[HN Gopher] The Untamed Rise of Hospital Monopolies
___________________________________________________________________
The Untamed Rise of Hospital Monopolies
Author : elliekelly
Score : 110 points
Date : 2021-07-20 18:07 UTC (4 hours ago)
(HTM) web link (www.npr.org)
(TXT) w3m dump (www.npr.org)
| deregulateMed wrote:
| Is there anything we can do to stop these cartels?
|
| The poor have nothing to worry about, Medicare is fantastic and
| keeps a large percentage of the population complacent in the
| feeding of the physician, hospital, and pharmacy cartels.
| clipradiowallet wrote:
| I used to work for a large health insurer(Blue Cross Blue Shield,
| in a southwestern state), and monopolistic trappings were all
| around us. A good example was our board was occupied by members
| who also held board seats at local [large] hospitals(Baptist /
| Methodist / Childrens), and vice versa. Often in the board
| minutes, phrases like "fix up the market" and "stitch up the
| market" were used. Other topics frequently discussed were how the
| 85/15 rule[1] ate into profit margins of both institutions, and
| what could be done about it. The common fix to 85/15 rule
| problems were inflating the cost of basic procedures, so the 15%
| of the 85/15 rule was a larger value.
|
| [1]: 85/15 rule is part of the ACA mandating that 85% of dollars
| taken in by an insurance provider must be paid to actual claims.
| The remaining 15% was the maximum gross profit an insurer could
| take in(before overhead and all expenses).
| ecommerceguy wrote:
| The 85/15 you are referring to is called the Medical Loss
| Ratio. This applies to ACA coverage only (group or individual),
| and does not include carriers' Self Funded or Short Term
| products. When an insurer comes under the MLR (say, claims are
| 79% of premiums) the remainder upto 80% or 85% (depends on
| state) is paid back to the policyholders. For instance if you
| were on a UHC ACA plan in my geography last year, you would
| have received a portion of premium returned in the form of a
| check because UHC ran at 77%.
| bhupy wrote:
| As far as I know, Self Funded plans in non-Dental/Vision are
| fairly rare due to the massive stop loss required. Even the
| Fortune 500 employers use fully funded plans for healthcare.
| missedthecue wrote:
| That rule along with the rule mandating healthcare benefits for
| all full-time employees seem like the most obviously and
| clearly short-sighted policy blunders, only a government could
| make them.
| syops wrote:
| It's a big stretch to say only government could make such a
| blunder. These rules were not blunders in the sense you make
| them out to be. They were the best option available given the
| reticence of roughly 50% of the population toward a single
| payer solution or other universal healthcare option. The
| designers of the ACA knew about these shortcomings but
| decided to kick the can down the road so to speak. Their goal
| was primarily to get far more people into the healthcare
| system and to get Americans used to the idea that pretty much
| everyone deserves access to healthcare. They achieved both
| goals.
| missedthecue wrote:
| But my point is that they could have achieved most of it
| without those specific policies. For instance, we now have
| a situation where instead of working 40 hours per week
| without health insurance, people in many occupations can
| only get 29 hours scheduled. So not only did it utterly
| fail in its goal of getting more people signed up for
| insurance, but it actively made the lives of those people
| worse by stunting their earning power unless they try to
| piece two part jobs into one week with all the chaos that
| involves.
|
| It's just awful incentive alignment and I see it time and
| time again in government policies that were developed with
| good intentions in mind.
| syops wrote:
| You should do some research on the topic. Far more people
| are insured now than before the ACA.
| bhupy wrote:
| Not sure why you're getting downvoted, but this is an
| observation I've had as well, working in the industry.
|
| What we're seeing in healthcare costs is analogous to what
| you might see happen to airline ticket costs if we all got
| our air tickets through our employers: the vast majority of
| us would fly business class, while the unemployed would be
| simply unable to pay for business class fares out of pocket.
| Employers (especially medium-to-large businesses) have a much
| higher purchasing power (and hence, willingness to pay) than
| individuals.
|
| If you take this behavior and combine it with the fact that
| health insurers' profit margins are capped by law, insurers
| pay more absolute dollars for treatments (which doctors
| happily accept), charge more to employers (who are generally
| less price conscious vs individuals), thus bring in more
| absolute revenue, and therefore more profit because a capped
| profit percentage of a higher revenue is higher than a capped
| percentage of lower revenue. It's somewhat counter-intuitive,
| but the policy combination of an employer mandate and
| insurance profit cap results in the mother of all local
| optima.
