34 replies »

1. Peter is price regualtion the same as reimbursement regualtion? No one is forced to sell their product in Canada or under NHS at a price, if you do sell it they are only willing to pay a set amount. As far as I know I think Pharma is free to sell at any price they want in Canada but if they don’t accpept government reimbursement the patient would need to pay full price. I might be wrong but I am pretty certain that is how it works. I know under NHS you can personally buy non covered drugs at street price for cancer treatment as an example.

2. “My John Doe above may be purchasing the same exact product from insurers, but the price he pays (including employer “contribution”) will differ based on his place of employment. That doesn’t make any sense and I’m not sure there are any other similar “markets”.”
   Group Life and Auto
   Sam’s Club and Costco
   Credit Unions
   Taxes
   Cost of Beer at the bar, Ladies night should be outlawed, Bunch of women getting drunk and making poor decisions…never mind that one is ok
   Life is full of discrimintory pricing based on nothing more then where you work, what county or state you live in, and all sorts of arbitrary qualifiers. I think it would be near impossible to find something not priced arbitrarly by that standard.
   In Vegas if you work at a casino you get all sorts of discounts. In Ohio if you work for one of the car manufacturers you get discounts. If your a teacher you get all sorts of deals even preferential government treatment and deals.

3. “When has price regualtion worked in a non real market?”
   Interesting comment Nate when you send your clients to Canada for less cost healthcare – a price regulated market.

4. I am very sorry for your situation. Your story is yet another example highlighting the absurdity of the regional and employment-based insurance structure in the United States. One wonders what the ability to shop for insurance out-of-state would have been able to provide for you in terms of more affordable options. We can only hope that Obamacare can deliver on this.
   Please visit my blog on the business of health care in America:
   http://www.shereefelnahal.com

5. By regulation, I mean regulation of hospital and provider fees, not insurer premiums. Those should follow the provider prices and be regulated, as the current bill suggests, by fixing the MLR.
   By arbitrary, I don’t mean capricious or random. I mean a decision without merit, unrelated to the intrinsic status of the person, and enforced with no input from the affected person.
   My John Doe above may be purchasing the same exact product from insurers, but the price he pays (including employer “contribution”) will differ based on his place of employment. That doesn’t make any sense and I’m not sure there are any other similar “markets”.
   And if the bigger the pool, the cheaper it gets, then why not have the absolute biggest pool possible?

6. Margalit – According to an acquaintance who owns an insurance brokerage firm in CA, individuals in CA that can pass the underwriting screen generally can buy health insurance for 20% LESS on average than small and medium size businesses buying in the small group market (defined by the broker as 2-99 people). This is because in the group market, the insurer has to accept the whole group including anyone who may be sick.
   I’ve said many times that there is no reason why medical care can’t work like a normal market with the exception of care delivered under emergency conditions which is not a large piece of the pie. What’s missing is price and quality transparency for both patients and referring doctors. For many hospitals, 35%-40% of their revenue is from outpatient care which, with the exception of treatment in the ER, is scheduled in advance by definition. A sizeable piece of their inpatient care is for surgical procedures that are also often scheduled well in advance. Patients and referring doctors need to start to care about costs even when insurance is paying all or most of the bill. To do that, however, they need good price and quality transparency tools. Hospital charges for care delivered under emergency conditions need to be regulated in some way. As Nate might suggest, charges could be limited to 125% of costs. Chargemaster rates (billed to the uninsured) are arbitrary multiples of cost and unreasonable by any standard, in my opinion.

7. do you know what the word arbitrary means? There is nothing arbitrary about it, sorry to but you on the spot but get specific about what you think is arbitrary or stop calling it arbitrary.
   What makes no sense about two groups of people paying different rates? hint the group in group health insurance means more then one person. They have different rates becuase the other people in the group aren’t exactly the same. Group rates are based on the group not the individual.
   When has price regualtion worked in a non real market? Consumption is what drives insuranc rates! regualting insurance prices forces insurance to ration consumption, either way consumption is rationed in the end. The logical thing to do is didrectly ration consumption in a manner you know so the desired result is more likly to result then indirectly regualting it through premium and not knowing how it will manifest

8. Nate, pools may be well defined, but it’s an arbitrary definition aimed at segmenting people to maximize insurer profit. Why is John Doe paying one premium while employed by AT&T and a different one while employed at Jack’s Fine Crab Shack? It’s the same person, shouldn’t his estimated costs be the same? I know the answer, but from an individual person POV, it makes no sense.
   Price regulation works fine when you are not dealing with real markets. Health care is in no way a real market, yearning to be free. And why would I regulate consumption? All that will accomplish is to switch the “industry” to a lower volume-higher margin model to keep profits at the same level.
   It always seems more sustainable to clobber people rather than corporations.

