Everyone we know is paying the hospital already.
August 19, 2019 7:24 AM Subscribe
“Lots of medical cases again today,” the judge said, and then he called court into session for another weekly fight between a hospital and its patients, which neither side appears to be winning. (SLWaPo; here's a non-paywalled mirror)
So far this year, Poplar Bluff Regional Medical Center has filed more than 1,100 lawsuits for unpaid bills in a rural corner of Southeast Missouri, where emergency medical care has become a standoff between hospitals and patients who are both going broke. Unpaid medical bills are the leading cause of personal debt and bankruptcy in the United States according to credit reports, and what’s happening in rural areas such as Butler County is a main reason why. Patients who visit rural emergency rooms in record numbers are defaulting on their bills at higher rates than ever before. Meanwhile, many of the nation’s 2,000 rural hospitals have begun to buckle under bad debt, with more than 100 closing in the past decade and hundreds more on the brink of insolvency as they fight to squeeze whatever money they’re owed from patients who don’t have it.
So far this year, Poplar Bluff Regional Medical Center has filed more than 1,100 lawsuits for unpaid bills in a rural corner of Southeast Missouri, where emergency medical care has become a standoff between hospitals and patients who are both going broke. Unpaid medical bills are the leading cause of personal debt and bankruptcy in the United States according to credit reports, and what’s happening in rural areas such as Butler County is a main reason why. Patients who visit rural emergency rooms in record numbers are defaulting on their bills at higher rates than ever before. Meanwhile, many of the nation’s 2,000 rural hospitals have begun to buckle under bad debt, with more than 100 closing in the past decade and hundreds more on the brink of insolvency as they fight to squeeze whatever money they’re owed from patients who don’t have it.
This post was deleted for the following reason: Poster's Request -- frimble
Meanwhile, A Mexican Hospital, an American Surgeon, and a $5,000 Check (Yes, a Check) -- A novel twist on medical tourism to avoid the high cost of U.S. health care saves an employer money and even earns the patient a bonus. (Phil Galewitz for New York Times, Aug. 9, 2019)
posted by filthy light thief at 8:13 AM on August 19, 2019 [24 favorites]
The hospital costs of the American medical system are so high that it made financial sense for both a highly trained orthopedist from Milwaukee and a patient from Mississippi to leave the country and meet at an upscale private Mexican hospital for the surgery.Both the OP and this story point to the same obvious conclusion: the American medical system is broken.
Ms. Ferguson gets her health coverage through her husband’s employer, Ashley Furniture Industries. The cost to Ashley was less than half of what a knee replacement in the United States would have been. That’s why its employees and dependents who use this option have no out-of-pocket co-pays or deductibles for the procedure; in fact, they receive a $5,000 payment from the company, and all their travel costs are covered.
Dr. Parisi, who spent less than 24 hours in Cancún, was paid $2,700, or three times what he would have received from Medicare, the largest single payer of hospital costs in the United States. Private insurers often base their reimbursement rates on what Medicare pays.
posted by filthy light thief at 8:13 AM on August 19, 2019 [24 favorites]
We're in a Republican trifecta here, but we are trying to get it as a ballot initiative in 2020.
I don't know how successful this will be since the voters passed minimum wage increase and turned down right to work and those are being fought against in the state legislature. Thank you for subscribing to Missouri Facts.
posted by fluttering hellfire at 8:16 AM on August 19, 2019 [13 favorites]
I don't know how successful this will be since the voters passed minimum wage increase and turned down right to work and those are being fought against in the state legislature. Thank you for subscribing to Missouri Facts.
posted by fluttering hellfire at 8:16 AM on August 19, 2019 [13 favorites]
Also Medicaid expansion may help juice turnout for State Auditor Nicole Galloway vs Replacement Governor Mike Parson. That's the big name race here in 2020. I'd put MO-2 (Ann Wagner's incumbency) as the second most important.
posted by fluttering hellfire at 8:21 AM on August 19, 2019 [5 favorites]
posted by fluttering hellfire at 8:21 AM on August 19, 2019 [5 favorites]
And Poplar Bluff? Well, you get what you vote for, MO-8.
posted by fluttering hellfire at 8:28 AM on August 19, 2019 [2 favorites]
posted by fluttering hellfire at 8:28 AM on August 19, 2019 [2 favorites]
And Poplar Bluff? Well, you get what you vote for, MO-8.
Are you sure the black family profiled in the story got what they voted for?
posted by clawsoon at 8:34 AM on August 19, 2019 [15 favorites]
Are you sure the black family profiled in the story got what they voted for?
posted by clawsoon at 8:34 AM on August 19, 2019 [15 favorites]
Both the OP and this story point to the same obvious conclusion: the American medical system is broken.
My consistent snarky response to this declaration, first given to Keith Ellison when touring an American Cancer Society house, is "What system?"
posted by Mental Wimp at 8:59 AM on August 19, 2019 [5 favorites]
My consistent snarky response to this declaration, first given to Keith Ellison when touring an American Cancer Society house, is "What system?"
posted by Mental Wimp at 8:59 AM on August 19, 2019 [5 favorites]
Thanks for the not-paywalled version.