| merpnderp wrote:
| Inflating the cost of procedures to drive up profits has been
| around a lot longer than the ACA. My biggest disappointment
| with the ACA was not fixing that very issue, where insurance
| companies and hospitals both have an incentive to maximize
| costs.
| spaetzleesser wrote:
| "A good example was our board was occupied by members who also
| held board seats at local [large] hospitals(Baptist / Methodist
| / Childrens), and vice versa"
|
| Same for municipalities who have hospitals. The local
| government leaders like mayors or country boards are often
| connected with groups of doctors, developers and construction
| companies who make sure they make as much money as possible. Or
| intentionally mismanage a public hospital to then sell it to
| their friends for cheap who can then raise prices and rake in
| the money.
| briffle wrote:
| One of the busiest emergency rooms on the west coast is Salem,
| OR. It has a population of around 150k, but is the only major
| hospital between Eugene, and Portland (Portland has several
| hospitals) It has more than 110,000 visits a year.
|
| Last year, Blue Cross threatened to remove it from its network,
| because its pricing is so high compared to other areas that have
| actual competition. But since they are the only game in town,
| they set the price.
|
| Not sure what came out of that, but their list prices sure didn't
| go down. Must have cut them a special deal to keep them.
| toomuchtodo wrote:
| Cost controls imposed by the government will be required at
| some point.
| handrous wrote:
| I'm not aware of a single example of an OECD state (the USA
| aside, obviously) that doesn't apply significant price
| controls on healthcare, either explicitly, or by imposing a
| state-controlled monopsony. Across all the various approaches
| to healthcare systems in the developed world, that seems to
| be the single most consistently-adopted measure for keeping
| healthcare costs from going crazy, as far as I can tell.
| wefarrell wrote:
| Consolidation is not necessarily a problem. 1/3rd of US
| healthcare spending is for administration[0], twice Canada's
| percentage. This is due to fragmentation and it doesn't make a
| ton of sense for each hospital to have a dedicated finance
| department, HR department, etc...
|
| The free market is not a solution to the problem of healthcare
| spending. Consumers do not have enough information, they aren't
| in position to refuse treatment if it's too expensive, and
| hospitals aren't in a position to turn someone away if they can't
| pay. The rest of the developed world has figured this out but
| we're too stubborn to adopt what is undoubtedly a better system.
|
| [0]https://www.healio.com/news/primary-care/20200106/a-third-
| of...
| bhupy wrote:
| I work in this industry (on administration, no less) and
| sometimes even adjust claims myself, so I can speak to this
| with experience.
|
| 1/3 of US healthcare spending is absolutely not from
| administration fees. Here is a more concrete breakdown of all
| of the cost components, compared with the same in peer
| countries: https://www.healthsystemtracker.org/brief/what-
| drives-health...
|
| If you look at the breakdown, the vast majority of the cost
| difference comes from just the raw cost of inpatient and
| outpatient care. Even if you were to completely zero out the
| administrative costs per capita, you'd hardly make a dent in
| bridging the gap.
|
| > The free market is not a solution to the problem of
| healthcare spending. Consumers do not have enough information,
| they aren't in position to refuse treatment if it's too
| expensive, and hospitals aren't in a position to turn someone
| away if they can't pay.
|
| It depends on what you mean by "healthcare". "Healthcare" is
| way too broad to have useful conversations. What constitutes
| "healthcare"? Getting the flu? Vaccines? Annual physicals?
| Routine treatments? Brain surgery? Cancer? It's a spectrum.
| There are some parts of healthcare that are highly predictable
| and fungible, and some that aren't. Whether or not a market can
| provision predictable/plannable healthcare is quite debatable.
|
| Also, what we have in the US is nowhere close to a free market
| in healthcare, so making this argument is a bit of a non
| sequitur.
|
| > The rest of the developed world has figured this out but
| we're too stubborn to adopt what is undoubtedly a better
| system.
