Right.
1. When Commonweal killed the blog, they offered me a job writing two articles a month for the online edition for which they would pay be $200 a month. But when I was writing for the blog, they paid me $200 a month to write two articles a week. I burned out.
Background. From August 2013 to August 2014, I had cancer, a heart attack, depression, got "laid off" by my insurance company (they didn't want a sick executive), and I found out that my wife had been cheating on me through all of this so I also lost my wife, family, house, and almost everything that I owned (the ex blamed me for everything so she kept most of my stuff and discarded it and I ws too poor to stop her).
Bad times. I was out of work for three years (no one wants to hire an old CFO who had health problems).
And Trump was elected.
So it's been a rough patch. I am now working night shift as a grocery clerk at a buck and a half above minimum wage. Despite the cancer and heart attack, I have not been to a doctor since 2015. Can't afford it. Somehow all of this has had a bad affect on my writing. I ended up not being able to write for Commonweal anymore. Or for anyone. About anything. Too bad,
so sad.
Anyway, to the important stuff.
2. Trump has decided that he wants to run (in part) on health care. He has no plan, of course, despite saying once again that he has one. But he is trying to do something. He wants to sign an executive order requiring providers and insurers to publish all of their discount data. That is, they are to tell us what kind of discounts all providers receive from insurers. It won't work Why? Here are some points.
Insurers don't want to give this information out, because they think that if the discounts came out:
a. Everyone would discover that the largest insurer in any market has the best discount, so why go to any competitor whatsoever
b. They would discover that while a is true, the largest insurer in any market does not necessarily have the best discount with every single provider
c. Some providers have sweetheart deals with some insurers in order to get "steerage" to their facility, a deal that can only work if it is subsidized by all the other insurers
d. The public might actually see that providers mark up their prices, on average (for hospitals) 300 to 400 percent (and up to 1,000 percent in some cases).
There is a nice capitalist theory behind this. The theory goes that if all prices were transparent, then providers and even insurers would have to start forcing prices down, since consumers would now have enough information they need to shop around. The move would make everyone competitive and, naturally, they would compete.
Please allow me to piss on this parade.
a. People don't buy their own medical services. They use the insurance that has been bought for them by the companies they work for. And if they were to find that Blue Cross has the best discount for their hospital, they are not then going to march to their HR department and demand that their company switch from Humana to Blue Cross. Why? Because they don't do it for anything else. They don't even do it if they find out that the company across the street is paying more. Why? Because every company in the US is designed to keep workers from doing this. Unless, of course, they have a union. That's the point of not having a union, from the company point of view.
b. Price is irrelevant in several ways. First, it doesn't reflect what's really going on. The true deals and side deals are more complicated than any price point. Any significant treatment involving multiple doctors or providers (primary care doctors plus specialists plus radiology plus other testing plus hospitalization plus post hospitalization care and testing etc etc means that there are multiple actors with multiple price points all of which may have a higher or lower average but which you the patient can't mix of match yourself to line up all the best deals. Medicine is heavily integrated from the point of all these deals. You can't just take it apart and reintegrate it because Milton Friedman says you could. Second, you might find out exactly what the price is, but unless you know that the costs are to the provider so what? There can be tons of bogus "administration" costs crammed into the "price" and all the "best price" does is reify this. In other words, knowing relative charges doesn't address at all the problem that many of the charges are unnecessary. Your good "free market" theorist will say that this is not a problem, because providers will then be driven to eliminate these charges via price transparency to lower their prices, which is what price transparency is supposed to do. But we get thrown back into the problem that Trump wants prices posted, but not costs. The costs behind the prices will still be opaque. And this is not irrelevant in a market that is as monopolized as the American healthcare market. The providers all know what's going on with the other providers. They are monopolizing in order to keep prices high. It's a nice theory that despite this price transparency will keep prices low. However:
3. Medical care doesn't work that way with a market. It's not like deciding whether you want crab legs or Kraft dinner for dinner. For the truly expensive stuff, price is only one of a number of considerations. People simply do not shop for medical services based solely on price. They don't. And if they don't, then a movement to create the conditions to cut costs solely on price considerations is simply going to fail.
Let's review.
a. People don't consume medical services based on price. They go where their company, who hires the insurer, tells them where they are allowed to go.
b. Companies don't hire insurers based on price differentials between providers. They hire them on the basis is price differentials between insurers. But
c. Insurers average all costs between both providers and between the various discounts they have with each provider AND the unrelated facts of the kind of medical utilization they pay for. Still
d. If the free marketeers are correct, it will emerge that on average the largest insurer in the market has the best discounts. Free market logic says that consumers will flock to that insurer, which even by the free market theory means that that insurer will obtain more of a monopoly which of course is something that makes prices go up.