Dealing with my Primary Care Provider's marginally competent billing office is such a huge drag I haven't gone to the doctor lately. Profit margins in health care must be rising spectacularly, though, and that's what counts.
posted by theora55 at 9:06 AM on August 19, 2019 [3 favorites]
Dealing with my Primary Care Provider's marginally competent billing office is such a huge drag I haven't gone to the doctor lately. Profit margins in health care must be rising spectacularly, though, and that's what counts.
posted by theora55 at 9:06 AM on August 19, 2019 [3 favorites]
I work in a very customer-facing position that's not medical for a large hospital network. I'm in a swing state, but a lot of the locals are very conservative, we're in the south. I can tell you, none of them want to say they want socialized medicine, but they all want to have access to it. I get dozens of people complaining why something doesn't work a certain way, and the way they're describing is either as or more socialist than the ACA.
posted by FirstMateKate at 9:38 AM on August 19, 2019 [26 favorites]
posted by FirstMateKate at 9:38 AM on August 19, 2019 [26 favorites]
The medical "system" (I like Mental Wimp's comment above) in the US is really good a pitting all the interested parties, whose main concern should be taking care of patients, against one another. It's hospitals against insurance companies against physicians and sometimes it seems like they are all against the patients (at least those who can't pay). And I say this a a physician in the non-system. It is outside of the scope of this particular article, but since employers pay for much of the health care here, they also get in on the brawl. For example, I just got a letter from my insurance company as well as an email at work stating they needed to to an audit of all the dependents in the system to make sure no one's kids are getting a free ride with healthcare they don't deserve. Now you think it would make more sense to look for outliers that might not be eligible for coverage and examine them on a case by case basis, but instead they are asking everyone to send in documentation that their dependents are, in fact eligible for health insurance. And in case you think they aren't serious, here is a quote from the email I got today reminding me of this (despite the fact I have already confirmed my daughter's eligibility with them):
You will have the opportunity to voluntarily drop ineligible dependents from the plan at any time during the audit. However, after the conclusion of the audit process, if you knowingly continue to cover an ineligible dependent, you could be subject to further disciplinary action, in addition to the loss of coverage for those dependents, as well as possible referral for criminal prosecution.
In other words, they are threatening you with not just disciplinary action at work, but criminal charges if you screw this up. In my case they only needed a picture of her birth certificate, but for other dependents such as adopted and foster kids, the requirements are greater. And in my case they have insured my daughter since the day she was born and should already have what they need on file. I'm sure out of the tens of thousands of people in the system some will miss a deadline or otherwise make an error that results in their child losing coverage, while others will lose coverage due to bureaucratic screwups and may or may not have the stamina to fight until it is fixed. It seems to me the main purpose of this exercise is not so much to root out dependents who shouldn't be on the plan, but to reduce the number of dependents on the plan overall and save my employer money.
All this effort spent trying not to pay for healthcare is a big part of why our healthcare costs are so high, despite such objectively poor results.
posted by TedW at 10:07 AM on August 19, 2019 [29 favorites]
You will have the opportunity to voluntarily drop ineligible dependents from the plan at any time during the audit. However, after the conclusion of the audit process, if you knowingly continue to cover an ineligible dependent, you could be subject to further disciplinary action, in addition to the loss of coverage for those dependents, as well as possible referral for criminal prosecution.
In other words, they are threatening you with not just disciplinary action at work, but criminal charges if you screw this up. In my case they only needed a picture of her birth certificate, but for other dependents such as adopted and foster kids, the requirements are greater. And in my case they have insured my daughter since the day she was born and should already have what they need on file. I'm sure out of the tens of thousands of people in the system some will miss a deadline or otherwise make an error that results in their child losing coverage, while others will lose coverage due to bureaucratic screwups and may or may not have the stamina to fight until it is fixed. It seems to me the main purpose of this exercise is not so much to root out dependents who shouldn't be on the plan, but to reduce the number of dependents on the plan overall and save my employer money.
All this effort spent trying not to pay for healthcare is a big part of why our healthcare costs are so high, despite such objectively poor results.
posted by TedW at 10:07 AM on August 19, 2019 [29 favorites]
The sending to everyone is intentional. They've found that they can drop more dependents because people will miss the email or not provide exactly the right documentation, so they can drop legitimate dependents, rather than trying to find illegitimate dependents.
posted by jmauro at 10:23 AM on August 19, 2019 [10 favorites]
posted by jmauro at 10:23 AM on August 19, 2019 [10 favorites]
What Moore found in some of those detailed receipts made no sense to him either: $75 for a surgical mask; $11.10 for each cleaning; $23.62 for two standard ibuprofen pills; $592 for a throat culture; $838 for a pregnancy test.
...
Moore asked for three identical charges on the account labeled "IV Push", which cost $365 respectively.
"An IV push, if I understand it, is the act of sticking the needle in that little door and then squeezing it," Moore said. "It's right?"
"Yes," the billing manager said.
"So it takes maybe five seconds, right?"
"Yup."
"So you, the hospital, do you think you act alone, not counting the drugs inside the IV, which cost thousands of dollars more – that acting alone is worth $365.38?"
"Yes," he said again.
Hospitals are likely going to have to get better about explaining why that is. On the one hand, no, it should not cost $300+ to push a button. On the other, having someone available to push it on schedule, checking that the conditions are still right for pushing it, confirming that the dosage is correct and the labels match what the prescription says, watching for adverse reactions, and noting on the chart that it was done and when, is worth something.
... Not sure it's worth over $350, though.
posted by ErisLordFreedom at 10:32 AM on August 19, 2019 [7 favorites]
...
Moore asked for three identical charges on the account labeled "IV Push", which cost $365 respectively.
"An IV push, if I understand it, is the act of sticking the needle in that little door and then squeezing it," Moore said. "It's right?"
"Yes," the billing manager said.
"So it takes maybe five seconds, right?"
"Yup."
"So you, the hospital, do you think you act alone, not counting the drugs inside the IV, which cost thousands of dollars more – that acting alone is worth $365.38?"
"Yes," he said again.
