Sparky Polastri
Footballguy
knowledge and effort....takes a ton of both to navigate the crap show system we have.
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US Healthcare stinks thread (1 Viewer)
- Thread starter Terminalxylem
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3C's
Footballguy
Maybe, but you never know when you're going to have a major event. My wife had a brain bleed and the total charges for ICU/surgery/etc was $250k. And since she went through that I had to promise to get hip surgery and that was $100k+ Nearly $400k in the span of 6 months. That's a lot of a person's savings if they want to pay out of pocket.
fruity pebbles
Footballguy
Yeah, self insuring is nearly impossible unless you just stay lucky or don’t plan on paying the bill. The cost for even a simple surgery will bankrupt most. Guy I know decided to not pay for insurance. Got in a car accident and broke his femur, nothing else. Not the end of the world. Went to the ED via ambulance, stayed one night and had a nail put in the next morning. A 45 minute surgery. Went home that afternoon. Got his bill, 80 grand.
NutterButter
Footballguy
That's the thing. You never know when that major medical event can happen and it can happen to anyone. All it takes is one car accident and you can be financially crushed especially if it happens early on before you start to building up the savings from those premiums. You're not getting those far better rates that an insurance company negotiates either. I always ask myself who actually pays these billed rates when I look at an eob. They're just nuts. I was going through this decision this year when deciding on whether to switch to a high deductible plan. If anything happens in the next 2 years that causes me to reach the max oop, I'm worse off than if i just stuck to my old plan that has no additional costs other than the premium. So its a bit of a gamble but at least there's a ceiling to the risk. No insurance, good luck.
Nugget
Footballguy
BCBS serves as a middle man. I guess they negotiate the billing for me? I'm not sure the actual value they bring to the table and how much profit they are scooping for their "service". $200B/year?
El Floppo
Footballguy
#1 reason people go bankrupt here.
And now imagine you had insurance, but they denied all or most of that.
We're going through similar with moms ALS. She had dull time care insurance for years. It's a freaking battle Royale to get anything from them after having to go all out of pocket for her essential care.
Ultimately, this is true of most insurance of all kinds (auto, homeowner, renter, term life, etc.). That's how insurance is supposed to work.
That said, insurance (especially health care insurance) is not supposed to be what it currently is, in which providers frequently default to "deny" without regard to the facts or circumstances.
matttyl
Footballguy
And I’m willing to bet that just having insurance would have over cut that in half. I work in the insurance industry. Two years ago my wife goes to ER with stomach pains that wouldn’t go away. Appendicitis- simple surgery and 2 nights in hospital. Hospital and insurance fought over amount and stuff for 8 months before hospital got fed up and sent us a bill for full amount saying insurance wouldn’t cover it - $42k. That’s when I got involved and got the claim handled, and just the insurance “in network discount” (meaning the hospital had to accept the pre negotiated amount for what was billed) knocked it down to $13k.
Most people don’t realize it, but often, the most valuable part of health insurance is that in network discounted rate. Even if insurance didn’t pay anything at all, just having insurance knocked the price tag down by $29k.
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matttyl
Footballguy
Read my story above.
Wife has them through work. She had hip and back issues this year and they have paid everything. X-Rays, MRI's, hip injections, back injections and PT.
matttyl
Footballguy
It’s #2 - #1 is loss of income (job loss). Often those are tied together as loss of job often means loss of employer sponsored health insurance (if you don’t accept cobra continuation).
CletiusMaximus
Footballguy
Personally I have had a great experience moving my health care insurance from Humana to UHC. It's partly a function of switching from my employers plan to my wife's but the coverage and customer service is far better at about the same monthly cost. That said the fact that UHC and similar healthcare conglomerates are so insanely profitable is surely an indicator of a terrible health care system in our country. The crime itself is of course shocking and I hope this guy is caught and punished to the max allowed under NY law.
BCBS is the worst. Deny everything and force the doctor to appeal. Docs getting fed up with it.
For better or worse, I'm self insuring next year.
$1167/mo x 12 = $14,004
OOP Limit = $9,200
$23,204 before I'd see any benefit to the positive. That assumes they'll pay everything and not not deny which is very unlikely.
Let's say I have a $40,000 event. I'm pretty confident I can negotiate that to $30,000. If I pay that amount, I'll realize $6,000 saving on my income taxes. That means I'm out of pocket $24,000. Pretty much a push.
$1167/mo x 12 = $14,004
OOP Limit = $9,200
$23,204 before I'd see any benefit to the positive. That assumes they'll pay everything and not not deny which is very unlikely.