9. Hello chaves, regualting prices has enjoyed such a long successful life. I mean it almost always works doesn’t it? I’ll end the sarcasim, price regualtion always fails and distorts the market, you need to regualte what drives the price if you want to succeed…..that is your goal isn’t it? If you want to regualte you need to regualte consumption, its ugly but atleast it is sustainable.

10. “prices for insurance are calculated based on arbitrary “pools” and arbitrary “rules””
    LOL um no Margalit that is not true. prices for insurance are based on prices for care you mentioned above.
    You obviously have no idea what a pool even is if you think it is arbitrary. This is so well definded and codified no one can claim it is arbitrary.

11. Peter, see page 329 of the PPACA:
    http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590PP/pdf/BILLS-111hr3590PP.pdf
    (e) EXEMPTIONS.—No penalty shall be imposed under subsection (a) with respect to—(1) INDIVIDUALS WHO CANNOT AFFORD COVERAGE.—
    ‘‘(A) IN GENERAL.—Any applicable individual for any month if the applicable individual’s required contribution (determined on an annual basis) for coverage for the month exceeds 8 percent of such individual’s household income for the taxable year described in section 1412(b)(1)(B) of the Patient Protection and Affordable Care Act.
    Or the summary by the CRS.
    http://bingaman.senate.gov/policy/crs_privhins.pdf

12. “…a legal requirement to commit less than 8% of your income to health insurance (above 8% you either get subsidies or are exempted).”
    Show me the text.

13. There are two types of prices and neither one is “fair”. Prices for care delivery, particularly hospitals, are extorted based on market power and prices for insurance are calculated based on arbitrary “pools” and arbitrary “rules”. So here is something to think about for all those who receive payments from the health care system: the “market” cannot bear the current prices, let alone any increases. The good times are over.
    So we either go with option 1, and every working citizen of this country lives with the knowledge that if he/she, or their children, get really sick, they will have the freedom to go out with a tin can and beg for money to pay for treatment (a.k.a. charity), or we go with option 3 and make everybody pay into the pool, while drastically regulating prices and predatory practices (a.k.a. Obamacare). Calcutta or Zurich….

14. Peter, your bank account will not by emptied because of a legal requirement to commit less than 8% of your income to health insurance (above 8% you either get subsidies or are exempted). What might empty your bank account is opting not to get insurance and then getting sick.

15. “its fair price”
    Only those that profit from the system think the price is fair. I actually agree on a mandate, just not one that forces everyone to pay the cadillac prices the “system” has defaulted to.
    “But realistically, you are not going to get prices to go down.”
    Then any system insituted here will fail, because it’s the high prices that are killing us. I don’t want my bank account emptied by force because no one has the balls to take on high prices, and I won’t become poor just to give the insurance industry some profit time until the system implodes due to unsustainable mismanagement and inflation.

16. Peter, I have no financial interest in the insurance industry. I also have no ideological preference on who should own and manage the health care payment system. I just want the system to work.
    High prices are a problem, one that hurts both taxpayers and patients. But realistically, you are not going to get prices to go down. At most, we can hope that growth in prices will slow down a bit.
    There are only 3 ways of dealing with people who need care and cannot get health insurance: (1) you let them look for charity, (2) you give them the legal right to obtain health insurance even if they haven’t paid for its fair price, (3) or you force everyone who can afford it to obtain appropriate lifetime coverage and subsidize the rest. Choice (2) is not fair nor sustainable, and has the perverse effect of encouraging people to not insure their health care needs until they get sick. Your only reasonable choices are (1) and (3).

