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View Diary: ACA's narrow networks allow insurance companies to gouge public, doctors (97 comments)

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  •  As my children used to say, "Duh." (8+ / 0-)

    The insurance companies are trying to maintain profits?  I'm shocked, SHOCKED I tell you.  

    Yes, that was sarcastic, but the point is, this is the inevitable result of the ACA, as it was structured, doubling down on the for-profit insurance model.    Three points:  

    1.  The ACA does put some limits on profits.  Insurers must pay at least 80% in the small and individual markets, 85% in the large markets, on actual medical care.  Presumably, all non-medical overhead involved in running a company (including the executive salaries) and profit has to come out of the rest.  

    2.  The ACA took away the insurers biggest tools for assuring that they remained profitable -- the ability to write a large number of different types of policies (you could write policies where all routine medical costs would come out of pocket, and insurance would only kick in if there was something catastrophic, or policies that excluded maternity care, pediatric care, non-catastrophic mental health care, for example, for people who did not want to pay extra for those) and the ability to charge those who were lower risk (younger, healthier, without pre-existing conditions) significantly less, and the higher risk significantly more.  Any sane person knew that those limitations meant that the insurers would then look to make up those profits elsewhere.  And right now, they are looking to (1) higher premiums and deductibles;  (2) narrower networks, and (3) lower reimbursements as a way of making up profits.  All of this is exactly what every sane person EXPECTED would happen when you looked at the ACA as a whole.  No sane person thought the insurance companies would simply say, "Ok, you cut our ability to make profits, that's fine, we won't try to find other ways to make profits."  

    3.  I strongly suspect that if the ACA continues in largely its present form, we will turn into a two tier medical system.  There will be one system for the ordinary people -- the less well known hospitals, doctors who can't command the highest payments, etc. -- and a separate system for those who can pay more for extra benefits plus perhaps can pay something on top of what the insurance pays.  I've already seen doctors, if you want to keep that doctor, to pay an up-front "annual fee retainer" ($1200 a year is a number I've seen here in New Orleans).  In other words, you'll pay an "access fee" and they'll agree to accept your insurance reimbursements if you have something really significant you need them for.  If you don't need them, or if you only need your annual checkup, they keep your $1200.  In exchange, you get them, you get shorter waits for appointments, you get them to spend more time with you when you come in.  The most prominent doctors and hospitals will demand -- and get -- this.  The most prominent hospitals will be limited to the well off who can pay the extra, over and above insurance.  The less well off will be relegated to the second tier of hospitals and doctors.

    I don't like that system, but I've seen moves in that direction already.  

    •  Two tiers (1+ / 0-)
      Recommended by:
      VClib

      That's going to be inevitable under any approach toward unversal care, whether single payer, insurance, etc. Rich folks will find ways to get better care and will pay for it. an interesting take on that issue from Britain is here

      Private insurance in a single payer, government run healthcare system is a funny animal: one part incest, one part conflict of interest, and three parts strange bedfellows. And it’s infinitely fascinating. Here’s how it works:

      “Texas is a so-called red state, but you’ve got 10 million Democrats here in Texas. And …, there are a whole lot of people here in Texas who need us, and who need us to fight for them.” President Obama

      by Catte Nappe on Sun Nov 24, 2013 at 04:03:36 PM PST

      [ Parent ]

      •  The problem we have is that people here (1+ / 0-)
        Recommended by:
        OrganicChemist

        are used to the "average" person, with employer provided insurance, is used to getting to see the doctors he/she wants, and going to the hospital he/she wants. For example, I'm in New Orleans, and many people here diagnosed with some serious form of cancer choose to go to M.D. Anderson in Houston.  You hear about that regularly.  

        It may well be that, five years from now, people in the exchanges (and I expect that to be more and more people as time goes on), or people who don't make enough to pay for that "extra tier" coverage, are not going to have access to those resources, and will find fewer choices and longer waits for care, and will find doctors spending less time with them, as insurers limit their options to doctors who will accept lower reimbursements, and therefore must crowd in more patients in a day so as to cover expenses and still make money..  The "best" hospitals, doctors, and care facilities, the notion of calling and getting an appointment fairly quickly, the notion of a doctor spending 30 or 45 minutes with you, will be largely for those who pay for that "extra tier" coverage.

        And I'm not sure how well that will be received  here, frankly.

        •  Hahahahahaha (2+ / 0-)
          Recommended by:
          Roadbed Guy, Tonedevil
          the notion of a doctor spending 30 or 45 minutes with you
          I've got pretty darn good employer provided insurance. I can't recall if I've ever - EVER - had 30 - 45 mins with a doc. They've been crowding in more patients a day for years.

