This sort of thing gets to two critical problems of the American system:
1. It is largely designed to make money, not actually help patients. So every step in the healthcare chain that can extract a bit of value will do so, largely to boost profits.
2. Insane complexity with limited transparency. How much will something cost? Hard to tell. Will it be covered? Who knows?
On the opacity, I have one informative anecdote. I had a single blood test done awhile back and no one knew if insurance would cover it, or which of the dozen or so billing codes it involved (taking the sample, delivering the sample, testing the sample, etc.) might be covered. It was an expensive test so I spent days bouncing between the doctor's billing team and the insurance company until the settled answer was: No one knows, do the test and insurance will decide. So I did it and insurance denied covering the doctor-recommended test. The salaries involved for all the billing people (and my time) would have covered the cost of the test. </rant>
I lost some money, or at least had a hard time using it, because I was quoted a price for something, set the FSA for the next year based on that, and then the billing ended up where only some of the price was eligible for FSA.
Combined with the PITA level, there's no way I'm doing it again. I can't see how it's worth my time. One of these three options is very likely:
a) my income level is low, so every dollar counts, but my marginal tax rate is also low, so spending a ton of extra time on this is not worth saving ~ 15% on taxes for health care
b) my income level is high, so my marginal tax rate is high, but saving 40% of taxes for health care is not worth the time, because health care is not a meaningful amount of income
c) my health care spending is high relative to income, and I can deduct health care costs on my tax return. Then I can deduct a lot more than the FSA will reimburse for, and the records don't need to satisfy a third party, unless I'm audited by the IRS.
It is a relatively easy fix tbh. You spend on medical bills through the account like you do right now, but the way you fund it is your post tax contributions. At the end of the year the account sends you a statement of what you used and you can use it to get the tax paid on the money back when you file the taxes.
FSA does have the concept of rollover of up to $600 but its up to the employer to decide. I imagine that full rollover is not allowed because otherwise people would use the FSA to defer some tax payments to end of year. But there are ways they could have handled it better.
I don’t understand why any decision maker in any business in the USA chooses to offer their employees (and hence themselves) health FSAs at all, especially when the much superior in every way Fidelity HSA is available.
All the FSA money in your account is available immediately at the beginning of the year. Ironically that would make it a better choice for anyone with a lot of medical expenses on an HDHP if it wasn’t for the fact that FSAs are capped by law.
As someone who does deal with enough medical stuff to clear the deductible (and sometimes the OOP max) on their normal health plan annually, it’s still much more convenient, again because the money is all there at the beginning of the year when the expenses are highest
HSAs are only available alongside high deductible plans (HDHP), which aren't necessarily ideal in all situations. FSAs are the only option like that if you don't have an HDHP.
What is the point of having a low deductible when you could put the premium difference in a HSA and use it on either the deductible or something uncovered?
Surely, that is offset by having to forfeit or waste any FSA money not needed by the end of the year. It really only makes sense if you have a minimum amount of guaranteed healthcare expenses every year.
Medicine not in formulary. Their clinical department decided it was not worth covering for $reasons. The Pharmacy, likely to be considered a preferred pharmacy, signed a contract to be bound by that company's clinical formulary for policyholders.
$45 was probably cash price, the they can let it go for if they do their ordering through a pharmacy supply group.
$12 may be a price with a discount program like GoodRx applied. Data changes hands behind the scenes to make the lower price at the till possible. Don't know how GoodRx works, but been around long enough to know you're probably the product.
You'll be amazed the complexity of the pharmacy benefits management complex.
t. Been there, seen it, tried to fix it best I could, left in abject horror.
I've had numerous encounters where doctors (and dentists) attempt to charge me for services they've already been reimbursed for from the insurance company.
It's only after hours of scouring my EOBs and being on the phone with my insurance that I then come back to the practice's office with evidence in hand, and they dismiss the charges.
I'm pretty sure this is just a racket because they expect most people not to put up a fight and just pay, or get sent to collections hell.
The amount of work you need to do as a patient in our health system is so dumb.
> No one knows, do the test and insurance will decide
Oh, someone knew but the doctors office wanted to do the expensive thing and get paid (either by you or the insurance)
Not saying the blood test was unnecessary but we have no idea what communication happened between the doctor and insurance company. Did they possibly recommend a less expensive test and the doctor decided that'd make him less money so he went forward anyway?
Health insurance companies have told me, on the phone, that they will not tell me the codes the doctor needs to charge for preventative visits in order to for my visit to be covered as preventative care (meaning I don’t have to pay anything).
However, I could tell the insurance customer service person a code, then they could tell me if it was classified as a covered preventative service.
So I, the insurance company’s customer,
Googled medical procedure codes and found some on random PDFs, and checked which ones were covered, and then I asked the doctor to provide me the services for that code.
That is American healthcare.
On the flip side, I also had a doctor’s office try to bill my insurance $25 for towels used to wipe the ultrasound jelly off my wife’s belly. My insurance didn’t pay, so the doctor’s office sent me the bill for what insurance didn’t cover, so I called the doctor’s office and asked why I am being charged $25 for the few pieces of paper towel (not even linen towel), and the receptionist said they would waive the charge.
So, moral of the story is bring your own paper towel roll when you expect to get messy at the doctor’s office.
No, I assure you, it is very common for doctors' offices not to know whether a particular procedure will be covered.
This is not just because of the capriciousness of insurance adjusters, but because they have to deal with all the 273 different variations of insurance plans that people who come through their offices might have.
In general, a doctor's primary goal will be to get you good care.
An insurance company's only goal nowadays is to make as much money as possible for as little effort as possible.
> An insurance company's only goal nowadays is to make as much money as possible
How can that be true when their profits are capped on collected premiums? Look up the Medical Loss Ratio (MLR) rule to see what I'm referring to. If you wanted to squeeze money out of people, health insurance would be the least appealing industry to do that in since you're required to spend 80-85% of premiums on medical care.
The linked article is about insurers trying to reduce spending by downcoding.
So which is it? Insurers unfairly denying reimbursement for what should be valid claims, or insurers unfairly increasing spending on claims so they can increase their profits.
Also, go look at 5, 10, and 15 year returns for the big insurers (UNH/Elevance/CVS/Cigna/Humana/Molina/Centene) if you think health insurance is a good business for earning money. Spoiler alert: they’re less than desirable, stick with SP500.
