Canadians are one in a million -- while waiting for medical treatment

[Dashinka 24,764]

Just now, bcking said:

I believe that the number of doctors doing that is growing, mostly because they are sick of dealing with insurance companies. They generally aren't seen as "more affordable". They are usually styled as "exclusive". When I was working in NYC there were several Pediatric outpatient clinics that were entirely "cash only" and they catered to the UES/UWS, people who likely have health insurance. 

 

Primary care would run you maybe 150-200 dollars for a doctor's visit. That may be within some people's budget, but if you need diagnostics or treatment then it's going to quickly balloon beyond what many people can pay.

Let's do cash for everything, CTs, MRIs, etc.  Let people know what they are paying for.

[Dashinka 24,764]

1 hour ago, bcking said:

We are talking about wait numbers for "medically necessary treatments" in Canada. The study in the original article was looking at non-emergent care.

 

Yes obviously the UKs problems with their A&Es is unacceptable. Regardless of how we manage general health of our population, we need to be able to efficiently manage emergency care as a priority. I'll never defend the issues going on in A&Es in the UK. They are understaffed and underfunded.

 

Source for uninsured population is below. I admit I was wrong as I accidentally used 2013 numbers from prior to the ACA. We are now at 28 million.

 

https://www.google.com/amp/s/www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/amp/

If the ACA is available to all, why are there still 28 million uninsured?  Choice?

[Boiler 46,013]

1 minute ago, Bill & Katya said:

If the ACA is available to all, why are there still 28 million uninsured?  Choice?

They do not realise how Affordable it is?

[Ontarkie 14,435]

~~6 Posts removed some for importing drama some for quoting. Any further similar posts will result in admin action.~~

Edited June 14, 2018 by Ontarkie

[Steeleballz 7,550]

14 minutes ago, Bill & Katya said:

Why don't more doctors offer a cash price option?

 

    More are, but you have to have the money. It doesn't really work for surgeries, major diseases or any type of hospital stay. 

 

    There are also a lot of regulatory issues. In some states if you have a specific type of insurance and the doctor is a participating provider, they can risk fines and even fraud charges for going outside of that. I haven't met my deductible yet so I am paying 100% but the doctor has to bill insurance first then send me a bill even though I told the office I will owe 100% of the charge. It can take a couple of months for this. I asked them a while back if they had a cash rate (just because I wanted to pay and get it over with). They did have a cash discount rate but only available for people who don't have insurance. It's not a choice if you do have insurance. 

[Steeleballz 7,550]

36 minutes ago, bcking said:

Well said. Essentially what I was trying to say.

 

Healthcare in the US is incredibly rationed. As you said, it's rationed based on money. Healthcare in Canada and the UK is also rationed, but it is rationed based on a combination of need and "first come, first serve". Which system is better is up for debate (I have my opinion, but I'm sure others would disagree). Even among Doctor's that is an incredibly common misconception. They compare our system to those countries and think "Oh my god, I would never want to ration the care patients receive, that is just evil". The reality is we do it implicitly every single day. At least "wait lists" are explicit, with clear methodology for how the line is created and who gets in line.

 

   We also see more people avoid health care in the USA, and a large part of that is the inherent cost, and fear of how much treatment would end up costing in the long run. One of the things I have seen too many times over the years. Our system in the USA often turns non urgent procedures into emergencies because the treatment is delayed based on cost analysis by the patient themselves.

 

  IMO, if you have good insurance and/or are very wealthy, you likely do have a statistically measurable probability of better outcome in the USA over the course of a lifetime. In Canada, wealth is not as big of a factor in access to healthcare or in outcomes. This has always been an underlying factor in the analysis that biases the discussion, and is not always apparent. Many who discuss policy have good health care and the US probably is best for them. The bottom line doesn't change though. For a pure outcomes based approach on what would be better for most people, most of the time, the US system does not really rank very high.  

[Dashinka 24,764]

27 minutes ago, Steeleballz said:

 

    More are, but you have to have the money. It doesn't really work for surgeries, major diseases or any type of hospital stay. 

