I already have a solution to the downcoding practices of these health insurance carriers.
I recently created an application called EMpowerAI that uses AI to analyze clinical notes and assign appropriate billing codes based on medical complexity or documented time. It also can enhance the Assessment/Plan to justify higher billing codes if the note content supports it.
As a Cardiac Electrophysiologist, I optimized the application for cardiology and EP, though it is scalable to other specialties. I am looking for beta testers and would appreciate any feedback. Here is a link to the app:
If someone invoices me, and I don’t pay the full amount in a timely manner, what do you think will happen? Late fees, reports to credit bureaus, collections agencies hounding me, maybe even lawsuits?
If insurance companies underpay, doctors should treat that no differently. Don’t appeal through the insurance company itself. Imagine I go to a store and pay less than the full amount at the register, and then the grocery store appeals to ME to decide whether I actually should have paid the correct amount. It’s absurd.
Doctors should treat the insurance companies like anyone else who owes them money and isn’t paying in full on time.
Most insurances won't publish their fee schedules. So doctors don't know what they will pay. So what they do is bill insanely high knowing the insurance will come back with "Nah, we only cover $X". They'll collect $X, then write off the remainder. Because the fear is not getting the maximum money possible. If the doctor would bill $100 and the insurance pays up to $200, then the doctor "lost" $100.
Regardless of how much it actually cost the doctor to provide the service.
It's also why the "cash price" is usually much cheaper, because it's closer to what it costs the doctor to provide the service.
I'm 90% certain that submitting claims to an insurer subjects doctors to resolving any disputes via an appeal followed by an arbitration process, and that the right to sue or handle the debt in the regular way is severely attenuated.
Ah yes, this is a fight between the practices (sometimes not the doctors!) upcoding their visits and the insurance companies wanting to push back and downcode the visits to what they actually entailed.
Healthcare practices want to maximize revenue and push up the “level” of a doctors visit and they can do it with just adding one or two extra little questionnaires or an extra test or two that you might not pay attention to so they can get an extra several hundred dollars a day for billing higher level cases daily.
This doesn't surprise me: The "fee for service" system encourages doctors to perform as many services as they can so they can bill for more. I've certainly had my fair share of tests and procedures where I wonder if the provider was just trying to find something to bill for.
I'm also not surprised that some providers will try to figure out which codes they can use to get the most revenue. ("Hey, if I do procedure A instead of B, I get paid more, so why would I do B?")
That being said, I also wouldn't be surprised if many of these turn into lawsuits, or ultimately push to revise the whole "fee for service" system.
"Figure out which codes they can use to get the most revenue" is a billion dollar industry with many players, subspecialties and surprisingly few lawsuits.
The counter to this is that now when you go to urgent care, they're only allowed to do one thing and send you to the ER for any other concurrent problems where you pay 10x more because it's an "emergency"
I went to the dentist a couple of weeks ago and had the shortest dental visit I've had. They did the X-rays, then the dental assistant spent five minutes cleaning my teeth and pronounced them good. The dentist came in and looked for about one minute and said they were fine. I was sent on my way.
They billed my insurance for over a thousand dollars.
Indeed. Part of the problem is news vendors will only tell one side of the story. If that dentist only billed, say, $150 ($40 per x-ray including time, wear, consumables), $20 for teeth cleaning time, $50 for rent, property rates, taxes, profit) then you'd pay far less in insurance. They all bill more because they can.
My pediatrician always charges us for an office visit + preventative care when we go in for a preventative care visit. It's obviously to get more $$ from insurance. I feel like this goes both ways...
An obligation to pay is always good for the billing side. Think about the sociopathic prices of US pharmaceuticals.
Afaik any other country with mandatory health care also puts a ceiling on prices. In germany, there is a price catalog for any service, with only few exceptions, and doctors/hospitals cannot legally charge anything else for these covered services. Now guess what the US does not have, even thought obama had foreign consultants explicitly advising for it.
