yzerman19

Are you a hospitalist then? If you'd prefer full anonymity, I will not be offended if you defect the question. You are clearly speaking from a position of knowledge, which is very helpful in this thread.

I want to know how insurers are taking advantage of it. I really want to hear the logic... Follow me on this: 1. Exchanges encourage transparent competition- forcing insurers to try and be price competitive 2. Actuarial value and MLR (80% on individual 85% on group) say that insurers can't price fix high 3. Benefit requirements and no underwriting and no maxes push costs up for providing coverage 4. Provider consolidation push costs up I could go on and on, but insurers are not taking advantage of anything here, they are on the ropes.

Not a doc, but depending on the situation it is usually only 2 or 3. There are situations where the bill will be broken into technical and professional component or kept packages as global. All doctors can read basic xrays, but radiologists are trained to look for everything. You want that oversight...many a person's life has been saved by a radiology overread- iding a cancerous spot that appeared in the image that was taken for an entirely different purpose. The cynic says the overreads are to protect against lawsuits. Also, unfortunately true. So, usually there are 2 professional reads of an xray. Might end up with 3 if an ER situation or an odd read.

Historically, hospitals loved doctors, because they were the net that brought business to them. Build high-end specialty services with huge margins, cast a wide net of primary care, then reap the $$$ for all the admits and procedures. The fundamental challenge with market transparency is that the system is based on an incomprehensible matrix of retrospective coding, and payment is tied to the coding. I could, in theory, find out the reimbursement rate at a particular provider for say a 99213- let's say its $75. If I have a high deductible plan, I can then assume that the provider will probably bill about $150, they will accept $75 per the insurance contract, and I will owe all of the $75 assuming I haven't met my deductible. Easy right? Wrong. What if the physician finds something unusual or has to do some research into a medication interaction and it now warrants a 99214. Well now the reimbursement rate just went up to $100. Oh, and wait, a lab test needs to be ordered. That's another $30. Total owed is now $130 assuming I haven't met my deductible. I went it with the same problem...my throat hurts...I am paying $75 in one scenario and $130 in another scenario...with the same issue. That was a simple example...sore throat...now imagine it with something complicated Difference is $750 vs $1300 or much, much worse...

magnified by more RVUs for the procedures the specialists perform. A specialist can earn/produce more RVUs in the same time period, and be paid more per RVU.

So you're not calling my post bull, you're agreeing that it is bull that you can't write off Ed interest when you clear an arbitrary threshold. I agree! That's why you take loans- to earn a good income!

A year of junior will do Yon well. He looks like he's got the skils to be a solid player here. He should've finished a couple times...

This is a great post. The ER element is interesting, because the hospital makes money. It ties into "medical arms race" where normal economics are thrown out the window, and competition drives costs up- because the insurers are stuck- if they don't pay up, the provider might go non-par and the employers will dump the insurer. The exec issue is an interesting one- insurance is usually thought of more as finance than as healthcare. $500k for a CEO of a company with a billion in revenue is pretty pedestrian. Agree on dermatology...if I wanted to be a doc (and I don't, because I am money first, and that made me not go to med school) I would be a dermatologist. Ortho and Cardi can make way more, but they work like dogs. Its not just med school- my business school debt is $100k. It is a problem. The bigger insult is that when you make more than I think $160k per year, you can't even write off student loan interest.

That is an unethical, illegal action by a set of individuals. Shouldn't be held against the industry.

Don't 47% of people net a zero tax liability?

True, they did, in conjunction with tax cuts. Raised spending, lowered taxes. Expansionary fiscal policy that has mortgaged us to the hilt. Obama doing the same. We've spent like Drunken sailors getting us out of the Carter years, with the exception of the Gingrich/Clinton era- where an explosion in tech and com and a balanced budget stopped the bleeding.