17. “Yes, Peter, at these prices and at any prices.”
    No, it is these “prices” that this whole debate and reform attempts is trying to solve. You speak as if the present system of costs and prices are just OK and the reason we have so many uninsured is there is no mandate. I guess if you’re in health insurance or getting your health insurance paid for by someone else then that would be an acceptable position. From your answer though you are in insurance, because that is the political view of the insurance industry, that the problems is either we don’t “subsidize” insurance at any price, or we don’t mandate insurance at any price. In the end long term healthcare security does not trest with the healthcare insurance industry, quite the contrary, it is an impediment to security.

18. “At these prices?”
    Yes, Peter, at these prices and at any prices. The responsibility for payment is independent of the payment amount. Whether it is a $1 thousand or a $1 million life-saving procedure, the primary responsibility for securing that amount rests on the patient. Only when the amount is not affordable in a long-term sense (person cannot earn enough money during her lifetime to adequately insure herself) does societal responsibility kick in.
    Of course, lower prices are better than higher prices for both patients and the taxpayer. But high prices do not justify taxpayers subsidizing patients who could have afforded payments through proper lifetime financial and insurance planning.
    I don’t blame people like the Caldwells for their fate. I blame the system that did not provide a clear mechanism (let alone a mandate) to obtain long-term health care security.

19. Minnesota’s pool charges 25% more than the average insurance premium. Other states can charge significantly more. The new federal high-risk pool that starts next month charges 0% more, but its admission requirements are more stringent. The difference between what a pool spends in care and charges in premiums is paid by the taxpayer.

20. “Medicaid”
    Assuming he even comes close to the income and asset restrictions.
    The thing here I’m reading is that why should it be necessary to know the in’s, out’s and fine details of work-around plans, dead lines, laws and options, especially when your severally ill, just to get adaquate treatment. And I’m sure Medicaid (if he even qualifies) will give Mr. Caldwell and his wife the same first class and necessary treatment with the doctors he choooses, just as if he had full paying private coverage.
    “A better way is to subsidize equitably everybody who cannot afford their health care needs, but only after everybody is mandated to pay for their own current and future health insurance while they can afford it.”
    At these prices?
    “In the case featured in this post, this might have meant the couple paying higher insurance premiums while they were doing well in exchange for the guarantee of continuing to get insurance after getting sick, losing the job, and not being able to afford new premiums.”
    Sure, it’s their fault, poor planning. We’ll just spend all our disposable income on health insurance.
    I’d like for Mr. Caldwell to work through this with Nate’s suggestions and get back to us with how he actually got this to work.

21. The UK and France which both offer universal care also have high tax burdens on tobacco for which to help pay for that care. $7 and $6.50 per pack respectively compared with $1 federal tax for the US (which until one year ago was only 39 cents).
    One in three cancers are caused by tobacco. By taxing tobacco to pay for the health care costs of these cancers and other tobacco related diseases such as heart disease and COPD then you can cover these unfortunate suffers. Simply replicate what UK and France have done and raise the federal cigarette tax to $7 per pack.

22. Vikram,
    COBRA is no more expensive than normal employer-based health insurance and most likely cheaper than individual health insurance. The maximum allowed premium is 2% more than the cost of a similar person being employed. It may appear to be more expensive only because the employer is no longer subsidizing the premium.
    Similarly, state high-risk pools (when available) have premiums that are somewhat higher but comparable to private individual health insurance for healthy people. Minnesota’s pool charges 25% more than the average insurance premium. Other states can charge significantly more. The new federal high-risk pool that starts next month charges 0% more, but its admission requirements are more stringent. The difference between what a pool spends in care and charges in premiums is paid by the taxpayer.
    A perverse effect of high-risk pools is that only people wealthy enough to pay the relatively high premiums can join them. So the taxpayer ends up heavily subsidizing the health care needs of a few people who are relatively wealthy. Those who are too rich to enroll in Medicaid, but too poor to afford the pool’s premiums get no government help.
    A better way is to subsidize equitably everybody who cannot afford their health care needs, but only after everybody is mandated to pay for their own current and future health insurance while they can afford it. In the case featured in this post, this might have meant the couple paying higher insurance premiums while they were doing well in exchange for the guarantee of continuing to get insurance after getting sick, losing the job, and not being able to afford new premiums.