A free marketeer might argue that if these larger monopolies cause prices to go up, then rugged capitalist entrepreneurs will come in and create insurance companies that will compete at lower cost. Nice theory. I love that theory. It gets me very excited. Except that it depends on providers working for even less money from the rugged capitalist entrepreneur's company. Good luck with that.
SO, once again, the Trump plan won't work, although it looks good on a napkin after a few drinks.
(At this point I was going to talk about Medicare for All and why I think it won't work given what we need, but I am out of space. And energy. Please remember me in your prayers. And forgive me for whining.)
Patrick, I am sorry that you've been going through a very rough patch. You will be in my continued prayers. It's certainly easy to understand how all that has been going on in your life would induce a case of writer's block.
ReplyDeleteIt seems that all the obfuscation that goes on in the insurer/provider/hospital networks is a feature, rather than a bug. We are both on Medicare now. It has been educational. My husband has benign (so far) prostate enlargement with elevated PSA which we have to keep an eye on. The latest test was last fall, a contrast MRI guided biopsy. We freaked out when we got a bill from the University of Nebraska Medical Center for the MRI part, which was in excess of $3000. Both Medicare and the supplemental insurance turned it down as being "unauthorized" even though the urologist had recommended it. Which resulted in frantic calls to the UNMC billing department. They basically said, "chill out, we deal with this all the time, they always turn it down the first time." After much back and forth, Medicare paid a bit over $ 300. The rest went away. Presumably the only patients who would have had to pay the whole $3000 would be the ones who were uninsured. Which would be the ones who could least afford it.
Thank you for explaining!
ReplyDeleteCouple of observations:
1. As an Obamacare patient, I do have some ability to choose my insurer. I have chosen cheaper policies, but it always averages out in uncovered services or higher deductibles. I'm going to end up paying about $300 per month for medical care no matter which carrier or product I choose.(Except for that $5,000 stress test, of which I have to pay $1,600. If I didn't have heart problems before I got 'em when I saw that bill!)
2. I will be 65 in September, and, since January, I have not answered the phone or the doorbell because I get calls every 20 minutes from 9 a.m. to 9 p.m. from companies and agents wanting to sell me supplemental insurance.
If you have a retirement package from your job, you get what your employer decided to put into that package, same as when you were working. It may or may not be the best deal, but you don't have to think about it.
If, like me, you retired with nothing but some very modest savings and have to put together your own Medicare supplemental plan, you know that it is impossible to compare plans side-by-side because they all cover different things. For instance, some supplementals cover out-patient care plus meds. But they may not cover a lot of meds. Some med-only supplementals cover more meds, but then you're left with having to find another plan to cover out-patient costs.
If you need specialist care, the variables become even more complicated because some supplementals restrict you to care within a network--and you are screwed if your network doesn't include all your damn doctors.
Finally, you can get great deals on medication plans if you agree to go to a specific pharmacy or get by-mail drugs. The problem is that the pharmacy will start dictating what meds you can take and how many of them. (Ask me how my 80-year-old mother ended up in the hospital for benzo withdrawal and alcohol poisoning because her policy decided she should only be taking half of what she had been taking for the last 40 years. It was real fun.)
I am guessing none of this will be simplified in my lifetime because the confusion is advantageous for the supplemental companies.
So Medicare for All? It's like insanity for all, and I hope you will share your thoughts as you are able.
Oh, also, you can hire an agent, but these people will try to sell you the plans that give them the biggest commissions.
3. People got paid for being official bloggers at dot.Commonweal?! Hell, I was giving it away. Story of my life.
4. My meds give me insomnia. When I can't sleep--which is two or three times a night--I pray for the sick, the friendless, the worried, and sad. I got you covered.
The Medicare Advantage plans look attractive on the surface. But everyone we talked to said "don't do it." So we didn't, we went with traditional Medicare. The trouble, as I understood it, was that once you go with an Advantage plan, it's really hard, if not impossible to go back to traditional if you don't like Advantage. Most providers will take Medicare (at least around here) but it sounds like Advantage is more like an HMO and you're more limited as to providers
DeleteYes, I heard the same thing in my cancer group. Take regular Medicare and supplement it. If the cancer progresses to something trickier and more acute and you get Advantage, you will be stuck in the network and unable to access more knowledgeable doctors at the university hospital. Also difficult if you plan to move, which we do in the next two to five years, and the network doesn't extend to where you want to go.