This doesn't surprise me: The "fee for service" system encourages doctors to perform as many services as they can so they can bill for more. I've certainly had my fair share of tests and procedures where I wonder if the provider was just trying to find something to bill for.
I'm also not surprised that some providers will try to figure out which codes they can use to get the most revenue. ("Hey, if I do procedure A instead of B, I get paid more, so why would I do B?")
That being said, I also wouldn't be surprised if many of these turn into lawsuits, or ultimately push to revise the whole "fee for service" system.
If someone invoices me, and I don’t pay the full amount in a timely manner, what do you think will happen? Late fees, reports to credit bureaus, collections agencies hounding me, maybe even lawsuits?
If insurance companies underpay, doctors should treat that no differently. Don’t appeal through the insurance company itself. Imagine I go to a store and pay less than the full amount at the register, and then the grocery store appeals to ME to decide whether I actually should have paid the correct amount. It’s absurd.
Doctors should treat the insurance companies like anyone else who owes them money and isn’t paying in full on time.
> Recovery is beyond the scope of most small practices.
Seems like a business opportunity. Could probably work very similar to other collections agencies where they either buy the debt for pennies on the dollar or take a percentage of the collected amount.
Yeah, there's an industry of companies that insert themselves between the medical record and the insurance company to upcode claims and get better payments. This article is about the reverse process, where the insurance company looks at the claims and downcodes them to send worse payments.
IMHO, in office care should be more of a time and materials billing than billing based on procedures done. Of course, then the doctors' billing office would aggressively measure time the doctor spent, and the insurance company would suggest the doctor took too long for whatever.
You'll notice the doctor's office in the article already has a team of billing experts. But instead of working on new claims, they are being forced to relitigate claims they already submitted that weren't accepted.
Sending your patient's 'debt' to collections promptly is very unpopular with the patients, and the insurance companies will 100% insist that the patient is responsible.
It's much easier to treat it like identity theft where the business's problem becomes the customer's problem to solve. In this case, insurance didn't pay what was required so the patient does. There's already a potential collections agency involved if the patient doesn't pay.
Who do you think is easier to squeeze the money from? A mega-insurance corporation or your sick grandma?
Insurance companies hold tremendous leverage over care providers, up to and including the power to effectively put them out of business on a whim. Care providers don't like picking fights with insurance companies.
Doctors have extensive contracts with insurance companies, and often have employees dedicated to billing. I wouldn't make assumptions here, other than "downcoding" is probably just subtle enough to not be worth it to fight.
I was thinking the same thing. Would it be permissible to bring each underpayment to small claims court as a separate case? If enough doctors did this, it would very quickly be a legal DDoS attack, like we've seen happen with mandatory arbitration.
So what should happen when Docs lie about what procedures they did? Because it happens quite frequently and for some reason is always left out of these discussions.
A reasonable wage or salary isn’t usually considered “profit” in a legal sense. This is why nonprofits can still pay employees. Any money that is left over after costs (including wages/salaries) needs to be reinvested, spent on the organizational mission, or held for future use, not distributed through dividends or other distributions as in a for-profit enterprise.
I have no problem with it being for profit. The issue is the alignment of interests and the thumb on the scales by government and vested interests. If health insurance worked like car insurance I think we'd be in a better state.
Vets are really the most amazing doctors and I hate to see what is happening to their industry. Hopefully in exchange for dealing with the bullshit of human health care, at least maybe the money is getting a little better for them (a lot of them are just criminally underpaid).
Most insurances won't publish their fee schedules. So doctors don't know what they will pay. So what they do is bill insanely high knowing the insurance will come back with "Nah, we only cover $X". They'll collect $X, then write off the remainder. Because the fear is not getting the maximum money possible. If the doctor would bill $100 and the insurance pays up to $200, then the doctor "lost" $100.
Regardless of how much it actually cost the doctor to provide the service.
It's also why the "cash price" is usually much cheaper, because it's closer to what it costs the doctor to provide the service.
Sure but imagine you hire a landscaper and they send you a $40 invoice for $20 of law cutting and $20 of leaf cleanup. You go look outside and see a ton of leafs so you just send them $20.
That's the insurance companies' stance. The work you performed is this and so our agreed upon rate is this.
But in reality, the landscaper bills you for $100, you say you’re only going to pay $90, and then you write them a check for $31.50.
(That’s because you’re a major, well-known insurer and pay an industry high 35%. The guy who mows the Medicare yard might pay 40 cents on the dollar. The person mowing the Medicaid yard has to file 87 forms to get paid his $6.)
but the landscaper has a photo of the clean yard after they finished. They send it to you but you ( as the insurance company) say they need to call a specific time and speak to your 12y/o who is the yard representative of the house.
The 12 y/o say ‘no you stink’ and hangs up. Then you send the landscaper a letter saying ‘sorry your peer to peer was denied’
( I know this is exaggerating a bit and made to sound funny but it mostly works like that in healthcare )
My pediatrician always charges us for an office visit + preventative care when we go in for a preventative care visit. It's obviously to get more $$ from insurance. I feel like this goes both ways...
Yeah enough gets talked about insurers acting in bad faith, but let’s not forget hospitals also acting in bad faith for their end. Some personal examples:
1. Sitting in a Urgent care. They get you in the exam room. You sit there for 15 mins, doctor comes and sees you for 5 mins (mostly rushes the exam), do a blood draw, ask me to sit around while they run the test, doctor leaves, as soon as 45 mins are over the nurse comes over to let me know it’s taking longer to run the test so I can go home and they’ll call when the results are out. A month later charge thousands of dollars to insurance for a 45 min Urgent Care visit that doesn’t cover the lab work.
2. Go to PCP with cold symptoms that haven’t cleared in 10 days. I insist it’s a sinus infection, they send me back with no antibiotics and ask to schedule and online appointment in 2 days. I insist I come in in person, but they schedule an online appointment anyway. Nothing gets better and I see the doctor online after 2 days, they say I’ll have to come in so that they can evaluate me in person and prescribe antibiotics. I go in person, get antibiotics and get cured. Insurance gets charged for 3 separate hour long visits ($750 each and none of them lasted more than 10 mins).
An obligation to pay is always good for the billing side. Think about the sociopathic prices of US pharmaceuticals.
Afaik any other country with mandatory health care also puts a ceiling on prices. In germany, there is a price catalog for any service, with only few exceptions, and doctors/hospitals cannot legally charge anything else for these covered services. Now guess what the US does not have, even thought obama had foreign consultants explicitly advising for it.