23. Nate,
    Isn’t COBRA supposed to be pretty expensive?
    I don’t know much about high risk pools, but how does it get funded?
    BTW, with reference to your clients, it’s not that they refuse to pay for, they seem to be refusing to pay more.
    How do you contract with your providers? Are you willing to pay for (or more)? Say a provider is willing to contract guaranteed rate for next ten years with 7% hikes on annual basis, would you take that? You know that this is lesser than average healthcare inflation rate of 9%.
    I can sympathize with your situation as a harbinger of bad news (aka price hikes).

24. Both Minnesota and Wisconsin offer high-risk pools to its residents. Both are pretty good plans compared to what most other states offer. The premiums also seem to be pretty reasonable. If the person is HIPAA eligible (which appears to be the case here), there is no waiting period for pre-existing conditions.
    There are many cracks in the system, but this doesn’t seem to be one of them. Is there any reason why the person featured in this post can’t get coverage through one of these state risk pools?
    I agree with the statement that one-year term renewable health insurance does not provide adequate coverage. Health insurance should be mandatory and long-term. The premiums that a young person pays during one year should not only reflect what that person may cost during that year; it should also reflect future costs that may take place when the person’s health expenses surpass what the person can pay in future premiums.
    Not having such a system allows people to not have insurance (or underpay when young) and then become a burden to society when they get sick or older. Everybody who can afford it should be responsible for insuring their current and future health care needs.

25. A few years ago, a friend suffered a seizure and was diagnosed with brain cancer. She was put on Temador, manufactured by Schering Corp. It’s a capsule which she took for between 6 and 12 (can’t remember exactly) four week cycles consisting of 21 days on the drug and 7 days off. The cost, which was paid by insurance in her case, was over $10,000 per month. Virtually all cancer drug regimens are wildly expensive, especially the newer biotech drugs. If the commenter’s wife is taking Temador, it would certainly be worth looking into whether or not Schering offers a patient assistance program. In my friend’s case, the only follow-up treatment needed was an MRI every three or four months since stretched out to every six months.
    Nate – Perhaps you could tell us what Temador would cost from the cheapest source. Separately, that was an interesting insight regarding convincing the hospital to pay the insurance premium if the episode involves expensive hospitalization. I never would have thought of that.

26. Margalitthat is not how our healthcare system works at all. First off very very few people work and pay premiums their whole life then have a problem. he much more common scenerio is people don’t pay premium, wait until they are sick then try to buy coverage. It’s that abuse of the system that creates all the problems that come after.
    To take a sledge hammer to your theory, its a fact, not an opinion, that historically only 2% of those offered COBRA elect it, that means 98% of people are doing exactly the opposite of what you said.
    Next COBRA has been law since 1986 meaning any honest hard working person has 18-36 month of continued private coverage after they lose their job.
    Since 1996 HIPAA has guarnteed any honest person the ability to buy a HIPAA plan once their COBRA expires, this give the honest person indefinite coverage.
    The only problem with our multi-payer system is politicians have been to generous in allowing people to game it, then act shocked that it can’t control cost better.
    In fact it has been our government ran public plans that have created the financial burden on individuals and employers.
    In every other country I am aware of when you pay your taxes for public insurance your actually allowed to be on he public insurance plan.
    In the US we collect Medicare taxes to cover people when they turn 65, that was costing washington to much money so they changed the law, after people had been paying taxes for 30 years, that you had to stay on your private plan if you were working still. Any liberal that wants to argue American Businesses are at a disadvantage because of the cost of healthcare needs to start there. If Medicare would cover everyone once they turned 65, like it was suppose to, the cost of private insurance would drop 10-15% over night, if not more.
    Next every other country I can think of off the top of my head considers those unable to work due to sever disability or handicap as a public welfare case. Society as a whole shares the cost of insuring those individuals. If there are 5 million such people and 300 million share the cost it doesn’t work out to much per person and is affordable.
    Not here in America, were our supposed saftey net, Medicaid, activly tries to push people off into private insurance plans. Instead of 300 million people sharing the cost the unfortunate 40 people that work with one of their parents get to split the cost up amoungst themselves.
    Your next failure is math, these people didn’t pay the cost for 10 year term health or whole life health, they bought a policy that is underwritten for 1 year and then reunderwritten. The premium they pay isn’t reserved for future claims 5 years from now, it is paid out to them and other policy holders in that year.
    Over the years carriers have sold multi year policies and rate caps and people just don’t buy them, exactly opposite of what you claim they prefer to roll the dice knowing if they lose someone else will get stuck with their bill. I was in a meeting yesterday where they could renew the dental for one year with a 0% increase or two year guarantee for 5%, they took the one year.
    You can’t demand something you refuse to pay for, well actually you can its a very liberal thing to do, but that doesn’t make it true or you the victum. If they had paid 5% more each year or even set aside 5% in an HSA, now when they need a HIPAA policy they would have the money sitting there and it would be no big deal. Instead they spent that 5%, living a slightly better life with more luxary then they otherwise could and want someone else to pay for it, that Margalit is a handout. Its an outrage how you blame everyone but the people that made the poor decisions.