 

    There are also a lot of regulatory issues. In some states if you have a specific type of insurance and the doctor is a participating provider, they can risk fines and even fraud charges for going outside of that. I haven't met my deductible yet so I am paying 100% but the doctor has to bill insurance first then send me a bill even though I told the office I will owe 100% of the charge. It can take a couple of months for this. I asked them a while back if they had a cash rate (just because I wanted to pay and get it over with). They did have a cash discount rate but only available for people who don't have insurance. It's not a choice if you do have insurance. 

 That is just sad.  If you are willing to save them the wait time for the money and the avoidance of having to send anything to the insurance company you would think they would be happy to have you pay cash.  I heard a similar story about pharmaceuticals related to pharmacies not being about to offer a cash price to someone that has an insurance policy.  I know personally, I told my doctor I want a shingles shot and she told me my insurance would not cover it until I turn 60, I said I would pay cash now since I don't want to go through shingles when I turn 55.  I think I can get it, we shall see.

[Steeleballz 7,550]

1 minute ago, Bill & Katya said:

 That is just sad.  If you are willing to save them the wait time for the money and the avoidance of having to send anything to the insurance company you would think they would be happy to have you pay cash.  I heard a similar story about pharmaceuticals related to pharmacies not being about to offer a cash price to someone that has an insurance policy.  I know personally, I told my doctor I want a shingles shot and she told me my insurance would not cover it until I turn 60, I said I would pay cash now since I don't want to go through shingles when I turn 55.  I think I can get it, we shall see.

 

   I think they normally will give you the shot, as long as you understand you might have to pay the full cost. Places like Walgreen's also have it on a walk in in basis, but I'm not sure if it would be cheaper.  If your doctor bills insurance and insurance doesn't cover it, you might end up paying more than if you just walked in to a Walgreen's and payed the cost without insurance. It might be worth calling and checking both ways. 

 

  

[bcking 3,157]

2 hours ago, Steeleballz said:

 

    More are, but you have to have the money. It doesn't really work for surgeries, major diseases or any type of hospital stay. 

 

    There are also a lot of regulatory issues. In some states if you have a specific type of insurance and the doctor is a participating provider, they can risk fines and even fraud charges for going outside of that. I haven't met my deductible yet so I am paying 100% but the doctor has to bill insurance first then send me a bill even though I told the office I will owe 100% of the charge. It can take a couple of months for this. I asked them a while back if they had a cash rate (just because I wanted to pay and get it over with). They did have a cash discount rate but only available for people who don't have insurance. It's not a choice if you do have insurance. 

Interesting. I was able to pay directly to a Dermatologist for a procedure since they said they would bill my insurance, but I would be subject to my deductible (sounds like a pretty similar story). They took my money no problem. That may be office/clinic specific and not a general policy about insurance (I can't speak from personal work experience since I don't see patients outside of the hospital).

 

2 hours ago, Bill & Katya said:

 That is just sad.  If you are willing to save them the wait time for the money and the avoidance of having to send anything to the insurance company you would think they would be happy to have you pay cash.  I heard a similar story about pharmaceuticals related to pharmacies not being about to offer a cash price to someone that has an insurance policy.  I know personally, I told my doctor I want a shingles shot and she told me my insurance would not cover it until I turn 60, I said I would pay cash now since I don't want to go through shingles when I turn 55.  I think I can get it, we shall see.

Our pharmacy (Kroger pharmacy) will allow us to pay the "cash price" if we want for our prescriptions. Not sure why we would. It is 10 dollars with our insurance, and around 150 dollars without, for the one prescription we fill (I won't go into specifics about the medication for obvious reasons).

 

Hopefully you can get the shot. If you are of the age where it is approved, but insurance doesn't cover it, that shouldn't be a problem. I believe that is different than a situation where insurance does cover something, but you want to instead choose to pay out of pocket. There are very few situations where the latter would make sense for an individual person (other than in situations like Steeleballz mentioned, which I don't believe is a general rule but more individual clinic/office discretion). Financially though, if insurance will cover something you are better off letting them (I'm struggling to think of an exception). 