Health ensureance companies are certainly not the most altruistic but any profit oriented company trying to cut cost where ever possible is hardly a supprise.
I wonder what would happen if we moved the "medically necessary" requirement burden of proof from the doctor/patient to the insurer. So the insurer would be required to pay out a claim regardless of whether the insurer thought it was medically necessary, but their recourse could be to try to claw it back post-payment.
They'd most likely go bankrupt. There is already an incentive for them to spend on medical care due to the Medical Loss Ratio (MLR) which caps their profits on collected premiums.
If you're saying they need to be forced to pay whatever invoice comes to them and start legal battles for each suspect case then yeah... that doesn't seem feasible.
Doctors/patients are human too and your proposed system would be ripe for abuse. If you're well versed in submitting claims, and you know they have to pay out, then you could inundate them with fraudulent ones.
> That to me would imply that doctors/patients are submitting a huge amount of incorrect claims
UnitedHealthcare says that 10% of claims go through additional review for various reasons[0].
I don't know if there are stats for the industry as a whole, but my guess is that they deal with a lot of errors.
I'm not proposing that all guardrail responsibilities be shifted to the insurer. Just the "medically necessary" provision.
Doctors would still have a Duty to Code Services Accurately and a Duty to Maintain the Medical Record (which would clearly enable an insurer to prove a non-medically necessary therapies). There would be plenty plenty of evidence for an insurer to immediately respond.
So claims could be rejected on the basis of failing to code accurately or lack of record.
IT is beyond our control because we have setup a system where the people who are paying don't want to control things.
My boss wants insurance to be expensive - if I could afford it I would be more willing to quit (retire early).
Finding cheaper services isn't in my interest - I'm not paying any bills anyway.
Insurance companies like the complexity because it means I can't understand the system and so I have to use them.
Doctors don't really care as they just have administrators play the game for them. Once in a while they look at the game and say something, but really this is just they don't understand how the game is played (they shouldn't - they are doctors, they should be looking at medical issues not administrative ones).
Doctors have also spent a lot of time lobbying to make becoming a doctor harder so that the fewer doctors will be able to command better salaries. It sounds like they are attempting to reverse that and open up more spots for residencies but I imagine that there is a lot of momentum to overcome.
There's an old mechanics saying "if X was covered by insurance it'd cost what Y does" where X is some routine thing (tires/brakes/etc) and Y is autobody or glass services typically covered by insurance.
This proverb seems to also apply to health insurance and the things they do/don't cover.
Putting routine stuff under the purview of insurance is stupid regardless of context. There are other cheaper, faster, simpler and more transparent ways of doing that.
Other countries are making efforts to keep things in check though https://www.npr.org/2025/01/04/nx-s1-5246231/potential-fraud.... The US for some reason can’t even address blatant fraud. One example is the stuff insurers do with Medicare Advantage. There is fraud and Congress knows about it but besides some hearings nothing is happening.
And having lived 10 years in Canada and 10 years in the US and used both their healthcare systems quite a bit, I have seen both sides. Let me just say I moved to the US for healthcare 10 years ago and we do not regret it one bit. The US is easy to point and laugh at, but that just comes from ignorance.
I can quickly see something like this turning in an AI arms race between insurance and the provider with each auto-approving/denying/disputing the other. All the while locking out smaller players because they can't afford the 3rd party disputotron.
You would have to leverage the law (if you have one) that involves the state resolving the dispute because otherwise the automated disputes would probably be dropped on the floor. The insurance company has the leverage because they're actually in possession of the money and the contract that gives them stupidly high discretion on how much to pay out.
Doing nothing but flipping the burden, doctors get paid whatever they invoice and insurance have to claw it back would make a lot of this stonewalling bullshit go away. But with an openly corrupt government paid by insurance it'll never happen.
the health insurance industry needs to be razed to the ground and rebuilt from scratch. there's no saving something that is ostensibly designed to help people get healthcare but realistically denies them what they're entitled to for years (in some cases, they just try to keep the ball in the air until the patient dies, then there's no one to appeal) and then once the care is approved steals from the service provider by automatically altering the bills without any evidence of fraud or theft.
It's a system that supports two set of clients, doctors and patients, and fails them both. Yet, Congress has considered it sacred and infallible for a hundred years. Democrat's most earnest attempt ended up strengthening and expanding that system, and Republicans for their part have fought tooth and nail to stack the system even further against the people it's supposed to serve.
People get annoyed at insurers who will deny treatment but most of the time you can just pay it yourself. The government has decided that everyone should pay for health insurance but you'll never be denied care if you pay for it yourself.
So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's unlikely someone else will if they have to pay on your behalf.
Essentially, place yourself in the role of each participant:
- patient: wants to maximize care, money no object since it isn't theirs
- medical practice: wants to maximize money spent on care
- insurer: wants to minimize money spent on care
Normally, the first two would be happy to collude to charge the third any amount of money since they'd both get what they want. And that is indeed what happens. So you get the natural result that the insurer doesn't want to support certain payments even if they were kind and pure-hearted. That they don't want to when they're neither should then not be a surprise.
You can remove that pressure by turning the interaction into:
- patient: wants to maximize care with minimized cost
- practice: wants to minimize care with maximized cost
The pressures between the two parties are now opposite and you can find the market equilibrium. With this opposition you'll suddenly find that patients start complaining about doctors ordering unnecessary procedures and so on, just like insurers claim in the other model.
You can also work through with the other versions to model where equilibrium will set in and see if it's where it does. Most of the time you don't need to assume any moral valence for the participants. They might as well be machines. It is their roles that determine how they act, not their personalities.
>So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's unlikely someone else will if they have to pay on your behalf.
Ok, hear me out for a minute.
What if I wanted to pool with several people, so that if any of us had unexpected medical needs, it wouldn't bankrupt any of us. Knowing that most of us would not need it.
And then, since we're all on the hook for each other's general health, we also agreed to share the cost of preventative care, because it was literally cheaper for us to all pay for preventative care than to try to just solo it and then hit the group with the cost of terminal cancer care instead of catching it early and doing a small excision. (and other such examples.)
And then what if we made the pool HUGE, to even further spread out the costs?
Sure wish there was a system that just did that, without trying to also generate insane profits off it.
There's nothing stopping you from starting your own non-profit health insurance company. If greedy health insurance companies are really the root of the problem, you should be able to out-compete them fairly easily.
That assumes the humans will do their best to take care of themselves but given the ability they will be bailed out, they let their health go knowing they don't need to actively take care of themselves.