|
| The rest of the developed world isn't a monolith. Singapore,
| Switzerland, the UK, Denmark, Germany, and the Netherlands all
| have wildly different healthcare systems, but all produce
| fairly good outcomes! All have dramatically different levels of
| privatization, market mechanisms, and welfare generosity.
| wefarrell wrote:
| I also work in the industry, specifically in claims
| processing and you're wrong. In the link that you sent they
| are not including administrative costs from providers:
|
| > Administrative costs include spending on running
| governmental health programs and overhead from insurers but
| exclude administrative expenditures from healthcare providers
| bhupy wrote:
| Yes, and that's because administrative expenditures from
| healthcare providers (specifically in claims processing,
| again I do this every day for a living) amortized per
| capita like it's done in this study is negligible. There's
| an upfront cost to setting up EHR systems to facilitate
| claims processing, and there's a variable cost to handling
| claims disputes, but they're a drop in the bucket compared
| to the actual patient costs, which we know to be in the
| tens of thousands of dollars per capita.
|
| There are a bajillion different reasons why raw costs are
| so high, but admin overhead isn't one of them.
| wefarrell wrote:
| That's simply not true. Administrative costs account for
| 25% of a hospital's budget and 1.43 of GDP:
|
| https://www.commonwealthfund.org/publications/journal-
| articl...
|
| In the study that you sent they would be included under
| the inpatient and outpatient costs rather than
| administrative.
| bhupy wrote:
| Yeah but you're mixing up denominators. The question is
| how you factor in 25% of a hospital's budget to the _per
| capita_ cost of healthcare provision in the link that I
| included, which includes all other costs. Those other
| costs are so high that that even zeroing out the
| administrative cost doesn 't do much to bridge the gap.
|
| I'll try to describe it in a different way. In the link
| that I provided, the US pays (on average) $8,021 per
| capita on non-admin costs, while peer countries pay
| $3,602 per capita on non-admin costs. _Even accounting
| for the fact that 25% of a hospital 's revenue is
| administrative_, it 1) is not at all the case that admin
| costs are in the same ballpark as the difference between
| the two ($4,500 per person), 2) doesn't do much to bridge
| the non-admin gap, which forms the lion's share of the
| cost difference, since if you zero out the admin costs,
| even the costs that provider offices pay (25% of their
| total revenue), you're still left with the fact that the
| US pays over 2x peer countries.
|
| Keep in mind that the "in-patient and outpatient costs"
| and prescription drug costs do NOT include provider
| office costs either.
| handrous wrote:
| Combining the two links, it looks like this:
|
| > I'll try to describe it in a different way. In the link
| that I provided, the US pays (on average) $8,021 per
| capita on non-admin costs, while peer countries pay
| $3,602 per capita on non-admin costs. Even accounting for
| the fact that 25% of a hospital's revenue is
| administrative, it 1) is not at all the case that admin
| costs are in the same ballpark as the difference between
| the two ($4,500 per person), 2) doesn't do much to bridge
| the non-admin gap, which forms the lion's share of the
| cost difference, since if you zero out the admin costs,
| even the costs that provider offices pay (25% of their
| total revenue), you're still left with the fact that the
| US pays over 2x peer countries.
|
| Isn't a useful analysis.
|
| The admin costs in the US are roughly $937 + ($8,021 *
| 0.25) = $2942.25--and possibly worse, depending on how
| much of the stuff from other categories might fall under
| "hospital budget", though that may be evened out by the
| difference between budget and revenue (which is the
| biggest unknown factor here, trying to combine the info
| from the two links).
|
| Hospital admin costs in comparable states seems to be 20%
| _in the worst case_ plus that $201 of non-hospital admin
| costs. Worst case, $201 + ($3,602 * 0.20) = $921.40
|
| How is that not a _very_ large part of the difference in
| costs? It looks like ~40% of the difference in _total_
| per capita spending, in fact. I 'm sure that's a little
| off, but where am I going wrong that allows it to become
| negligible in your analysis?
| bhupy wrote:
| > The admin costs in the US are roughly $937 + ($8,021 *
| 0.25) = $2942.25--and possibly worse, depending on how
| much of the stuff from other categories might fall under
| "hospital budget", though that may be evened out by the
| difference between budget and revenue (which is the
| biggest unknown factor here, trying to combine the info
| from the two links).