DeleteIn my case, I will probably do OK, at least to start, with A, B, and a good D (prescription drugs, the biggest expense for people with chronic, progressive illnesses).
Everyone I know who uses Kaiser Permanente Sr. Advantage is very happy. Don't know why the people Katherine knows don't like theirs. But KP is a huge network and has been known to send difficult cases to Stanford or UC San Francisco (one of THE VERY BEST IN THE WEST). I'm still covered by my hubby's group health plan (he has been on LTD since 2003 and still is considered an employee) but one of these days I/we will switch to KPSrAdv.
DeleteOK, neophyte here, but isn't an advantage plan a private plan instead of Medicare? It has to cover parts A and B, just like Medicare, but what advantage plans cover beyond that varies by company and product.
DeleteAdvantage plans also vary from state to state, just as Obamacare plans do. I won't say this 100 percent certainty, but Kaiser was either not one of the plans available to me in Michigan or it was so expensive that I rejected it out of turn.
California is a healthier demographic than Michigan, so advantage plans are going to be cheaper there, and likely more plentiful.
I am glad for folks out there who have recourse to a good advantage plan that offers great coverage, of course.
Yeah, we don't have Kaiser here either. I've heard good things about it in California, but it must be a regional thing. The Advantage plans here are "proceed at your own risk".
DeleteAdvantage plans are HMO's for Medicare. If you join one, Medicare pays a premium (called in this case a "capitation") directly to the insurance company. The company sends it on to the provider and like an HMO, the provider takes all the risk but "manages" all the care. Hospitals and physician groups that like HMOs like these. They will even sign a contract for less than 100 percent of what they get for straight Medicare. This, because it steers people to their practice and because, being an HMO, they get the capitation every month whether the patient goes to the doctor or not. Whole older people do get ill, we have had almost a decade of very high medical prices and people are much more careful about going to doctors than they used to. So these are pretty profitable compared to how they used to be.
DeleteIt's easy to understand why people go to the doctor less if they have no insurance or have a high deductible. But surprising that it is true of those in an HMO. I have to think it is in part due to demographics. People with children are more likely to take them to the doctor. Speaking for myself, older people are more likely to wait and see if a minor illness improves on its own. I think there's a trust (or lack of it) thing going on, too.
DeletePatrick, I am so sorry about all those personal difficulties. You're right up there with Job.
ReplyDeleteIf you don't mind my asking, are you a member of a union now?
Jim, I am a member of a "union".
DeleteInterestingly, I worked for this company for eight years in the 1970's when I was in high school and college. Then, they had a union and I was the union steward in our store for a couple of years. It was an excellent union. But in my last year as a steward, the union sold out. Before they did this, there was no differential between full and part time wages. Food stores are staffed at least half by part timers. In the sellout, the union allowed the company to roll back part time wages significantly. We were told that current employees would be grandfathered in. I was at the convention where we had to vote on this. I stood up and said that the following would happen. First, current grandfathered workers would get fired. Second, the store would increase the number of cheaper part time employees. Third, gradually full time wages would fall back towards part time levels. The union exec told me that it was impossible that any of this would happen.
Forty years later, it has all happened. My starting wage was minimum wage plus enough extra to pay the union dues. The store I work at has not had a union steward for many years. Being a rather active person, in about a year I have clawed my way up the first rung of the ladder. I switched to nights and became night crew chief. The promotion netted me fifty cents an hour.
The company, like the union, has passed through many hands since the seventies. It is now owned by a California chain. It's business model seems to be to run it on a shoe string and to suck out as much as possible. It has more of a feel of an "investment" than of a neighborhood food store. It's infuriating.
So, does the union in its present incarnation provide any benefits for its members, or is it more or less just a professional organization?
DeleteI wouldn't dignify this union with the term "professional organization".
DeleteWhere it is sort of strong is in forcing management to adhere to the rules around labor discipline (punishments and firing). It's rather hard to get fired there. But they are rotten on wages and benefits. My store is part of Chicago. The PPO that's available is Blue Cross of Idaho (sic). What I know that my co-workers don't know is that the mothership didn't even bother to get an Illinois insurer. They are piggybacking on the fact that the different Blue Crosses allow Blue Crosses in each state share networks. But for a fee, which would not have to be paid if my company (which is the largest food store chain in Northern Illinois, so there's no excuse) would deal with a local payer.
I think this post, and Jean's comment, both do a good job illustrating the difficulty in being heath care consumers.