Health ensureance companies are certainly not the most altruistic but any profit oriented company trying to cut cost where ever possible is hardly a supprise.
Yeah enough gets talked about insurers acting in bad faith, but let’s not forget hospitals also acting in bad faith for their end. Some personal examples:
1. Sitting in a Urgent care. They get you in the exam room. You sit there for 15 mins, doctor comes and sees you for 5 mins (mostly rushes the exam), do a blood draw, ask me to sit around while they run the test, doctor leaves, as soon as 45 mins are over the nurse comes over to let me know it’s taking longer to run the test so I can go home and they’ll call when the results are out. A month later charge thousands of dollars to insurance for a 45 min Urgent Care visit that doesn’t cover the lab work.
2. Go to PCP with cold symptoms that haven’t cleared in 10 days. I insist it’s a sinus infection, they send me back with no antibiotics and ask to schedule and online appointment in 2 days. I insist I come in in person, but they schedule an online appointment anyway. Nothing gets better and I see the doctor online after 2 days, they say I’ll have to come in so that they can evaluate me in person and prescribe antibiotics. I go in person, get antibiotics and get cured. Insurance gets charged for 3 separate hour long visits ($750 each and none of them lasted more than 10 mins).
This sort of thing gets to two critical problems of the American system:
1. It is largely designed to make money, not actually help patients. So every step in the healthcare chain that can extract a bit of value will do so, largely to boost profits.
2. Insane complexity with limited transparency. How much will something cost? Hard to tell. Will it be covered? Who knows?
On the opacity, I have one informative anecdote. I had a single blood test done awhile back and no one knew if insurance would cover it, or which of the dozen or so billing codes it involved (taking the sample, delivering the sample, testing the sample, etc.) might be covered. It was an expensive test so I spent days bouncing between the doctor's billing team and the insurance company until the settled answer was: No one knows, do the test and insurance will decide. So I did it and insurance denied covering the doctor-recommended test. The salaries involved for all the billing people (and my time) would have covered the cost of the test. </rant>
>Here are the magic words in US Health Care: "What is the cash price?"
I'm not so sure about that. Especially in a hospital setting.
Many years ago, I was admitted to the hospital for several days as it was suspected (wrongly, but that's another issue with the perverse incentives in US "healthcare") that I had MRSA and the doctor wanted me on IV antibiotics while testing proceeded.
I spent three days in the hospital, getting discharged when the tests came back negative for MRSA.
Shortly thereafter, I received a detailed "explanation of benefits" (EOB) from my insurer, which put the cost of my hospital stay at ~USD$12,000 which included stays in two hospital rooms simultaneously as well as a pap smear (despite the fact that I do not have a cervix). When I complained about this, the insurer tried to make it seem unimportant, but I pressed the issue as both the hospital and the insurer seemed to be involved in some sort of fraud WRT billing.
I was told I shouldn't care because I wasn't actually paying, but I persisted as I was concerned that there was something hinky going on. That culminated in a conference call with my insurance company, the hospital's accounts receivable group and me.
The two other parties talked in insurance billing jargon for a while, but when pressed, they stated that the charges on the "explanation of benefits" was a fiction and that the insurance company and hospital group's contract set a USD$1,500/day flat rate for patients admitted to the hospital's facilities -- roughly 1/3 of the "costs" cited in the EOB.
The made up stuff (which they didn't even try to hide that it was made up) was there as "protection" for the hospital group as the "cash price" of such services, even though I couldn't have received such services (two rooms at the same time? A pap smear[0] despite the fact that I don't have a female reproductive system, nor do/did I present as anything other than a cis male?).
I imagine that there may be some cases where a "cash price" actually does reflect costs and might even be less than insurance costs (although that seems unlikely given my experience), but insurers and healthcare providers do and have for decades gamed the "cash price" to justify the insane overcharging of healthcare services. YMMV.
I've had numerous encounters where doctors (and dentists) attempt to charge me for services they've already been reimbursed for from the insurance company.