Edited June 14, 2018 by bcking

[Dashinka 24,764]

1 hour ago, Steeleballz said:

 

   I think they normally will give you the shot, as long as you understand you might have to pay the full cost. Places like Walgreen's also have it on a walk in in basis, but I'm not sure if it would be cheaper.  If your doctor bills insurance and insurance doesn't cover it, you might end up paying more than if you just walked in to a Walgreen's and payed the cost without insurance. It might be worth calling and checking both ways. 

 

  

 

15 minutes ago, bcking said:

Interesting. I was able to pay directly to a Dermatologist for a procedure since they said they would bill my insurance, but I would be subject to my deductible (sounds like a pretty similar story). They took my money no problem. That may be office/clinic specific and not a general policy about insurance (I can't speak from personal work experience since I don't see patients outside of the hospital).

 

Our pharmacy (Kroger pharmacy) will allow us to pay the "cash price" if we want for our prescriptions. Not sure why we would. It is 10 dollars with our insurance, and around 150 dollars without, for the one prescription we fill (I won't go into specifics about the medication for obvious reasons).

 

Hopefully you can get the shot. If you are of the age where it is approved, but insurance doesn't cover it, that shouldn't be a problem. I believe that is different than a situation where insurance does cover something, but you want to instead choose to pay out of pocket. There are very few situations where the latter would make sense for an individual person (other than in situations like Steeleballz mentioned, which I don't believe is a general rule but more individual clinic/office discretion). Financially though, if insurance will cover something you are better off letting them (I'm struggling to think of an exception). 

I guess what I would like to see is if there is a reduced cost for the shot if the Dr.'s office doesn't have to submit it to the insurance company.  I mean why submit something and incur whatever that cost is, that is being paid for with cash.  Is there a rule that everything has to go through the insurance company?

[Steeleballz 7,550]

1 minute ago, bcking said:

Interesting. I was able to pay directly to a Dermatologist for a procedure since they said they would bill my insurance, but I would be subject to my deductible (sounds like a pretty similar story). They took my money no problem. That may be office/clinic specific and not a general policy about insurance (I can't speak from personal work experience since I don't see patients outside of the hospital).

 

 

  Most of the other physicians we have seen will charge the deductible amount if it's not met, and usually the copay at time of service. As I said earlier, many even require this prior to seeing the patient. Lot's of patients are taking too long to pay apparently.

 

   My primary care physician won't take it until after they bill though. In fact the regular office visit is billed at $87 so I even said last time why can't I just pay that amount since I'm still paying my deductible and the receptionist said they don't know how much it will actually be until they submit it to insurance. I told her it's $87 and she said then I'll get a bill in the mail.

 

   It's a hassle when they over bill too though. Not just for the patient. We payed about $400 extra for my wife's surgery last year. I told them they were wrong when they asked for the co-pay, and they said if we wanted to reschedule the surgery we could go home and have the insurance company confirm the exact amount. Obviously we were not going to do that, and I knew we would get the money back. I didn't realize it would take months though. First they wanted to wait until all charges were billed even though my wife was at the point where the insurer was paying 100%. Then they wanted to wait until all follow up visits were done. We eventually called the insurer to set up a 3-way call to explain all this and the insurer just went off on the billing receptionist. In the end, we found out their provider contract has a provision that they are not supposed to be billing anything in advance except deductibles, and they are not supposed to be holding onto money that should be refunded to apply towards anything that is not already due.

 

[Steeleballz 7,550]

3 minutes ago, Bill & Katya said:

 

I guess what I would like to see is if there is a reduced cost for the shot if the Dr.'s office doesn't have to submit it to the insurance company.  I mean why submit something and incur whatever that cost is, that is being paid for with cash.  Is there a rule that everything has to go through the insurance company?

