judgment or other measures with a clear conscience, because we were defrauded here. We can show the examiners and auditors how it's just not our fault. The big bonus, if it's a brokered or correspondent loan, is that we can put it back to someone else, even if we actually made the underwriting determination. No rep and warranty relief from fraud, you know.

It is in the health insurer's interest to have application fraud, not only because it saves time and expense on the front end, but also because it lets them get out of any policy that isn't going well for them. If the health insurer had to verify the information – if, in essence the insurance company had to behave as an accredited investor with adequate expertise to make a decision without reliance – it wouldn't have the opportunity to bail out. It would catch more genuine liars, but many of these liars would have turned out to be healthy, profitable customers, and what the carrier really wants is a population devoid of expensive claims, not devoid of liars.

Years ago, the shameful business was the tobacco industry. There was a certain roguish charm to them; they had great ads and were fun outgoing people, and of course they made a product that if used as directed would kill you.

Say this for the tobacco folks: they printed the dangers right there on the pack. Few people who took up smoking after World War II did so with ignorance of the health consequences. Society wants tobacco, it might as well be produced in clean factories and wrapped in cellophane as opposed to sold on street corners. I hope we legalize marijuana and let Altria and RJR make joints and put the Mexican cartels out of business.

No, the health insurance companies sneak around. They have nice facades, they speak in the bureaucratic language of statistics few understand, and they make the eminently reasonable argument that they just need to protect themselves. They promise great coverage, and when many years later it comes time to pay out and the petitioner is sick and unable to function, sorry, wish we could do better, but there was an error and rules are rules. We're keeping the premiums. It's actually far more like this guy:

Bernard%20Madoff%20large.jpg

Bernie Madoff made people promises, and people believed them, because was it really possible that the former chairman of the NASD was running a scam? Come on. But he was, and his reputation was no more a shield to the defrauded than the huge balance sheets of the health insurance companies mean an individual claimant is going to get covered. The minute he began transferring money from one account to another and then raising external capital to try to square the numbers, he knew exactly where this was going. The insurance companies know too; they just know well enough to avoid outrunning the law.

I don't know if this case is going to be the lever the Democrats need to get meaningful healthcare reform. The Democrats don't even seem to be able to line up on the same side, which is probably a necessary precursor to getting something passed. The Taunter Drug Plan for lower prescription drug costs doesn't seem to have taken the Internet by storm, so I give this post low odds of breaking through. But I will make this simple point in the hope some speechwriter pressed for a deadline picks it up: if a bank manager went to half of his highest net worth clients and said "sorry, you misspelled your address when you opened your account, I'm confiscating your balance," he would be lucky to get himself assigned to minimum security.


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Posted in Corruption, Health Care, Labor Policy, Meltdown, Movies | 122 Comments

122 Responses

  1. on July 28, 2009 at 5:10 am | Reply anne

    I wish your rescission percentages got more play. It is unconscionable that 10 percent of seriously ill people get dumped from their plan because they actually need it.

    The pre-existing condition thing has always bugged me – people need insurance precisely because they are ill – they shouldn't be prevented from getting it because of their illness.

    Love that you're comparing insurance execs to Madoff…. it is a scam, pure and simple, to take money from people and cut them off of what you've promised, precisely at the moment they need it most.


    • on July 28, 2009 at 10:12 am | Reply Taunter

      Best way to get people to notice is to talk about it…

      Funny thing is that I am generally sympathetic to the pre-existing condition argument. It would be unfair to allow people to sit out of the pool for years and then jump in only when they develop a chronic condition; it's a bit like taking out fire insurance when the hoses arrive. That's why I support mandates and a public product, so people actually have the opportunity to maintain continuous coverage. But the companies have no desire to make this a general fraud prevention thing. If it were, they would verify all incoming customers' medical histories.

      There is one key difference between the insurance companies and Madoff: Madoff's investors were accredited investors; in the case of Fairfield Greenwich, it was a hedge fund paid massive fees with precisely one investment. They made the affirmative statement that they were qualified to analyze investment funds. An overwhelming majority of any health insurer's clients are neither doctors nor actuaries, and have a difficult time understanding what is going on. Furthermore, at the time the carrier decides to renege on its obligations, the client is sick. I can barely think when I have a cold; it's asking an awful lot to expect someone with cancer or ALS to be a robust advocate of his rights.


      • on July 31, 2009 at 8:19 am TomK

        The other continuous care benefit is reduced employee abuse. I know a guy who has been passed over for raises every year since he had an autistic son. What's he gonna do, leave? He's uninsurable anywhere else, so the insurance system has put him in chains to his employer.


      • on August 3, 2009 at 11:44 am Timmay

        I think health insurance is a scam all around. If we could pay doctors cash for the services they provide, we wouldn't need health insurance. Here's an example: my fiance had to get an MRI. The price you had to pay for that scan if you were uninsured was $4,000. The doctors were paid $400 for that scan by the insurance company.

        So, what's better for me, the consumer? To pay $400 every few years when I need the service, or to pay $400 to the insurance company every month, just in case I need the service? They have rigged the system so that you CANNOT afford health coverage without them.

        If you ask me, the whole debate of the "rising health care costs in America" is simply the Insurance companies moaning about their shrinking profits because their customers are getting old and are starting to actually use the service.

        I think the whole crisis could be solved by eliminating today's typical health insurance companies and allowing the free market to set fair prices at hospitals (we already know approximately what those prices are because we see on our EOB's what the doctors accept from the insurance co.). Catastrophic coverage should still be available for the companies & people willing to gamble on who will lose that game, and declaration of relevant pre-existing conditions would be a fair part of setting up that business relationship.


    • on August 5, 2009 at 6:54 am | Reply Fred

      >The pre-existing condition thing has always bugged me – people need insurance precisely because they are ill – they shouldn't be prevented from getting it because of their illness.

      What!? That's like saying it's OK to wreck your car, then go out and buy collision insurance, make one payment, and demand that they give you a new car.

      That's ridiculous. It's *insurance*, not some magical "pay a low price, get unlimited medical care" scheme.


      • on August 5, 2009 at 8:36 am Chris Taylor

        Your not getting it! YOUR RIGHT ITS REDICULOUS

        but that is EXACTLY what they put it FORWARD AS. pay us this monthly fee for life and your covered for life.

        THAT IS HOW THEY SELL IT so why in the world would you think it insane that people think THAT IS WHAT IT IS?

        It did not always cost LITERALLY a fortune to see a doctor. I am only 32 years old and I remember when it was AFFORDABLE to see a doctor for something normal like a check up or shots or basic dental work.

        The Pharma/Insurance industry has EXPLODED this field into this YOUR FRAKING LIFE IS OVER expense to FORCE people to buy what was originally OPTIONAL insurance for that just in case life altering event (cancer heart failure massive accident etc..)

        Now its backfiring on them.

        People are USING IT AS ADVERTISED and they are going OH SHIT this artificially inflated market WE CREATED is now BURNING US.

        so now instead of eating there medicine they are making US EAT IT with recission and socialised care.

        oh trust me they WANT socialized health care.

        it means unlimited funding because it goes from being an OPTIONAL pay out of pocket plan (part of which is HIDDEN by the employer paid out half and you get LESS PAY as a result)

        to a MANDATORY TAX whether I want it or not.

        since when it is SANE for a "bill" to come to more dollars than some people make in there ENTIRE LIFE TIME.

        sorry for the language but this entire structure needs a good old bitch slap across the face.

        I went to the dentist a few years ago. I take decent care of my teeth. clean x-ray fill a tiny cavity (so small no Novocaine was needed)

        Its also the last time I will ever go to the dentist again without insurance (that means a long time) for that bill came to $700

        $700 to sit in his chair for 30 minutes (if that)

        You so much as LOOK at an emergency room and your bill STARTS AT $10,000 and up.

        only on THIS insane planet is there any logic in that.


      • on August 5, 2009 at 10:07 am Barbara

        The "pre-existing condition" problem is a serious issue, and the people most affected by it, unfairly, are the very ones who have been paying for health insurance for years, get dumped by their providers (or lose their insurance for some other reason) and have to find new insurance. Good Luck. They are pretty much screwed.


  2. on July 28, 2009 at 12:53 pm | Reply Stephen Dodson

    Well articulated explanation of a truly atrocious practice. To me, it was surprising that Assurant CEO Don Hamm is so open about their rescission process. My first reaction was that he's a pretty stupid guy to admit that they go out of their way to drop individual subscribers.

    Yet, your question "If someone asked you to call the third of three coin tosses in a row, you wouldn't change your pick if the first two were heads, would you?" reminded me of something that I witnessed quite recently. An otherwise intelligent finance guy wanted to bet against the Yankees even though he was a Yankees fan. Why? They had won seven in a row. What were the changes they would win eight in a row?

    Maybe Don Hamm's understanding of the common man and common Congressman is exceptional, and I'm the one who's stupid.


    • on July 28, 2009 at 1:27 pm | Reply Taunter

      I take it your friend is not one of this nation's more successful sports gamblers.

      There is a curiously persistent misunderstanding of the concept of mean reversion. Many people seem to believe that sequences of events are self-correcting: if I have flipped ten heads in a row, and I know that the expected value for thirty flips is fifteen heads, surely I should expect more than ten tails in the next twenty flips to bring me back to the mean. They even receive reinforcement for this belief every time they play cards with their buddies – get a disproportionately high number of face cards early, expect fewer face cards later.

      This is a confusion between determined and undetermined outcomes. A deck of cards, once shuffled, will only play out one specific permutation (a major reason for the house to use a "large" number of decks and stop playing before the number of cards remaining ceases to be large – they want so many cards of each type in the deck that probability on each draw is similar to the probability for the first card out of 52). In the case of coin tosses, however, the next toss does not exist when the first toss has happened. The coin will fly with no conception of previous events. A running tally will "revert" to the mean only to the extent that future 50/50 results overwhelm the determined history.