It's only after hours of scouring my EOBs and being on the phone with my insurance that I then come back to the practice's office with evidence in hand, and they dismiss the charges.
I'm pretty sure this is just a racket because they expect most people not to put up a fight and just pay, or get sent to collections hell.
The amount of work you need to do as a patient in our health system is so dumb.
The biggest problem with the American system is that it's just illegal for me to sell you good, simple insurance.
Let's say I draft an insurance contract that says for any treatment if >5 of 10 randomly selected doctors agree that the procedure was warranted, then I have to pay out the cost of the procedure, no questions asked. This contract is less hassle, clear, and doesn't require arguing with an insurance company since it specifies how disputes are resolved.
But I'm not going to give it to you for free. I need to know the expected payout in order to come up with a price and sell it to you. You know, like how all other insurance works. There is a price that is positive EV for me, but better aligns with your risk tolerance, and is therefore positive utility for you as well. In America, pricing it is illegal. I cannot, by my own methods, determine a fair price and sell it to you.
That's why we can't have nice things, because it's illegal for two people to agree on a price and terms and create a good deal for themselves.
It was not designed to make money. It was designed to cost less, in the same way the USSR was designed to make workers rich - it simply failed spectacularly.
Neoliberals dislike both regulation and public ownership, but made a Faustian bargain where they replaced public ownership with more regulation, thinking that regulation was the lessor of the two evils. In reality, it's not - like in the USSR where they had corporatised but heavily regulated "companies". A heavily regulated company doesn't make money by offering better value to customers, it makes money by finding loopholes in regulations, and regulators will always lose the cat and mouse game of closing these loopholes.
Neoliberals end up creating a system that's actually a lot like the USSR (if the famous "Well intentioned Commissaire" essay is representative of the USSR) - heavy regulations, with corporate entities outsmarting the regulators to enrich their owners (or managers) while minimising the value they create. Neoliberals deny the need for pubic management, but are forced to badly reinvent it (via heavy regulation). Communists deny the need for incentives, and are forced to badly reinvent it (once again via regulation), ending up not a million miles away from where neoliberals end up - with endless regulation and lost efficiency.
It's worth noting that the US spends far more tax dollars (per capita) than Australia on health (Australia has a hybrid public / private model). Medicare, Medicaid and the VA costs about as much as Canada's expensive public system (per capita) since the US is so insanely inefficient.
In Australia I just take my blood test form to any pathology place and they do it for free (for me) and bill the government a set price from the medicare benefits schedule.
I wonder what would happen if we moved the "medically necessary" requirement burden of proof from the doctor/patient to the insurer. So the insurer would be required to pay out a claim regardless of whether the insurer thought it was medically necessary, but their recourse could be to try to claw it back post-payment.
What would happen is that costs to self-funded employers would increase so much that many of them would simply stop offering health insurance benefits and choose to pay the tax penalty instead. The only way the current system sort of works is with health plans maintaining strict utilization management.
(In general society would be better off if access to healthcare wasn't tied to employment but that's a separate issue.)
People get annoyed at insurers who will deny treatment but most of the time you can just pay it yourself. The government has decided that everyone should pay for health insurance but you'll never be denied care if you pay for it yourself.
So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's unlikely someone else will if they have to pay on your behalf.
Essentially, place yourself in the role of each participant:
- patient: wants to maximize care, money no object since it isn't theirs
- medical practice: wants to maximize money spent on care
- insurer: wants to minimize money spent on care
Normally, the first two would be happy to collude to charge the third any amount of money since they'd both get what they want. And that is indeed what happens. So you get the natural result that the insurer doesn't want to support certain payments even if they were kind and pure-hearted. That they don't want to when they're neither should then not be a surprise.
You can remove that pressure by turning the interaction into:
- patient: wants to maximize care with minimized cost
- practice: wants to minimize care with maximized cost
The pressures between the two parties are now opposite and you can find the market equilibrium. With this opposition you'll suddenly find that patients start complaining about doctors ordering unnecessary procedures and so on, just like insurers claim in the other model.