Hospitals are likely going to have to get better about explaining why that is. On the one hand, no, it should not cost $300+ to push a button. On the other, having someone available to push it on schedule, checking that the conditions are still right for pushing it, confirming that the dosage is correct and the labels match what the prescription says, watching for adverse reactions, and noting on the chart that it was done and when, is worth something.
... Not sure it's worth over $350, though.
posted by ErisLordFreedom at 10:32 AM on August 19, 2019 [7 favorites]
I have a co-worker who was railing on and on about how things were fine and they better not jack up their health coverage. At the time, they were covered through their spouse's job, and they had a sweet, sweet plan with super low premiums, tiny co-pays, and very small deductibles. Then the spouse changed jobs and they had to go shopping for health insurance between the spouse's new job and their current job. There was outright disbelief at what the rest of us were paying for the coverage we were getting. Now, instead of "don't touch my healthcare," I'm hearing about how badly the system is broken. And this is someone who once worked in hospital billing. Hey, welcome to reality for most people.
posted by azpenguin at 10:39 AM on August 19, 2019 [5 favorites]
posted by azpenguin at 10:39 AM on August 19, 2019 [5 favorites]
The hospital I work for insurance doesn't cover its own hospital in network. Even on the PPO.
posted by AlexiaSky at 10:50 AM on August 19, 2019 [17 favorites]
posted by AlexiaSky at 10:50 AM on August 19, 2019 [17 favorites]
If literally any other first or zeroth world country had a government in power that was honestly trying to turn their health care system into what the US has, it would be max one week before a country-wide indefinite general strike resulted in a complete change-over of government.
That this hasn't happened in the US to get away from it is an amazing testament to hate- and fear-based marketing.
posted by seanmpuckett at 11:18 AM on August 19, 2019 [7 favorites]
That this hasn't happened in the US to get away from it is an amazing testament to hate- and fear-based marketing.
posted by seanmpuckett at 11:18 AM on August 19, 2019 [7 favorites]
it would be max one week before a country-wide indefinite general strike resulted in a complete change-over of government.
Maybe today but back in the '70s the conservatives in Australia got rid of national healthcare in '76 when they were voted in, were promptly voted out at the next election, and then the Labor party restored it in '84.
posted by Your Childhood Pet Rock at 12:06 PM on August 19, 2019 [3 favorites]
Maybe today but back in the '70s the conservatives in Australia got rid of national healthcare in '76 when they were voted in, were promptly voted out at the next election, and then the Labor party restored it in '84.
posted by Your Childhood Pet Rock at 12:06 PM on August 19, 2019 [3 favorites]
That this hasn't happened in the US to get away from it is an amazing testament to hate- and fear-based marketing.
It's more that people tend to be more risk averse to unknown changes, since historically changes got people killed. So the status quo has a lot of inertia and the US has let the health care mess go on way, way too long so entrenched interests understand (maybe not like, but they understand) the current system so they don't want a change. And the US has let the health care system fester uncontrolled for such a long time that there are a lot if entrenched interests. It's like this in all countries for all sorts of things, global warming, health care, justice reform, etc. You see it when the UK tries to make any changes to the NHS. There really isn't a way to fix it if you're needed to deal with the humans since the fear of change is pretty hardwired into the human brain.
posted by jmauro at 12:17 PM on August 19, 2019 [1 favorite]
It's more that people tend to be more risk averse to unknown changes, since historically changes got people killed. So the status quo has a lot of inertia and the US has let the health care mess go on way, way too long so entrenched interests understand (maybe not like, but they understand) the current system so they don't want a change. And the US has let the health care system fester uncontrolled for such a long time that there are a lot if entrenched interests. It's like this in all countries for all sorts of things, global warming, health care, justice reform, etc. You see it when the UK tries to make any changes to the NHS. There really isn't a way to fix it if you're needed to deal with the humans since the fear of change is pretty hardwired into the human brain.
posted by jmauro at 12:17 PM on August 19, 2019 [1 favorite]
Don't get sick in America. But then I already knew that.
posted by Gwynarra at 1:39 PM on August 19, 2019
posted by Gwynarra at 1:39 PM on August 19, 2019
I have an acquaintance in Toronto who works in health care here. I tried to explain what the health care system was like in the US and she couldn't believe it. I sent her this article yesterday. Now she DOES believe it. She was floored by the IV push costs. My impression is that doesn't even become a line item here.
She said, "Well, at least there's one good thing left about your system – you never have to wait for health care."
I said, "Yeah, about that..."
posted by rednikki at 2:43 PM on August 19, 2019 [7 favorites]
She said, "Well, at least there's one good thing left about your system – you never have to wait for health care."
I said, "Yeah, about that..."
posted by rednikki at 2:43 PM on August 19, 2019 [7 favorites]
The hospital I work for insurance doesn't cover its own hospital in network. Even on the PPO.
This brings to mind a similar situation reported by NPR: A Tennessee Hospital Sues Its Own Employees When They Can't Pay Their Medical Bills:
"What makes matters worse, employees say, is that Methodist's health insurance benefits only allow employees to seek medical care at Methodist facilities, even though the financial assistance policies at its competitors are more generous.
A specialist in hospital billing practices says that if the hospital is suing a fair number of its own employees, it's time to examine both the insurance provided to workers and the pay scale.
[...]
Employees in scrubs sat just feet away from the attorneys in dress suits — attorneys their employer had hired to sue them. The hospital's role as a tax-exempt organization that both employs the defendants and is suing them went unremarked upon by judges, attorneys and the defendants themselves.
