I have been spending a fair amount of time in hospitals over the last few days as my aunt probably had a stroke.

I for one hate hospitals, healthcare and generally stay far away from it in my professional investing life. Just too complicated and difficult.

But I am totally lost by how we can ration healthcare in the us.

If the emergency room does not refuse service cause someone is sick who bears the cost. Unless hospitals say no health insurance - 911 ambulance take patient somewhere else - someone has to bear the cost.

Average hospital stay

http://www.beckershospitalrevi...cross-50-states.html

Average household liquid worth

https://www.marketplace.org/20...financially-insecure


So end of day who bears the costs?

Mike

Just like taxes on corporations, we all do. Either in the form of higher insurance premiums due to increased hospital charges to cover the "no pays", or higher costs for routine work, etc. etc. That's why we have the multi-tiered cost system in the US, which I absolutely detest. The 4 tiers are, broadly speaking, no pays, medicare or medicaid, insurance payments, people who pay their own way who really get screwed. Generally, as a percent of costs, these equal, 0, about 30-40, about 50, and about 100, depending on whether the private payer can cut a deal.

We also have the highest costs for "parts" of anywhere in the world, usually by far. This would include but far from being limited to pacemakers, knee/hip replacements, etc. etc.

quote:

Originally posted by Gatogordo:
Just like taxes on corporations, we all do. Either in the form of higher insurance premiums due to increased hospital charges to cover the "no pays", or higher costs for routine work, etc. etc. That's why we have the multi-tiered cost system in the US, which I absolutely detest. The 4 tiers are, broadly speaking, no pays, medicare or medicaid, insurance payments, people who pay their own way who really get screwed. Generally, as a percent of costs, these equal, 0, about 30-40, about 50, and about 100, depending on whether the private payer can cut a deal.

We also have the highest costs for "parts" of anywhere in the world, usually by far. This would include but far from being limited to pacemakers, knee/hip replacements, etc. etc.

This has to be the worst healthcare resource allocation in the developed world.

If someone does not have insurance and gets sick - 99 percent of the time they are insolvent.

Healthcare providers are forced to provide service to customers who cannot afford then. After the service is provided they forced to hold a creditors claim that is largely worthless.

Anyone force this type of service provision on a restaurant.

Hungry customer comes in - we all know food is a necessity.

He is fed a high end steak dinner with all the trimmings.

It is already know he cannot pay for it but customer is still forced into insolvency.

Restaurant has a worthless claim.

Something is totally wrong in this health care system.

We dont force Ruth Chris to serve steaks to non paying customers.

If we are going to force healthcare service onto hospitals and emergency rooms - the state should bear the cost or we should allow the healthcare provider to discriminate using a price mechanism.

Mike

It used to be that many (all?) of the states had what they called "Charity Hospitals" or similar. They were usually attached to a university and were used for teaching, learning, etc while the patients who were typically destitute were cured or killed.

Somewhere along the line, the Feds decided this wasn't "fair" and said that patients had to be at least stabilized before they could be transferred somewhere else.

To give you a little background, a BIG part of our healthcare problem goes back to the Federal Gov. No surprise there, I'm sure. But it is true. Before WWII, doctors typically made a good living, but were not guaranteed a life of easy living like most are today.

What happened was that prices and wages were frozen by the Feds due to the war effort so GM and others that were building necessary war materiel, such as tanks, trucks, airplanes, etc could not find enough workers at prevailing, frozen wages, so.....they asked Control Board (whatever it was called, not really necessary to look it up for basis of this discussion) if they could give benefits, not monetary raises, to induce workers to come work for them. Answer was yes, so they offered healthcare insurance and that was the start of both the Doctor/Hospital Benefit Plan (fictitious to those who want to nitpick) because, unlike prior to War, when someone felt ill, he didn't have to take the Doctor a chicken, or, gasp, hard cash to pay for his services, so, no incentive to hold down fees, costs, duh!, they went up and medical costs have been beating the general rate of inflation ever since. A considerable part of this is due to the patients having no skin in the game, "the insurance will take care of it." It is obvious to any informed individual that the system, whether Obamacare, Trumpcare, or whatever, can not last as it is structured indefinitely or eventually it will absorb ALL the money.