You can also work through with the other versions to model where equilibrium will set in and see if it's where it does. Most of the time you don't need to assume any moral valence for the participants. They might as well be machines. It is their roles that determine how they act, not their personalities.
>So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's unlikely someone else will if they have to pay on your behalf.
Ok, hear me out for a minute.
What if I wanted to pool with several people, so that if any of us had unexpected medical needs, it wouldn't bankrupt any of us. Knowing that most of us would not need it.
And then, since we're all on the hook for each other's general health, we also agreed to share the cost of preventative care, because it was literally cheaper for us to all pay for preventative care than to try to just solo it and then hit the group with the cost of terminal cancer care instead of catching it early and doing a small excision. (and other such examples.)
And then what if we made the pool HUGE, to even further spread out the costs?
Sure wish there was a system that just did that, without trying to also generate insane profits off it.
The problem is that patients are usually not in a position to determine if the care the doctor says is needed is really needed or not. This is the same as taking your out-of-warranty car to the mechanic. How do you know if the mechanic is telling the truth?
Still, this would be better than the current system. Even when you don't know if the doctor is telling the truth you can go by their reputation for telling the truth. Reputations will matter more, and doctors will care about maintaining their reputations in their community.
> but you'll never be denied care if you pay for it yourself.
If you can pay. You're still required to have insurance anyways. Which is a regressive tax and harms the people most in need of these services. It's a cruel joke.
Those living paycheck to paycheck are screaming at you right now.
It's a system that supports two set of clients, doctors and patients, and fails them both. Yet, Congress has considered it sacred and infallible for a hundred years. Democrat's most earnest attempt ended up strengthening and expanding that system, and Republicans for their part have fought tooth and nail to stack the system even further against the people it's supposed to serve.
People who have always lived in the USA have no idea how many things about life in the USA are batshit crazy. This is probably the top of the list. At least before we turned to fascism...
the health insurance industry needs to be razed to the ground and rebuilt from scratch. there's no saving something that is ostensibly designed to help people get healthcare but realistically denies them what they're entitled to for years (in some cases, they just try to keep the ball in the air until the patient dies, then there's no one to appeal) and then once the care is approved steals from the service provider by automatically altering the bills without any evidence of fraud or theft.
> More than half of societal work is pointless, both large parts of some jobs and five types of entirely pointless jobs:
> Flunkies, ...
> Goons, who act to harm or deceive others on behalf of their employer, or to prevent other goons from doing so, e.g., lobbyists, corporate lawyers, telemarketers, public relations specialists; <-- YOU ARE HERE
It's pretty obvious to everyone that doctors have been abusing these levels. See doc for 20 minutes for a low complexity item but get charged for a 30 minute medium complexity. The insurance companies aren't blind. They've got the stats in hand for each doctor. I mean some of the ranking data is already built into the portal tools they give consumers for finding a doc.
For those looking for a fix to US healthcare I think it's something like this:
- (user incentive to reduce cost) insurance is structured as co-pay of [20+]% on all expenses, no exceptions
- (price transparency) require healthcare providers to quote upfront for care, via API/website/phone/in-person. Price paid by anyone is the same except for expenses related to billing. E.g
- (create competition) enable creation of small scale clinics, testing facilities, and laboratories
And for God's sake, get the government out of it!!
One (social) system that may work well is the South Korean one: private provision of healthcare services; government run insurance scheme with mandatory payments by those that can afford to pay
I love markets, but health insurance really is a tough one given the govt can't seem to let people make their own mistakes on healthcare, so I think it might make sense to make it govt run.
Edit: the thing to acknowledge here is that it probably won't push the frontier of healthcare as much as the current US system does, but at least it would be high quality and affordable (not people's largest or second largest expense item).