  3. on July 28, 2009 at 5:13 pm | Reply More on Rescissions " The Baseline Scenario

    [...] Taunter wrote an insightful post about rescission, expanding on a comment he left on this blog. He drives home a point I thought I made in my [...]


  4. on July 28, 2009 at 6:15 pm | Reply Bond Girl

    Brilliant post, Taunter.

    I actually did manage to get kicked out of a casino once when I was underage, however – even before I won anything :)


  5. on July 28, 2009 at 6:45 pm | Reply Manshu

    One of the most insightful posts I have read for a while. Thank you.


  6. on July 28, 2009 at 9:00 pm | Reply Ben

    Fantastic post. I'll leave it at that.

  7. on July 28, 2009 at 9:45 pm | Reply Stephen Dodson

    Maybe something about health care and gambling make math idiots of everyone? Or maybe some are idiots to being with: http://mediamatters.org/mmtv/200907270052 (via Krugman).


  8. on July 28, 2009 at 11:01 pm | Reply Jackybird

    Wonderful post.

    I paid for individual insurance for most of twenty years until it became prohibitively expensive. All that time, I always had the sneaking suspicion it was a scam but I was told it was the responisible thing to do. Now I know it was a scam.

    The other day Krugman referred to young people who don't buy insurance as "gaming" the system, or something to that effect. But is it gaming the system to decline to buy into a Ponzi scheme? If you think that the insurance won't be there when you need it why buy it in the first place?

    I feel almost certain that without a public option mandates will be a disaster.


    • on July 28, 2009 at 11:59 pm | Reply Taunter

      I think Krugman's perspective is in the context of a public option and mandates.

      Because health costs vary enormously by individual, with a few individuals accounting for enormous amounts of cost, a system that aims to provide broad coverage needs a large amount of people whose premiums exceed their cost usage. For every person paying $10,000/year and consuming $50,000/year, you need four people who pay $10,000/year and consume nothing. If the people who consume nothing know that they will consume nothing (or think that they will consume nothing), they will be tempted to opt out of the system and only join later, when they think the expected value of their costs is equal to or greater than $10,000. If all four healthy people opt out, however, the sick person needs to be charged $50,000 to keep the system in balance – which defeats much of the pooling benefit.

      I doubt Krugman supports rescission in cases where the applicant has not intentionally defrauded the carrier. Even the Republicans are repulsed by the practice, and I think they would be far more horrified if they knew how widespread the practice is among very sick individual insurance clients


  9. on July 29, 2009 at 7:52 am | Reply StatsGuy

    The same light bulb went off when I read the 0.5%, but I could not have explained it _nearly_ as well. Very nice post.

    I still wonder, though, whether it might be slightly worse than even this picture.

    1) I believe your data is for the US population as a whole. (If I'm wrong, then this comment is meaningless – apologies.) But, in fact, much of the sickest part of the population receives health care via Medicare because older people are (to use your technical term) sicker.

    So the % of people in the top tier AMONG PEOPLE NOT ON MEDICARE is much lower, which means that the conditional probability of suffering recission given that you need treatment is much higher. Roughly, if the % of people among under-65 (and not on Medicaid) in the top bracket was half of what it is for the entire population, then the probability of suffering recission given that you have a large claim is double even your current estimates.

    2) The probability of losing the policy given that you really need it may be X% in any given year. But there's a cumulative effect – over time, you build up a reservoir of uninsurable who lost insurance due to recission, and now cannot get it back because they have a chronic condition.


    • on July 29, 2009 at 10:03 am | Reply Taunter

      You are absolutely correct about #1, and this is a huge error factor. 10% of Medicare costs take place in the last month of life alone, and Medicare is roughly 45% of the national health care spend. So all of those patients are clogging up the top end of national distribution and not on private insurance in the first place. Unfortunately, I can't find a private-only, or individual-pay-only distribution, and of course if I did find an individual-pay-only distribution it would be skewed on the top with denied claims (some people should be spending a lot, but actually spend much less, because their policy was pulled). The Reuters article says Medicare spends 30% of its outlay on the top 5% of its population, which means it has a flatter curve than non-Medicare (I would assume, without evidence, that fewer Medicare beneficiaries have negligible health expenses). This implies non-Medicare spending is even more highly concentrated with a few very high spenders.

      On #2, I'm a little less confident, and it was one of the reasons I may have misunderstood James' original post. There is a cumulative effect, but that effect is blunted to some degree by the fact that the people who account for the very high medical expenditures do not necessarily change much from year-to-year (with the obvious exception of the end-of-life expenses typically borne by Medicare). In fact, one of the reasons I suspect rescission became such a powerful phenomenon is that if Sally has breast cancer at a young age, she is going to be in the 99th percentile several times; the carrier is weighing years of such expenses against her premium. So it might not be the case that in a forty year career an average person has a 33% chance of ending up at some point in the top percentile (1-(.99^40)); it is probably the case that most people have a tiny chance of ever getting an expensive chronic condition (or at least an expensive, chronic condition before turning 65), and some people have a large chance of repeatedly being in the top percent.


      • on August 4, 2009 at 8:20 am DataBob

        Fascinating – and horrifying – insight, Taunter.

        While the odds you show are bad enough, I wonder if there is another factor to make them worse:

        The insurance executive used 0.5% as the recission rate, but that is for ALL insureds.

        Shouldn't the insureds who are covered under an employer's 'forced insurance' policy be excluded from the potential pool of 'recission candidates'?

        I have no idea what percentage of people covered under an employer's plan are not subject to potential recission, but whatever the number, they would make the potential pool of recission candidates even smaller.


  10. on July 29, 2009 at 12:21 pm | Reply Vinnie

    As Mark Twain once said, "Figures don't lie, but liars figure."

    Excellent post.


  11. on July 29, 2009 at 9:28 pm | Reply jenn

    What a terrific explanation of the unfairness of rescission!

    I do understand what Krugman says about young people "gaming" the system, an in theory I can see how mandates would fix that. But, in Massachussetts, it seems to me that they still have a problem with this. I presume this is because the penalty for failing to buy health insurance (on the order of $1000 in taxes, or less) is much lower than the cost of purchasing health insurance (at least $3000, up to $12000).

    It seems to me that a solution would be to make a law that insurance companies cannot drop or raise rates on anyone who has been continuously covered by insurance for x years (let's say, 5 years or so). This would incentivise young people to contribute to the insurance pool during the years when they don't need expensive care.

    In theory, if the federal government manages to enact some kind of Obamacare, the problem of the non-contributing youth would disappear as we would all be mandated to buy insurance. But, I suspect nothing will be enacted.

    At the very least, the government should restrict insurance companies from predatory practices such as rescission. Without such legislation, companies that don't use rescission would be outcompeted by companies that DO use rescission. Anti-rescission legislation would just take that factor off the table altogether and level the playing field.


    • on July 29, 2009 at 9:41 pm | Reply Taunter

      You are right, the penalty needs to create the incentive to sign up.

      Rescission could easily be stopped by imposing an affirmative obligation on the insurance company to verify its information. So in the Taunter world, there would be a standstill period (30-60 days) from inception of a policy during which time each side could review and verify health information and break the policy if it didn't work. Beyond the standstill, the carrier would be on the hook. Once admitted to a pool (eg women born in 1960 living in Boston), individual rates could not change – change one rate, change the entire pool.

      The flaw with my plan (apart from the politics) concerns actions the client takes that increase his risk. If he begins smoking, for example, or decides to become an ice road trucker. But I would think customer-initiated change could be recognized as a policy reset without affecting the system overall.


  12. on July 30, 2009 at 7:05 am | Reply Thursday Links " Rortybomb

    [...] Posted in Uncategorized by Mike on July 30, 2009 I follow up on Taunter's excellent post on rescission over at The Atlantic. It's a ramble that I had fun with, about zombies and end [...]


  13. on July 30, 2009 at 10:40 am | Reply ngbstl

    This is whack. Why don't they simply pass an "incontestability" rule/law/statute? In LIFE insurance, there is a clear-cut 2-year incontestability rule that says policies cannot be rescinded after that 2-year period, and evern further that if insured dies due to something adverse omitted in the application, the insurer cannot contest the death benefit if this occurs after 2 years from policy start. Wouldn't that resolve this in health insurance too?…


    • on July 30, 2009 at 10:53 am | Reply ngbstl

      …also, I forgot to address this too: I've read that it would be "impractical" for insurer's to comprehensively investigate applicants, so they only spend $ to do this if/when big claims arise that they wanna get out of. Not totally accurate, as insurers (life/health/disability/long-term-care) DO spend a decent chunk of change underwriting applicants, with paramedical exams, APS (medical records review), the new (and spooky) filled-Rx records check, etc…in addition to applications that rest on applicants honesty. Granted not everything will show up thru this underwriting, but most will get caught; insurers are well aware of 'adverse selection'. Issue is symptom of macro problem w/ our system. Finding a (politically do-able) way to have EVERYone be covered and in the pool (+ incontestability rules or what jenn said, rules based on continous coverage) would go a long way towards fixing it.


      • on August 5, 2009 at 4:43 am godspiral

        the underwriting screening process may be done to gather information for a later recision rather than to disqualify applicants, and refuse their premiums.


    • on August 4, 2009 at 1:52 pm | Reply David Klein

      They do have this. In California it is Insurance Code section 10350.2.


  14. on July 30, 2009 at 4:57 pm | Reply Patrick C

    I'm totally with you on rescissions. In general, I'm in favor of a strong health care reform with a serious public option.

    But I thought I'd point out a consequence of making rescissions illegal. Either #1, it becomes the Insurer's responsibility to identify preexisting conditions.(although denial of a new policy for pre-existing conditions might become illegal, as well). or #2 Health insurance coverage becomes mandatory.

    #2 is probably a necessary consequence of making rescission illegal. But enforcing mandatory health insurance is actually quite tricky. Assumedly, the government would track people's insurance(or lack thereof) and a fine would be issued.