The problem is that patients are usually not in a position to determine if the care the doctor says is needed is really needed or not. This is the same as taking your out-of-warranty car to the mechanic. How do you know if the mechanic is telling the truth?
Still, this would be better than the current system. Even when you don't know if the doctor is telling the truth you can go by their reputation for telling the truth. Reputations will matter more, and doctors will care about maintaining their reputations in their community.
I went to the dentist a couple of weeks ago and had the shortest dental visit I've had. They did the X-rays, then the dental assistant spent five minutes cleaning my teeth and pronounced them good. The dentist came in and looked for about one minute and said they were fine. I was sent on my way.
They billed my insurance for over a thousand dollars.
Ah yes, this is a fight between the practices (sometimes not the doctors!) upcoding their visits and the insurance companies wanting to push back and downcode the visits to what they actually entailed.
Healthcare practices want to maximize revenue and push up the “level” of a doctors visit and they can do it with just adding one or two extra little questionnaires or an extra test or two that you might not pay attention to so they can get an extra several hundred dollars a day for billing higher level cases daily.
Because the common interaction people have with their insurers is "We are denying this because of <REASON>" which they have to fight to get healthcare.
When a provider rips off an insurer it's invisible to the general public.
Also, incidentally, when people talk about fraud in Medicare/Medicaid, the providers are almost always where that happens (yet that's often not pointed out).
FWIW I hate most medical billing departments (and hospitals are the worst) about as much as I hate insurance.
They're at least as likely to fuck something up (curiously, always in their favor, not yours) as insurers, from what I've seen. And they're almost as unpleasant to deal with—at least they don't generally keep you on hold for literal hours, but it's still not great.
And one of the ugliest public-facing roles in all of American medicine has to be the insurance-vultures whose job is to hover about emergency rooms pestering very-sick people for their billing information. Fucking gross.
Every party at every point in the system is various shades of complicit in fleecing us. That's the magic of the system. It's all divided up in so many ways and so many of the feedback loops touch through the people getting screwed that it's impossible to build a "these guys might not be wholly responsible, but they're responsible enough things will get better if we push them off a cliff or legislate them into poverty or whatever" consensus you need to build to change things
17% of the US GDP is healthcare, now obviously there's a lot of nurses and random courier drivers and all sorts of other stuff in there, but they would all need to take some amount of haircut for us to get fleeced less.
The GDP contribution of slavery was ~13% just preceding the civil war and credible moves (i.e. electing Lincoln) to make them take a haircut caused, you know, the civil war.
There is likely no "clean" way to fix this problem other than a century long frog boiling exercise
You think nurses and couriers are the ones who need to take pay cuts to get healthcare expenses under control??? Lm, and I cannot stress this enough, fao.
There is immense pressure on insurance companies to lower costs, as they get blamed for the "American health care system". The only one on the side of the payer is the insurance company, they're the only one who wants to keep costs down for the consumer. Given the massive amounts of fraud in government health insurance (medicare) it would of course be prevalent in the private insurance market.
“ they're the only one who wants to keep costs down for the consumer.”
They don’t. They want to increase profits by pushing more and more cost to the patient while squeezing providers. The patient is always the loser in this system. One reason is that most patients don’t even have a choice of insurance because their employer picks the insurance that’s best for the employer.
My employer switches insurance carriers every 4 years or so because another carrier has a more competitive rate. "What's best for the employer" is also what's best for me -- I can walk across the street and get a new job if I become unhappy. They want to keep their healthcare costs down so they can keep my salary high as dollars lost to my healthcare compensation are invisible to me.
People who have always lived in the USA have no idea how many things about life in the USA are batshit crazy. This is probably the top of the list. At least before we turned to fascism...
This sort of thing gets to two critical problems of the American system: 1. It is largely designed to make money, not actually help patients. So every step in the healthcare chain that can extract a bit of value will do so, largely to boost profits. 2. Insane complexity with limited transparency. How much will something cost? Hard to tell. Will it be covered? Who knows?
On the opacity, I have one informative anecdote. I had a single blood test done awhile back and no one knew if insurance would cover it, or which of the dozen or so billing codes it involved (taking the sample, delivering the sample, testing the sample, etc.) might be covered. It was an expensive test so I spent days bouncing between the doctor's billing team and the insurance company until the settled answer was: No one knows, do the test and insurance will decide. So I did it and insurance denied covering the doctor-recommended test. The salaries involved for all the billing people (and my time) would have covered the cost of the test. </rant>
Here are the magic words in US Health Care: "What is the cash price?"
It's usually less than you think and often worth avoiding the insurance company hassle. Then you can just get reimbursed with your FSA or HSA anyway.
FSAs are insane, conceptually.
"Guess how much money you're spending in a year on healthcare! But beee caaareful: if you guess too high, YOU LOSE IT"
I still used mine while I still had access to one, but it was grumpy-making and was usually almost more trouble than it was worth.
I lost some money, or at least had a hard time using it, because I was quoted a price for something, set the FSA for the next year based on that, and then the billing ended up where only some of the price was eligible for FSA.
Combined with the PITA level, there's no way I'm doing it again. I can't see how it's worth my time. One of these three options is very likely:
a) my income level is low, so every dollar counts, but my marginal tax rate is also low, so spending a ton of extra time on this is not worth saving ~ 15% on taxes for health care
b) my income level is high, so my marginal tax rate is high, but saving 40% of taxes for health care is not worth the time, because health care is not a meaningful amount of income
c) my health care spending is high relative to income, and I can deduct health care costs on my tax return. Then I can deduct a lot more than the FSA will reimburse for, and the records don't need to satisfy a third party, unless I'm audited by the IRS.
It is a relatively easy fix tbh. You spend on medical bills through the account like you do right now, but the way you fund it is your post tax contributions. At the end of the year the account sends you a statement of what you used and you can use it to get the tax paid on the money back when you file the taxes.
FSA does have the concept of rollover of up to $600 but its up to the employer to decide. I imagine that full rollover is not allowed because otherwise people would use the FSA to defer some tax payments to end of year. But there are ways they could have handled it better.
I don’t understand why any decision maker in any business in the USA chooses to offer their employees (and hence themselves) health FSAs at all, especially when the much superior in every way Fidelity HSA is available.
All the FSA money in your account is available immediately at the beginning of the year. Ironically that would make it a better choice for anyone with a lot of medical expenses on an HDHP if it wasn’t for the fact that FSAs are capped by law.