Right now, you have a 4 party healthcare delivery system, the doctors, the hospitals, the insurance companies, and the Feds. The only one with any real incentive to control costs is the Feds, since they are the payers for Medicare and Medicaid. It is obvious why Doctors and Hospitals don't want to lower prices, and unlike what they say, without Federal prodding, insurance companies don't give a damn what something costs, they simply raise their rates to cover them plus a profit, of course. That leaves the Feds, and we all know how good they are at controlling costs.

The biggest problem facing us is the idea that healthcare is a right and everyone deserves it. In that sense, Obamacare was very successful.

I work for a company that ones and manages urgent care centers. Before Obamacare we did not accept Medicaid. With the advent of obamacare, the increase of 'minute-clinics' and the increase of co-pays our business model has changed. We now accept Medicaid. Our income has increased.

We see and treat patients who should be seen by their family doctor. We cost the system more than a family doctor, government or private insurance. The three top reasons people come to us instead of their family doctor are:
1. They don't have a family doctor.
2. They can't get in to their family doctor.
3. We are more convenient than their family doctor.

You can not add 20+ million people to the healthcare system and provide doctors for them.

The biggest problem with Medicaid is no incentive to not use it when unnecessary. We will see the same people for the same thing multiple times in one week. If these people had a $2 copay we might see them once. As a taxpayer it drives me crazy.

It is hard for me to imagine we will not end up with single-payer healthcare in the future. This will lead to rationing of healthcare and will take medical decisions out of the patient and doctors hands.

We are also going to see middle-level practitioners, nurse practitioners and physician assistants, with more and more responsibilities. They are not doctors! The good ones know their limitations.

The lobbyists have way too much input into the legislative process. They will make sure they don't lose their piece of the pie.

I work with a nurse who gets her healthcare through the VA. What I hear from her is not good. But, it is a snapshot of what single payer will be.

Tom

quote:

Originally posted by TWall:
I work with a nurse who gets her healthcare through the VA. What I hear from her is not good. But, it is a snapshot of what single payer will be.

Tom

An uncomfortable analogy. We've had the occasional medical problem while on the road and it's nice to be able to hit the nearest emergency room.

Problem is, not a bad thing, the US has the most options of care, when it comes to treating a disease or injury. Some countries it's take an aspirin and hope the problem goes away. Lot cheaper but not nearly as effective, way more people gonna die.

Grizz

The quality of healthcare available to Americans (us citizens) over 65 is very good.

The problem is a large number of Americans have no insurance or household balance sheets to pay for any real medical healthcare that requires hospitalization.

As a society we have said no right to healthcare but we hve also told hospitals you cannot deny medical services.

Eventually this issues (uninsured) and the increase in medical costs has to be addressed.

Like Warren Buffett said this weekend healthcare cost is a tapeworm on the us economy.

Mike

Here is another frustration. When I go to my dentist they can tell me to the dollar what my out-of-pocket cost will be for a procedure. Healthcare, no idea until claims are processed, appeals filed, etc.

I had outpatient surgery for skin cancer last year. I had to fight with the insurance company over prior authorization. First none was done. Then the doctor and procedure were done but not the facility where it was done. Eventually, it was all taken care of. But, it took multiple calls from me, my employer and the insurance broker my employer buys our insurance from.

We have good insurance. I pour over the EOB's when they come to try and understand what is covered and who is paid. I know lots of people don't. This is a scam by the insurance companies to reduce costs and get individuals to pay more out of pocket.

Tom

Mike,
As I have the utmost respect for your knowledge of statistics and dollars...I would be interested in hearing what you think the logical solution (knowing logic would never play a role) is.

quote:

Originally posted by ledvm:
Mike,
As I have the utmost respect for your knowledge of statistics and dollars...I would be interested in hearing what you think the logical solution (knowing logic would never play a role) is.

Lane

I second what Trump said - this is really complicated.

I dont know all the details of the us medical system cause I have tried my best to stay away from it in my professional (investing) and personal (healthcare) life.

I just see our current system as fundamentally flawed/half baked/inefficient.

