Net cost. As in not counting the money paid to insurers that then gets paid to providers.
Looking up the numbers, in 2021, the net cost of health insurance was 6%. of healthcare spending nationally. Still that was $255.7 billion and substantially more than government administration.
Our spending though, on a per-capita basis is over twice that of other developed countries. Public insurance (Medicare, Medicaid, CHIP, etc.) pays out 42% of healthcare payments. On a per-capita basis, that works out to around what Canada spends on Medicare, except they manage to cover the entire population.
Uh. That’s administration of Medicare billing. That’s always been outsourced. That has nothing to do with the Physician Fee Schedule (PFS) which are used as a basis for Medicare and Medicaid.
Medicare rates are dictated by CMS (or raised by Congress). They are different per region because the rates are set based on the estimated cost of the procedure - which varies by region.
There’s also Medicare Advantage which does involve private insurers but those rates don’t affect Medicaid.
Still not how it works. CMS accepts rates set by the intermediates. Formally, that means that CMS sets rates but they rarely if ever deviate from the intermediates’ recommendations for changes, which are based on percentage adjustments of actual payments by both insurers and medicare.
Not directly but any bump in private insurance rates gets echoed in Medicare and Medicaid. Because if the rates for those are too low, many physicians will just stop accepting those patients, particularly specialists.
CMS determines payment amounts for physicians’ services based on the underlying relative values that CMS assigns to about 10,000 services included in the physician fee schedule. Specifically, for each of these services, there are three relative value units (RVU) that correspond to the three components of physician payment
I mean, yeah, lobbyists exist. After CMS publishes the Proposed Rule for new rates in the Federal Registrar, there’s a 60 day comment period. That’s dominated by the RVS Update Committee (RUC) which is just an AMA-related lobbying group.
CMS does not, however, hand over decision making on fee schedules nor does any of it involve insurer rates. The model used by CMS doesn’t allow it. Everything has to be justified based on provider cost.
I’m not going to derail this thread with an exercise in futility. Been down that road before. No thanks. But how you think it works on paper is not how it works in the real world.
Because uncompensated care means increased rates on government. And it means that health problems are ignored till there’s a crisis and it costs more.
Whereas a holistic system would include those costs, lower the administrative overhead for uncompensated care, remove the excess used for shareholder profits and provide health care earlier- before it becomes a crisis - and not using the ER.
CMS does use a surveys of the providers themselves, but of expenses rather than the provider’s inflated asking price for a service. That does include provider invoices though - but ones sent to the provider. They’re also using information on pricing of equipment, supplies, wages, etc. sources from data vendors or other government sources like the VA.
Everything CMS uses to determine its fee schedule is required by law to be documented when they posts their yearly fee schedule update. It’s long.
Honestly, I think CMS does a good job. My ire is directed towards Congress’ endless bowing to the massive healthcare provider lobby to prevent CMS’ cost cutting measures from going into effect.
It’s insane, and it’s obscene. I note they also don’t mention basic things like why tylenol IV is $1000/dose, or how patients get billed $50 every time the practitioner changes gloves. I’m sure everyone is helped by a 1000 page exhaustive description of why it’s necessary to increase those costs by CPI+10%, without ever mentioning how inflated the costs as charged to patients is in the first place.
You’re buying into the bullshit by looking where the industry is telling you to look. Take a very large step back: how much profit do the Insurance companies make? Like, just the profit. $20billion a year here, $16billion there, $5billion here and here and here, that all adds up to money which patients and the government are paying and isn’t going to healthcare: that’s all getting skimmed off. That’s not taking into account the accounting fuckery that makes the recording and movie industries blanche and say “oh, that’s going a bit far”. See prices above. There are entire industries in health insurance claims (read: finding ways to say “no”) and insurance code interpretation that are parasitic on health care: even discounting the profits made, all those people working there, all the business costs, all the tax deductions, are entirely parasitic on, and sucking resources away from, the core business of “providing health care to people”, and a massive amount of the costs of doing that are going into the administration of the absurdly complicated way they’ve arranged doing it.
There are other countries were people don’t pay more for healthcare than for rent (only to be told that whatever they’ve been paying doesn’t actually cover whatever it is that’s wrong), where people can walk into a hospital with a problem, and the biggest charge they’ll be hit with is parking, where hospitals and doctors still manage to do very nicely thank you, and where the total cost of health care is an order of magnitude lower than it is in the US.
Your Health Care system is pathological: you pay orders of magnitude, on the state and the personal level, more than anyone else in the world, for worse average health care.
Pointing to some 1000 page annual report and saying that they’ve justified something or other with a carefully considered analysis of the blah blah blah… it’s a distraction. It’s avoiding answering the wrong question. It’s a magic trick, drawing your attention to the yellow ball in the magician’s left hand, tracking which cup it’s going into, so that you don’t notice the bloody great big tiger that’s about to eat you.
Without going into endless detail, when I had a severe medical problem a couple of years ago all the ER visits, specialist appointments, CT scans, MRIs, biopsies etc. etc. in three different provinces cost me NOTHING.
I still bitched about the cost of parking, though.
Yes, all this! Thank you! Our health care system is for profit (generally speaking) and so all of it is shaped by that for-profit motive, even non-profits, public hospitals, and public insurance (medicaid especially).
We can do better by adopting other models found in Western Europe, up in Canada, or down under, but we don’t, because so many of us have bought into the delusion that the free market can fix all our shit. It can’t. In the case of health care, it’s literally killing people.
The argument i hear most often is that under those systems, there is a longer wait for elective procedures. Elective procedures. Yes, indeed, you will have to wait for non-urgent care, with the trade-off that your fellow citizens can access necessary care. Of course, to the fascists, this violates the “all for me, none for thee” rule. To which i can only reply, fuck off.
Not sure about Alabama, but in Texas, it’s for ideological reasons. Pretty sure lobbying has something to do with it, as well.
There’s the problem; it is profit-driven, with toll-keepers everywhere.
The post by @RickMycroft sums it up…
According to this chart, those yearly income limits vary from inadequate to cruel…
For a family of 3, the limit in Wisconsin is a bit over $21k, while in Texas it is the princely sum of $3.6k. Alabame is little better at $3.8k.
If you are single with no children, Wisconsin deems you worthy of assistance if you make less than about $12.5k. In the rest of that list of infamy, you are SOL if you have any income at all.
Republican health care:
“Don’t get sick. If you get sick, die quickly. Thoughts and prayers…”
If the christofascists get in power, I wouldn’t be surprised if they shut down health care in this country completely [except for the Chosen Few, of course]:
“Too bad you got sick/injured, but it’s part of God’s Plan. Besides, you must have offended him, so it’s your fault, anyway. Begone, heathen!”
IDK about the rest of Europe and so on but here in the UK there is private medicine if you want to have speedy elective procedures, on top of the free at point of need National Health Service.