As long as providers have an incentive to overtreat and overcharge, I don't see how we can control costs without an adversarial system, as infuriating and dysfunctional as it is. I never had to deal with any of this while enrolled in a nonprofit HMO (there must be some internal adversarial dynamics there, though).
There's plenty of upcoding going on with doctors as well though.
I go to a particular doctor and I'll see a bunch of random things on the bill that don't seem to have anything to do with my visit. Like a thousand dollars worth.
But then insurance rejects them, but I still don't have to pay a cent -- the doctor never actually charges me.
It seems quite clear they're just trying to throw things at the wall and see what sticks.
I've seen a lot of upcoding on my bills and it really aggravates me. It's fraud and the doctors should be happy that the insurance company is just reducing their payments instead of dropping them or trying to get them prosecuted. When someone loads their grocery bag full of cosmetics and razor blades, they get on the news and YouTube, but when a doctor systematically bills for services he didn't perform to the tune of millions of dollars, almost nothing happens.
I'm on the side of the insurance companies. they are likely the only "responsible adults" keeping providers in check. Providers are extremely wasteful and "creative" with their billing. Staff are generally idle, and staff-to-patient ratios are 10-20:1 if not more. There is little urgency around the clinic, staff take off at 4pm and are impossible to catch on a Friday. Every procedure bills a redundant and pointless "consult"-- a $1500 meeting that could have been an email.
Providers benefit from possibly the best PR of any industry. Insurance companies are the "Ticketmaster" of the healthcare industry. Their entire objective is to be the punching bag for wasteful healthcare providers.
I mean aside from the fact that insurance in healthcare don’t provide any value at all, and healthcare providers provide, you know, actual healthcare, then sure.
Healthcare insurance companies are completely pointless because healthcare is a human right. All other developed countries have figured this out and provide healthcare universally. We could fully socialize “healthcare insurance companies” and have exactly zero negative repercussions. The only outcome would be eliminating a useless industry and saving ~$500 billion a year.
62 comments
[ 3.6 ms ] story [ 73.8 ms ] threadI recently created an application called EMpowerAI that uses AI to analyze clinical notes and assign appropriate billing codes based on medical complexity or documented time. It also can enhance the Assessment/Plan to justify higher billing codes if the note content supports it.
I presented it at the HRX conference in Atlanta on 9/4/2025 in the top 5 abstracts session. Here is the abstract: https://www.heartrhythmopen.com/article/S2666-5018(25)00291-...
As a Cardiac Electrophysiologist, I optimized the application for cardiology and EP, though it is scalable to other specialties. I am looking for beta testers and would appreciate any feedback. Here is a link to the app:
http://em-billing-assistant.onrender.com/
Leave your name and email here if you would like to receive updates:
https://forms.gle/MoVhdna81pq9F45NA
If insurance companies underpay, doctors should treat that no differently. Don’t appeal through the insurance company itself. Imagine I go to a store and pay less than the full amount at the register, and then the grocery store appeals to ME to decide whether I actually should have paid the correct amount. It’s absurd.
Doctors should treat the insurance companies like anyone else who owes them money and isn’t paying in full on time.
Most insurances won't publish their fee schedules. So doctors don't know what they will pay. So what they do is bill insanely high knowing the insurance will come back with "Nah, we only cover $X". They'll collect $X, then write off the remainder. Because the fear is not getting the maximum money possible. If the doctor would bill $100 and the insurance pays up to $200, then the doctor "lost" $100.
Regardless of how much it actually cost the doctor to provide the service.
It's also why the "cash price" is usually much cheaper, because it's closer to what it costs the doctor to provide the service.
Healthcare practices want to maximize revenue and push up the “level” of a doctors visit and they can do it with just adding one or two extra little questionnaires or an extra test or two that you might not pay attention to so they can get an extra several hundred dollars a day for billing higher level cases daily.
Many medical administrations do everything they can to upcode in order to bill for more money.
The whole system is a mess.