          “Texas is a so-called red state, but you’ve got 10 million Democrats here in Texas. And …, there are a whole lot of people here in Texas who need us, and who need us to fight for them.” President Obama

          by Catte Nappe on Sun Nov 24, 2013 at 04:41:47 PM PST

          [ Parent ]

          •  My doctor does. Both (1+ / 0-)
            Recommended by:
            Catte Nappe

            my internist and my Ob-Gyn -- generally, it's half an hour or more at my annual checkup.  That counts the exam, and questions (my internist discusses lifestyle, diet, risks, etc.).  

            I actually checked at may last annual checkup with the internist because someone asked me.  that one was 40 minutes.  

            •  I'm lucky to have the same experience... (2+ / 0-)
              Recommended by:
              coffeetalk, Tonedevil

              My primary care physician never rushes my visits. She will take time every visit to review all my health history and talk about what is happening with my family, etc. I once commented on the time she seems to be able to take and she commented that as long as the Medicare and Medicaid load on the practice is low, she can take as much time as necessary. If she and her partner were to accept Medicare patients, then they would need to resort to shotgun doctoring to stay in business. Right now, they do no Medicaid and only accept Medicare patients who have "graduated" from being regular billing patients.

          •  But I frankly think that the limits on (0+ / 0-)

            hospitals and such facilities will be the biggest problem.  How upset will people be who are diagnosed with serious cancer, and then find out that M.D. Anderson is "not in network"?  

            I have a friend just diagnosed here in New Orleans with serious lung cancer (very sad -- never a smoker, in her late 50's).  She immediately chose to go to M.D. Anderson rather than stay at the hospital in New Orleans.  I suspect those kinds of options will be less and less available, unless you can avoid extra for the higher tier insurance.  

            •  What ought to be our basic level of care? (0+ / 0-)

              Should we insure that everyone who gets cancer goes to the most expensive prestigious hospitals to be treated? I don't see how that is possible.

              •  That's probably realistic. But my point is (0+ / 0-)

                that people with "average" employer provided heath insurance are used to that -- like the friend I mentioned. She and her husband have good jobs, but are certainly not what I would consider "rich."

                I think a lot of people are going to be unhappy when they discover that their former expectations no longer realistic.

                I think you are right -- it probably is necessary.  But it' will come as an unpleasant surprise to people who were promised that the ACA could cover a lot of additional people without any downside to those who had insurance that they liked.  The Administration did not manage expectations well at all, and I think they are feeling the results of that, and may feel them over the next year as well.  

                •  I think you are right (0+ / 0-)

                  I've heard acquaintances in California lamenting that the most expensive hospitals are no longer in their network. They maintain that they ought to be able to see any doctor, go to any hospital, and their insurance should pay. They are furious that they have to pay more for insurance, and it doesn't cover any hospital they want to go to.

          •  My son's doctor always spends that much time (1+ / 0-)
            Recommended by:
            Catte Nappe

            during every visit.  Hence one of the reasons I have chosen him to be my son's doctor.

      •  Britain basically has a two-tier system (1+ / 0-)
        Recommended by:
        Catte Nappe

        Which might not be so bad, actually.  Even though Britain is one of the most "socialized" in medicine, there is still a distinction between the NHS, which is available to everyone for free or low cost, and "going private" for the more affluent, who can either purchase supplemental insurance or, if they are well-heeled enough, just pay the freight.  

        That doesn't bother me too much.  As long as everyone gets a reasonable standard of care, there's no reason not to let the more affluent pay for more comfort, quicker service, etc.  It is probably true that, under the ACA, the wealthy will continue to get whatever services they want, because they can pay for them, which the majority will be required to use mainstream providers with negotiated rates.  Still a lot better than no care at all.  

    •  I expect Health Insurers to spend less on control (1+ / 0-)
      Recommended by:
      JesseCW

      of unnecessary care.  If 15% of premiums is for administrative expenses, taxes and profit, it is much easier to increase profits by reducing admin expenses.  As it costs money to monitor unnecessary procedures, this would be a great way to increase profits.  If the result is higher premiums, then there is just more revenue to apply the profit margin on.

      If competing insurers largely act this way, they don't risk fewer customers from price competition.

      The most important way to protect the environment is not to have more than one child.

      by nextstep on Sun Nov 24, 2013 at 04:32:58 PM PST

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    •  That's why nations around the world have (1+ / 0-)
      Recommended by:
      JesseCW

      healthcare systems with a quality of care standard that provide the most affordable and highest quality of care for the most people. And having done so leave the US 38th or 42nd in healthcare outcomes for much more money per patient.

      The rich in every country will get better healthcare than the average citizens. So because of this we should do nothing to extend more care to more people?

      If the 2nd tier hospitasl 99% of us will have to be treated in, provide as good of care as a hospital in the Netherlands or France, whats to beef about?

      ACA is the start.

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