Let's say I have a $40,000 event. I'm pretty confident I can negotiate that to $30,000. If I pay that amount, I'll realize $6,000 saving on my income taxes. That means I'm out of pocket $24,000. Pretty much a push.
1
What if it's a $200,000 event?
matttyl
Footballguy
Why are you adding in the max OOP? Hitting the max OOP (most of the time) means you had a huge medical event (over $40k). I can understand adding in your deductible (and those two could be the same on your plan).
Also, explain to me the $6k “savings” you’d get off your taxes. (Pretty sure I know what you’re trying to say, but your math is off).
Dr_Zaius
Footballguy
We've had pretty good luck until this year - wife and her Doctor have been fighting to get the insurance to cover a claim that the Doctor is insistent legally has to be covered. Two months in and it's just been an appalling experience. Between my premiums and my employer's share we pay ~$25K a year, so you'd think we wouldn't have these issues.
It's not just insurance either - I live less than 10 minutes from the main campus of the big area hospital so I've met a couple of the executives over the years and let's just say what those guys make versus what they're doing seems a little off, and makes the "non-profit" designation seem laughable. Don't get me wrong, I know there are many good nurses, doctors and others in the healthcare industry. The hospice people when my dad was terminally ill were particularly amazing. But like anything else that is a cash cow, you get a bunch of grifters that find a way to make a lot of money for not much in return.
dgreen
Footballguy
We have BCBS (federal). I can really only remember two instances and neither were really a big problem. First, my wife has MS and the treatment plan is infusions twice a year. When she first started this, the neurologist told us that he'd put in the request for the infusions, insurance will initially deny it, he'll appeal, and it will then be approved. Within a few days, we heard it was approved by insurance. So, if there was an initial denial, we would only know about it because the neurologist told us that's what's going to happen. If this happens a lot, it's been hidden from me as the consumer so doesn't really bother me (although I obviously understand that it annoy the doctors). Second, we recently had our primary care miscode something and send us a bill because they said the visit was out of network. We called them and said, "You've been in network for many years and now you're out of network?" They said, "Oops, nope. We made an error. We'll resubmit and it will be covered."
That's it from 25ish years with BCBS and both of those were in the last couple years.
HellToupee
Footballguy
Grabbing a coffee like almost anyone before going to work. But that’s the weird part. If he’s a professional killer you would think he knows he would be on camera inside Starbucks and how did he pay.
IvanKaramazov
Footballguy
BCBS is an insurance company that pools risk across a large number of consumers. By exploiting the law of large numbers, they can pay for people's health care by charging them a price above its actuarial value (allowing the firm and its investors to make a profit) while removing a lot of risk from individual policyholders (which risk-averse consumers like). It's basically the same business model as auto insurance and home insurance.
That's where the value of this industry comes from. Consumers benefit because they can smooth out their health care spending (pay a little every month, but you never have to worry about the $250K meteor strike), and investors benefit because they charge a +EV price for each policy.
I honestly think a lot of our problems today stem from the fact that people literally don't understand how the world works. Insurance is an important product, but it's not immediately obvious to the median person why it's important or even what it does. Lots of things are like that, and we're in the place that we're in because folks have knocked down walls that they had no idea were load-bearing.
djmich
Footballguy
Yah I get that...that's typically called value when a company provides expertise, effort and catastrophic insurance. Just weird to see the rest of the thread talk about how insurance has been working for them, but simultaneously some people thinking up to 99% of people don't need it. Something is off in that equation and leads to this weird "yah, I don't think about the guy that was just murdered and his family, but for the people impacted by his company".
HellToupee
Footballguy
Hmm. Deny , defend & depose
Dr_Zaius
Footballguy
I agree with this, but even if the industry as a whole is providing something that's a net good for society, you can still have annoyingly bad service and/or a tendency to try to take advantage of people. My daughter is going through a preposterous battle with a lab where they screwed up and submitted the claim incorrectly to the insurance. They've been extremely unhelpful in trying to rectify their mistake, instead opting to just try to browbeat my daughter into paying, threatening collections and credit score hits, which to a rule follower like my daughter are scary threats. I think it's instances like this that drive people into the "big corporations are bad" camp, even if they only happen in a minority of cases. Ironically in this particular case it was the insurance company representatives that came off as the good guys, because they told her to not pay the bill and get it submitted properly.
HellToupee
Footballguy
Same here. We have BCBS Basic and have had zero issues throughout the years
matttyl
Footballguy
Good post. To tack on another point, which at least I find interesting, is what their average profit margin is for doing that. In Q1 ‘24 the four largest carriers in the US (United, Cigna, Elevance (formerly Anthem), and CVS (Aetna)) had an average profit margin of 3.2%.