We not have nationalized healthcare neither do we have free market healthcare. We have socialized medicine for citizens over 65. There is no real private healthcare system over 65 that does not largely depend on medicare.

The costs in the US are bloated but the quality of healthcare when you get it is A+.

I have self insured my Mom between 63-65 and it was terrifying cause if you get a medical emergency there is no cap or control or limit on costs. Imagine if one has $1 mil in the bank in cash and gets a stoke in the US and is self insured/uninsured. The costs of medical services has crazy mark ups with preferred discounts that an individual would never get. Like a steak dinner costing $1K but then massive discounts if you have a amex or visa card. The menu pricing for US healthcare is crazy.

I dont see healthcare costs as being sustainable. There is massive push back at the corporate level. My buddies with corporate jobs who had family health insurance as a employment benefit are every year getting more and more cost shifted to them via cost sharing. Some are paying 10K per year for insurance thru their companies.

At some point this has to be addressed and it will be addressed via national/single payer healthcare. Its coming weather I like it or not. I dont like it but If society says you cannot be denied healthcare there is no real alternative. Right now we have emergency healthcare coupled with individual/family insolvency for uninsured (most have little assets anyway).

The most import person in all this becomes some appointed but unelected official. Someone like Seema Verma

https://en.wikipedia.org/wiki/Seema_Verma

I would argue she is more important that most cabinet members or senators today.

Also single payer is not some simple solution that insures the unisured today in a clean sweep by government. What happens with a single payer is massive transfer from private companies to public - companies will just cut insurance and move workers to single payer.

The only way out is a decline in the quality of healthcare and increase in costs to get healthcare. People hate to hear decline in quality of healthcare.

We like to say healthcare is not a right but somehow we have managed to make a quality level of healthcare a right. And we have not denied emergency access to that level of healthcare.

There are no free lunches and this is all catching up. Cans will get kicked down the road - but economic reality always has a way of biting back.

Mike

Thanks for that Mike.

I agree Gato,jut look what Diners Club started in 1957 by starting "credit cards".

All i know is insurance Is getting ridiculous. Through my employer I pay $294 a week with a $6500 deductible. That's just insane. I don't know what the answer is but something has too give. In the part of the country where I live the average income is probally $25-$32000 and insurance is running $1200 a month a lot of people can not afford it.

Ask yourself why the the CEO of the country's largest insurer United Healthcare made $110 million in 2010 and $64 million in 2014. The businessmen, executives and administrators are bleeding the system dry.....yet the public thinks doctors make too much. How much is the 4 years of med school and 8 years of residency I did to become a specialist surgeon worth? I'm happy making a tiny fraction of those obscene salaries and I actually put a scalpel to skin. The system is grossly broken.

Norton,
I would be interested in hearing what you think the solution should be. Are you for single-payer?

I would love to hear a solution as well. My step daughter had a grant to Smith then went to med. school + is now + has been for several years a Dr.in Houston specializing in HIV related illnesses. Dedicated girl,she spends her free time going to Haiti or Africa doing seminars.When she 1st got out of med school she was approached by big pharm for a sign on bonus of $7,000,000.00. Thats right,7 million. And she was only one of many graduating students.She did'nt take it,but there you have another example of an out of balance system.

chicken or egg

The goal is (should be) to fix healthcare. So do we have to fix healthcare "insurance" before we fix healthcare? I think we do. The only way to do that is to charge people who can pay for people who can't. Just like Social Security. Am I missing anything?

I don't know if multi payer vs government(single) makes any different except for the spread of corruption.

I'd like to know what would happen if the cap on SSI was removed. I think it $110k now.

Once this is done (or maybe a parallel effort) we can try to lower the cost. I know I'm being simplistic.

http://www.motherjones.com/kev...st-markup-healthcare

The problem always becomes that when one entity pays the expense...that same entity controls the procedures/treatment/medication. How to proceed with any of those...should be a 'choice' of the patient and made with input and consent of the doctor.

With single payer...medicine becomes a fixed algorithm that doctor/patient must follow to be paid for. It is happening to a great extent now under ACA.

Prior to ACA...I am sure it went on but to a much lesser extent.