    Therein lies the rub. If the fine is lower than the insurance premium, it is in by interests to not get insurance, pay the fine, and then sign up for a policy when I get sick.

    But selecting the appropriate fine is tricky business, in some senses, it is equivalent to insurance underwriting. At the same time, legislators are under pressure to make the fine as small as possible, to prevent alienating their constituents. Moreover, the tendency of government, is to specify the fines in the legislation itself. This means that an appropriate fine at the time of passage, even if it is initially significantly larger than the cost of an insurance premium at the time, will eventually become less valuable than the premium due to dollar inflation and health cost inflation.

    I don't mean to imply this is a bad idea. In fact, if we're lucky, the legislation is written poorly, it kills health insurers, and we end up with the public option. But I just think it is important to understand how making practical legislation to make rescission illegal, is actually quite tricky.


  15. on July 30, 2009 at 8:10 pm | Reply Business101

    After paying $550 per month for health insurance, they'd better not recission me!


  16. on July 30, 2009 at 8:19 pm | Reply Morgan Dy

    Very nicely written article… but I can't help but wonder about your bias towards a national healthcare. Let's just take a couple of examples.

    First, you liken rescission's statistic to an underage person playing in a casino. True, the house advantage is 100%–but this is only because the underage person IS BREAKING THE RULES. Likewise, companies should be able to disqualify people if they lie on the insurance form.

    Ok, so secondly, you assert that "…the very nature of the forms is designed to create inaccuracies…" Are you serious? Far more people are covered under group insurance plans than individual insurance plans… and HIPAA has explicit language that prohibits discrimination against employees and their dependent family members based on any health factors they may have–including prior medical conditions, previous claims experience, etc. So your numbers MUST be faulty because the only people who could be rescissed are those who happen to have been diagnosed, quit/lose their job, and chose not to go with COBRA before finding another job and lying on the form. And even if you somehow got excluded for a preexisting condition, that exclusion can only apply for 12 months (18 if you enroll late).

    So I have to doubt the veracity of your article. Very well written though.


    • on July 30, 2009 at 9:05 pm | Reply Taunter

      No need to wonder about my bias – I advocate a single payer system for basic and catastrophic health care and a private system for supplemental coverage. Call it the French or the Swiss systems.

      The key point I hoped to make is that the casino doesn't care about underage gamblers, they care about gamblers who win, and when there is an intersection of the sets (underage gamblers) and (winners) they act. If they really cared about underage gamblers they would universally card for the games, as they do for the bars.

      On your second point, the entire post concerns individual health insurance. Assurant, not Taunter, provided the population estimate for rescissions. If you think the pool of candidates is even smaller – filing deadlines, excluded clauses, etc – you are arguing for a higher percentage of rescissions within the suspect class. It is the same point Stats Guy made above, and would argue even more strongly for insurer bad faith when presented with large claims.


      • on July 30, 2009 at 11:24 pm Morgan Dy

        You and I have the same desires for a national health care system–having just returned from my stay in Europe (and having had to partake of an ambulance call and emergency health care), I know I do not want to see what Congress is planning ever come to fruition; in Europe, if you're not a citizen, you must sign a paper to acknowledge that you agree to reimburse the cost. The American proposal–to officially legislate to pay the health care for non-Citizens is ludicrous.

        Back to the article: my point is that the article makes the implication that people who lie on their forms and perpetrate that lie by paying premiums should be allowed to have health care; the HIPAA explanation I provided was to illustrate reasons that honest, rule-obeying folk don't need to lie because in most cases by law they cannot be excluded; and if they are, they cannot be excluded indefinitely.

        If someone were to hop over your fence and lay $5 bills on your doorstep every morning… would you complain? Now how about if the guy starts taking the cars that you parked in the driveway for joyrides? Are you trying to tell me that just because you overlooked his trespass when he was laying money down on your doormat you are willing to let them get away with taking your car?

        People who lie on their insurance forms are committing fraud. It sounds to me like the article is whining that it isn't fair that high cost patients can't get away with fraud like low cost patients can, doesn't it?


      • on August 3, 2009 at 4:42 pm Miguel Lacruz

        … in Europe, if you're not a citizen, you must sign a paper to acknowledge that you agree to reimburse the cost …

        This is definitely not so in Spain, where you have the constitutional right to free health care just because you are stepping on its territory, regardless of your citizenship, even if you are an illegal alien. What country in Europe do you refer to?


      • on August 4, 2009 at 8:55 pm Jack K

        If you're not a citizen in certain European countries you have to agree to reimburse the cost? That seems a bit unfair for legal non-citizen residents of that country who work and pay taxes.


  17. on July 30, 2009 at 8:22 pm | Reply Noel Clark

    Patrick C, I agree healthcare insurance has to be mandatory, otherwise the funding base becomes too narrow. But there are better ways to go than fines. Here in Oz we have universal healthcare supported by a taxation levy. This guarantees treatment in the public system of hospitals. But the government would prefer people used the parallel private hospital system instead, to reduce the call on the public system. There is a tax break that encourages people to take out private health insurance that covers private hospitals. This means high income earners take out private health insurance to use private hospitals and cover some of the additional cost by reducing their tax bill. Admittedly, there are downsides to this system, as with all parallel systems; one will inevitably be better funded. But I've never heard of rescission in Australia…


  18. on July 30, 2009 at 8:43 pm | Reply Rob Steele

    I used to think I was getting ripped off by insurance unless I was filing claims but then I had a wreck. Now I happily throw money down that rat hole and devoutly hope to never see it again. The only real solution I see is to accumulate enough wealth that you can self-insure. In the meantime save an emergency fund and carry high deductibles so you only file when it's a big deal.


  19. on July 30, 2009 at 9:16 pm | Reply skipjim

    I guess my family got lucky last year when we had our twin daughters 12 weeks early. Between my former employer's health insurance and medicaid we didn't pay anything for their 3 months of neonatal care.

    We were definitely in the the top 1% bracket, I think the final bill came out to be $750,000 for the two of them, not including the delivery. I can pay health insurance premiums for the rest of my life and not hit that number.


    • on August 3, 2009 at 11:56 am | Reply Timmay

      Is $750K the amount that you would have been charged if you did not have health insurance, or the total amount the insurance company actually paid to the hospital?


    • on August 5, 2009 at 6:01 am | Reply Kevin Camp

      "We were definitely in the the top 1% bracket, I think the final bill came out to be $750,000 for the two of them, not including the delivery. I can pay health insurance premiums for the rest of my life and not hit that number."

      You think so?

      First, let's factor in what the insurance company actually paid out. Most people here seem to think it would have been about 75k. To be on the safe side, we'll double that to 150K.

      Second, let's figure out what you actually pay in premiums. Between your premiums and what your company pays for you, money that they could be paying you if they weren't paying for your insurance, it's costing you probably 2000-2500 a month. Again, to be safe, we'll take about half that and call it $1200.

      Now, let's say you invested that $1200 a month and got a below average return on 8% and guess how long it would take you to hit that 150K number?

      Less than 8 years. And yours is pretty much a worst case scenario.


  20. on July 30, 2009 at 9:51 pm | Reply David Sickmiller

    Very interesting article.

    The $7,000 you cited for an individual adult insurance plan is incorrect. The source you linked to explains that this number is the 2005 "Estimated Average Total Medical Expenditures for Low-Income Medicaid Beneficiaries, If They Were Covered Instead by Private Insurance". The main problem there is that it's total expenditures by the insurer, not premiums paid by the person.

    Instead, consider using $4,704, the 2008 average annual premiums for employer-sponsored health insurance for single coverage. http://ehbs.kff.org/images/abstract/7791.pdf

    Alternatively, it was $2,613 for non-employer-sponsored single coverage in 2006-2007. http://www.ahipresearch.org/pdfs/Individual_Market_Survey_December_2007.pdf


    • on July 30, 2009 at 10:04 pm | Reply Taunter

      That's a fair point, but the challenge with using the overall average for non-sponsored coverage is that many of these plans are stripped-down policies for people who believe themselves to be in particularly excellent health. I was trying to find a population that is large and contains people who might develop chronic conditions and are not being pruned.

      If you believe my estimate of policy revenue is too high, use a different intersection point of revenue and medical loss. I think you will still find that the power series of medical loss puts extensive pressure on insurers to look carefully at a small segment of the population. Skipjim's comment above that his premature daughters ran an insurance company and the government $750,000 shows what one client can do to a carrier.


      • on August 1, 2009 at 2:48 pm anne

        Dave – I'm a freelancer who knows quite a few self-insured freelancers – We talk A LOT about health insurance and its costs.

        If you're 21 and just out of school and have NO pre-existing health conditions – never saw a therapist for depression, don't have allergies, no asthma or ADHD – you probably can find a policy for $2600 a year. Once you marry and have a family, costs for insurance grow exponentially. Or once you start aging but remain single, your costs grow exponentially. Just how it works with the for-profit market.

        The PDF you link to is provided courtesy of America Health Insurance Plans – a group devoted to the interests of health insurance companies, not consumers. Show me where I can get a $2600/year policy that provides the same coverage our Senators get, and I'll stop advocating for health care reform now.

        Unfortunately, such a policy is not readily available to people who actually need it.


  21. on July 31, 2009 at 2:13 am | Reply Understanding the 'rare' practice of recission " Becky's Weblog

    [...] Source:http://tauntermedia.com/2009/07/28/unconscionable-math/ Tags: assurant, cancellation, ceo, hamm, health insurance, health insurance policies, individual health insurance, individual health insurance policies, insurance, medical care, population [...]


  22. on July 31, 2009 at 5:48 am | Reply Understanding the 'rare' practice of recission " Diychica's Blog

    [...] Source:http://tauntermedia.com/2009/07/28/unconscionable-math/ Tags: assurant, cancellation, ceo, hamm, health insurance, health insurance policies, individual health insurance, individual health insurance policies, insurance, medical care, population [...]


  23. on July 31, 2009 at 8:10 am | Reply Mike O.