27. The new health care bill is going to have a lot of different pros and cons. I guess we’ll see over time of how it works out.

28. “by the way Affordable health insurance when you are in your condition is a handout.”
    That’s exactly what is wrong with this multi-payer system. People work and pay their premiums all their lives and then through no fault of their own, they happen to loose a job and dare to get sick at the same time, at which point the “system” conveniently forgets all those years of collecting premiums, and the clock is reset to the current date.
    It’s not a handout, Nate. It’s an outrage.

29. Medicaid
    Depending on the timing of the disability there is an extension to 29 months if someone becomes disabeled. That would appears to cover you until she hits medicare, which oddly enough might bump your COBRA rights to 36 months.
    * Disability Extension – The 18 months may be extended to 29 months if a Qualified Beneficiary is Certified Disabled by the Social Security Administration (SSA) and the date of disability is prior to or within the first 60 days of COBRA coverage. The administrator must be notified of the disability during a period of COBRA coverage and within 60 days from the date of SSA’s disability certification letter.
    * Multiple Qualifying Event – The 18 months may be extended to 36 months for a Qualified Beneficiary who encounters, during a period of COBRA coverage, a second COBRA Qualifying Event (such as divorce, legal separation, death of the employee, Medicare entitlement of the employee, and dependent loosing dependent status under the plan).
    If you don’t mind sharing the name of the drug there is an 80% chance you can get it for 1/2 the price or less from other sources.
    Very good chance you would also qualify for the PAP by the manufacturer
    “We are exploring very expensive high risk insurance pools but there is no guarantee of acceptance.”
    Not sure who you are talking to but its a pretty big federal law called HIPAA that guarantees once your COBRA expires you are entitled to a continuation policy, unless you drop the ball you will always have the option to purchase a plan.
    If your wife is having ongoing care ask the hospital or her oncologist to pay the premium, usually they will be more then glad to in order to secure payment for future treatment. We see it all the time. While expensive HIPAA policies are affordable with all the assistance out there.
    Start a business, small group reform guarantees you the right to buy a guarantee issue policy with capped rates due to underwriting.
    WAL MART or Whole Foods, they offer insurance to part timers and they are easy jobs to get.
    What value do we serve Matt, you need to hurry up and get rid of us…
    by the way Affordable health insurance when you are in your condition is a handout. Your asking someone to assume tens if not hundreds of thousands of dollars in claims for a fraction of that amount in premium. Be it charity or other premium payors someone is going to be funding your care. Your best bet is the COBRA extension, if that doesn’t work the HIPAA policy. HIPAA was passed for this very reason, so no one that plays by the rules will ever be without insurance.

30. Nate, Exhausted MD, MD as Hell: Any suggestions?

31. May I also suggest meditation and some other alternative treatment. They may not cure but hopefully might help slow down disease and help you feel better.

32. It’s sad to see the situation. May I suggest contacting hospitals who might have charity budget. Or, you could also contact some foreign hospitals who will also be more than willing undertake this at low cost, hoping this might also help them build public relations. I have written about your case to Apollo Hospital in Delhi. You may also want to contact your insurer to see if they can provide you insurance if you are willing to receive care abroad. Many of them have signed up overseas hospitals but few have availed of the opportunity. They might be keen to have someone avail their overseas network.

33. As a family physician I see this type of thing all the time. It is a disgrace that America cannot do better. I don’t have the answer, but some simple changes like indefinate Cobra time limits and shortening the time until eligibility for Medicare disability insurance in some situations would be interim measures that would help some people in these desparate situations.

34. Working as a medical assistant, I see this type of thing all the time. I think things will get better soon.