 

  I was curious about that too. Just from looking online, I think some of that is regulatory and varies by state. It may be something that also is specified in the contract between the provider and insurance. Probably some of it is office policy too though. 

 

  When we had Kaiser a while back, my doctor could see the cost of prescriptions and things directly as he entered it in the computer. Kaiser had a flat $10 copay for prescriptions at that time, and my doctor would often ask if we wanted a written prescription if something was cheaper outside without insurance than the $10 copay at Kaiser. 

[bcking 3,157]

1 hour ago, Bill & Katya said:

 

I guess what I would like to see is if there is a reduced cost for the shot if the Dr.'s office doesn't have to submit it to the insurance company.  I mean why submit something and incur whatever that cost is, that is being paid for with cash.  Is there a rule that everything has to go through the insurance company?

In a clinic that likely submits 90+% of their billable charges through an insurance company, they probably aren't saving much money by not submitting your one case to insurance. The overhead to manage insurance reimbursement is already in place, and an additional insurance charge is not a big deal. So it doesn't really save them money to just accept your cash. 

 

That being said, it gets a little trickier when you compare what they charge insurance and what they actually get reimbursed, and then factor into account whether you are "in network" versus "out of network. In many cases (most?), if you are seeing a doctor in an established network with your insurance company, they aren't allowed to charge you above what insurance reimburses. So if they feel their service is worth 300 dollars, but insurance pays them based on an "allowable charge" of 150 dollars, they can't go to you for the remainder. If they are "out of network", then all bets can be off and you would have to negotiate with the clinic regarding the remainder of the bill after whatever your insurance paid. Keep in mind here we are talking about the "allowable charge" (many insurance companies base it on the medicare allowable fee) for that service. We aren't talking about the percent reimbursement that different insurance plans cover. 

 

For the cost of a shot, most insurance plans will cover that 100% (preventative medicine). Again though that is 100% of what they consider the "allowable charge" for that service, not whatever the clinic makes up. If you are "in network" with that clinic, even if they make up some higher number they can't charge you the remainder. If you are out of network however, they can do what they please. So if your clinic charges your insurance 200 dollars (and the allowable fee is 200 dollars), then insurance will pay that 200 dollars. The clinic isn't going to really benefit from taking the money from you directly, except in the sense that the transaction will happen quicker but most clinics don't really care that they don't actually get reimbursed by insurance for a month (it's usually not actually that long).

 

For hospital care, you can actually get a "reduced fee" if you go to the billing department ahead of time (if it's planned), or as soon as you can (if it's unplanned). Take child birth, for example. Many hospitals will offer you a lower rate if you show up during the prenatal period and state you wish to pay up front in cash.  Is it going to be lower than what insurance would pay them? It wouldn't be if you have insurance, and they know they can get reimbursed a specific amount from your insurer. If you don't have insurance however, they know that hunting you down later to pay is a hassle, and they end up selling a lot of "debt" to collectors at a much lower rate. They'd rather take more up front from you then have to deal with that in the long run. For something like child birth though that may happen less often, since they can also always refuse to "plan" for you to deliver there (though you could always show up on the day of anyway).

 

1 hour ago, Steeleballz said:

 

  Most of the other physicians we have seen will charge the deductible amount if it's not met, and usually the copay at time of service. As I said earlier, many even require this prior to seeing the patient. Lot's of patients are taking too long to pay apparently.

 

   My primary care physician won't take it until after they bill though. In fact the regular office visit is billed at $87 so I even said last time why can't I just pay that amount since I'm still paying my deductible and the receptionist said they don't know how much it will actually be until they submit it to insurance. I told her it's $87 and she said then I'll get a bill in the mail.