ReplyDeleteI probably exemplify all of the dysfunctions of being a health care consumer. I'm not knowledgeable at all about medicine. I don't have a lot of time (or rather, thus far haven't had to carve out the time) to shop around, price-compare, etc. My company gives us insurance, we use it. I guess we shop to this extent: my wife's company also offers insurance, so every year during open-enrollment time, we compare the cost of her plan to the cost of my plan, and pick the one that is cheapest. Even that may not be a pure price decision, though - if her plan is cheaper but would require us to get new doctors, we'd probably pay more. Not that our current doctors are necessarily the greatest in the world, but we've settled on them over the years because we're basically happy with them, and we know from experience that choosing a new doctor is fraught with risk.
Donald Trump exemplifies many of Patrick's critiques of capitalism: he's personally dishonest, his companies operate in bad faith, he exploits workers, and he wouldn't hesitate to put his thumb on the scale via government influence if given the opportunity. His only free-market theory, to the best of my knowledge, is "Screw everyone else". I don't look to him to solve any marketplace issues. I'd rather he just left everything alone until the nightmare of his presidency ends.
His idea will go nowhere.
DeleteHe proposes ideas to regulate the health care industry for the same reason he threatens tariffs on foreign governments every 10 minutes: To extort favors.
In this case, he'll withdraw the whole idea once Big Healthcontributes to his re-election campaign.
His idea to require drug companies to publish the cost of their medications in TV ads died, likely because Big Pharma coughed up some $$.
We must all gird up our loins, grit our teeth, and focus on getting rid of him.
If some new (please God) POTUS will get a hand on prescription drug costs and get the elected paid representatives of the lobby industry to force the ability to negotiate the prices (as does Medicare and the VA), that will go a long way toward lowering medical costs in the US.
DeletePatrick, don't worry about whining. You've got the right to sing the blues. You're back in my prayers daily.
ReplyDeleteSo I sashayed into my primary's office and said my hip hurt mightily and my leg almost gave out and made me fall, what's going on? And he said, "OMG! You probably broke your hip. Go to the ER and get an MRI quick!" I suspected he was hysterical because he has diagnosed Mersa when I didn't have it and an aneurysm in my stomach when I didn't have one. I suspected a blood clot. So my friend drove me to the ER at the hospital where my heart and prostate guys have privileges. The ER said they don't do MRIs, but they would see what I have, and they took X-rays and did an echo, and pronounced it's arthritis. To which I said hooray, since the diagnoses, my doctors or mine, were worse.
But my question to Mr Trump (which Unagidon, of course, has answered) is: While I was at my primary's office, should I have comparison shopped for ERs to see if there is a cheaper one I've never been to? And should I have checked the prices that hospital puts on hip replacements, just in case? Because at the time, I was interested in getting my pain diagnosed, not in playing CPA with charts designed to cover up the fact that Trump had not repealed and replaced Obama care.
When the EMs come to scrape someone off the road after a traffic accident, the patient really has neither the time nor the desire to comparison shop before telling them where to take him. Even if there is plenty of time, what good would price lists do?
I got my current primary by asking my urologist who he'd suggest. If I had had a between taking advice from a doctor who knows me or what a price list shows is the cheapest doc in town for an ordinary office visit, who should I have chosen?
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DeleteOh, man, I am laughing out loud at your "hysterical doctor" story. "Go to the ER and get an MRI quick!"
DeleteMy doc is really blase. I told her about my heartburn, and she rolled her eyes and asked, "Do you take Zantac?"
I said no.
She said, "Well, start. Get the generic OTC to save money."
It seems like if we put all the money that presently goes into the healthcare "basket" into a single system, we ought to be able to do it, and have money to spare. Of course it's not that easy. For one thing, around 55% of people in the USA have employer based insurance. Most of those who have it, like it, or at least don't hate it. It could be said that if employers put the same money into a single system, the single system could be made to work. Except employers don't want to do that, because health insurance is one way they attract and keep employees. The more libertarian and capitalist based suggestions have said that employers should just add to people's pay the amount that they spend on health plans and let them choose their own. Except they're not going to do that. My former employer spent about $13,000 on insurance for "employee plus one" coverage. there was no way they wanted to pay that amount directly to me, or to the government in the form of taxes to fund single payer, because there was no advantage to them. As it is, they can take it off their taxes, and it wasn't counted against us on our taxes. So people who have good insurance through their employers aren't very strongly in favor of single payer. The problem arises when they lose their job and the coverage is no longer there. I'm not sure what the answer is.