|
| This is incorrect, the inpatient and outpatient costs do
| not include the hospital admin fees. That figure only
| includes the fee-schedule payments per procedure. The
| fee-for-service model makes it rather easy to isolate
| that amount.
|
| That's why your statement here:
|
| > How is that not a very large part of the difference in
| costs? It looks like ~40% of the difference in total per
| capita spending, in fact. I'm sure that's a little off,
| but where am I going wrong that allows it to become
| negligible in your analysis?
|
| doesn't quite make sense. You can't take that 25% and
| apply t against the in-patient and out-patient costs,
| because it's not at all clear that it fits into that
| bucket.
| handrous wrote:
| > doesn't quite make sense. You can't take that 25% and
| apply t against the in-patient and out-patient costs,
| because it's not at all clear that it fits into that
| bucket.
|
| Well, if it's not accounted for in that figure then where
| is it? There's another amount somewhere around $3k just
| not accounted for, then? I don't see anywhere anything
| like that much could be hiding in the rest of the data.
|
| I mean, these are from the link:
|
| > inpatient and outpatient care, which includes payments
| to hospitals, clinics, and physicians for services and
| fees such as primary care or specialist visits, surgical
| care, and facility and professional fees (see Methods for
| more details)
|
| and
|
| > Administrative costs include spending on running
| governmental health programs and overhead from insurers
| but exclude administrative expenditures from healthcare
| providers.
|
| So... where is it if not in the "inpatient and outpatient
| care" bucket? Sure, maybe minus whatever portion of that
| represents profit, OK, but that can't be _so much_ as to
| render it anywhere near being negligible.
|
| Or is the 25% figure from the other link off by, oh, 5x
| or more?
| bhupy wrote:
| > So... where is it if not in the "inpatient and
| outpatient care" bucket? Sure, maybe minus whatever
| portion of that represents profit, OK, but that can't be
| so much as to render it anywhere near being negligible.
|
| > Or is the 25% figure from the other link off by, oh, 5x
| or more?
|
| No, the 25% figure from your link isn't off at all, it's
| that you're mixing up denominators. You can't take the
| 25% figure from hospital costs, the $10,637 from the per
| capita figure, and then conclude that hospital admin s
| 25% of $10,637. If you want to insert your number into my
| number in an apples-to-apples way, you have to actually
| look what hospitals pay _per capita_. There 's a huge
| normalization step that you just skipped.
|
| Fortunately, your own link does this work:
|
| "Hospital administration costs ranged from 1.43 percent
| of gross domestic product (GDP) in the United States
| ($667 per capita) to 0.41 percent of GDP ($158 per
| capita) in Canada."
|
| $667 per capita is a drop in the bucket. If I were to
| guess, the reason why the analysis I linked didn't factor
| it in was because it doesn't change its conclusion:
|
| "The U.S. also spends more on administrative costs, but
| perhaps not as much as people think, and spends
| significantly less on long-term care."
|
| This is in line with my observation on the ground as
| well, especially the observation that admin costs
| typically involve extremely high upfront costs (setting
| up EHR systems, EDI integrations, book-keeping systems),
| but lower variable costs from an operating standpoint
| _especially_ relative to the sheer cost of care itself
| (doctors, equipment, maintenance, etc etc etc).
| handrous wrote:
| > You can't take the 25% figure from hospital costs, the
| $10,637 from the per capita figure, and then conclude
| that hospital admin s 25% of $10,637.
|
| I didn't--I multiplied 0.25 times the _inpatient and
| outpatient_ costs, which is why it wasn 't even higher
| (though, when added back with the $937 other-admin costs,
| it did come very close to 25% of the total, true)
|
| > "Hospital administration costs ranged from 1.43 percent
| of gross domestic product (GDP) in the United States
| ($667 per capita) to 0.41 percent of GDP ($158 per
| capita) in Canada."
|
| Ah, I see-- _hospital_ admin costs, only, plus government
| and insurance admin costs, being $667 + 937 = $1604,
| which comes very close to 10% of total ($10,637) per-
| capital healthcare expenditure in the US, not ~25%. Left
| unaccounted for are all non-hospital, non-insurance, and
| non- admin costs (non-hospital healthcare office &
| facility admin costs, that kind of thing), and who knows
| what those are. But with just what's in front of us, ~10%
| of the total per-capita cost. So we could save perhaps 6%
| of total per-capita healthcare spending by bringing those
| in-line with other developed states.