Been 20 years since I took macro economics, but my recollection of one of Keynes' tenets was that you could generate economic growth through government spending. That is what I am getting at. You and I are of different opinions on moving location or switching careers, and docs aren't paid by the hour- they are paid on production- or migrating back towards # of patients in primary care and other triple aim incentives. Why is there a primary care shortage? because even doctors (most of them)who know they want to be doctors choose every other option first, because the difference in comp is so dramatic. Be a cardiologist, make $900k, be a pediatrician, make $120k. The commonality- investment banking, law, medicine- long hours equals big wallet. Kill the incentive, kill the work. Good post. This is good conversation

Not Country Club Edina...the debate to live out on tonka vs in Edina is more about commute IMO

I've never worked in the NoDak market, but my understanding is that it is monopoly virtually everywhere, on both sides. I guess you have oligopoly on the provider side in Fargo. Compare that to the Twin Cities, where there are really 3 giant health systems and 3 more medium health systems, a few specialty cartels, and pretty decent competition among 4 payers. Different competitive market. Rural vs Urban healthcare is a very interesting topic from the health economics to the community economics.

Its kind of a keynesian debate then whether or not gov spending into private enterprise is the best way to expand economic growth. At this point we are addicted to it. The other issue is the mobility of labor/capital. If I am very bright and motivated, I want to get paid. If it isn't in healthcare, I go somewhere else. Think of the surgeon working 60-70 hours per week for $400k per year. if that becomes $200k, he/she isn't going to work 60-70 hours, requiring more surgeons to keep up with demand. If I am an very talented 22 year old, I then question the value of incurring $200k in debt and foregoing an decent income until I'm 30. Then you lose docs or lose docs with talent.

Subsidy equals a redistribution, no?

Provider consolidation certainly plays a role. There are many, many drivers. Deteriorating population health. Better care, extending life and quality of life, but at extra expense, supporting small independent rural providers in order to ensure access. ACA benefit requirements do also play a role

The trouble with the talking heads is that they are very, very smart, but they have a single outcome in mind. They seek not construction from industry experts, but rather validation of their beliefs. My interactions with policy makers has been that they ask your opinion, listen, talk it through, appear to grasp it, then ignore it in their final report and simply state that as part of their due diligence they had thought leaders from industry. Implying a consensus, when none was reached.

Not my intent. You also seem to be very well versed in the subject matter

You're referring to economies of scale, which should occur at a large enough level of membership. The problem is those economies of scale just don't come to fruition on anything other than claims processing, which is truly as close to the clerical at you represented. So, a huge chunk of CEO comp is simply supply and demand on Wall Street. I mean its mostlymstockmoptions and grants that have nothing to do ( other than distantly) from the actual profit margin if the company. Also, united is a big, international conglomerate that makes more margin on non-insurance. Read big data and Optum. Ever wonder why every health plan is looking at vertical integration with providers or selling health and wellness? It's cause they need to find margin outside of insurance.

I've spoken with her and Zeke Emmanuel

Methodology is all Rbrvs, but the CF is negotiated. To those unfamiliar, physician compensation is based on a series of codes called CPT. Codes have a weight tied to them based on the resource intensity of the service they represent (RVU-relative value units). A simple office visit would have little RVUs, a heart bypass will have a lot of RVUs. The Conversion factor is negotiated. The conversion factor times the RVU nets the payment allowed by contract for the service. This is called the allowed amount.

I appreciate people's passion, and I'd really like to be able to convert that passion into an educated understanding. Not to share my political opinion, but just to understand how the industry works. I'll put my credentials in this space up against anyone- and by anyone, I really mean ANYONE- not trying to boast, just trying to make clear (without posting my resume) that I know what I'm talking about- AND i do not work for Blues of ND

Thanks Mate. The industry is hard to understand for most people, because it is a mystery of things like coding, actuarial science, and benefits that historically were designed to deter utilization or cost shift to employees. The other HUGE thing to remember with that maximum 15% gross margin is that I have to fund investment in the future and also (because we are talking fully insured) insulate myself from catastrophic claims. If they price too high, they won't sell policies in a competitive environment. If they price too low, they will not sufficiently manage the risk of high cost claims. In fact, any surplus (called risk based capital) is often a set large amount required by regulators to ensure the viability of the system in a crisis where no premiums are coming in, but people need services (read: pandemic or gov shutdown or depression) The question regarding % vs actual margin- it has to be %. Investors think about %.

9 year old is a freaking squirt...no way... Bantam is when I've seen real scouting happening, and usually for junior. Then junior and high school for college and pro.