 

   It's a hassle when they over bill too though. Not just for the patient. We payed about $400 extra for my wife's surgery last year. I told them they were wrong when they asked for the co-pay, and they said if we wanted to reschedule the surgery we could go home and have the insurance company confirm the exact amount. Obviously we were not going to do that, and I knew we would get the money back. I didn't realize it would take months though. First they wanted to wait until all charges were billed even though my wife was at the point where the insurer was paying 100%. Then they wanted to wait until all follow up visits were done. We eventually called the insurer to set up a 3-way call to explain all this and the insurer just went off on the billing receptionist. In the end, we found out their provider contract has a provision that they are not supposed to be billing anything in advance except deductibles, and they are not supposed to be holding onto money that should be refunded to apply towards anything that is not already due.

 

A visit to your primary care physician shouldn't apply to your deductible. I don't have occupational experience with that since it's not my profession, but in my personal experience primary care is always covered 100% (aside from a copay), and shouldn't apply to a deductible. 

 

Many clinics may just say "You'll get the bill" because they deal with dozens of insurance providers and plans. You may know that every time it costs X amount, but they don't want to bother dealing with it if for whatever reason you happen to be wrong that one time. They'd rather process it like every other charge.

 

I've had the "overbill" as well. The example I gave from the Dermatologist ended up actually NOT applying to my deductible, even though the clinic thought it did. So they initially asked if I wanted to pay the 800 dollars because I hadn't applied any care that year to my deductible (which was like 850), or wait until they bill insurance. I opted to just pay it. I then found out (by accident when I went to a physical therapy appointment a couple months later) that the procedure I had done actually DIDN'T apply to my deductible and I was actually only responsible for my co-pay (40 bucks). The dermatologist didn't contact me, and if I didn't realize that it didn't go to my deductible by seeing a PT later (where they told me my deductible was still at 0), I never would have known. Once I called them they quickly refunded me the 760 dollars. It was actually pretty crazy that no one contacted me about such a huge mistake. 

[bcking 3,157]

1 hour ago, Steeleballz said:

 

  I was curious about that too. Just from looking online, I think some of that is regulatory and varies by state. It may be something that also is specified in the contract between the provider and insurance. Probably some of it is office policy too though. 

 

  When we had Kaiser a while back, my doctor could see the cost of prescriptions and things directly as he entered it in the computer. Kaiser had a flat $10 copay for prescriptions at that time, and my doctor would often ask if we wanted a written prescription if something was cheaper outside without insurance than the $10 copay at Kaiser. 

Systems like Kaiser will always be easier since it is all one system. If you are part of Kaiser, you are in your own little "universal healthcare system" where provider and insurance are the same entity. 

 

Generally speaking medical care in the US is incredibly fragmented, which most of the time makes it far more complicated. Most doctors (myself included) can't really tell a patient anything about how much what they are doing will cost. In my case it's especially hard since we are talking about an entire hospital stay that is unplanned. These days some insurance providers are reimbursing based on a DRG, but your specific DRG adjustments may not be set until the hospital stay is over (depending on what complications develop during the hospitalization). Others will charge on a "daily" "fee-for-service" type system. Even in that situation most of what we do is bundled. They aren't going to see a bill for every single CBC we sent during the hospital stay, for example. 

 

In my view, for inpatient medical care, DRG-based payments are a significant improvement in the system assuming insurance providers create fair reimbursements. They reimburse for care based on "Diagnosis-related groups", based on what the primary reason for the care is (In my case something like premature infant born at 28 weeks, or something similar). The DRG can be adjusted based on complications (premature infant born at 28 weeks, complicated by NEC) and then the set reimbursement changes. It is then up to the hospital to provide care that is cost-effective based on what they are reimbursed. That puts more of the responsibility on us, which means we have an incentive to talk about issues like waste, over-treatment, over-diagnosis etc... Instead of just throwing the kitchen sink at everything knowing that we will generally get reimbursed for it.

Edited June 14, 2018 by bcking

[Steeleballz 7,550]

1 minute ago, bcking said:

In a clinic that likely submits 90+% of their billable charges through an insurance company, they probably aren't saving much money by not submitting your one case to insurance. The overhead to manage insurance reimbursement is already in place, and an additional insurance charge is not a big deal. So it doesn't really save them money to just accept your cash. 