Now I fully understand that’s 3.2% of a WHOLE LOT of dollars, but it’s still only 3.2%.
Being an agent, when speaking candidly with clients, I often ask what percentage of their (and everyone else’s) premiums they pay to the insurance company ultimately go to pay claims. I get some wild answers, from as low as 10%, to maybe around 70%. They’re often floored to hear that the carriers are mandated by law to pay at least 80% (for individual and small groups) or 85% (large groups). When you slice the dollar up, they realize just how valuable it is, and where all that money is going.
CletiusMaximus
Footballguy
The other benefit as it specifically relates to health insurance as opposed to auto or property are the network of negotiated rates. This is also one area where it becomes confusing and frustrating. My guess is that most people consume health care services without any knowledge of the cost of the service going into it. I was referred for an outpatient service last month that I viewed as pretty minor, but the EOB showed over $40,000 in charges. I don't care of course because I only paid a few hundred dollars but that area of healthcare is extremely opaque and confusing to most. There's no ability to shop around and compare costs as is completely normal with most any other purchase of goods or services. The difficulty comes when we undergo a health care process that our doctor referred us to, with seemly no ability to confirm actual cost to us as the consumer, and then get hit with a big invoice later because the coverage fell through somewhere along the line.
the moops
Footballguy
MOP is the new Encyclopedia Brown
Nugget
Footballguy
I'm sorry - I understand how insurance works. I'm wondering if the government model would be better for all - or if we could see a privitization of Medicaid/Medicare. I don't know if there should be a profit motive to deny claims. Difficult to tread without getting political.
CletiusMaximus
Footballguy
I could never go self-insured due to having kids, but even if that were not the case I don't think I could stomach the risk. The thing I think about is waking up with some big pain, or having a minor accident or something and then having to do the math in my head as to whether I should call an ambulance or tough it out. My wife took our daughter to the ER last year for a sports injury, mostly because the coaches and other parents were all telling her she had to rush there, when it turned out to be a sprained ankle. In that case we'd have been fine with urgent care or even self-treating, but she didn't know that at the time and I'm happy that personal finance wasn't part of her analysis under the time pressure in that moment.
Scoresman
Footballguy
All of you praising BCBS with anecdotal experiences better hope you don't need surgery anytime soon where you need anesthesia, because the surgeons are about to be racing against the clock while operating, trying not to go past the arbitrary point BCBS decided they would shut off coverage for anesthesia.
www.newsweek.com
Doctors rail against insurer's new anesthesia time limits
The proposed policy will no longer reimburse anesthesia services for the complete duration of certain surgical procedures.
www.newsweek.com
Dr_Zaius
Footballguy
I'm interested in what knowledgeable people like @matttyl think about the movements to try to make pricing more transparent and/or force more parity in the rates that providers charge to different parties. It seems a little cartel-ish that my insurer can pay a rate for a service that I could never in a million years get away with if paying cash, but of course these sorts of bulk discounts are in a lot of industries, so there might be all sorts of downstream consequences of banning or restricting them that are not obvious to a layman.
NutterButter
Footballguy
That would be my concern as well. I'm too frugal to pay for insurance out of pocket. Come colonoscopy time, I'd be looking at that $8k cost (the amount that was actually billed for my latest) and asking if I really need it.
IvanKaramazov
Footballguy
My bad. When you said that you didn't understand what value they brought to the table, I took you at your word.
Most of the problems associated with health care would still be there if it were provided by the government. The problem is that health care is scarce and expensive, and there's no magical solution to that. There is no world in which we get health care that is (a) high quality and (b) inexpensive and (c) never denies claims. You can get two of those, but not all three. It's like telling a contractor that you want a 10K sq ft house with solid gold fixtures for under $500K. That's not going to happen, and it's not because your builder is evil -- he's just not a wizard.
That's not to say that the private insurance industry couldn't be improved upon. I'm sure it can be. But this is industry is already very highly regulated, and besides, none of this is any reason to assassinate somebody who works there. It's kind of depressing that we even have to say that.
Scoresman
Footballguy
The US ranked last in an 11 nation study on this.
"Compared to residents of the US, residents of the Netherlands, the UK, Norway, and Germany are much less likely to report that their insurance denied payment of a claim or paid less than expected. Residents of these countries are also less likely to report difficulty in paying medical bills,” the report says."
Does a perfect system exist? No. But you can't say the US' system is anywhere near decent.
matttyl
Footballguy
All of you praising BCBS with anecdotal experiences better hope you don't need surgery anytime soon where you need anesthesia, because the surgeons are about to be racing against the clock while operating, trying not to go past the arbitrary point BCBS decided they would shut off coverage for anesthesia.