Methodist's financial assistance policy stands out from peers in Memphis and across the country, MLK50 and ProPublica found. The policy offers no assistance for patients with any form of health insurance, no matter their out-of-pocket costs."
posted by cynical pinnacle at 3:22 PM on August 19, 2019 [2 favorites]
This brings to mind a similar situation reported by NPR: A Tennessee Hospital Sues Its Own Employees When They Can't Pay Their Medical Bills:
"What makes matters worse, employees say, is that Methodist's health insurance benefits only allow employees to seek medical care at Methodist facilities, even though the financial assistance policies at its competitors are more generous.
A specialist in hospital billing practices says that if the hospital is suing a fair number of its own employees, it's time to examine both the insurance provided to workers and the pay scale.
[...]
Employees in scrubs sat just feet away from the attorneys in dress suits — attorneys their employer had hired to sue them. The hospital's role as a tax-exempt organization that both employs the defendants and is suing them went unremarked upon by judges, attorneys and the defendants themselves.
Methodist's financial assistance policy stands out from peers in Memphis and across the country, MLK50 and ProPublica found. The policy offers no assistance for patients with any form of health insurance, no matter their out-of-pocket costs."
posted by cynical pinnacle at 3:22 PM on August 19, 2019 [2 favorites]
The really dark thing about these stories is that by squeezing 100 people a month out of $100, they're looking at $120,000/year, which maybe covers the salary and benefits of the lawyer they have to hire to do this, and that's assuming they actually get that money instead of everyone declaring bankruptcy after a little while. These are hospitals with budgets in the hundreds of millions, the money that is feasibly recoverable from the ludicrous bills is practically nothing to them, but they still feel the need to grind people down for what to them is a pittance but to someone working a crummy job is the difference between a minimal level of comfort and oblivion.
posted by Copronymus at 3:41 PM on August 19, 2019 [3 favorites]
posted by Copronymus at 3:41 PM on August 19, 2019 [3 favorites]
which maybe covers the salary and benefits of the lawyer they have to hire to do this
As a general rule, lawyers on these cases aren't salaried. They work piece work and it's a mill. This only makes matters worse, as their sloppy work taints the whole process.
posted by praemunire at 4:04 PM on August 19, 2019 [1 favorite]
As a general rule, lawyers on these cases aren't salaried. They work piece work and it's a mill. This only makes matters worse, as their sloppy work taints the whole process.
posted by praemunire at 4:04 PM on August 19, 2019 [1 favorite]
For example, I just got a letter from my insurance company as well as an email at work stating they needed to to an audit of all the dependents in the system to make sure no one's kids are getting a free ride with healthcare they don't deserve.
What really chaps my buns is that our healthcare financing "system" requires so much labor on the part of the customers to service the needs of the payers, as in this example. Same with resolving payment discrepancies, coordinating different payers, making sure records get from provider A to provider B, etc. Single payer is the way to go, hands down.
posted by Mental Wimp at 5:23 PM on August 19, 2019 [4 favorites]
What really chaps my buns is that our healthcare financing "system" requires so much labor on the part of the customers to service the needs of the payers, as in this example. Same with resolving payment discrepancies, coordinating different payers, making sure records get from provider A to provider B, etc. Single payer is the way to go, hands down.
posted by Mental Wimp at 5:23 PM on August 19, 2019 [4 favorites]
I thought it was bothersome that the article tended to blame the high cost of rural healthcare mostly on labor cost to entice qualified personnel to the area but overlooked the fact that folks there are, on the whole, less healthy than a comparable individual with more means and access. So the hospital has to take on more patients, usually through the ER (as the article did point out), and most of them are going to be near- or total-losses. And since the hospitals around it have failed, it's now the service point for thousands more people than before with all the same problems as their local population, but magnified by the lack of a local service point.
What does the hospital do, then? It marks up IV pushes to $365 to pay for all the other IV pushes for which the reimbursement was nothing. Because, what choice do they have, really?
A bunch of my family is from Fulton, MO, maybe 150 miles north as the crow flies. 5,000 fewer residents than Poplar Bluff, and it's the home to the only hospital in its entire county. Get this: 37 beds. 37 hospital beds for an entire county of 45,000 residents. That's 1200:1. By comparison, San Francisco has over 4,000 beds for around 800,000 residents or about 200:1. And unlike Fulton, your doctor in the hospital isn't also your primary care physician. In Fulton, he probably is, or he's supervising a nurse practitioner who is. So there's no way you're getting a reasonable level of care, no matter who you are, because there aren't sufficient providers to begin with.
I remember asking my dad what happened to my great uncle in Fulton. "He fell off a tractor, cut his arm open, and died." But why didn't he go to the hospital? "There wasn't one. In the 70s, if you got hurt in Fulton, you died." Apparently in 2019, you don't always die. Sometimes you just go bankrupt.
posted by kochbeck at 6:59 PM on August 19, 2019 [7 favorites]
What does the hospital do, then? It marks up IV pushes to $365 to pay for all the other IV pushes for which the reimbursement was nothing. Because, what choice do they have, really?
A bunch of my family is from Fulton, MO, maybe 150 miles north as the crow flies. 5,000 fewer residents than Poplar Bluff, and it's the home to the only hospital in its entire county. Get this: 37 beds. 37 hospital beds for an entire county of 45,000 residents. That's 1200:1. By comparison, San Francisco has over 4,000 beds for around 800,000 residents or about 200:1. And unlike Fulton, your doctor in the hospital isn't also your primary care physician. In Fulton, he probably is, or he's supervising a nurse practitioner who is. So there's no way you're getting a reasonable level of care, no matter who you are, because there aren't sufficient providers to begin with.