 

That being said, it gets a little trickier when you compare what they charge insurance and what they actually get reimbursed, and then factor into account whether you are "in network" versus "out of network. In many cases (most?), if you are seeing a doctor in an established network with your insurance company, they aren't allowed to charge you above what insurance reimburses. So if they feel their service is worth 300 dollars, but insurance pays them based on an "allowable charge" of 150 dollars, they can't go to you for the remainder. If they are "out of network", then all bets can be off and you would have to negotiate with the clinic regarding the remainder of the bill after whatever your insurance paid. Keep in mind here we are talking about the "allowable charge" (many insurance companies base it on the medicare allowable fee) for that service. We aren't talking about the percent reimbursement that different insurance plans cover. 

 

For the cost of a shot, most insurance plans will cover that 100% (preventative medicine). Again though that is 100% of what they consider the "allowable charge" for that service, not whatever the clinic makes up. If you are "in network" with that clinic, even if they make up some higher number they can't charge you the remainder. If you are out of network however, they can do what they please. So if your clinic charges your insurance 200 dollars (and the allowable fee is 200 dollars), then insurance will pay that 200 dollars. The clinic isn't going to really benefit from taking the money from you directly, except in the sense that the transaction will happen quicker but most clinics don't really care that they don't actually get reimbursed by insurance for a month (it's usually not actually that long).

 

For hospital care, you can actually get a "reduced fee" if you go to the billing department ahead of time (if it's planned), or as soon as you can (if it's unplanned). Take child birth, for example. Many hospitals will offer you a lower rate if you show up during the prenatal period and state you wish to pay up front in cash.  Is it going to be lower than what insurance would pay them? It wouldn't be if you have insurance, and they know they can get reimbursed a specific amount from your insurer. If you don't have insurance however, they know that hunting you down later to pay is a hassle, and they end up selling a lot of "debt" to collectors at a much lower rate. They'd rather take more up front from you then have to deal with that in the long run. For something like child birth though that may happen less often, since they can also always refuse to "plan" for you to deliver there (though you could always show up on the day of anyway).

 

A visit to your primary care physician shouldn't apply to your deductible. I don't have occupational experience with that since it's not my profession, but in my personal experience primary care is always covered 100% (aside from a copay), and shouldn't apply to a deductible. 

 

Many clinics may just say "You'll get the bill" because they deal with dozens of insurance providers and plans. You may know that every time it costs X amount, but they don't want to bother dealing with it if for whatever reason you happen to be wrong that one time. They'd rather process it like every other charge.

 

I've had the "overbill" as well. The example I gave from the Dermatologist ended up actually NOT applying to my deductible, even though the clinic thought it did. So they initially asked if I wanted to pay the 800 dollars because I hadn't applied any care that year to my deductible (which was like 850), or wait until they bill insurance. I opted to just pay it. I then found out (by accident when I went to a physical therapy appointment a couple months later) that the procedure I had done actually DIDN'T apply to my deductible and I was actually only responsible for my co-pay (40 bucks). The dermatologist didn't contact me, and if I didn't realize that it didn't go to my deductible by seeing a PT later (where they told me my deductible was still at 0), I never would have known. Once I called them they quickly refunded me the 760 dollars. It was actually pretty crazy that no one contacted me about such a huge mistake. 

 

   Preventative is covered %100 for ours. The deductible applies for regular office visits (and even if you bring up too many issues at a preventative visit).  It's been a long time since I've seen an insurance that covers regular primary care visits at %100. We have a choice of Cigna, Kaiser and some other fly by night plan. They depend on what your employer wants to pay for though. A guy at work who came from New York said they still had a no deductible plan when he was there. They were unionized there  though, so they still had decent benefits. 

 

   For our over bill too, they never got back to us. Just that I knew it was wrong so I was watching the statements from the insurance company. We did have another one a few years ago where someone sent a check back because they billed us too much. I checked the insurer statement and they doctors office had issued the refund back a couple of days after they got reimbursed. Probably depends a lot on how on the ball the office staff are.