Doctors rail against insurer's new anesthesia time limits
The proposed policy will no longer reimburse anesthesia services for the complete duration of certain surgical procedures.
I don’t know this story specifically, and from the arrivals you really are only hearing one side of it - but I will say that the ASA and health insurers in general have been at each others throats for years. As far back as I can remember. Insurers used to get the blame for not covering the anesthesia at all - but that was largely because the anesthesiologists choose not to participate with private insurance (so they are “out of network”) - because honestly, who asks if their anesthesiologist is in network before surgery?
I recall my wife going into labor, and she “asked for the juice” near the end, and I remember thinking - I hope they’re in network, but it wasn’t something I was going to bring up at the time!
IvanKaramazov
Footballguy
Judge Smails
Footballguy
It’s misleading. Insurance companies by law have limits re profit. They get around it by paying exorbitant comp to execs and pouring money back in the business. Go to downtown Newark and compare the surrounding environment with the palace that is Horizon Blue Cross Blue Shield headquarters
Ministry of Pain
Footballguy
I'm sure someone mentioned it already but I read the bullets used had special words marked/etched into them that reference a health insurance book showing the dark side from like 2010/2012, sounds like someone really took their time planning this out
I do like to follow several of the murder cases that make the national headlines.
In another life I think I would have enjoyed police detective/homicide and help solve some of these crimes.
That said I give a lot of props to law enforcement, typically they catch the folks over time
The Rhoden Murders in Ohio, looked like they would never be solved but then careful work and eventually they got all of them.
Judge Smails
Footballguy
Same here. I had a widow maker after a peloton ride. Had angioplasty, stent and 2 night stay. $100K. Cost me next to nothing with my top tier insurance. Am going through melanoma now. Those EOB’s aren’t fun if you had to pay, either.
Scoresman
Footballguy
I completely agree, but at the same time I'm not surprised this happened. Our health care system is not anywhere near good.
matttyl
Footballguy
Oh I get that, but the fact remains that they HAVE TO pay at least between 80-85% of the premiums they collect directly on medical care. What they do with the other (at most) 15-20%, we can debate and pick apart for days.
ETA - they sure aren’t kicking it back in commissions!
And thus mattyl remained upright and breathing to this dayAll of you praising BCBS with anecdotal experiences better hope you don't need surgery anytime soon where you need anesthesia, because the surgeons are about to be racing against the clock while operating, trying not to go past the arbitrary point BCBS decided they would shut off coverage for anesthesia.
Doctors rail against insurer's new anesthesia time limits
The proposed policy will no longer reimburse anesthesia services for the complete duration of certain surgical procedures.
I don’t know this story specifically, and from the arrivals you really are only hearing one side of it - but I will say that the ASA and health insurers in general have been at each others throats for years. As far back as I can remember. Insurers used to get the blame for not covering the anesthesia at all - but that was largely because the anesthesiologists choose not to participate with private insurance (so they are “out of network”) - because honestly, who asks if their anesthesiologist is in network before surgery?
I recall my wife going into labor, and she “asked for the juice” near the end, and I remember thinking - I hope they’re in network, but it wasn’t something I was going to bring up at the time!
No matter how careful you think you are there is always something to trip you up. This guy is realistically a dead man walking at this point, someone will know who he is and will inform the police.
Looks young
Dr_Zaius
Footballguy
I do think it gets somewhat of a worse rap than it deserves from the outcomes standpoint. If you look at how a patient in the US with, e.g., a cancer diagnosis does versus Europe it really is top notch. And when comparing things like life expectancy one has to take into account that the US does have a population with very poor health habits as well as a violence problem, neither of which are really the fault of the healthcare industry. That said it's the most expensive by far, so that's obviously going to go in the "cons" category when comparing nations.
Ministry of Pain
Footballguy
Are you talking about the one at Starbucks where you can see the top half of his face above the mask?
@Chemical X referenced this yesterday, that photo has been circulating since at least last night and that's not a swipe at you at all. I do think someone will recognize this guy even with the mask, there are some very easy features to pull from that photo plus this guy looks pretty fit, you won't catch him at an ice cream parlor. Looks more like the type that runs 5 miles in the morning just to wake up.
I also want to say that i do not want to make the staff upset here
They have asked not to link to the shooting video and I respect that so unless we have some real evidence we can discuss it's all speculation to some degree
I agree with you though, that photo in the coffee shop needs to be shown everywhere they can get it out to the public. Someone is going to say "That looks like my neighbor" if enough folks see that photo. Again I am speculating but distributing that into every news and social media outlet is going to help.
jamny
Footballguy
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