    A well-reasoned article. You lost me, though, with the Monte Hall excerpt. Once you have been shown door X has the non-prize, doors Y and Z immediately assume 50% probabilities. If you had picked door Y in the beginning, door Z does not assume the 2/3 probability that X and Z had pre-knowledge of X.

    I don't know what they are teaching in Finance courses these days, but it doesn't match what I used to teach in Psych Stats.


    • on July 31, 2009 at 9:28 am | Reply Stephen Dodson

      Mike O., the odds are indeed 2/3 and 1/3. It was a famous problem that a lot of math professors and PhDs got wrong (and apparently former Psych Stats instructors).

      http://en.wikipedia.org/wiki/Monty_Hall_problem


      • on July 31, 2009 at 11:22 am Mike O.

        Thanks, Stephen (you too Andy), I stand corrected. The wiki entry was unclear until I read this:

        "Why the probability is not 1/2
        This difference can be demonstrated by contrasting the original problem with a variation that appeared in vos Savant's column in November 2006. In this version, Monty Hall forgets which door hides the car. He opens one of the doors at random and is relieved when a goat is revealed. Asked whether the contestant should switch, vos Savant correctly replied, "If the host is clueless, it makes no difference whether you stay or switch. If he knows, switch" (vos Savant, 2006).

        [edit] Increasing the number of doors
        It may be easier to appreciate the solution by considering the same problem with 1,000,000 doors instead of just three (vos Savant 1990). In this case there are 999,999 doors with goats behind them and one door with a prize. The player picks a door. The game host then opens 999,998 of the other doors revealing 999,998 goats-imagine the host starting with the first door and going down a line of 1,000,000 doors, opening each one, skipping over only the player's door and one other door. The host then offers the player the chance to switch to the only other unopened door. On average, in 999,999 out of 1,000,000 times the other door will contain the prize, as 999,999 out of 1,000,000 times the player first picked a door with a goat. A rational player should switch. Intuitively speaking, the player should ask how likely is it, that given a million doors, he or she managed to pick the right one. The example can be used to show how the likelihood of success by switching is equal to (1 minus the likelihood of picking correctly the first time) for any given number of doors."

        I'm suprised this is the first time I've encountered this problem (though the teaching I did was back in the 70s).


    • on July 31, 2009 at 10:49 am | Reply Andy Mail

      The best way I've explained it is this:

      Pick one of three doors. I open one of the doors you didn't pick and show that it's a loser. You are now left to decide between the one you've already picked and the one I have left. Would you change your pick?

      Compare that to:

      Pick a card out of a deck, but don't look at it. The goal is to pick the ten of hearts. I then look at all the rest of the cards and throw 50 away. Again, you are now left to decide between the one you've already picked and the one I have left. Now would you change your pick?


  24. on July 31, 2009 at 9:24 am | Reply Clearly New Mexico " Recission Roulette and Inside the Baucus Caucus (with Senator Bingaman)

    [...] is not rare. The odds are shockingly high that you'll get the axe if you get seriously ill. Taunter breaks down the [...]


  25. on July 31, 2009 at 12:27 pm | Reply Austin Barry

    One issue – it is not just one health insurance company, but many! One cannot count on all private insurers to have an even sample of the population. I'm sure I could improve my odds by buying into an "more healthy" plan (and I'm sure that info is very hard to come by). Also, I'm unlikely to stick with the same insurance plan my entire life (due to job change, location change, ETC) so if I change plans, the money I've been paying to some other company doesn't help my net profitability in the slightest.

    Luckily I don't have to worry about this for a few months – thanks in part to a flat tire. You see – I got a flat tire the day that I was supposed to be laid off. This happened to be the last day of the month. I found a spare can of fix-a-flat and came in anyhow, but since I had called in and said I'd work from home (and I needed to be there for the formalities) the paperwork was dated a day later so I got an extra month of coverage.


  26. on August 1, 2009 at 12:04 am | Reply Merci " Taunter Media

    [...] time to comment recently. Only eight of my posts have even broken the hundred view mark; to have one just shy of ten thousand is rather surprising. I suppose Malcom Gladwell was onto something when [...]


  27. on August 1, 2009 at 12:04 am | Reply Interesting Reads 1st August 2009

    [...] week I read a lot of great stuff. The best post by far was this post about rescissions. It's a very good read and if there is just one link you read from this collection, read this [...]


  28. on August 1, 2009 at 3:52 am | Reply mary b palin

    Three words, Single Payer System anything else is unconscionable.


  29. on August 2, 2009 at 4:17 am | Reply More about Health Insurance " The StoopidNoodle

    [...] a policy after a claim has been filed on said claim. Over at Taunter Media Taunter has a great piece about how both decisions are informed by the same logic: conditional [...]


  30. on August 2, 2009 at 6:56 pm | Reply EvilCON " Checking the Math on Health Insurance

    [...] This is a really good article on the misleading math health insurance companies are quoting when it …. While canceling the policy of 0.5% of the population is indeed a relatively small number, given the chain of events that lead to the cancellation, the chances of losing your coverage when bad things happen are a lot worse. It turns out that if you have an expensive condition, the probability of you losing coverage is around 50%! Why? Because insurance companies won't cancel the vast majority of people who don't claim enough in a year to make them lose money. So that leaves only the really sick people. If 1% of the population is really sick and insurance companies only cancel policies on really sick people, then 0.5% of the total population means half of the really sick people are going to lose their coverage. Insurance is there to cover losses we can't handle individual. If a misfortune hits and you lose your coverage because of that, what is the point of the insurance? Unlike things like car insurance, health problems often times involve more than one payment. Furthermore, insurance companies make it easier for them to cancel your coverage by purposely leaving the application vague and error-prone. That gives them an excuse to cancel your coverage when you really need it the most by claiming that you've lied on your application. As the article mentions, casinos don't card when you play but will when you cash in. So someone under 18 can lose all they want but when they go to take their winnings, the house will lay down the law. No comments yet [...]


  31. on August 3, 2009 at 3:09 am | Reply Harry

    Here's another question- for those who don't want to be forced to pay for an insurance policy:

    If you take your $7k a year for premiums, and instead of giving it to your insurance company, you give it to your mortgage company to pay off your 5% mortgage interest.

    In 20 years (so I'm still young and probably healthy) I have a nest egg of about $230k. That is a whole lot more than I can expect from an insurance company to pay out, and chances are it's more like 40 years before I get to pay out for a large medical bill.

    Now, you might say that's not fair, it only works for the rich. The $7k annual health insurance costs and mortgage rate has nothing to do with the rich. Even the working poor has to pay rent, which is usually higher than the mortgage payment for the same property.

    If employers can be forced to pay for the health insurance, they can also be forced to offer a "cash on the table" equivalent of the the health insurance.

    A plan like this could cure the housing market collapse and keep the insurance companies (or government) from taking this money and using it for other things (private profit, no bid government contracts)


    • on August 4, 2009 at 4:59 pm | Reply Barbara Saunders

      That is a gamble, though. Of my family members had the body go haywire in the early 30s. This is why I always worked health insurance into my budget when I was in my 20s and making 10 bucks an hour!


  32. on August 3, 2009 at 4:30 am | Reply David Merkel

    Don Hamm is an honest guy. Assurant is one of the few health companies not using "bait-and-switch" tactics in pricing. They don't automatically raise rates each year because they underpriced in year 1 to tease people in.

    How can Assurant do it? By making sure that there are few cheaters in the pool. You need to redo your analysis and look at what percentage of a claim costs arise in year one from an uninsured population. Then, compare that to an insured population. The insured population will be higher because some are sicker, and not revealing that on the application. Recission eliminates cheaters (and a few honest players as well), but keeps costs down for the healthy, and those who have unexpected negative changes in health.

    Those who are sick and don't reveal it should not be rewarded for their deception to insurance companies. It's a form of fraud.

    FD: long AIZ


    • on August 3, 2009 at 10:23 am | Reply Taunter

      If you believe that health insurance rescission is limited to those who intentionally made material misrepresentations on their insurance applications, we have a significant difference of opinion.

      There's an easy fix, which was proposed in the House hearings: limit rescission to cases where there is intent. You will note that it was the honest health insurers who declined to make this change.


  33. on August 3, 2009 at 4:54 am | Reply lambert strether

    Surely the public option will prevent neither "gaming the system" nor a Son of Rescission? The bill is 1000-pages long, and the system is complex and unproven. To the insurance companies, it must be screaming "Game me!" (And to the consultants who are busily scouring the 1000 pages for loopholes, too.)

    Medicare for All (single payer), with its "Everybody in, nobody out" policy, eliminates both problems by definition.


  34. on August 3, 2009 at 5:17 am | Reply eric anderson

    While I may agree that health insurance companies are the devil, it does not necessarily follow that I want to hand over control to the government, which is equally a devil in disguise.

    With people like Nancy Pelosi selling the House health care plan with statements like, health care reform means "a cap on your costs, but no cap on your benefit," I want someone to tell me why these liars are preferable to the liars who sell insurance. We've got Democrats trying to sell the people on some sort of economic perpetual motion. Benefits will automatically continue, but costs won't rise.

    I think we get more truth from folks like Rahm Emanuel's brother Ezekiel, who implies your heath coverage may be based on how many tax dollars you are worth to the government. Treatment priority will be weighted toward the young person who can recover, work, and feed the system. Old folks? Well, we can't waste too much resources on them. What are they worth, in dollar terms?

    He believes in a form of communitarianism, where health care for the chronically ill or elderly will be weighted with regard to the impact on the whole society.

    If I am not mistaken, this dude is an advisor to Obama on health care.

    Maybe the devil we know is preferable. The new health care legislation would not allow high-decutible policies, according to an article on the CNN's money site. But I think that is the direction to move. Let folks bear more ordinary costs, and only insure against the catastrophic. Also, make insurance companies live up to their contracts when something catastrophic does happen.

    But please, keep idiots like Pelosi and communitarians like Emanuel out of my health care. Please.