I'm also not surprised that some providers will try to figure out which codes they can use to get the most revenue. ("Hey, if I do procedure A instead of B, I get paid more, so why would I do B?")
That being said, I also wouldn't be surprised if many of these turn into lawsuits, or ultimately push to revise the whole "fee for service" system.
They billed my insurance for over a thousand dollars.
Afaik any other country with mandatory health care also puts a ceiling on prices. In germany, there is a price catalog for any service, with only few exceptions, and doctors/hospitals cannot legally charge anything else for these covered services. Now guess what the US does not have, even thought obama had foreign consultants explicitly advising for it.
Health ensureance companies are certainly not the most altruistic but any profit oriented company trying to cut cost where ever possible is hardly a supprise.
1. Sitting in a Urgent care. They get you in the exam room. You sit there for 15 mins, doctor comes and sees you for 5 mins (mostly rushes the exam), do a blood draw, ask me to sit around while they run the test, doctor leaves, as soon as 45 mins are over the nurse comes over to let me know it’s taking longer to run the test so I can go home and they’ll call when the results are out. A month later charge thousands of dollars to insurance for a 45 min Urgent Care visit that doesn’t cover the lab work.
2. Go to PCP with cold symptoms that haven’t cleared in 10 days. I insist it’s a sinus infection, they send me back with no antibiotics and ask to schedule and online appointment in 2 days. I insist I come in in person, but they schedule an online appointment anyway. Nothing gets better and I see the doctor online after 2 days, they say I’ll have to come in so that they can evaluate me in person and prescribe antibiotics. I go in person, get antibiotics and get cured. Insurance gets charged for 3 separate hour long visits ($750 each and none of them lasted more than 10 mins).
On the opacity, I have one informative anecdote. I had a single blood test done awhile back and no one knew if insurance would cover it, or which of the dozen or so billing codes it involved (taking the sample, delivering the sample, testing the sample, etc.) might be covered. It was an expensive test so I spent days bouncing between the doctor's billing team and the insurance company until the settled answer was: No one knows, do the test and insurance will decide. So I did it and insurance denied covering the doctor-recommended test. The salaries involved for all the billing people (and my time) would have covered the cost of the test. </rant>
It's usually less than you think and often worth avoiding the insurance company hassle. Then you can just get reimbursed with your FSA or HSA anyway.
I'm not so sure about that. Especially in a hospital setting.
Many years ago, I was admitted to the hospital for several days as it was suspected (wrongly, but that's another issue with the perverse incentives in US "healthcare") that I had MRSA and the doctor wanted me on IV antibiotics while testing proceeded.
I spent three days in the hospital, getting discharged when the tests came back negative for MRSA.
Shortly thereafter, I received a detailed "explanation of benefits" (EOB) from my insurer, which put the cost of my hospital stay at ~USD$12,000 which included stays in two hospital rooms simultaneously as well as a pap smear (despite the fact that I do not have a cervix). When I complained about this, the insurer tried to make it seem unimportant, but I pressed the issue as both the hospital and the insurer seemed to be involved in some sort of fraud WRT billing.
I was told I shouldn't care because I wasn't actually paying, but I persisted as I was concerned that there was something hinky going on. That culminated in a conference call with my insurance company, the hospital's accounts receivable group and me.
The two other parties talked in insurance billing jargon for a while, but when pressed, they stated that the charges on the "explanation of benefits" was a fiction and that the insurance company and hospital group's contract set a USD$1,500/day flat rate for patients admitted to the hospital's facilities -- roughly 1/3 of the "costs" cited in the EOB.
The made up stuff (which they didn't even try to hide that it was made up) was there as "protection" for the hospital group as the "cash price" of such services, even though I couldn't have received such services (two rooms at the same time? A pap smear[0] despite the fact that I don't have a female reproductive system, nor do/did I present as anything other than a cis male?).