As someone who does deal with enough medical stuff to clear the deductible (and sometimes the OOP max) on their normal health plan annually, it’s still much more convenient, again because the money is all there at the beginning of the year when the expenses are highest
HSA requires a high deductible health plan, not everyone could afford that deductible.
"To contribute to an HSA, you'll need to be enrolled in an HSA-eligible health plan, also called a high-deductible health plan (HDHP)."
HSAs are only available alongside high deductible plans (HDHP), which aren't necessarily ideal in all situations. FSAs are the only option like that if you don't have an HDHP.
What is the point of having a low deductible when you could put the premium difference in a HSA and use it on either the deductible or something uncovered?
Surely, that is offset by having to forfeit or waste any FSA money not needed by the end of the year. It really only makes sense if you have a minimum amount of guaranteed healthcare expenses every year.
[delayed]
Pharmtech: "With your current insurance we can't sell you this medicine at any price. We're under an agreement."
Me: "Okay, what if we don't go through insurance?"
Pharmtech: "$45 for the prescription."
Me: "That's a bit higher than last time."
Pharmtech: performs some sort of incantation "Okay, $12."
Me: "How did we go from not at any price to $12?"
for those of you keeping score at home, the medicine was generic colchicine which costs $.30/dose (https://pmc.ncbi.nlm.nih.gov/articles/PMC7851728/), and I was getting 12
Medicine not in formulary. Their clinical department decided it was not worth covering for $reasons. The Pharmacy, likely to be considered a preferred pharmacy, signed a contract to be bound by that company's clinical formulary for policyholders.
$45 was probably cash price, the they can let it go for if they do their ordering through a pharmacy supply group.
$12 may be a price with a discount program like GoodRx applied. Data changes hands behind the scenes to make the lower price at the till possible. Don't know how GoodRx works, but been around long enough to know you're probably the product.
You'll be amazed the complexity of the pharmacy benefits management complex.
t. Been there, seen it, tried to fix it best I could, left in abject horror.
I've had numerous encounters where doctors (and dentists) attempt to charge me for services they've already been reimbursed for from the insurance company.
It's only after hours of scouring my EOBs and being on the phone with my insurance that I then come back to the practice's office with evidence in hand, and they dismiss the charges.
I'm pretty sure this is just a racket because they expect most people not to put up a fight and just pay, or get sent to collections hell.
The amount of work you need to do as a patient in our health system is so dumb.
> No one knows, do the test and insurance will decide
Oh, someone knew but the doctors office wanted to do the expensive thing and get paid (either by you or the insurance)
Not saying the blood test was unnecessary but we have no idea what communication happened between the doctor and insurance company. Did they possibly recommend a less expensive test and the doctor decided that'd make him less money so he went forward anyway?
Health insurance companies have told me, on the phone, that they will not tell me the codes the doctor needs to charge for preventative visits in order to for my visit to be covered as preventative care (meaning I don’t have to pay anything).
However, I could tell the insurance customer service person a code, then they could tell me if it was classified as a covered preventative service.
So I, the insurance company’s customer, Googled medical procedure codes and found some on random PDFs, and checked which ones were covered, and then I asked the doctor to provide me the services for that code.
That is American healthcare.
On the flip side, I also had a doctor’s office try to bill my insurance $25 for towels used to wipe the ultrasound jelly off my wife’s belly. My insurance didn’t pay, so the doctor’s office sent me the bill for what insurance didn’t cover, so I called the doctor’s office and asked why I am being charged $25 for the few pieces of paper towel (not even linen towel), and the receptionist said they would waive the charge.
So, moral of the story is bring your own paper towel roll when you expect to get messy at the doctor’s office.
No, I assure you, it is very common for doctors' offices not to know whether a particular procedure will be covered.
This is not just because of the capriciousness of insurance adjusters, but because they have to deal with all the 273 different variations of insurance plans that people who come through their offices might have.
In general, a doctor's primary goal will be to get you good care.
An insurance company's only goal nowadays is to make as much money as possible for as little effort as possible.
> An insurance company's only goal nowadays is to make as much money as possible
How can that be true when their profits are capped on collected premiums? Look up the Medical Loss Ratio (MLR) rule to see what I'm referring to. If you wanted to squeeze money out of people, health insurance would be the least appealing industry to do that in since you're required to spend 80-85% of premiums on medical care.
A 25% margin is pretty good, and companies aren't hitting the limit currently.
So increase the health care spending, then you can raise premiums. An issue the ACA drafters already knew about, and tried (and failed) to deal with.
The linked article is about insurers trying to reduce spending by downcoding.
So which is it? Insurers unfairly denying reimbursement for what should be valid claims, or insurers unfairly increasing spending on claims so they can increase their profits.
Also, go look at 5, 10, and 15 year returns for the big insurers (UNH/Elevance/CVS/Cigna/Humana/Molina/Centene) if you think health insurance is a good business for earning money. Spoiler alert: they’re less than desirable, stick with SP500.
This doesn't surprise me: The "fee for service" system encourages doctors to perform as many services as they can so they can bill for more. I've certainly had my fair share of tests and procedures where I wonder if the provider was just trying to find something to bill for.
I'm also not surprised that some providers will try to figure out which codes they can use to get the most revenue. ("Hey, if I do procedure A instead of B, I get paid more, so why would I do B?")
That being said, I also wouldn't be surprised if many of these turn into lawsuits, or ultimately push to revise the whole "fee for service" system.
If someone invoices me, and I don’t pay the full amount in a timely manner, what do you think will happen? Late fees, reports to credit bureaus, collections agencies hounding me, maybe even lawsuits?
If insurance companies underpay, doctors should treat that no differently. Don’t appeal through the insurance company itself. Imagine I go to a store and pay less than the full amount at the register, and then the grocery store appeals to ME to decide whether I actually should have paid the correct amount. It’s absurd.
Doctors should treat the insurance companies like anyone else who owes them money and isn’t paying in full on time.
Insurers (payers in the industry lingo) simply don’t pay or underpay.
Proving this sucks bc smaller practices have horrible staff turnover, the EMRs are dog shit and the contracts are who knows where and in what format.
Recovery is beyond the scope of most small practices.
Its a nightmare where providers are often shorted millions of dollars and that ends up coming out of the patient’s pocket.
Everyone yammering about upcoding on this thread is blissfully clueless.
> Recovery is beyond the scope of most small practices.