  35. on August 3, 2009 at 5:56 am | Reply With Obamacare, it will be time to short private insurance stocks | The Swamp Report

    [...] insurance industry should be properly regulated to prevent abuse such as the rescission game, but to argue that private insurance should be driven out of existence because of such [...]


  36. on August 3, 2009 at 6:44 am | Reply Dave Lentz

    So when the CEO of Assurant testified that "Rescission is rare. It affects less than one-half of one percent of people we cover.", why did not any of the congress-buffoons respond with the obvious rejoinder: "Yes, and exactly what per cent of the people you cover actually file claims?"

    That would have put the matter into crystal-clear clarity. In fact, they could recall the CEO and ask him this question even now.

    But they will not, because the Congress is in on the scam, as well as the administration. Changing the rules of the health insurance game/scam is the last thing they have in mind.


  37. on August 3, 2009 at 7:12 am | Reply Loren Pechtel

    There's a big problem here: You are arguing on simple percentages without looking at whether the patient lied or not. You seem to be showing that about 10% of policies with high claims are rescissed. It says nothing about what percentage of these people perfectly well knew they had expensive problems and lied on the application.

    Mistakes certainly are made but it doesn't mean that it's the right thing to do to push welfare costs off onto insurance companies and probably destroy the industry in the process.

    As for the casinos–I've seen them card those who appear young plenty of times. It's just there is normally no human interaction when sitting down at a slot machine so they very well might gamble for a bit without being carded.


    • on August 3, 2009 at 10:44 am | Reply Greg

      Why do you care about the health insurance industry? They do NOTHING socially useful. They take $11+ dollars from you tp pay a $10 bill. THAT is all they do. Name another function they serve and tell me any innovation they have come up with that improves my life.


  38. on August 3, 2009 at 7:30 am | Reply Will catastrophic only health insurance be rescinded in the end? | Bear Market Investments

    [...] Taunter explains how the .5% rescission rate figure discussed in the hearings on health insurance premiums and coverage is used to dismiss Congressional concerns as inconsequential and actually is a good business practice that will not change. It is worth going to the post to accurately follow the train of thought. Taunter concludes that the chances for rescission for a serious illness is: If the top 5% is the absolute largest population for whom rescission would make sense, the probability of having your policy cancelled given that you have filed a claim is fully 10% (0.5% rescission/5.0% of the population). If you take the LA Times estimate that $300mm was saved by abrogating 20,000 policies in California ($15,000/policy), you are somewhere in the 15% zone, depending on the convexity of the top section of population. If, as I suspect, rescission is targeted toward the truly bankrupting cases – the top 1%, the folks with over $35,000 of annual claims who could never be profitable for the carrier – then the probability of having your policy torn up given a massively expensive condition is pushing 50%. One in two. [...]


  39. on August 3, 2009 at 8:22 am | Reply Required Reading - Just Throw It on the Pile Over There

    [...] is an absolute must-read regarding the workings (or not-working) of health insurance in the U.S. The 'Nuclear Option' in the Health Insurance Industry More importantly the abuse of statistics in logic/reasoning. There is nothing like statistics, and [...]


  40. on August 3, 2009 at 9:32 am | Reply Greg

    Back to the Monty Hall problem for a second.

    One poster suggested that if Monty didnt know which door held the prize and when opening the other door just luckily opened the one with the goat that you should not switch. That seems absurd, Montys knowledge does not affect the odds, the only thing that does is your original choice and whether or not the door that gets shown does NOT have the car.


  41. on August 3, 2009 at 11:02 am | Reply Recission: death by a thousand paper cuts.

    [...] illuminating blog post by blogger Taunter shows us exactly how the healthcare industry extracts it's profits from it's customers. [...]


  42. on August 3, 2009 at 11:13 am | Reply attitude_check

    Great article, but your probability example from Let's Make a Deal is flawed.

    It is true that at first the prob of your choice being right is 1/3 and being wrong is 2/3's.

    First when Monte opens a door with the goat – it is not random. Monte knows where the car and goats are, and no matter which door you pick, there is always a door with a goat that Monte can pick. After he opens the goat door, all that has happened is the odds have shifted to 1/2 and 1/2 – NOT 1/3, 2/3.

    Even if Monte doesn't know, and opens a door at random, it still is prob 1/2, 1/2. Once the open door event occurs, the prob that it is a goat is one. The issue with gampbling that gets people is trouble is the belief that "dice have a memory". Effectively a new "game" is initiated once more information is added (e.g. we know what is behind one of the doors, but still not the other two). Each door is now 1/2 and 1.2, and your odds don't change no matter which you pick.


    • on August 3, 2009 at 1:32 pm | Reply Stephen Dodson

      attitude_check,

      The odds are indeed 2/3 and 1/3. It was a famous problem that a lot of math professors and PhDs got wrong. Your "gampbling" analogy is also off. Yes, dice don't have memory. Each roll is a discrete event. But Monty specifically selecting the door with the goat (it can't be the door with the car or the door you originally picked) is a continuation of the same game.

      http://en.wikipedia.org/wiki/Monty_Hall_problem

      But let's not get distracted from the main message of this post.


  43. on August 3, 2009 at 12:46 pm | Reply Joshua Zader

    The article assumes that any cancellations must be unjust, and then uses math to show that there are more cancellations than one might suspect. But if the cancellations aren't unjust in the first place, then the article is all smoke and no fire.

    News flash – If you include fraudulent information on your insurance application, your insurance company may cancel your coverage when you need it most. Of course, if you filled out your application in good faith and they try to cancel it for frivolous reasons, you can take them to court and you'll probably win. What exactly is the problem here?

    Most of the urgency in his article comes from comparing fraudulent insurance applications to game show contestants and underage gamblers. Using these kinds of analogies obscures the more fundamental fact that insurance companies can only legally cancel your policy when you have supplied demonstrably fraudulent information.

    That hardly seems like a scandal, or anything that warrants additional government regulation in what is already an incredibly heavily regulated industry.


    • on August 4, 2009 at 9:33 pm | Reply rox0r

      News flash – If you include fraudulent information on your insurance application, your insurance company may cancel your coverage when you need it most. Of course, if you filled out your application in good faith and they try to cancel it for frivolous reasons, you can take them to court and you'll probably win. What exactly is the problem here?

      ======

      Does dying before you win your court case because you were denied a transplant count as a problem?

      http://articles.latimes.com/2009/jun/17/business/fi-rescind17
      "The committee investigation uncovered several rescission practices that one lawmaker called egregious, including targeting every policyholder diagnosed with leukemia, breast cancer and 1,400 other serious illnesses. Such investigations involve scouring the policyholder's original application and years' worth of medical and pharmacy records in search of any discrepancies."

      Why don't you wait until you have chemo, radiation, and a cold, and see how well you hold up trying to defend yourself?


      • on August 4, 2009 at 10:21 pm rox0r

        Actually here is the a link to the woman who had breast cancer: http://www.cnn.com/2009/POLITICS/06/16/health.care.hearing/index.html

        What's the problem?

        "Beaton turned to Texas Rep. Joe Barton for help. Barton said his staff went to work, but the insurance company, he said, was "unyielding." Barton appealed to the company's president, who promised to investigate personally. The president called Barton back within four hours and said the coverage would be reinstated.

        Beaton underwent surgery in October, but by then her tumor had grown from two to three centimeters to seven. She had to have all the lymph nodes removed in her arm"


  44. on August 3, 2009 at 1:48 pm | Reply slg

    Attitude check:

    Your analysis is the usual naive one, and it's wrong. There are three cases: (1) you've chosen goat A; (2) you've chosen goat B; (3) you've chosen the car. In cases (1) and (2)–2/3rds of the total–Monty has only _one_ choice of door to show the other goat. In that 2/3rds of the cases, the other door _must_ be the car. Hence you _do_ improve your odds by changing your choice.

    The analysis has nothing to do with the "dice-having-a-memory" fallacy. It has _everything_ to do with contingent probabilities resulting from new information.

    Don't believe me? Better run some simulations before you apply for that finance job.


  45. on August 3, 2009 at 1:49 pm | Reply Colin K

    Your analysis seems to assume that fraud is effectively nonexistent. Otherwise the injustice argument here falls flat pretty fast.

    In any case, a single-payer system will simply shift us from rescission to rationing. If we don't practice rationing then costs will continue to rise and we will get it taken from us in taxes that rise every year instead of premiums that rise every year.

    As an alternative, I would like to see a system more like life insurance, where individuals buy a contract that provides a defined benefit at a defined cost for a defined number of years (or life). People would have a strong incentive to buy young and it would be up to you to decide whether to spend your money on a treatment. If your odds of rescission hit 50% at some level, then this type of defined-benefit option could hardly be a worse gamble.


    • on August 4, 2009 at 9:50 pm | Reply rox0r

      Your analysis seems to assume that fraud is effectively nonexistent. Otherwise the injustice argument here falls flat pretty fast.
      ======

      How do you figure? 10% fraud is really high. What kind of fraud numbers are you thinking about?

      If fraud is high then the companies are making out even better, because they are taking in loads of money from people that they will NEVER pay out to.


  46. on August 3, 2009 at 5:18 pm | Reply More statistics abuse: Rescission is rare, unless your sick " Skepoet At Crossroads of Critical Thinking and the Humanities.

    [...] wrote how the claims that rescission is rare is a claim that should be taken with a grain of salt. Taunter Media breaks down the math: To understand why 0.5% of the people Assurant covers is a lot of people – a jarring, terrifying, [...]


  47. on August 3, 2009 at 7:28 pm | Reply Gordon Pasha

    When he claimed 0.5% was that 0.5% every year? If that is the case, and one is insured say, on average, 30 years, then the chance of getting rescinded is really high, isn't it? At least here, they claim the figure is per year,
    http://baselinescenario.com/2009/07/27/health-insurance-innovation/

    Regards

    Gordon


  48. on August 3, 2009 at 8:10 pm | Reply 3 August 09 (pm) " blueollie

    [...] Care and Statistics: Check out this post at Unconscionable Math: The House hearings on rescission – the retroactive cancellation of individual health insurance [...]