I remember asking my dad what happened to my great uncle in Fulton. "He fell off a tractor, cut his arm open, and died." But why didn't he go to the hospital? "There wasn't one. In the 70s, if you got hurt in Fulton, you died." Apparently in 2019, you don't always die. Sometimes you just go bankrupt.
posted by kochbeck at 6:59 PM on August 19, 2019 [7 favorites]
As for Tennessee's Methodist Le Bonheur, that sounds an awful lot like illegal tying to me: your employer is required to give you medical insurance, so they provide a self-insured "plan" that can only be used to buy from them, and they mark care up such that you have to pay over and above the reimbursement levels of the "plan." So by working there, one way or another, you'll end up stuck paying them. I realize Tennessee's regulatory posture is (ahem) lax. But since the owner is the UMC which is a multi-state entity, presumably one could bring suit in the Federal Courts. That seems like a job for an especially savvy attorney.
posted by kochbeck at 7:00 PM on August 19, 2019 [1 favorite]
posted by kochbeck at 7:00 PM on August 19, 2019 [1 favorite]
I have an acquaintance in Toronto who works in health care here. [...]
She said, "Well, at least there's one good thing left about your system – you never have to wait for health care."
I said, "Yeah, about that..."
This is the goto BIG lie that the forces trying to privatize service in Canada repeat over and over again. It resonates because who hasn't had to wait for an appointment? And wait times for non life threatening procedures that a person with a big stack of cash can have done next day in the US tend to be several months or even a year.
Of course the truth is that practically no one in the US outside the 1% has sufficient stacks of cash, that 30% or more of Americans regularly avoid going to the doctor when they think they should because they can't afford it, that the US infant mortality rate is 20% higher, and that in general the American system costs twice as much for similar services (for those who can afford it).
But, you know, the Canada system doesn't make mad stacks of cash for all sorts of medical providers and middlemen so Canadians constantly have to beat off privatization efforts.
posted by Mitheral at 7:11 PM on August 19, 2019 [4 favorites]
She said, "Well, at least there's one good thing left about your system – you never have to wait for health care."
I said, "Yeah, about that..."
This is the goto BIG lie that the forces trying to privatize service in Canada repeat over and over again. It resonates because who hasn't had to wait for an appointment? And wait times for non life threatening procedures that a person with a big stack of cash can have done next day in the US tend to be several months or even a year.
Of course the truth is that practically no one in the US outside the 1% has sufficient stacks of cash, that 30% or more of Americans regularly avoid going to the doctor when they think they should because they can't afford it, that the US infant mortality rate is 20% higher, and that in general the American system costs twice as much for similar services (for those who can afford it).
But, you know, the Canada system doesn't make mad stacks of cash for all sorts of medical providers and middlemen so Canadians constantly have to beat off privatization efforts.
posted by Mitheral at 7:11 PM on August 19, 2019 [4 favorites]
Because, what choice do they have, really?
They could spend less on lawyers and more on lobbyists who would go to JeffCity and DC to argue for universal health care, under which they'd make a very predictable amount of money without having to sue people for it.
posted by GCU Sweet and Full of Grace at 7:17 PM on August 19, 2019 [5 favorites]
They could spend less on lawyers and more on lobbyists who would go to JeffCity and DC to argue for universal health care, under which they'd make a very predictable amount of money without having to sue people for it.
posted by GCU Sweet and Full of Grace at 7:17 PM on August 19, 2019 [5 favorites]
I'm struck by how it appears that no-one is making any money from this. The hospitals are closing down and going bankrupt, surgeons say they'd be better paid in Mexico, patients going bankrupt, lawyers aren't even working on retainers etc. Who's making the profit here?
I suppose it's no one, healthcare is just so expensive to do that a rural area like Fulton can't actually be self-supporting even with Medicare's subsidizing effect.
I shudder to think that this is the kind of thing they want to bring to the NHS. The poor already have increased healthcare needs and get poorer care - if those areas were then financially responsible for raising their own healthcare costs I can imagine huge swathes of the UK without effective healthcare and mass closures of hospitals and GPs.
posted by zeripath at 10:55 PM on August 19, 2019 [1 favorite]
I suppose it's no one, healthcare is just so expensive to do that a rural area like Fulton can't actually be self-supporting even with Medicare's subsidizing effect.
I shudder to think that this is the kind of thing they want to bring to the NHS. The poor already have increased healthcare needs and get poorer care - if those areas were then financially responsible for raising their own healthcare costs I can imagine huge swathes of the UK without effective healthcare and mass closures of hospitals and GPs.
posted by zeripath at 10:55 PM on August 19, 2019 [1 favorite]
Things are beyond unsustainable, beyond immoral at this point. For health care providers such as myself our power lies in opting out. The system doesn’t work without us. Memail me if you’re interested in practicing medicine and you’re sick of the dysfunctional industry that bankrupts patients and makes themselves rich off of our labor and good intentions.
posted by Slarty Bartfast at 11:45 PM on August 19, 2019
posted by Slarty Bartfast at 11:45 PM on August 19, 2019
The really dark thing about these stories is that by squeezing 100 people a month out of $100, they're looking at $120,000/year, which maybe covers the salary and benefits of the lawyer they have to hire to do this, and that's assuming they actually get that money instead of everyone declaring bankruptcy after a little while. These are hospitals with budgets in the hundreds of millions, the money that is feasibly recoverable from the ludicrous bills is practically nothing to them, but they still feel the need to grind people down for what to them is a pittance but to someone working a crummy job is the difference between a minimal level of comfort and oblivion.
But we're not talking about some rich private hospital here, from the pull quote:
Meanwhile, many of the nation’s 2,000 rural hospitals have begun to buckle under bad debt, with more than 100 closing in the past decade and hundreds more on the brink of insolvency as they fight to squeeze whatever money they’re owed from patients who don’t have it.