Seems like a business opportunity. Could probably work very similar to other collections agencies where they either buy the debt for pennies on the dollar or take a percentage of the collected amount.
Yeah, there's an industry of companies that insert themselves between the medical record and the insurance company to upcode claims and get better payments. This article is about the reverse process, where the insurance company looks at the claims and downcodes them to send worse payments.
IMHO, in office care should be more of a time and materials billing than billing based on procedures done. Of course, then the doctors' billing office would aggressively measure time the doctor spent, and the insurance company would suggest the doctor took too long for whatever.
You'll notice the doctor's office in the article already has a team of billing experts. But instead of working on new claims, they are being forced to relitigate claims they already submitted that weren't accepted.
Sending your patient's 'debt' to collections promptly is very unpopular with the patients, and the insurance companies will 100% insist that the patient is responsible.
It's much easier to treat it like identity theft where the business's problem becomes the customer's problem to solve. In this case, insurance didn't pay what was required so the patient does. There's already a potential collections agency involved if the patient doesn't pay.
Who do you think is easier to squeeze the money from? A mega-insurance corporation or your sick grandma?
Insurance companies hold tremendous leverage over care providers, up to and including the power to effectively put them out of business on a whim. Care providers don't like picking fights with insurance companies.
Doctors have extensive contracts with insurance companies, and often have employees dedicated to billing. I wouldn't make assumptions here, other than "downcoding" is probably just subtle enough to not be worth it to fight.
I was thinking the same thing. Would it be permissible to bring each underpayment to small claims court as a separate case? If enough doctors did this, it would very quickly be a legal DDoS attack, like we've seen happen with mandatory arbitration.
So what should happen when Docs lie about what procedures they did? Because it happens quite frequently and for some reason is always left out of these discussions.
Man, it's almost like healthcare and human lives shouldn't be for profit...
You're welcome to come up with an alternative system of aligning interests, so far all of the other ones have failed horrifically.
Find some doctors, nurses, researchers, manufacturers etc etc who will work for no money and we can remove money from the problem.
> Find some doctors, nurses, researchers, manufacturers etc etc who will work for no money and we can remove money from the problem.
Not being for profit doesn't mean you don't pay people.
Further, I wonder how the Sixth Amendment works then? So many non-profit people working for... no money?
This "work for no money argument" is so incredibly weak, I had to make sure I quoted the argument so the person wouldn't change it.
Eventually everyone works for profit if they get paid. Spending time only is pure profit in money.
A reasonable wage or salary isn’t usually considered “profit” in a legal sense. This is why nonprofits can still pay employees. Any money that is left over after costs (including wages/salaries) needs to be reinvested, spent on the organizational mission, or held for future use, not distributed through dividends or other distributions as in a for-profit enterprise.
> reasonable wage or salary isn’t usually considered “profit” in a legal sense
This is a semantic punt to the word “reasonable.”
"It is not from the benevolence of the butcher, the brewer, or the baker, that we expect our dinner, but from their regard to their own interest."
Exactly. Glad you agree it shouldn't be for profit, either.
I have no problem with it being for profit. The issue is the alignment of interests and the thumb on the scales by government and vested interests. If health insurance worked like car insurance I think we'd be in a better state.
I wish health care worked like veterinary care. Except, now, veterinary care is becoming more like human health care, and it sucks.
Vets are really the most amazing doctors and I hate to see what is happening to their industry. Hopefully in exchange for dealing with the bullshit of human health care, at least maybe the money is getting a little better for them (a lot of them are just criminally underpaid).
It's truly fucked up.
Most insurances won't publish their fee schedules. So doctors don't know what they will pay. So what they do is bill insanely high knowing the insurance will come back with "Nah, we only cover $X". They'll collect $X, then write off the remainder. Because the fear is not getting the maximum money possible. If the doctor would bill $100 and the insurance pays up to $200, then the doctor "lost" $100.
Regardless of how much it actually cost the doctor to provide the service.
It's also why the "cash price" is usually much cheaper, because it's closer to what it costs the doctor to provide the service.
good luck suing when lawyers cost the doctor 2k/hour and the insurance companies have armies of in house counsel.
Sure but imagine you hire a landscaper and they send you a $40 invoice for $20 of law cutting and $20 of leaf cleanup. You go look outside and see a ton of leafs so you just send them $20.
That's the insurance companies' stance. The work you performed is this and so our agreed upon rate is this.
But in reality, the landscaper bills you for $100, you say you’re only going to pay $90, and then you write them a check for $31.50.
(That’s because you’re a major, well-known insurer and pay an industry high 35%. The guy who mows the Medicare yard might pay 40 cents on the dollar. The person mowing the Medicaid yard has to file 87 forms to get paid his $6.)
Source: I’ve co-owned doctors offices.
but the landscaper has a photo of the clean yard after they finished. They send it to you but you ( as the insurance company) say they need to call a specific time and speak to your 12y/o who is the yard representative of the house.
The 12 y/o say ‘no you stink’ and hangs up. Then you send the landscaper a letter saying ‘sorry your peer to peer was denied’
( I know this is exaggerating a bit and made to sound funny but it mostly works like that in healthcare )
My pediatrician always charges us for an office visit + preventative care when we go in for a preventative care visit. It's obviously to get more $$ from insurance. I feel like this goes both ways...
Yeah enough gets talked about insurers acting in bad faith, but let’s not forget hospitals also acting in bad faith for their end. Some personal examples:
1. Sitting in a Urgent care. They get you in the exam room. You sit there for 15 mins, doctor comes and sees you for 5 mins (mostly rushes the exam), do a blood draw, ask me to sit around while they run the test, doctor leaves, as soon as 45 mins are over the nurse comes over to let me know it’s taking longer to run the test so I can go home and they’ll call when the results are out. A month later charge thousands of dollars to insurance for a 45 min Urgent Care visit that doesn’t cover the lab work.
2. Go to PCP with cold symptoms that haven’t cleared in 10 days. I insist it’s a sinus infection, they send me back with no antibiotics and ask to schedule and online appointment in 2 days. I insist I come in in person, but they schedule an online appointment anyway. Nothing gets better and I see the doctor online after 2 days, they say I’ll have to come in so that they can evaluate me in person and prescribe antibiotics. I go in person, get antibiotics and get cured. Insurance gets charged for 3 separate hour long visits ($750 each and none of them lasted more than 10 mins).
An obligation to pay is always good for the billing side. Think about the sociopathic prices of US pharmaceuticals.