  49. on August 4, 2009 at 12:39 am | Reply Chris Taylor

    the monty puzzle seems to have a flaw to me.

    it assumes 3 solutions because there are 3 choices and that is how they come up with 2/3 1/3

    but this is false.

    there are FOUR solution.

    pick car open goat change to goat

    pick car open other goat change to goat

    pick goat open goat change to car

    pick other goat open goat change to car

    2 chances to lose and 2 chances to win

    the odds are 50/50 it seems to me.

    they "distort" the odds by displaying but IGNORING that initially selecting the car has TWO probable outcomes NOT ONE.

    so its NOT a 1/3 2/3 problem.

    its a 1 in 4 problem BECAUSE of the host interference.

    at least thats how my brain munges it though I am tired at 0436 in the morning :-)

    when you base the odds NOT on initial choice but on potential outcome paths its clearly 50/50 to me.

    BUT I have run the experiment to test with the cards and experimentally the results are correct you DO win more often by changing.

    my brain hurts. I still think the odds are 50/50

    by having the host interfere your not changing the odds your IGNORING THEM since now its no longer odds its "acting" on inside information (host opening a goat door)


    • on August 4, 2009 at 9:57 am | Reply amanasleep

      You are correct that there are 4 possible outcomes instead of 3, and have hit upon the crux of the misconception of this problem: these outcomes do not have an equal probability of occurring.

      That is, the first two options each have a 1/6 chance of occurring (Pick Car Open Goat 1 Change Goat 2 and Pick Car Open Goat 2 Change Goat 1), because the probability of the original choice (Pick Car) is itself 1/3.

      The probability of each of the remaining choices (Pick Goat 1 Open Goat 2 Change Car and Pick Goat 2 Open Goat 1 Change Car) is 1/3 (a total of 2/3 when combined).

      That means that the total chance of winning the car when switching is 2/3.

      In common sense terms:

      1. Everyone will agree that you had a bigger chance of initially picking a goat, ie 2/3.

      2. Therefore in 2/3 of the cases, the initial pick is wrong.

      3. Your chance of initially picking a Car is 1/3, and you can only get a goat on a switch if you pick a car. In fact if you pick a Car and switch you will always get a Goat! But since everybody agrees that your chance of initially picking a car is exactly 1/3 and your chance of getting a goat is 100% if you switch from the car, then your overall chance of getting a Goat by switching is also 1/3.

      4. Likewise, everyone can agree that your initial chance of picking a Goat is 2/3. Similarly, you can only switch to a Car if your initial choice was a goat (either one, since the host ALWAYS reveals the other one). In fact, your chance of switching to a car if you initially chose a goat is 100%! Therefore your overall chance of getting the car if you switch MUST be 2/3.


    • on August 4, 2009 at 10:10 am | Reply Shawn Crahan

      Hey Chris,

      You're right, there are four scenarios, but they aren't weighted equally.

      Two scenarios, pick car and Monty opens Goat, or Monty opens other Goat, only occur in 1/3 of the circumstances, because of the initial conditions. No matter what Monty does, you still only had a 1/3 likelihood of picking the car.

      Now if you were to follow the likelihood of all the situations occuring, Monty picking either Goat A or Goat B when you chose the Car initially will occur 1/6 of the time each, or any individual Goat is selected for 1/2 of the time for that 1/3. Then with the 1/3 likelihood that you chose Goat A, monty 1/1 of the time will choose Goat B. And for the Final 1/3, when you chose Goat B, Monty will 1/1 of the time chose Goat A. All together the (1/3)2 + (1/3)/2 + (1/3)/1 + (1/3)/1 equals 1, or the full set of possible scenarios.

      Make more sense this way?


  50. on August 4, 2009 at 2:18 am | Reply David Herr

    As an attorney, I agree that some recission stories are horrifying. But some regulatory tweaks will suffice to address the problem: allowing recission only if the undisclosed or erroneous information is medically relevant to the eventual insured event; requiring that it be an actual recission, in which premiums, with interest, are repaid, in the event the insurer successfully shows that the insured failed to disclose a relevant factor.

    The democrats portray the preexisting conditions rules as insurers looking out for their own profits, and there is always that in any business, but they are also looking out for me, their insured. If people with preexisting conditions who have not been contributing to the pool jump in at the last minute once they need money for medical care, insurance companies will not have enough money to pay out claims when they arise for those like me, who have been paying in since age 18.

    Indeed, I am now 38, and pay $180/mo for a Blue Cross policy. Nowhere near $7000. By design, I keep my premiums low, by maxing out the deductible and co-pay. My out of pocket limit is $7500 per year. As a 38 year old, I can pay that if need be. In healthy years, which, thankfully, all of them have been, save for a $1500/5 stitch finger cut this past Thanksgiving, I set aside some money, so that when the time comes that I do get sick or have a major injury, I can meet the out of pocket limit for several years.

    The total of premiums and saving for health care (NOT in an HSA - just plain old saving) are far less than $7000 per year.

    Ideally, health insurance would be reduced to a much simpler financial proposition, with flat payouts to insureds upon verification of various diagnoses. Then, people could choose how much coverage to buy, and then if anything happened they would get cash with which to pay bills. That $1500 finger cut would have been instantly bargained down to $750 or less, if I had lied and told the emergency room intake clerk that I had no insurance. Similarly, people who need a coronary bypass can bargain with the hospital if they are going to pay cash. In this, health insurance would become more like life insurance or house insurance. I can even see combined life and health policies, which would give the insurance company a lot of reasons to quickly pay out for medical events, if their failure to do so would cause a pay-out for death.

    Lastly, my advice to people is to pay a bit more in premiums, for a large company insurance policy that does not re-underwrite at the end of each annual period. I have had continuous coverage for 20 years, and have no preexisting conditions. I do not want what I have going for myself, and for which I have paid, to be taken away.

    Because make no mistake, requiring individual insurers to take all comers will raise my premiums. The most similar Blue Cross policy to mine in New Jersey is over 4 times as much per month. Please, don't raise my insurance premiums!


  51. on August 4, 2009 at 4:05 am | Reply Mr. Ant-Insurance

    These health insurances are the main protaginist in the mess the healthcare system is in. These insurances should be eliminated because they are after one thing……profit.

    Once the medical insurances are diminished, the doctor-to-patient relationship will be fully implemented and efficiency and proper treatment will take effect.

    Google PAINSCOURT for more info.


  52. on August 4, 2009 at 7:05 am | Reply Will catastrophic only health insurance be rescinded in the end? | ETF Fool

    [...] Taunter explains how the .5% rescission rate figure discussed in the hearings on health insurance premiums and coverage is used to dismiss Congressional concerns as inconsequential and actually is a good business practice that will not change. It is worth going to the post to accurately follow the train of thought. Taunter concludes that the chances for rescission for a serious illness is: If the top 5% is the absolute largest population for whom rescission would make sense, the probability of having your policy cancelled given that you have filed a claim is fully 10% (0.5% rescission/5.0% of the population). If you take the LA Times estimate that $300mm was saved by abrogating 20,000 policies in California ($15,000/policy), you are somewhere in the 15% zone, depending on the convexity of the top section of population. If, as I suspect, rescission is targeted toward the truly bankrupting cases – the top 1%, the folks with over $35,000 of annual claims who could never be profitable for the carrier – then the probability of having your policy torn up given a massively expensive condition is pushing 50%. One in two. [...]


  53. on August 4, 2009 at 7:31 am | Reply PetrieDish

    Incredibly interesting discussion!

    On the subject of rescissions: I assume the term refers to policies that are specifically terminated by the insurance company in response to a review of the application. But in this country, we have a system in which medical insurance is employer provided. If an individual becomes too sick to work for an extended period of time and loses his job, he also loses the insurance. While this seems logical, is it not also a form of rescission in response to excessive utilization? This seems similar to the gambling analogy: you can play but you can't win.

    On the subject of pre-existing conditions: Any time a claim is made on a medical insurance policy one is, by definition, creating a possible pre-existing condition. A vague definition of "pre-existing" can be used as an "effective rescission" without actual policy termination.


  54. on August 4, 2009 at 7:36 am | Reply Insurers only pull your coverage when it hurts - Paul Krugman Blog - NYTimes.com

    [...] Yves Smith, an important piece on "rescissions": cases in which insurance companies retroactively cancel your health [...]


  55. on August 4, 2009 at 9:28 am | Reply econoblog.info " Very Excellent Post on Health Insurance Recisions

    [...] Taunter explains the link between Monte Hall and Health Insurance. Brilliant. [...]


  56. on August 4, 2009 at 9:52 am | Reply Rescission: Why For-Profit Health Insurance is a Fraud " One Utah

    [...] of policies. It's a rare occurrence, they say. Rare, that is, unless you get sick. Blogger Taunter does the math (emphasis added): Half of the insured population uses virtually no health care at all. The 80th [...]


  57. on August 4, 2009 at 12:03 pm | Reply Janna

    This seems to be a bit confusing though-how many people are actually covered by individual health policies? Health insurance companies can't rescind group health coverage. If you have continuous coverage, you aren't subject to a pre-existing denial of benefits either (so the guy with the autistic son can leave on employer health plan for another employer health plan without losing coverage at all). And if you do have a pre-existing condition that you were treated for in the 12 months before you get group coverage (or if you have a break in coverage of 63 or more days) then the coverage for everything isn't denied-only for the condition you were treated for, and only for 12 months. This rule was one that came into effect in the 1997 HIPAA (the P is for Portability) regulation.

    I think to determine who might actually be at risk for rescission, or at least the actual number of people, you have to take only those people with individual health policies, then look at the top 5% of that.

    That being said, it's a horrendous practice. While those of us covered by group health plans have considerably more protection, as another poster said, if we are very sick, we lose our jobs and our coverage.