ReplyDeleteI will write about this soon. There is more than enough money flowing through the system to pay for universal healthcare. And in fact, businesses would even take a tax if the tax was predictable, since annual healthcare increases are not. Finding a tax revenue flow from other places, like say a tax on stock transactions, that could keep down or at least stabilize not costs but payments would help too, just like some of the adult countries do.
DeleteBut the subject, as you know, is complicated. I might have to do a three part presentation as I did once before just to get it all.
Patrick, I spend one to three hours per day listening to a divorced friend talk about his ongoing travails with his banshee ex. Ongoing because they have a 9 year old daughter and joint custody. It took almost all his savings to fight for joint custody which meant fighting the whole barrage of slanders including her claim he was molesting their daughter. He came out clean in the grilling by the DYFS psychologist. She not so well. At the very beginning of the process, he was contemplating suicide. He credits me with talking him out of it but I was listening a lot more than talking. If you want to unload here, it's all right by me. I hope you have someone around who can listen.
ReplyDeleteSuicide has occurred to me too. And another bit of bad luck that I have had (or rather and taking) is that all but one of my closest friends has died in the last four years, which makes me strangely braver about death. But I still have dependent kids (teens) and I know that if I ever did something stupid like that, it would kill them too.
DeleteIn general, I feel as though I am being punished. But being a sort of good old fashioned Catholic I am just trying to bear it. There it is.
Kurt Vonnegut said that children of suicides have a much higher suicide rate, and that's why he didn't blow his brains out. That thought has kept a lot of people going, I think.
DeleteLosing friends is very hard. I do understand.
Patrick, I am so very sorry about so many bad things happening to you in such a short period of time. A little too much like the trials of Job. I sure hope you've yelled at God like he did.
ReplyDeleteI get dizzy trying to understand our tangled health system,even with your guidance. We are both on medicare with an (expensive) supplement. Advantage plans don't work for us, because we travel a lot - domestically and internationally. Our supplement picks up overseas medical with a $200 deductible.
My husband is 78. (I'm 71) He looks 10 -12 years younger, very active and fit (and all his hair) but with several chronic issues. I have so far been lucky with my health - no chronic issues, no regular medications. I have never broken even with our supplement plan, but my husband more than pays for his supplement (unfortunately) almost every year, including a couple of trips to ERs while traveling.
When my husband was still working, he had a stroke while we were in France. Suddenly, we were immersed in the French medical system (rated as one of the best in the world, and considerably higher than the US). Our US internist assured us that he would get top notch care, and that France is known as having "the best neurology" in the world. Fortunately my husband made a full and rapid recovery. While there, he was overnight in two different hospitals (transferred to a hospital with better neurology from the first small hospital), had every expensive test - CAT, MRI, echocardiogram, ECG, etc, etc, including a swallow test at one point. He had been unable to swallow at all, so they had eventually put in a feeding tube. But he could swallow again after a few days. They let us fly home after a week, with special care, and a medication that he had to inject into himself during the flight. Once home he was immediately admitted to Johns Hopkins in Baltimore for further tests.
First difference - when we got to the ER in France he was immediately taken to the doctors - I was not asked to sit at an admissions desk and pledge either insurance, a credit card, or our eldest grandchild for payment. After the CAT to rule out a brain bleed, he was sent to another hospital 45 minutes away for an MRI. Back to the first where he spent the night, (the diagnosis of stroke was not clear yet - it was an unusual type) and then to a third - about an hour away - a hospital with a top neurology dept. So, 3 hospitals, 2 very long ambulance rides - without producing an insurance card or a credit card or even a mailing address. The 3rd hospital did ask for our address eventually and told us they would mail us a bill. The total was ~5000 euros, about $6000 at the time - for a non-citizen. If he had been French, he would have paid nothing. I looked at what the French pay to the system via taxes - about the same total as we did here, both when employed and via medicare+supplement. Accessible by everyone, including poor people and those with pre-existing conditions.
Two days at Hopkins was $80,000 (not what our insurance company paid of course, but what we would have been asked to pay had we not had health insurance). Partly that high due to a serious medical error - the new resident interventional radiologist dissected my husband's femoral artery, necessitating a 4 hour operation and 3 stents to repair. We pay for their errors too. This experience induced me to research the systems of other countries. The US spends FAR more/person on healthcare than any other OECD country, but is ranked far below them in terms of quality. It is the only major developed country that does not have some form of national health insurance. I hope the Dems running for Pres can offer some well-thought out alternatives, as our system is a scandal. “Medical error” is the 3rd leading cause of death here, and not even in the top 10 in the other OECD nations.