Afaik any other country with mandatory health care also puts a ceiling on prices. In germany, there is a price catalog for any service, with only few exceptions, and doctors/hospitals cannot legally charge anything else for these covered services. Now guess what the US does not have, even thought obama had foreign consultants explicitly advising for it.
Health ensureance companies are certainly not the most altruistic but any profit oriented company trying to cut cost where ever possible is hardly a supprise.
We'll never know, but:
I wonder what would happen if we moved the "medically necessary" requirement burden of proof from the doctor/patient to the insurer. So the insurer would be required to pay out a claim regardless of whether the insurer thought it was medically necessary, but their recourse could be to try to claw it back post-payment.
They'd most likely go bankrupt. There is already an incentive for them to spend on medical care due to the Medical Loss Ratio (MLR) which caps their profits on collected premiums.
If you're saying they need to be forced to pay whatever invoice comes to them and start legal battles for each suspect case then yeah... that doesn't seem feasible.
Health insurance companies are not immediately insolvent because they
1. pay out claims slowly
and/or
2. deny or downcode claims outright?
Really? That to me would imply that doctors/patients are submitting a huge amount of incorrect claims.
Doctors/patients are human too and your proposed system would be ripe for abuse. If you're well versed in submitting claims, and you know they have to pay out, then you could inundate them with fraudulent ones.
> That to me would imply that doctors/patients are submitting a huge amount of incorrect claims
UnitedHealthcare says that 10% of claims go through additional review for various reasons[0].
I don't know if there are stats for the industry as a whole, but my guess is that they deal with a lot of errors.
0: https://www.uhc.com/news-articles/newsroom/how-many-claims-a...
I'm not proposing that all guardrail responsibilities be shifted to the insurer. Just the "medically necessary" provision.
Doctors would still have a Duty to Code Services Accurately and a Duty to Maintain the Medical Record (which would clearly enable an insurer to prove a non-medically necessary therapies). There would be plenty plenty of evidence for an insurer to immediately respond.
So claims could be rejected on the basis of failing to code accurately or lack of record.
Are you talking overnight? If so, that’s an easy predictable outcome.
For what it's worth, this sort of gaming works both ways.
Many medical administrations do everything they can to upcode in order to bill for more money.
The whole system is a mess.
It's beyond our control, says only country where this happens daily.
IT is beyond our control because we have setup a system where the people who are paying don't want to control things.
My boss wants insurance to be expensive - if I could afford it I would be more willing to quit (retire early).
Finding cheaper services isn't in my interest - I'm not paying any bills anyway.
Insurance companies like the complexity because it means I can't understand the system and so I have to use them.
Doctors don't really care as they just have administrators play the game for them. Once in a while they look at the game and say something, but really this is just they don't understand how the game is played (they shouldn't - they are doctors, they should be looking at medical issues not administrative ones).
Doctors have also spent a lot of time lobbying to make becoming a doctor harder so that the fewer doctors will be able to command better salaries. It sounds like they are attempting to reverse that and open up more spots for residencies but I imagine that there is a lot of momentum to overcome.
There's an old mechanics saying "if X was covered by insurance it'd cost what Y does" where X is some routine thing (tires/brakes/etc) and Y is autobody or glass services typically covered by insurance.
This proverb seems to also apply to health insurance and the things they do/don't cover.
Putting routine stuff under the purview of insurance is stupid regardless of context. There are other cheaper, faster, simpler and more transparent ways of doing that.
Pretty sure fraudulent billing practices exist in a variety of nations and industries.
Other countries are making efforts to keep things in check though https://www.npr.org/2025/01/04/nx-s1-5246231/potential-fraud.... The US for some reason can’t even address blatant fraud. One example is the stuff insurers do with Medicare Advantage. There is fraud and Congress knows about it but besides some hearings nothing is happening.
It does.
And having lived 10 years in Canada and 10 years in the US and used both their healthcare systems quite a bit, I have seen both sides. Let me just say I moved to the US for healthcare 10 years ago and we do not regret it one bit. The US is easy to point and laugh at, but that just comes from ignorance.
But shitting on the US gets you lots of Internet upvotes, and isn’t that the important thing?
I wonder how this plays out with Kaiser and other integrated practices.
They try to convince you that you're fine and don't need any treatment.
Good startup idea would be to work with medical practices to use AI to automate the disputing of the "downcoding" by insurers.
Man this is a hellscape.
I can quickly see something like this turning in an AI arms race between insurance and the provider with each auto-approving/denying/disputing the other. All the while locking out smaller players because they can't afford the 3rd party disputotron.
The result will be that doctor AIs will be fighting insurer AIs and the loser will be the patient. As always.
Already working on this, let's connect if you are interested: https://forms.gle/cxQZg5Q27PsT65d97
Its a terrible business.
The data is a disaster. Turnover is high, errs everywhere. Disputing is the easy part. Hard part is finding the contracts lol.
The business will be very quickly bought up to kill the product.
If they can afford it. What's Mark Cuban been up to lately?
Edit: in case the reference isn't clear -- https://en.wikipedia.org/wiki/Cost_Plus_Drugs
And I think it is a sad state of affairs when the government has been so villified that we have to depend on billionaires for basic public good works.
> the government has been so villified that we have to depend on billionaires
https://knowyourmeme.com/memes/were-all-trying-to-find-the-g...
You would have to leverage the law (if you have one) that involves the state resolving the dispute because otherwise the automated disputes would probably be dropped on the floor. The insurance company has the leverage because they're actually in possession of the money and the contract that gives them stupidly high discretion on how much to pay out.
Doing nothing but flipping the burden, doctors get paid whatever they invoice and insurance have to claw it back would make a lot of this stonewalling bullshit go away. But with an openly corrupt government paid by insurance it'll never happen.
Hate it, thanks
the health insurance industry needs to be razed to the ground and rebuilt from scratch. there's no saving something that is ostensibly designed to help people get healthcare but realistically denies them what they're entitled to for years (in some cases, they just try to keep the ball in the air until the patient dies, then there's no one to appeal) and then once the care is approved steals from the service provider by automatically altering the bills without any evidence of fraud or theft.
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It's a system that supports two set of clients, doctors and patients, and fails them both. Yet, Congress has considered it sacred and infallible for a hundred years. Democrat's most earnest attempt ended up strengthening and expanding that system, and Republicans for their part have fought tooth and nail to stack the system even further against the people it's supposed to serve.