  58. on August 4, 2009 at 1:44 pm | Reply sTiVo

    I don't think I'm stupid but I don't get your Monty Hall logic.
    You made a choice. You had one chance in three of being right. Monty showed you one wrong answer. The other wrong answer is either the one you chose or the other one you didn't choose. Now, with this new data your original guess has one chance in two of being right. I see no compelling case for switching or not switching – the odds are equal. Monty Hall would have done the same thing had your first guess been right or wrong.

    Why is the above not correct?

    That said, I understand your point about recission very well, and thanks for it.


    • on August 4, 2009 at 11:33 pm | Reply josephdietrich

      sTiVo,

      Think of it as not as a 1 in 3 chance of being right, but a 2 in 3 chance of being wrong.

      That is, you are unlikely to be right. It is likely that the car is behind one of the other two doors. So when Monty eliminates one of the other two doors, he shows you which door the car is most likely behind.


      • on August 5, 2009 at 4:20 am sTiVo

        josephdietrich:

        Not buyin it. This thread is supposed to enhance mathematical understanding? It doesn't do that, it obfuscates it.

        Looking at it your way, okay, you had a 2/3 chance of being wrong. Monty now provides you with more information. Based on this new information, the odds on your original pick having been wrong are reduced to 1 in 2. The original 2 in 3 odds are no longer relevant. Should you switch? Based on this new information, it's a wash.

        And you haven't considered a point I made in my original posting: would Monty Hall have done anything differently had your original pick been right or wrong?

        This is a lousy example of conditional probability.


      • on August 5, 2009 at 8:02 am sTiVo

        josephdietrich:
        To elaborate further:
        >> That is, you are unlikely to be right. It is likely that the car is behind one of the other two doors.

        But which one? and is either of them any more likely to be right than the one you originally chose?

        >> So when Monty eliminates one of the other two doors, he shows you which door the car is most likely behind.

        Bad logic. Yes, the right answer is more likely to be ONE OF the doors you didn't choose, but that doesn't mean that your answer has NO probability of being right. It had some and it still has some. Your logic makes the leap that because the right answer is more likely to have been one of the group you didn't choose than the one you did, therefore the probability that your original guess was right can be discarded. That logical leap is faulty.


  59. on August 4, 2009 at 1:47 pm | Reply sTiVo

    For-profit health insurance has, no, IS an intractable conflict of interest that cannot be eliminated within itself.


  60. on August 4, 2009 at 1:58 pm | Reply Winter's Haven " Recission

    [...] an important bulletin on "rescission" (the retroactive cancellation of individual health insurance policies) [...]


  61. on August 4, 2009 at 5:58 pm | Reply BTMOM

    David Herr,

    If no health care reform is passed, you can be sure your premium will go up, because it will be a green light to the private insurers that their lobbying power and flooding of the right-wing media with disinformation has yet again deflected any effort to keep them honest. Many employers pay a higher per-employee rate than you pay. It boils down to where you are located, age, health history, and a multitude of other factors. When an insurer dumps an insured based on recission – fraud based or not – the public ends up carrying the cost, because that person will end up in an emergency room over and over again. They will undoubtedly suffer more, and probably die sooner, than if they had insurance, but their unpaid health care costs will be passed along to the rest of us. Emergency room care is the most expensive care available.

    A public option makes a rational plan of care possible for people without other coverage options. We are the only major industrialized nation that does not provide some public health care option. The private insurers will be just fine, and if they can't compete, then maybe they will have to make themselves competitive, won't they?


  62. on August 4, 2009 at 7:16 pm | Reply ALawyer

    As the retired CEO of a unit of one of the nation's largest insurance companies I commend you on having written one of the best articles outlining the problem with rescission I have ever seen.

    I heard Assurant's CEO testify that rescission occurs in less than 0.5% of all cases, and another CEO talk about less than 1%, and was outraged.

    Companies design insurance applications and their underwriting processes to accomplish multiple purposes.

    The most laudable is to be able to quickly reject those folks who are honest enough to acknowledge medical or health conditions that make them sub-par risks which are likely to cost more in benefits than they will pay by way of premium (or in some cases to justify charging them a significantly higher premium for their coverage in light of the higher risk). The companies weed out the bad risks, enabling them to hold down expected claims and the premium costs.

    While its great for the companies and the insureds who are in good health and qualify, the problem for society is these people still will have medical problems (sometimes more severe ones than if they had insurance and could be treated earlier in the process) and will still have to be cared for, resulting in financial strain for those with money and cost shifting for those without.

    Companies also often design their processes to make it easy for people to do business with them. Yet while that sounds like a commendable purpose often the motivation is perverse. Companies can make it very simple to complete the application and get a policy - using the easy application and lack of any meaningful underwriting process as a competitive advantage in attracting agents, customers and making sales.

    Those of us with industry experience know that agents often steer customers to those companies that pay higher commissions and/or are far more likely to issue a policy. Companies attract agents by making it fast and easy for their clients to complete the application and become approved. In that way the company can collect the premium and the agent can collect the commission. Light underwriting is also far less expensive upfront (except for the sales commissions) for the insurer.

    As people balk at long complicated applications (which often can uncover medical and health conditions likely to lead to more frequent or more severe claims) make them short. Don't ask specific questions which often would result in the application being denied. Instead, ask vague questions with lots of boxes people will not fill out so you can later claim failure to disclose. (The agent will not encourage you to be honest - s/he does not collect a sales commission if the application is rejected.) Agents quickly learn that submitting an application to company X will lead to a placed policy with a quick commission while applying to company Y that conducts rigid underwriting inevitably leads to delay and often to a rejection of the applicant or increased rates the applicant can not afford, and a lost client.

    Health insurance companies know that if they obtained a complete detailed application and conducted full underwriting - as life insurance companies do on high face value policies, usually with a medical or para-medic examination, blood tests, a request for and review of medical records - it would be expensive up-front, and regarded as unfriendly by the applicants and the agents. The trade off for loose underwriting is worse claims experience - it's just like turning the dial.

    The companies' ace in the hole is that if a big claim comes in - because the application was so simple and there was so little underwriting - they can use rescission as a weapon. Now the simplicity and vagueness of the application comes back to haunt the person who thinks s/he is insured.


  63. on August 4, 2009 at 7:51 pm | Reply Mike

    It is such a balancing act, between motivations to help people and turn enough profit to make it worth the effort to make the sacrifices many in the medical field make, although – from what I have seen, the pay is pretty good.


  64. on August 4, 2009 at 8:20 pm | Reply Conrad

    I'll speak up right here. I have diabetes2 for about two years and hold an individual policy from a major health insurer, the same company for about twelve years. Over the years they increased my premium annually about 10%. The latest increase was 20%. When I asked them to justify the double increase, they wrote that the reason was the part of New Mexico I live in. HMMMM….about 50 miles from Los Alamos National Lab. But why would that justify the sudden increase in premium hikes? I've lived in the same place for 15 years. When my agent offered a better deal through the same company – a new plan – he told me I wasn't eligible when I informed him of my pre-existing condition. So I am trapped. My current insurer won't admit me to a new, less expensive plan. My agent told me any other insurer will offer only an exorbitant premium. The American health care system offers me NO OPTIONS. For this reason, I completely favor a strong public option that covers pre-existing conditions at a reasonable premium. I hope the millions of Americans victimized by health insurers support a robust public option. It's the only way we'll get a fair deal.


  65. on August 4, 2009 at 8:38 pm | Reply brianbreed

    this infuriates me. i thank you for sharing.


  66. on August 4, 2009 at 8:51 pm | Reply Mary Saunders

    Another interesting phenomenon is that recovery money is being put into free clinics. I like free and low-cost clinics. The professionals running them are often doing it because they like people and want to see them get better. I don't suspect them of wanting to take something out or off because they want the fee. If we required everyone to carry catastrophic at a reasonable price, the difference from what we have now is that healthy people would be paying a premium for the care they would get anyway if they are hit by a bus, have no coverage, and become disabled. Make a public option with reasonable fees, and you go in and give them a baseline of your health and pay for the exam. They are responsible for assessing you, as if you were an as-is house where the buyer has to do his due diligence. At the same time, allow people to self-insure for little stuff, at their credit union. Let them use their set-aside funds for gym fees, yoga, tai chi or acupuncture or other other stuff not covered by catastrophic but that has research showing it is low side-effect and contributes to health. If what we want to do is increase health, what we have now doesn't do that. We need to let companies who are sure you will want to buy their health product if you try it, offer rewards to people for increasing their health, something like that. The present system makes everybody irritable, and that isn't good for health. Patch Adams has pitched for an endowed system. If everybody knows it's good and honest, people will volunteer in it and donate to it, and you can have fundraisers with musicians and artists. It's just that we have got to trust it, and that is the really hard part.


  67. on August 4, 2009 at 9:56 pm | Reply Stan Milgram

    Regarding your point about Las Vegas slots, it's worse than you think. When I was 20 years old, I played some slots at Las Vegas. When i got a big win, they asked for ID. I showed it and they informed me the legal gambling age in 21 and confiscated all my winnings. I protested and they said if I said another word they would call the police and have me arrested and I would face up to 10 years in Nevada State Prison for illegal gambling.

    I was not underage, I was an adult. There are no signs anywhere that say the age for gambling is 21 and not 18.


  68. on August 4, 2009 at 11:21 pm | Reply Asumu Takikawa (takikawa) 's status on Wednesday, 05-Aug-09 07:21:37 UTC - Identi.ca

    [...] http://tauntermedia.com/2009/07/28/unconscionable-math/ [...]