Unless you want to become a steer in feedlot receiving the generic mass treatment...healthcare decisions should be made by patient and doctor and a best fit for 'each individual.' Payment should be between the patient and its backing institutions.

Different people will choose and afford different levels care in that system and that is fine. Some will choose whatever someone will 'give' them. Others will take responsibility to provide for the best money can buy...nothing wrong with that.

For me personally...I want the right to dictate how my and my family's healthcare goes and don't want to be mandated by a preset algorithm arbitrarily decided by the controller of the purse-strings.

But for many...they are fine with the algorithm as long as it is free.

American "used to be" all about ensuring the freedom of the former...now it (USA) has become a guarantor of the latter.

I believe that is a huge step backwards.

quote:

Originally posted by richj:
chicken or egg

The goal is (should be) to fix healthcare. So do we have to fix healthcare "insurance" before we fix healthcare? I think we do. The only way to do that is to charge people who can pay for people who can't. Just like Social Security. Am I missing anything?


http://www.motherjones.com/kev...st-markup-healthcare

Did you not take note of something pointed out in Gato's other thread......50% of all births in this country are ALREADY paid for by medicaid. That's already "people who can pay paying for people who can't". Do you enjoy paying for people from womb to tomb?

Until EVERY single citizen of this country has "skin in the game" and people who can't afford to support themselves STOP having children they can't afford we're doomed to follow this unsustainable course.

Lane.....I don't think single payer is the answer. I will say that executives and the shareholders they're beholden to should not be getting obscenely wealthy from healthcare dollars (translated: YOUR AND MY TAX DOLLARS).

I'm part of a private group of physicians that provide value to patients, meaning excellent care at a fair price. Patients are consumers that pay hard earned money for care (except for the minions that don't/won't/can't), and in many cases what is provided by the current system that the public voted for sucks. Socialized medicine sucks! Ask the Danes that the last assclown in the WH used to invoke as what we Americans should aspire to.

One major problem: our legislators live in a different world than the one they advocate for by virtue of a system whereby political office leads to vast wealth.

You can't sterilize the poor (stop paying after the nth kid??)
you can't dictate wages to healthcare/insurance providers
you can't overthrow congress.

next

Well we're one step closer since November aren't we?

Sterilize the poor
Cap executive compensation in publicly traded companies
Overthrow Congress



next

I agree with you, wish someone would jump in and do it.

Thank you for the reply Norton.

Some Obamacare exchange premiums could increase an average of 44 percent next year in New Hampshire due in large part to Medicaid expansion and the opioid and mental health crises, according to a document obtained by the New Hampshire Union Leader.

Awesome.

The issue still is you cannot have nationalized healthcare over 65, a bloated healthcare cost system, A+ healthcare when available, no mechanism to deny healthcare in emergency situations, 40 mil plus uninsured who use the healthcare system via emergency medicine and no real means to privately pay for healthcare (try being a stroke victim and negotiating your hospital bill).

Something has to give - there is no free lunch and the can can only be kicked so far down the road.

Mike

https://fee.org/articles/the-c...s-healthcare-system/

Well said Mike. Look at the graph in the article I linked above. The number of administrators in healthcare has grown over 3000% since 1970 while physician numbers only 100% in comparison. The system is bloated beyond recognition by everyone but physicians.

So, do we simply let people die or are we looking at Soylent Green in America's Future???

Personally I( would rather die of a massive heart attack + have it be quick + not lose everything I have built up over a lifetime to leave to my boys. Not looking forward to dying but it is one of lifes guarantees.We don't get that choice unless one contemplates suicide which I do not. I don't have the answer but would be willing to listen to good ideas. Goverment sponsered medical is not the answer if looking at Government housing is any indicator.

I'm am open to reasonable ideas, but I can't help but wonder how many that are complaining are willing to watch their wife/parent or child die, because they can not afford the care needed.

None of us are guaranteed to be in the exact same shape, physically/financially that we are in today!

It is really easy to pontificate on a subject, until we are put into the situation.

This is the single most difficult public policy issue.

It's choices are tough political social and economic decisions by a society thru it's elected officials.

Don't worry Randall you are in the protected class - over 65 - just like my Mom.