People get annoyed at insurers who will deny treatment but most of the time you can just pay it yourself. The government has decided that everyone should pay for health insurance but you'll never be denied care if you pay for it yourself.
So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's unlikely someone else will if they have to pay on your behalf.
Essentially, place yourself in the role of each participant:
- patient: wants to maximize care, money no object since it isn't theirs
- medical practice: wants to maximize money spent on care
- insurer: wants to minimize money spent on care
Normally, the first two would be happy to collude to charge the third any amount of money since they'd both get what they want. And that is indeed what happens. So you get the natural result that the insurer doesn't want to support certain payments even if they were kind and pure-hearted. That they don't want to when they're neither should then not be a surprise.
You can remove that pressure by turning the interaction into:
- patient: wants to maximize care with minimized cost
- practice: wants to minimize care with maximized cost
The pressures between the two parties are now opposite and you can find the market equilibrium. With this opposition you'll suddenly find that patients start complaining about doctors ordering unnecessary procedures and so on, just like insurers claim in the other model.
You can also work through with the other versions to model where equilibrium will set in and see if it's where it does. Most of the time you don't need to assume any moral valence for the participants. They might as well be machines. It is their roles that determine how they act, not their personalities.
>So if you think you do require some care, just ask the medical practice whether they accept self-pay and then you can decide if it's worth paying or not. If you think it's not, it's unlikely someone else will if they have to pay on your behalf.
Ok, hear me out for a minute.
What if I wanted to pool with several people, so that if any of us had unexpected medical needs, it wouldn't bankrupt any of us. Knowing that most of us would not need it.
And then, since we're all on the hook for each other's general health, we also agreed to share the cost of preventative care, because it was literally cheaper for us to all pay for preventative care than to try to just solo it and then hit the group with the cost of terminal cancer care instead of catching it early and doing a small excision. (and other such examples.)
And then what if we made the pool HUGE, to even further spread out the costs?
Sure wish there was a system that just did that, without trying to also generate insane profits off it.
There's nothing stopping you from starting your own non-profit health insurance company. If greedy health insurance companies are really the root of the problem, you should be able to out-compete them fairly easily.
That assumes the humans will do their best to take care of themselves but given the ability they will be bailed out, they let their health go knowing they don't need to actively take care of themselves.
The outliers drain the coffers
The problem is that patients are usually not in a position to determine if the care the doctor says is needed is really needed or not. This is the same as taking your out-of-warranty car to the mechanic. How do you know if the mechanic is telling the truth?
Still, this would be better than the current system. Even when you don't know if the doctor is telling the truth you can go by their reputation for telling the truth. Reputations will matter more, and doctors will care about maintaining their reputations in their community.
How about this one:
- patient: wants to maximize care, money no object since it isn't theirs
- medical practice: wants minimize care since money is based on number of patients not care
- insurer (government): wants to minimize money spent on care while maximizing care because money comes from healthy citizens who pay taxes
I went to the dentist a couple of weeks ago and had the shortest dental visit I've had. They did the X-rays, then the dental assistant spent five minutes cleaning my teeth and pronounced them good. The dentist came in and looked for about one minute and said they were fine. I was sent on my way.
They billed my insurance for over a thousand dollars.
Ah yes, this is a fight between the practices (sometimes not the doctors!) upcoding their visits and the insurance companies wanting to push back and downcode the visits to what they actually entailed.
Healthcare practices want to maximize revenue and push up the “level” of a doctors visit and they can do it with just adding one or two extra little questionnaires or an extra test or two that you might not pay attention to so they can get an extra several hundred dollars a day for billing higher level cases daily.
I never understood why insurers get all the flack while the providers get a pass.
Because the common interaction people have with their insurers is "We are denying this because of <REASON>" which they have to fight to get healthcare.
When a provider rips off an insurer it's invisible to the general public.
Also, incidentally, when people talk about fraud in Medicare/Medicaid, the providers are almost always where that happens (yet that's often not pointed out).
FWIW I hate most medical billing departments (and hospitals are the worst) about as much as I hate insurance.
They're at least as likely to fuck something up (curiously, always in their favor, not yours) as insurers, from what I've seen. And they're almost as unpleasant to deal with—at least they don't generally keep you on hold for literal hours, but it's still not great.
And one of the ugliest public-facing roles in all of American medicine has to be the insurance-vultures whose job is to hover about emergency rooms pestering very-sick people for their billing information. Fucking gross.
Every party at every point in the system is various shades of complicit in fleecing us. That's the magic of the system. It's all divided up in so many ways and so many of the feedback loops touch through the people getting screwed that it's impossible to build a "these guys might not be wholly responsible, but they're responsible enough things will get better if we push them off a cliff or legislate them into poverty or whatever" consensus you need to build to change things
17% of the US GDP is healthcare, now obviously there's a lot of nurses and random courier drivers and all sorts of other stuff in there, but they would all need to take some amount of haircut for us to get fleeced less.
The GDP contribution of slavery was ~13% just preceding the civil war and credible moves (i.e. electing Lincoln) to make them take a haircut caused, you know, the civil war.
There is likely no "clean" way to fix this problem other than a century long frog boiling exercise
You think nurses and couriers are the ones who need to take pay cuts to get healthcare expenses under control??? Lm, and I cannot stress this enough, fao.
There is immense pressure on insurance companies to lower costs, as they get blamed for the "American health care system". The only one on the side of the payer is the insurance company, they're the only one who wants to keep costs down for the consumer. Given the massive amounts of fraud in government health insurance (medicare) it would of course be prevalent in the private insurance market.
https://www.azcentral.com/story/news/local/arizona-health/20...
why dont other countries have similar amounts of healthcare fraud in their single-payer systems?
“ they're the only one who wants to keep costs down for the consumer.”
They don’t. They want to increase profits by pushing more and more cost to the patient while squeezing providers. The patient is always the loser in this system. One reason is that most patients don’t even have a choice of insurance because their employer picks the insurance that’s best for the employer.
My employer switches insurance carriers every 4 years or so because another carrier has a more competitive rate. "What's best for the employer" is also what's best for me -- I can walk across the street and get a new job if I become unhappy. They want to keep their healthcare costs down so they can keep my salary high as dollars lost to my healthcare compensation are invisible to me.
Except that the insurance plans charge the employer and so the cheaper plans mean more haggling and potentially out of pocket for you later
People who have always lived in the USA have no idea how many things about life in the USA are batshit crazy. This is probably the top of the list. At least before we turned to fascism...
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