I imagine that there may be some cases where a "cash price" actually does reflect costs and might even be less than insurance costs (although that seems unlikely given my experience), but insurers and healthcare providers do and have for decades gamed the "cash price" to justify the insane overcharging of healthcare services. YMMV.
[0] https://www.mayoclinic.org/tests-procedures/pap-smear/about/...
It's only after hours of scouring my EOBs and being on the phone with my insurance that I then come back to the practice's office with evidence in hand, and they dismiss the charges.
I'm pretty sure this is just a racket because they expect most people not to put up a fight and just pay, or get sent to collections hell.
The amount of work you need to do as a patient in our health system is so dumb.
Let's say I draft an insurance contract that says for any treatment if >5 of 10 randomly selected doctors agree that the procedure was warranted, then I have to pay out the cost of the procedure, no questions asked. This contract is less hassle, clear, and doesn't require arguing with an insurance company since it specifies how disputes are resolved.
But I'm not going to give it to you for free. I need to know the expected payout in order to come up with a price and sell it to you. You know, like how all other insurance works. There is a price that is positive EV for me, but better aligns with your risk tolerance, and is therefore positive utility for you as well. In America, pricing it is illegal. I cannot, by my own methods, determine a fair price and sell it to you.
That's why we can't have nice things, because it's illegal for two people to agree on a price and terms and create a good deal for themselves.
It was not designed to make money. It was designed to cost less, in the same way the USSR was designed to make workers rich - it simply failed spectacularly.
Neoliberals dislike both regulation and public ownership, but made a Faustian bargain where they replaced public ownership with more regulation, thinking that regulation was the lessor of the two evils. In reality, it's not - like in the USSR where they had corporatised but heavily regulated "companies". A heavily regulated company doesn't make money by offering better value to customers, it makes money by finding loopholes in regulations, and regulators will always lose the cat and mouse game of closing these loopholes.
Neoliberals end up creating a system that's actually a lot like the USSR (if the famous "Well intentioned Commissaire" essay is representative of the USSR) - heavy regulations, with corporate entities outsmarting the regulators to enrich their owners (or managers) while minimising the value they create. Neoliberals deny the need for pubic management, but are forced to badly reinvent it (via heavy regulation). Communists deny the need for incentives, and are forced to badly reinvent it (once again via regulation), ending up not a million miles away from where neoliberals end up - with endless regulation and lost efficiency.
It's worth noting that the US spends far more tax dollars (per capita) than Australia on health (Australia has a hybrid public / private model). Medicare, Medicaid and the VA costs about as much as Canada's expensive public system (per capita) since the US is so insanely inefficient.
(edit: The essay I mentioned - https://highered.blogspot.com/2009/01/well-intentioned-commi...)
Flood insurance protects against the rare disaster where there's a flood.
Health insurance protects against the rare disaster where somebody's actually able to get healthcare.
I wonder what would happen if we moved the "medically necessary" requirement burden of proof from the doctor/patient to the insurer. So the insurer would be required to pay out a claim regardless of whether the insurer thought it was medically necessary, but their recourse could be to try to claw it back post-payment.
(In general society would be better off if access to healthcare wasn't tied to employment but that's a separate issue.)
So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's unlikely someone else will if they have to pay on your behalf.
Essentially, place yourself in the role of each participant:
- patient: wants to maximize care, money no object since it isn't theirs
- medical practice: wants to maximize money spent on care
- insurer: wants to minimize money spent on care
Normally, the first two would be happy to collude to charge the third any amount of money since they'd both get what they want. And that is indeed what happens. So you get the natural result that the insurer doesn't want to support certain payments even if they were kind and pure-hearted. That they don't want to when they're neither should then not be a surprise.
You can remove that pressure by turning the interaction into:
- patient: wants to maximize care with minimized cost
- practice: wants to minimize care with maximized cost
The pressures between the two parties are now opposite and you can find the market equilibrium. With this opposition you'll suddenly find that patients start complaining about doctors ordering unnecessary procedures and so on, just like insurers claim in the other model.