|
| (I did verify with your link's OECD source that all
| _provider_ administration is included in the prices
| _paid_ to them--$6,624 _does_ include hospital, doctor 's
| office, outpatient support, et c., admin costs, somewhere
| in it, so this article's conclusions about the role of
| admin costs are... not particularly thorough, according
| to its own source--the above of 10% is surely closer to
| correct, though still lower than the actual % of total
| spending that's admin costs)
| wefarrell wrote:
| The link that I spent specifically mentions hospital
| admin costs per capita and per GDP:
|
| >"Hospital administration costs ranged from 1.43 percent
| of gross domestic product (GDP) in the United States
| ($667 per capita) to 0.41 percent of GDP ($158 per
| capita) in Canada."
|
| > Reducing U.S. spending on a per capita basis to
| Canada's level would have saved $158 billion in 2011
|
| They are a significant expense. They're certainly not the
| only expense in healthcare and there is no single area
| that is driving up costs. There is substantial waste
| throughout the system.
|
| > Keep in mind that the "in-patient and outpatient costs"
| and prescription drug costs do NOT include provider
| office costs either.
|
| How are you so sure of that? I see no indication in the
| study that provider administration wouldn't be lumped
| under the provider costs.
| bhupy wrote:
| > They are a significant expense. They're certainly not
| the only expense in healthcare and there is no single
| area that is driving up costs.
|
| They are certainly a "significant" expense, but zeroing
| it out isn't going to bridge the gap.
|
| > How are you so sure of that? I see no indication in the
| study that provider administration wouldn't be lumped
| under the provider costs.
|
| Because they say so:
|
| "inpatient and outpatient care, which includes payments
| to hospitals, clinics, and physicians for services and
| fees such as primary care or specialist visits, surgical
| care, and facility and professional fees (see Methods for
| more details)"
|
| The fee-for-service model makes it easy to isolate this
| amount. For every CPT/CDT code, there's a charged amount,
| an allowed amount, and a paid amount, and they're
| specific to the medical procedure.
| onlyrealcuzzo wrote:
| > The rest of the developed world isn't a monolith.
| Singapore, Switzerland, the UK, Denmark, Germany, and the
| Netherlands all have wildly different healthcare systems, but
| all produce fairly good outcomes! All have dramatically
| different levels of privatization, market mechanisms, and
| welfare generosity.
|
| This is why I'm interested why so many people are obsessed
| with the idea that we need to completely burn down our system
| and start anew to improve it.
| spaetzleesser wrote:
| "This is why I'm interested why so many people are obsessed
| with the idea that we need to completely burn down our
| system and start anew to improve it."
|
| I don't see how the current system can be reformed
| realistically. There are way too many well funded groups
| who benefit from the current situation and will fight any
| kind of change tooth and nail.
|
| In my view Medicare for All is the only realistic path. It
| works already and could be tweaked to accept more people.
| Unfortunately Biden doesn't want it so that opportunity is
| gone for the next decades probably.
| bhupy wrote:
| > In my view Medicare for All is the only realistic path.
|
| > Unfortunately Biden doesn't want it so that opportunity
| is gone for the next decades probably.
|
| These two sentences are at odds with one another.
| JohnFen wrote:
| > why so many people are obsessed with the idea that we
| need to completely burn down our system and start anew to
| improve it.
|
| I'm not only not obsessed with the idea, but I'm not sure
| that would be a desirable way to go. That said, the
| healthcare system in the US is way beyond broken, and I
| don't see how it can possibly be fixed by half measures.
| Something really drastic is required. It's not hard to see
| why some people reach the "burn it all down" position.
| iammisc wrote:
| What is broken about it really? Having been insured my
| whole life, I've never dealt with hospital issues, and
| we've had several major medical events (complicated
| pregnancies mainly, lots of time in the emergency room,
| etc). For the most part, I pay the max out-of-pocket
| every year, and then I pay nothing more. It's not
| particularly difficult to deal with.
|
| The only annoying part is after your first ER / doctor
| visits each year, you end up with a bunch of different
| random charges from people that you have to pay
| separately. It's an annoyance, but hardly one that
| requires us to 'burn it all down'.