Its a shitty system for everyone, and going after people may be the only way the hospital stays open, and that such an incredibly shitty situation. Ideally, these rural hospitals would have extra funding to provide indigent care. Scratch that, ideally we would have single payer and then this wouldnt be a problem.
posted by LizBoBiz at 1:05 AM on August 20, 2019
But we're not talking about some rich private hospital here, from the pull quote:
Meanwhile, many of the nation’s 2,000 rural hospitals have begun to buckle under bad debt, with more than 100 closing in the past decade and hundreds more on the brink of insolvency as they fight to squeeze whatever money they’re owed from patients who don’t have it.
Its a shitty system for everyone, and going after people may be the only way the hospital stays open, and that such an incredibly shitty situation. Ideally, these rural hospitals would have extra funding to provide indigent care. Scratch that, ideally we would have single payer and then this wouldnt be a problem.
posted by LizBoBiz at 1:05 AM on August 20, 2019
Because, what choice do they have, really?
They could spend less on lawyers and more on lobbyists who would go to JeffCity and DC to argue for universal health care, under which they'd make a very predictable amount of money without having to sue people for it.
I don't really want to delve into how much of what you've just said I have done in my life, but suffice it to say that California (with a population greater than all of Canada) is on the verge of getting universal healthcare because folks like me went and beat the bushes for decades.
And you know what? A lot of people died waiting for us to do it. And we still haven't achieved it. We might still lose yet another round in this fight.
I once got into an argument with a senior executive of the AFT. I let her vent at me for awhile about how my stopgap solutions weren't perfect. Then I said, "So how should we handle the 50,000 kids who are going to drop out of high school this month then? If only a perfect solution will do, shall we tell them now that they're screwed so they have extra time to look for their permanent minimum wage job? Because if we're not going to have a stopgap, we are, effectively, giving up on them and everyone else till we have a perfect solution. Do you want to call them or shall I?"
Stopgaps are good government. Forget everything you've ever heard: stopgaps save lives.
You know what happens if the hospitals--the last stop in a long, long chain of societal neglect and institutional racism and classism--in Poplar Bluff or Fulton or any underserved area stops trying to collect? They fail. And then there will be no hospital. And then what? I'll tell you what: then a whole lot more decent people who are trying to get by in the world die for no real reason.
Sick people aren't going to wait for long-term policy change. They're going to get sick and die now. Underfunded hospitals' vendors aren't going to wait for long-term policy change. They're going to sue the hospitals and put them out of business. So the challenge is, what shall we do in the meantime, between today and universal healthcare?
It turns out there are a bunch of things between here and universal healthcare. For instance, states with a crisis could re-institute limited prescribing powers for pharmacists and RNs. They could indemnify telemedicine providers for certain procedure codes so it would be cheaper for providers to offer care remotely. As it happens, I just named two de-regulations that could likely fly in red states.
There are tons of possible things to try, but first we'd need to step back and acknowledge that we can't have the perfect solution today, and that we need to put 20% of our energy behind eventually getting an ideal solution while putting 80% of our energy behind taking care of the people who need our help today. And that means not coming for the hospitals with torches and pitchforks and platitudes until we have some reasonable alternative that allows them to operate all the way to Friday rather than demanding that they commit suicide on principle.
Give them a replacement stopgap, and I guarantee they'll take it. They're not monsters. They just can't see another option. And they can't wait for utopia.
posted by kochbeck at 1:07 AM on August 20, 2019 [10 favorites]
They could spend less on lawyers and more on lobbyists who would go to JeffCity and DC to argue for universal health care, under which they'd make a very predictable amount of money without having to sue people for it.
I don't really want to delve into how much of what you've just said I have done in my life, but suffice it to say that California (with a population greater than all of Canada) is on the verge of getting universal healthcare because folks like me went and beat the bushes for decades.
And you know what? A lot of people died waiting for us to do it. And we still haven't achieved it. We might still lose yet another round in this fight.
I once got into an argument with a senior executive of the AFT. I let her vent at me for awhile about how my stopgap solutions weren't perfect. Then I said, "So how should we handle the 50,000 kids who are going to drop out of high school this month then? If only a perfect solution will do, shall we tell them now that they're screwed so they have extra time to look for their permanent minimum wage job? Because if we're not going to have a stopgap, we are, effectively, giving up on them and everyone else till we have a perfect solution. Do you want to call them or shall I?"
Stopgaps are good government. Forget everything you've ever heard: stopgaps save lives.
You know what happens if the hospitals--the last stop in a long, long chain of societal neglect and institutional racism and classism--in Poplar Bluff or Fulton or any underserved area stops trying to collect? They fail. And then there will be no hospital. And then what? I'll tell you what: then a whole lot more decent people who are trying to get by in the world die for no real reason.
Sick people aren't going to wait for long-term policy change. They're going to get sick and die now. Underfunded hospitals' vendors aren't going to wait for long-term policy change. They're going to sue the hospitals and put them out of business. So the challenge is, what shall we do in the meantime, between today and universal healthcare?
It turns out there are a bunch of things between here and universal healthcare. For instance, states with a crisis could re-institute limited prescribing powers for pharmacists and RNs. They could indemnify telemedicine providers for certain procedure codes so it would be cheaper for providers to offer care remotely. As it happens, I just named two de-regulations that could likely fly in red states.
There are tons of possible things to try, but first we'd need to step back and acknowledge that we can't have the perfect solution today, and that we need to put 20% of our energy behind eventually getting an ideal solution while putting 80% of our energy behind taking care of the people who need our help today. And that means not coming for the hospitals with torches and pitchforks and platitudes until we have some reasonable alternative that allows them to operate all the way to Friday rather than demanding that they commit suicide on principle.