You can also work through with the other versions to model where equilibrium will set in and see if it's where it does. Most of the time you don't need to assume any moral valence for the participants. They might as well be machines. It is their roles that determine how they act, not their personalities.
Ok, hear me out for a minute.
What if I wanted to pool with several people, so that if any of us had unexpected medical needs, it wouldn't bankrupt any of us. Knowing that most of us would not need it.
And then, since we're all on the hook for each other's general health, we also agreed to share the cost of preventative care, because it was literally cheaper for us to all pay for preventative care than to try to just solo it and then hit the group with the cost of terminal cancer care instead of catching it early and doing a small excision. (and other such examples.)
And then what if we made the pool HUGE, to even further spread out the costs?
Sure wish there was a system that just did that, without trying to also generate insane profits off it.
Still, this would be better than the current system. Even when you don't know if the doctor is telling the truth you can go by their reputation for telling the truth. Reputations will matter more, and doctors will care about maintaining their reputations in their community.
If you can pay. You're still required to have insurance anyways. Which is a regressive tax and harms the people most in need of these services. It's a cruel joke.
Those living paycheck to paycheck are screaming at you right now.
Because anyone can afford that, right?
Oh, and by the way, if you are in Texas abortion is illegal. In case you didn't actually __decide__ to get (yourself, your partner) pregnant.
So it's either 40-80K or 40 years. Easy choice.
That's...not a lot of money.
Have health sharing plans been successful? Those require a religious affiliation IIRC.
I exclude single payer solely because it’s impossible with our current leadership.
I’m surprised there isn’t a Costco like medical group that’s nationwide, has a membership, and works solely to provide care efficiently.
> Flunkies, ...
> Goons, who act to harm or deceive others on behalf of their employer, or to prevent other goons from doing so, e.g., lobbyists, corporate lawyers, telemarketers, public relations specialists; <-- YOU ARE HERE
> Duct tapers, ...
> Box tickers, ...
> Taskmasters ...
- (user incentive to reduce cost) insurance is structured as co-pay of [20+]% on all expenses, no exceptions
- (price transparency) require healthcare providers to quote upfront for care, via API/website/phone/in-person. Price paid by anyone is the same except for expenses related to billing. E.g
https://surgerycenterok.com/
- (create competition) enable creation of small scale clinics, testing facilities, and laboratories
And for God's sake, get the government out of it!!
One (social) system that may work well is the South Korean one: private provision of healthcare services; government run insurance scheme with mandatory payments by those that can afford to pay
https://en.wikipedia.org/wiki/Healthcare_in_South_Korea
I love markets, but health insurance really is a tough one given the govt can't seem to let people make their own mistakes on healthcare, so I think it might make sense to make it govt run.
Edit: the thing to acknowledge here is that it probably won't push the frontier of healthcare as much as the current US system does, but at least it would be high quality and affordable (not people's largest or second largest expense item).
I go to a particular doctor and I'll see a bunch of random things on the bill that don't seem to have anything to do with my visit. Like a thousand dollars worth.
But then insurance rejects them, but I still don't have to pay a cent -- the doctor never actually charges me.
It seems quite clear they're just trying to throw things at the wall and see what sticks.
Everything about American healthcare is bad.
If you see this sort of thing happening in the U.S., the place to complain is your state's insurance board.
Medicine is hard enough without people TRYING to do harm.
And actuarial science is brutal enough WITHOUT glossy justifications for assuming that healthcare providers are bad actors.
What does this part mean? I don't follow.
Providers benefit from possibly the best PR of any industry. Insurance companies are the "Ticketmaster" of the healthcare industry. Their entire objective is to be the punching bag for wasteful healthcare providers.
Healthcare insurance companies are completely pointless because healthcare is a human right. All other developed countries have figured this out and provide healthcare universally. We could fully socialize “healthcare insurance companies” and have exactly zero negative repercussions. The only outcome would be eliminating a useless industry and saving ~$500 billion a year.