|
| This year I have an HDHP and an HSA, so I have more of
| those, but I also have an HSA.
|
| As an example, my wife's first pregnancy probably cost
| about $200k nominally, but I paid... $2000-3000 at most.
|
| The only real 'issue' I see is the tying of health
| insurance to employment, but there are straightforwards
| ways to get around that (federal incentives to purchase
| your own health insurance, and then employers can pass
| along savings so employees can purchase themselves). For
| me, I've never been unemployed longer than COBRA so it's
| not been an issue.
|
| There are a lot of good things about America's system. My
| wife's pregnancies are extremely complicated. Many
| doctors said to give up. However, we searched and
| searched for a doctor to help, and we figured out what
| works. Basically, for unknown reasons (although many
| plausible ones that cannot be confirmed), she needs to
| take an expensive blood thinner during pregnancy or the
| baby dies. Since her tests don't come back for the
| 'standard' conditions this works for, it is difficult
| finding a doctor willing to prescribe. In fact, we didn't
| even know it was an option, until we went all over the
| country to various experts. Due to the free market, we
| were able to get to these experts in a matter of weeks.
| Similar experts in countries with socialized systems have
| long queues.
|
| When it comes to the medication, due to the fact that we
| are the ones that pay (via insurance), not the
| government, as long as we can pay, we can continue to
| live our lives and have our children. Based on our
| conversations with other women in my wife's position in
| countires with socialized medicine, they have to really
| advocate for themselves in ways we do not in order to get
| their government to even provide the medication or pay
| for it. Many wait months before they are able to get
| someone. Every once in a while the government revokes
| access because some bureaucrat says it's not medically
| indicated. We've never had that. Should her doctor decide
| to do that and sentence our child to certain death, we
| have several backup doctors willing to prescribe the
| medication. Some moms in other countries we're in contact
| with have been cut off from the medication and
| subsequently had miscarriages in the second or third
| trimester. This is insane. I'm glad to live here.
|
| We recently moved, and just scheduled a bunch of
| appointments and asked the doctors point blank whether
| they'd consider it based on her history. Some said no,
| others said yes. In a few weeks, we figured out what her
| friend over in Canada took many, many months to figure
| out. When it comes to pregnancy, months matter. 24 months
| of waiting can drastically change the spectra of outcomes
| in a women's pregnancy, especially given the age at which
| many women have children these days.
|
| Same with things like surgeries and such. My relatives in
| countries with socialized care are waiting many months
| for things Americans get in a few days.
| tdfx wrote:
| You're part of the (I would guess) about 25-30% of the US
| population where the stars align perfectly and you
| receive a mostly positive experience from the US
| healthcare system. You are employed full-time, with an
| employer that provides a generous health plan, have had
| no long interruptions of employment/coverage, and you
| don't appear to have any serious chronic issues.
|
| You're still being robbed of a ton of money (US
| healthcare procedure costs, i.e. pregnancy, have no
| actual bearing on what it costs to provide that service),
| but the system is so opaque and convoluted that there's
| no personal benefit for you to track down how much. You
| and I and many others live in more or less ignorant bliss
| about how much money is being redirected from our pockets
| to parasites in the insurance/provider system because we
| don't know any better.
|
| We're still losing in this situation, it just doesn't
| feel as acutely painful to us as it does to those who are
| outside the upper middle class bubble.
| bhupy wrote:
| Depends on what you mean by "half measures". One way we
| can dramatically improve the status quo is by decoupling
| health insurance from employment (effectively bringing
| the US to parity with Switzerland).
|
| Tactically speaking, it could conceivably be achieved by
| enacting a series of what some might consider "half
| measures":
|
| - Simply getting rid of the Federal employer mandate as
| well as the payroll tax deductibility for group health
| insurance premiums could go a long way. A lot of
| employers really don't want to be in the business of
| hiring monster HR teams that spend the majority of their
| time becoming health insurance experts...
|
| - Expanding ICHRAs
| (https://news.ycombinator.com/item?id=22527102) can also
| go a long way.