Give them a replacement stopgap, and I guarantee they'll take it. They're not monsters. They just can't see another option. And they can't wait for utopia.
posted by kochbeck at 1:07 AM on August 20, 2019 [10 favorites]
What really chaps my buns is that our healthcare financing "system" requires so much labor on the part of the customers to service the needs of the payers, as in this example. Same with resolving payment discrepancies, coordinating different payers, making sure records get from provider A to provider B, etc. Single payer is the way to go, hands down.
Yes, this is just madness. I am incredibly grateful to have had good and *easy* healthcare for most of my life. Currently I have Kaiser, with most of my premium paid by my employer, and copays which are quite reasonable. I can make appointments as soon as I need them, all my doctors can pull up my info from any of my visits if needed, and most importantly, I just show up and pay my copay and then never worry about any further costs.
Everyone should have it so good! All this business about submitting claims and fighting your insurance company is horrifying, not to mention the fact that it can easily become a part-time job for someone with serious health problems.
posted by ktkt at 1:22 AM on August 20, 2019 [1 favorite]
Yes, this is just madness. I am incredibly grateful to have had good and *easy* healthcare for most of my life. Currently I have Kaiser, with most of my premium paid by my employer, and copays which are quite reasonable. I can make appointments as soon as I need them, all my doctors can pull up my info from any of my visits if needed, and most importantly, I just show up and pay my copay and then never worry about any further costs.
Everyone should have it so good! All this business about submitting claims and fighting your insurance company is horrifying, not to mention the fact that it can easily become a part-time job for someone with serious health problems.
posted by ktkt at 1:22 AM on August 20, 2019 [1 favorite]
I'm struck by how it appears that no-one is making any money from this. ... Who's making the profit here?
I post this a lot, but I think Alex Harrowell’s concept of “Coasian Hells” is a really good framework for thinking about the US healthcare system.
His argument is that highly fragmented private systems driven by enormously complex webs of contracts inevitably lead to these perverse outcomes, with costs becoming unmoored from reality and everything getting extremely expensive and confusing. That’s because the nature of contracts means that contracting isn’t actually a very effective way of collaborating, and in fact that’s why “organisations” exist as a concept in the first place.
In The Eternal Inferno, Fiends Torment Ronald Coase With The Fate Of His Ideas
posted by chappell, ambrose at 4:10 AM on August 20, 2019 [6 favorites]
I post this a lot, but I think Alex Harrowell’s concept of “Coasian Hells” is a really good framework for thinking about the US healthcare system.
His argument is that highly fragmented private systems driven by enormously complex webs of contracts inevitably lead to these perverse outcomes, with costs becoming unmoored from reality and everything getting extremely expensive and confusing. That’s because the nature of contracts means that contracting isn’t actually a very effective way of collaborating, and in fact that’s why “organisations” exist as a concept in the first place.
In The Eternal Inferno, Fiends Torment Ronald Coase With The Fate Of His Ideas
Also, as we will see, in Coasian hell it is usually impossible to finger any particular guilty party, because its problems are system-level properties, driven by the interactions between firms in the system. Reductionism just leads to finger-pointing.A bit more on Coasian hells
Healthcare in the United States is an especially egregious example of this. Americans, notoriously, spend much more than any other nation, have worse results, and leave lots of people uncovered. People blame, variously, insurance companies, doctors, drug companies, intermediary organisations, public policy, and patients themselves for getting ill. But none of this has ever solved anything. Everyone who has tried to nail down exactly what costs so much money has ended up concluding that the whole system is weirdly expensive and wasteful. That is, of course, the point. Its awfulness is an aspect of the system, not any one component or group of components.
...
The purpose of the system is what it does, as they say, but it’s worth noting that Stafford Beer’s aphorism refers to the system, not to any particular actor within it. Even trying to bear down on the pure administrative overhead is likely to run into the problem that, although hordes of claims managers, lawyers, and claims-management software developers are a parasitic load on the whole system, they are vital for any given hospital, insurer, or whatever. Therefore, the system is likely to unite in homeostatic self-defence against change unless some drastic triggering event intervenes.
First, there is an argument from transaction cost. This is simply that all those contracts need some lawyering.The alternative “organisation” in the case of US healthcare would of course be something akin to a national health service, i.e. single payer.
...
Second, there is an argument from time. Lawyers will tell you that a transaction implies a contract, but I would draw a distinction between a transactional relationship and a contractual one. [...] A genuinely contractual relationship binds the parties for part of the unknowable future. Both parties therefore take on risks, commit to actions in advance, and have to consider how they would alter the contract if that became necessary. This means either that someone can make decisions on a discretionary basis, or that the contract will eventually become too restrictive. To put it another way, if it lasts, it will evolve towards organisation, or else it won’t last.
...
Third, there’s an argument from uncertainty/information. At the time of signing, you don’t know what will happen in the future. You don’t even know what you will do in the future as well as you think you do. And – this is crucial – it may well be impossible to state literally everything in the contract that the parties would want to.
...
Points two and three converge. We can’t specify the future. We also cannot specify terms we don’t know. This suggest either that we should ignore them – reduce the problem to a succession of transactions – or else internalise them into an organisation.
posted by chappell, ambrose at 4:10 AM on August 20, 2019 [6 favorites]
kochbeck: I hear what you're saying and I should have been less specific. What could they do? Work towards any number of policy changes that might provide a steadier and more certain, but lower, profit.
posted by GCU Sweet and Full of Grace at 5:00 AM on August 20, 2019
posted by GCU Sweet and Full of Grace at 5:00 AM on August 20, 2019
Even easy health care in the US is complicated. Most likely employment benefits have been concidered and insurance benefits change on yearly basis . Nothing about anyone health care now says much about it 12 months from now as a whole, unless you are already on medicare or medicaid(and medicaid based on income is based on doing ask the paperwork stuff right and consistently). The ACA marketplace changes drastically year to year. An employer can change insurance on a whim. There deductables and out of pocket costs and FSA and networks and or preathorization and that's for health, medications have formularies, mental health is usually different department or division all together. Then you need to account for your location, availability of doctors, waitlists AND that's for the conditions you know about.