But the decision on healthcare is a tough one and given that ar members can point the problem but not the solution reflects the tough decision.

Mike

quote:

Don't worry Randall you are in the protected class - over 65 - just like my Mom.

Wrong!!!!

Don't know about your Mother, but about half, maybe a little more than half of my Social Security pays for my Medicare monthly.

Working for the City of Fort Worth for 25 years gives me enough insurance to get me by.

The only thing protecting me is that I am in reasonably good health!

What is pitiful is that you and so many like you, hold it against those of us that played the game that was in effect when we began working.

It isn't our fault we are living longer and followed the rules that were in place!

How about people like myself and your Mom simply fall over dead, would that make you happy????

Stumpy.......you didn't plan for your future.......and now you are a bitter old coot.

.

Cap public funded medical expenses at some large but reasonable number, say 250K lifetime. No extra private insurance, no further treatments. Period.

People should quit clinging to the "one more day" hope and accept mortality. Not going to happen until there is no money left to waste on terminal cases and such things as organ transplants, but it should and likely will at some point.

And yes, I would willingly "morphine out" to save my kids vast sums of wasted money prolonging my life. There is a time to say "the parties over, turn out the lights". And I have told my family "Do not resuscitate".

quote:

Originally posted by Crazyhorseconsulting:

quote:

Don't worry Randall you are in the protected class - over 65 - just like my Mom.

Wrong!!!!

Don't know about your Mother, but about half, maybe a little more than half of my Social Security pays for my Medicare monthly.

Working for the City of Fort Worth for 25 years gives me enough insurance to get me by.

The only thing protecting me is that I am in reasonably good health!

What is pitiful is that you and so many like you, hold it against those of us that played the game that was in effect when we began working.

It isn't our fault we are living longer and followed the rules that were in place!

How about people like myself and your Mom simply fall over dead, would that make you happy????

Over 65 are subsidized thru Medicare. For a good many their social security goes to cover gap insurance. But the core cost of healthcare are borne by the government.

For all the talk of death panels and fall over dead - the federal government thru CMS makes administrative decisions on what healthcare to provide and how much to provide. We have socialized medicine in the us for those over 65 with the federal government making critical decisions on what to fund, what healthcare to provide and a whole bunch of other decisions (medical versus custodial care).

There is no fixed pay in or pay out - the government can change at will what is provided in Medicare. Just look at trump's proposed budget.

Mike

quote:

Originally posted by Norton:
Ask yourself why the the CEO of the country's largest insurer United Healthcare made $110 million in 2010 and $64 million in 2014. The businessmen, executives and administrators are bleeding the system dry.....yet the public thinks doctors make too much. How much is the 4 years of med school and 8 years of residency I did to become a specialist surgeon worth? I'm happy making a tiny fraction of those obscene salaries and I actually put a scalpel to skin. The system is grossly broken.

The cost of overhead isn't visible to the patient, in general. Maybe it should be broken out on the billings. When I cost things out, G&A is an explicit item on the list.

quote:

And I have told my family "Do not resuscitate".

Lora and I have both clearly made that decision.

Problem is, unless it has been done in writing, children and Grand Children can/will and do circumvent such wishes and keep parents/grand parents and siblings on life support, long after they should be let go.

Point is, Americans are living longer and combining that with the birth rate and an economy that is in trouble, health care for the masses is going to be a problem for decades to come.

There are no easy solutions or answers for anyone, especially when it comes to themselves or their family! It is really easy for any of us to say "Let Them Die", until "Them" is a parent or child in our own family.

The fact is....those of us that pay into the system our entire lives will suffer because of vast numbers of people draining it who contribute nothing.

Here's one reason we're all drowning....

quote:

The fact is....those of us that pay into the system our entire lives will suffer because of vast numbers of people draining it who contribute nothing.

That is the price that is paid when a countries population expands beyond what its economy can support.

People living longer, increased immigration, jobs lost due to manufacturers leaving the country or advances in technology resulting in mechanization replacing human workers, all combine to place pressure on the systems that were in place.

There are no easy answers, any action taken to reduce the stress one segment of the population is dealing with only places new/added stress on another segment.