| username90 wrote:
| Making it illegal for health insurance companies to
| discriminate based on employment status would be a good
| first step. This includes not being allowed to giving
| rebates to company plans. Such a law would have popular
| support, but probably will never be done since
| politicians are friends with the insurance companies who
| needs the costs to be opaque.
| jellicle wrote:
| You have to burn down the current system _no matter which_
| other system you have your eyes on as a desirable goal. The
| reason is simple: the system fights change.
| username90 wrote:
| Since everyone else seems to do better chances really high
| that burning it and just doing anything at all would be
| better than what we have today.
| legitster wrote:
| > The free market is not a solution to the problem of
| healthcare spending. Consumers do not have enough information,
| they aren't in position to refuse treatment if it's too
| expensive,
|
| I may partially agree. Consumers do not have enough information
| because hospitals _intentionally keep it from them_.
|
| Even in situations where I can call around or schedule a
| procedure, it's amazing how few places even know or will tell
| me. Or straight up lie without consequences.
| logosmonkey wrote:
| Mostly they don't really know. Or they don't know if you have
| insurance anyway because it's so all over the place with what
| gets covered and what that specific Healthcare provider has
| negotiated.
|
| Maybe they have some actuaries who could actually tell you
| what a close approximation would be but that info never
| really filters down to folks in the call centers or at a
| front desk.
|
| I have worked on the supply side, the insurance side and
| currently the provider side and it is all messed up. Across
| the board it's just a travesty of inefficiencies and opaque
| rules.
|
| There just isn't a real way to shop around with our current
| system even though proponents of the system love to say
| that's what we all should be doing.
| 908B64B197 wrote:
| It's funny how bashing on "Big Tech" became fashionable,
| especially using anti-trust laws. But looking at healthcare, it's
| cartels, price gouging and rackets all the way down, from
| hospital construction, insurance to medical residents quotas.
|
| I guess they must have better lobbyists than "Big Tech"!
| majormajor wrote:
| Bashing on the US healthcare industry has been fashionable for
| a long time... and the industry already faces a lot more
| regulation, and ongoing calls for even more, than tech does.
| decebalus1 wrote:
| Good. I hope this industry implodes altogether so we can all
| start from scratch. Business-friendly neoliberal patching
| policies will never work to reshape access to US healthcare to
| first world levels.
|
| I salute this. Fuck it, consolidate everything so it would be
| easier for the government to nationalize it.
| spicyusername wrote:
| > That's because President Biden recently signed an executive
| order saying his administration was serious about promoting
| competition, and he specifically singled out hospitals as an area
| where growing monopolization is a concern.
|
| It's good to see there is at least some attention on the issue.
| TeeMassive wrote:
| There needs to be a focus on making healthcare more competitive,
| efficient and decentralized. Healthcare in the US is killing both
| the economy and people.
| spaetzleesser wrote:
| Very true. I think generally all big companies are bad for the
| economy in the long run and large company size should be
| discouraged.
| jonnycomputer wrote:
| I know that insurance companies are rich targets, but I believe
| that when it comes to the cost of health care, the rise of
| hospital monopolies is a very significant factor. If a hospital
| is effectively a monopoly for an entire region, then they just
| have a lot of leverage bargaining on prices with insurers.
| missedthecue wrote:
| I agree with this. It really is a curiosity to me how much
| blame gets pinned on healthcare insurance firms. Many are
| already non-profit, (Kaiser, BCBS, Wellmark, etc...) and the
| ones that are for-profit (Humana, Aetna, United) have net
| profit margins around 2-5%. Eliminate their profitability, and
| suddenly we all save a whopping $10 a month on our premiums.
| tdfx wrote:
| Insurance companies easy to hate. It's harder to vilify the
| doctors because people have a more personal relationship with
| them. Also, many people don't realize they're paying the
| doctor in the US 300-500% more than other countries where
| they would receive more or less the exact same level of care.
| It's not just hospitals charging ridiculous amounts... going
| to see your PCP for a sore throat can cause a $200
| consultation bill to your insurance company. The $25-50 co-
| pay you're paying out of pocket is just the tip of the
| iceberg of what these doctors are charging for routine,
| unremarkable services.
| JohnFen wrote:
| I think that the rise of hospital monopolies and the abuse by
| insurance companies are related.