Single payer all the way. I think if there needs to be a transition, increasing the income limit qualifications for medicaid while simultaneously lowering the the age limit for medicare by increments every year until everybody was covered would be a great start. It would also give private insurance companies a way to adjust and create whatever the market will look like afterwards.
posted by AlexiaSky at 6:42 AM on August 20, 2019 [4 favorites]
Single payer all the way. I think if there needs to be a transition, increasing the income limit qualifications for medicaid while simultaneously lowering the the age limit for medicare by increments every year until everybody was covered would be a great start. It would also give private insurance companies a way to adjust and create whatever the market will look like afterwards.
posted by AlexiaSky at 6:42 AM on August 20, 2019 [4 favorites]
Because, what choice do they have, really?
What they could have done in Missouri is absolutely nothing. If they had done nothing they would have had Obamacare's Medicaid expansion which would have paid the medical bills of every poor person in the state absolutely free with federal money. The hospitals would have their bills paid with free federal money. The hospitals wouldn't need to hound poor people to pay their bills because their bills would have been already paid.
Instead, in Missouri, they actually had to pass a bill to refuse to take the free federal money, an act of pure bitter spite. They would have been better off doing nothing.
posted by JackFlash at 7:13 AM on August 20, 2019 [13 favorites]
What they could have done in Missouri is absolutely nothing. If they had done nothing they would have had Obamacare's Medicaid expansion which would have paid the medical bills of every poor person in the state absolutely free with federal money. The hospitals would have their bills paid with free federal money. The hospitals wouldn't need to hound poor people to pay their bills because their bills would have been already paid.
Instead, in Missouri, they actually had to pass a bill to refuse to take the free federal money, an act of pure bitter spite. They would have been better off doing nothing.
posted by JackFlash at 7:13 AM on August 20, 2019 [13 favorites]
But we're not talking about some rich private hospital here,
There is absolutely no way that a total amount of money in the low six figures is making a significant impact on the bottom line of even a struggling hospital. This is an institution with more than 1000 employees and a budget in the hundreds of millions. Dedicating any effort to a deeply uncertain recovery of maybe a tenth of a percent of their revenue is pointless, and the fact that it's ruining people's lives makes it immoral to boot. The resources they're spending on squeezing a hundred bucks a month from people hovering near poverty would be better expended on almost anything else in the entire world.
posted by Copronymus at 10:39 AM on August 20, 2019 [4 favorites]
There is absolutely no way that a total amount of money in the low six figures is making a significant impact on the bottom line of even a struggling hospital. This is an institution with more than 1000 employees and a budget in the hundreds of millions. Dedicating any effort to a deeply uncertain recovery of maybe a tenth of a percent of their revenue is pointless, and the fact that it's ruining people's lives makes it immoral to boot. The resources they're spending on squeezing a hundred bucks a month from people hovering near poverty would be better expended on almost anything else in the entire world.
posted by Copronymus at 10:39 AM on August 20, 2019 [4 favorites]
Give them a replacement stopgap, and I guarantee they'll take it. They're not monsters. They just can't see another option. And they can't wait for utopia.
For a long time, they had that stop gap. How do you think those hospitals got there in the first place and made it until now/recently? State support, at one time with a bit of their own money along with programmed federal dollars, more recently with block grant funds that have become increasingly irregular and grossly insufficient as inflation has eroded their value.
Time was, they got paid by the state for that indigent care. As the funding shortfall has increased, bills have been raised and we have found ourselves in a ridiculous cycle that can't be interrupted by restoring the status quo ante. Of course, simply expanding Medicaid would stave off the immediate disaster, as would actually implementing much of the stuff in the ACA that has fallen by the wayside under maladministration.
That's nowhere near enough, but it's something that could be done by next year and would save people's lives by keeping rural providers in business while we work on better solutions if we (including those of us in states with recalcitrant government) decided to just freaking do it. The severity of the crisis is entirely intentional. Better to let people die than make the Nazis who fund state officials' campaigns a little bit sad, at least in the minds of elected Republicans.
posted by wierdo at 4:23 AM on August 21, 2019
For a long time, they had that stop gap. How do you think those hospitals got there in the first place and made it until now/recently? State support, at one time with a bit of their own money along with programmed federal dollars, more recently with block grant funds that have become increasingly irregular and grossly insufficient as inflation has eroded their value.
Time was, they got paid by the state for that indigent care. As the funding shortfall has increased, bills have been raised and we have found ourselves in a ridiculous cycle that can't be interrupted by restoring the status quo ante. Of course, simply expanding Medicaid would stave off the immediate disaster, as would actually implementing much of the stuff in the ACA that has fallen by the wayside under maladministration.
That's nowhere near enough, but it's something that could be done by next year and would save people's lives by keeping rural providers in business while we work on better solutions if we (including those of us in states with recalcitrant government) decided to just freaking do it. The severity of the crisis is entirely intentional. Better to let people die than make the Nazis who fund state officials' campaigns a little bit sad, at least in the minds of elected Republicans.
posted by wierdo at 4:23 AM on August 21, 2019
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posted by xingcat at 7:49 AM on August 19, 2019 [85 favorites]