  69. on August 5, 2009 at 3:30 am | Reply Jennifer

    I agree with the reader who recommended the Swiss healthcare system as a model for the US. As a recent college graduate, I have been working here for a pharma company for 8 months now. Before the company would "officially" hire me, I had to show proof of my private health insurance, which is mandatory for anyone living and/or working here. At the not-unreasonable fee of 250 swiss francs (approx. $225) per month for a healthy 23 year old female, I am covered for all basic medical procedures and emergencies. Had I wished for more comprehensive coverage that allowed for more choice in doctors/specialty clinics and a private hospital room, my fees would have doubled. As I am only here for a temporary time period, I opted out of the extra fees and, therefore, better coverage. By requiring residents of Switzerland to be accountable for their own insurance, the healthcare system here has maintained extremely high standards as well as reasonable costs that need not be subsidized by the government or private citizens. Whether or not this would work in our much larger and more diverse country is debatable, particularly since many people would rather just have the wealthy subsidize their costs through higher taxes.


  70. on August 5, 2009 at 4:47 am | Reply Doc Rox All

    Ok…here's the thing…would you rather have healthcare funded by (behind door #1) those seeking a profit, or (behind door #2) those seeking power over your lifestyle, or, (behind door #3) not at all, I'd rather pay cash. Now, I'll let you choose any 2 of the three without knowing what's behind the doors…same deal here. I understand that statistics, and how there's "lies, damn lies, and statistics", but let me point out that we aren't given "infinite possibilities" in solving problems, we're given "options". So, back to our three doors. If you choose the door with profits, oh, you'll get screwed, potentially, if you hit the special combination of conditions/triggers that actuaries at the insurance company have set up, to assure they are profitable. Yes, these folks exist. They pool loss numbers together and put together what's called "underwriting policy" that decide whether or not you get covered, and what your premium will be. Hey, you chose door #1, and its about profit. Sorry, if you trigger a premium increase, or loss of coverage, you lose.

    Ok…so you chose door #2…nice for you…the not-for-profit-but-for-bureacratic-control-of-your-life is there. Nice. Now, you are overweight, because you work at an IT job for an insurance company (wait, that's me), and you sit on your butt all day, and you have arthritis, which dramatically limits your physical activity (not the weenie kind, the kind where you have your knees replaced at age 50 because you can't stand to stand up for more than 5 mins because of the pain). Wait a minute…YOURE FAT! GASP. You are putting the government healthcare plan at risk with all your type II Diabetic meds and your knee replacements and your generally poor health. You are EFFECTING NATIONAL SECURITY by being a FAT SLOB. Oh, and wait, YOU make alot of money at that IT job…why, you're a RICH FAT SLOB. Oh…you don't think your premiums will go up to ridiculous levels? Wait…you hit 70, and some GOVERNMENT actuary has decided you are within 2 years of your mortality date? Hmmm, here's some pain pills, here's a nice "end-of-life-counselor", Soylent Green is people! How nice that you are still innocent, how convenient for the government run health care lobbyists. We appreciate your vote.

    Ok…behind door #3 and, lucky you, YOU get to pay cash for your medical coverage. Now, this one is a complete pipe dream, because, see, the government already controls 60% of the health care in America (Medicare and Medicaid). Now, let's not forget the fact that THEY control the pricing of EVERYTHING health oriented in America. They do…the GOVERNMENT sets the prices of every procedure in America…I'm sorry, its a fact. So…unfortunately, you can't GET health care for a modest profit over what the provider pays. You can't, because the government sets the prices, and see, part of that price is TAXES they get paid on that procedure…but let's just say, in this fantasy world of "Let Make a Health-Care Deal" that the government butts out through some miracle. And…prices drop to demand. Now, you have a life-threatening condition. Oh…lots of people have that…its in high demand. High demand = high prices, oh, wait, you don't have the money? How about a second mortgage on the house? Oh, right, the economy is in the pisser…sorry, well, so sad, you die.

    So, there you have it folks, 3 doors, you choose any one of them, and someone, somewhere, loses. I prefer my current plan, where I don't lose most of the time, versus, where I lose ALL of the time, my freedom. I choose to have freedom, and I choose to let those who are covered by the government now, in a losing scheme, called Medicare and Medicaid, to continue. Heck, expand it to cover ALL American's, fine, and prove to me that its worth me going on it…and I'll jump. Right now, mine looks better. Oh, and those folks that are dropped and can't get back on to a "for-profit" scheme…they can go there too.

    So here's my question…if Medicare and Medicaid exist (door #2 by default)…WHY does the government need to control 100% of healthcare? Why? It works for me! I don't need it. Medicare and Medicaid are there? Where's the SCAM here?

    Regards,

    Doc Rox All


  71. on August 5, 2009 at 5:38 am | Reply Baerton

    medical costs… and perhaps those of the seriously afflicted.
    …the "Unconscionable Math" here is in the heavy use of the term "insurance" without care as to its mathematical meaning or basis.

    Actuarial insurance can only be based upon mathematical/statistical probabilities of risks. Actuaries are mathematicians who put a price tag on future risks. But not all risks can be calculated, priced, nor fairly "insured".

    In stark contrast to normal actuarial-insurance, discussions of "health insurance" quickly toss away any
    objective concepts of insurance - we all just want 'somebody else' to pay our
    An actuarial insurance system can NOT possibly provide health-care to everyone.

    "Health-Care" is an undefined, open-ended, and non-insurable risk for a national population. The trivial focus on rescission here… entirely misses the big-picture.


  72. on August 5, 2009 at 7:52 am | Reply Why Reasoned Debate is Difficult " blueollie

    [...] (see here) [...]


  73. on August 5, 2009 at 8:02 am | Reply Political Irony › What if a bank told half their highest net worth clients 'sorry, you misspelled your address when you opened your account, we're confiscating your balance'

    [...] the much bigger lie is carefully documented in a brilliant article in Taunter Media, which points out that calling rescission rare is, shall we say, misleading at best. Yes, the [...]


  74. on August 5, 2009 at 9:19 am | Reply We Canadians REALLY don't get the U.S. health insurance debate | Rambling Dave Scharf

    [...] For the whole blog, CLICK HERE. [...]


  75. on August 5, 2009 at 9:28 am | Reply How the U.S. health care system doesn't work – The Blogs at HowStuffWorks

    [...] Unconscionable Math [...]


  76. on August 5, 2009 at 10:30 am | Reply Wednesday Linkage | The Big Picture

    [...] The Unconscionable Math of Health Insurance Rescission (Taunter [...]

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Vol 25, No.12 (December, 2013) Rational Fools vs. Efficient Crooks The efficient markets hypothesis : Political Skeptic Bulletin, 2013 : Unemployment Bulletin, 2010 :  Vol 23, No.10 (October, 2011) An observation about corporate security departments : Slightly Skeptical Euromaydan Chronicles, June 2014 : Greenspan legacy bulletin, 2008 : Vol 25, No.10 (October, 2013) Cryptolocker Trojan (Win32/Crilock.A) : Vol 25, No.08 (August, 2013) Cloud providers as intelligence collection hubs : Financial Humor Bulletin, 2010 : Inequality Bulletin, 2009 : Financial Humor Bulletin, 2008 : Copyleft Problems Bulletin, 2004 : Financial Humor Bulletin, 2011 : Energy Bulletin, 2010 : Malware Protection Bulletin, 2010 : Vol 26, No.1 (January, 2013) Object-Oriented Cult : Political Skeptic Bulletin, 2011 : Vol 23, No.11 (November, 2011) Softpanorama classification of sysadmin horror stories : Vol 25, No.05 (May, 2013) Corporate bullshit as a communication method  : Vol 25, No.06 (June, 2013) A Note on the Relationship of Brooks Law and Conway Law

History:

Fifty glorious years (1950-2000): the triumph of the US computer engineering : Donald Knuth : TAoCP and its Influence of Computer Science : Richard Stallman : Linus Torvalds  : Larry Wall  : John K. Ousterhout : CTSS : Multix OS Unix History : Unix shell history : VI editor : History of pipes concept : Solaris : MS DOSProgramming Languages History : PL/1 : Simula 67 : C : History of GCC developmentScripting Languages : Perl history   : OS History : Mail : DNS : SSH : CPU Instruction Sets : SPARC systems 1987-2006 : Norton Commander : Norton Utilities : Norton Ghost : Frontpage history : Malware Defense History : GNU Screen : OSS early history

Classic books:

The Peter Principle : Parkinson Law : 1984 : The Mythical Man-MonthHow to Solve It by George Polya : The Art of Computer Programming : The Elements of Programming Style : The Unix Hater’s Handbook : The Jargon file : The True Believer : Programming Pearls : The Good Soldier Svejk : The Power Elite

Most popular humor pages:

Manifest of the Softpanorama IT Slacker Society : Ten Commandments of the IT Slackers Society : Computer Humor Collection : BSD Logo Story : The Cuckoo's Egg : IT Slang : C++ Humor : ARE YOU A BBS ADDICT? : The Perl Purity Test : Object oriented programmers of all nations : Financial Humor : Financial Humor Bulletin, 2008 : Financial Humor Bulletin, 2010 : The Most Comprehensive Collection of Editor-related Humor : Programming Language Humor : Goldman Sachs related humor : Greenspan humor : C Humor : Scripting Humor : Real Programmers Humor : Web Humor : GPL-related Humor : OFM Humor : Politically Incorrect Humor : IDS Humor : "Linux Sucks" Humor : Russian Musical Humor : Best Russian Programmer Humor : Microsoft plans to buy Catholic Church : Richard Stallman Related Humor : Admin Humor : Perl-related Humor : Linus Torvalds Related humor : PseudoScience Related Humor : Networking Humor : Shell Humor : Financial Humor Bulletin, 2011 : Financial Humor Bulletin, 2012 : Financial Humor Bulletin, 2013 : Java Humor : Software Engineering Humor : Sun Solaris Related Humor : Education Humor : IBM Humor : Assembler-related Humor : VIM Humor : Computer Viruses Humor : Bright tomorrow is rescheduled to a day after tomorrow : Classic Computer Humor

The Last but not Least Technology is dominated by two types of people: those who understand what they do not manage and those who manage what they do not understand ~Archibald Putt. Ph.D


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Last modified: July, 24, 2021