| m-ee wrote:
| Or not working with insurers at all. SF general chose to be out
| of network with all insurance providers which led to patients
| getting astronomical bills. SF has other hospitals, but SFGH is
| the only trauma center in town. If you're injured in a auto
| collision you'll end up there whether you want to or not.
| huitzitziltzin wrote:
| Health economist here.
|
| This matters A LOT. This is a big, big deal in terms of making
| prices higher.
|
| For all of the sh?t pharma companies get about high drug prices
| (some of it _quite_ well deserved), we spend _vastly_ more on
| hospitals - about four times as much. For a good source on
| specific numbers, see the Kaiser Family Foundation [1].
|
| We spend a lot on healthcare in large part because hospital
| prices are high. Hospital prices are quite high in the US even
| though our utilization is lower than many other OECD countries.
| And let's not get started on our outcomes which (certain cancers
| excluded) are frequently a lot worse than countries which spend a
| small fraction of what we spend.
|
| If some of these markets can be made more competitive (no easy
| feat - this executive order is step 0 at best), that has the
| potential to make prices meaningfully lower, though note that
| that would be achieved by an insurer _excluding_ from its network
| one high-priced hospital in favor of a lower price hospital (or
| threatening to do so).
|
| For a specific example in a large market, consider the case of
| the Jefferson health system in Philadelphia, which is now a
| nearly-20-hospital behemoth - the Philadelphia Inquirer did a
| nice article covering the release of documents as a result of an
| FTC lawsuit concerning their acquisition of the Einstein system
| [2].
|
| It is clear from the unearthed documents that the CEO of the
| system understands perfectly well what he is trying to do with
| his acquisitions: "We [Jefferson] have to continue strategically
| on the path to essentiality and Einstein is the key".
|
| What this means is that he wants his system to be so large and
| systematically important that every insurer in the market MUST
| deal with him (and pay his prices).
|
| AFAIK the Biden administration dropped its objection to the
| acquisition of Einstein by Jefferson. Here their concern was one
| of the other problems in applied anti-trust law: it might be the
| case that a firm either gets acquired or exits the market (goes
| bankrupt). That is (apparently) a concern with Einstein.
|
| Whatever the truth is about the future of Einstein absent a
| merger, I would expect that hospital prices in Philadelphia will
| increase at an even higher rate than before in the next few
| years.
|
| [1] https://www.kff.org/interactive/health-spending-explorer/
|
| [2] https://www.inquirer.com/business/health/jefferson-
| einstein-...
| legitster wrote:
| This doesn't even mention Certificate of Need. In some places in
| the country, you are not even allowed to establish a new hospital
| unless you prove existing hospitals are not fulfilling demand.
| Sometimes, _other hospitals_ are part of the approval process.
|
| https://en.wikipedia.org/wiki/Certificate_of_need
| jonnycomputer wrote:
| Yes, indeed, that does seem an oversight.
| OrvalWintermute wrote:
| > you are not even allowed to establish a new hospital
|
| Depending on the state, this also goes for surgery centers, and
| other types of procedure rooms for minor outpatient surgery.
|
| As soon as you go to a hospital, the hospital tacks on a giant
| facility fee which may be the single largest expense. This,
| despite the hospital regularly owning half the practices
| involved in providing care too!
|
| Those "nonprofit" executives with their multimillion dollar
| salaries, and the legion of nonclinical administrators have to
| come from somewhere. It is on the back of the clinical doctors.
|
| This is highly detrimental to the high volume, low dollar value
| medical practices where we want to increase volume, and reduce
| costs, such as opthamologists & dermatologists. This, because
| our aging population has increased needs for ocular and skin
| care.
| Y_Y wrote:
| > A number of factors spurred states to require CONs in the
| healthcare industry. Chief among these was the concern that the
| construction of excess hospital capacity would cause
| competitors in an oversaturated field to cover the costs of a
| diluted patient pool by overcharging, or by convincing patients
| to accept hospitalization unnecessarily.
|
| That's pretty absurd isn't it? Were the plebs really worried
| about too many hospitals being built? And that that would drive
| prices _up_?
| 6gvONxR4sf7o wrote:
| "This industry is so messed up and opaque, we're worried that
| competition is bad for the costumer and monopolies are the
| best we can get."
| legitster wrote:
| Well, you often times hear people make the same argument
| today about houses...
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