|
Hieronymous Alloy posted:No, that supports my point and is in line with what I expected. That's just the people that they caught and charged. The most conservative estimates I've seen put it at the dozens of billions per year, with most going $100+ It's extremely hard to catch, which is why preventative measures and proper incentives are more important than literal actual enforcement.
|
#
?
Aug 30, 2017 17:19
|
|
|
|
| # ? May 15, 2024 04:12 |
|
|
Hieronymous Alloy posted:No, that supports my point and is in line with what I expected. what you're arguing doesn't make any sense at all even if we accept all of your premises as true your argument is bizzare: "currently, there is a moderate to low level of fraud within tolerable ranges, therefore there is no need for our fraud detection and prevention measures." do you see the inherent problem here?
|
|
#
?
Aug 30, 2017 17:22
|
|
|
esquilax posted:That's just the people that they caught and charged. The most conservative estimates I've seen put it at the dozens of billions per year, with most going $100+ Who is defining what fraud is here though?
|
|
#
?
Aug 30, 2017 17:24
|
|
|
hobbesmaster posted:Who is defining what fraud is here though? Illegally charged or obtained services, probably as determined by whoever does the study. If you want an actual source, the Institute of Medicine (division of the National Academies of Sciences) estimated $75b in CY2009
|
|
#
?
Aug 30, 2017 17:30
|
|
|
evilweasel posted:if you modify how reimbursement works - from public or private insurance - if that reimbursement makes fraud easier or more profitable you will need to consider fraud detection and punishment systems, regulatory or otherwise. if you change from private insurance to mostly or purely public insurance you may change how seriously the insurer monitors and reports fraud because you may lose the direct financial incentive, so you need to make sure that you have well-funded fraud detection and punishment organizations in the doj. Ok, now I'm not on a phone any more so I can go into a little more detail. The argument being made above was that if we 1) switched to Medicare for all, that then 2) we would need capitation based models to reduce fraud, and/or some other system to reduce fraud. My counterargument is that, in practice, there are two ways to reduce or combat fraud: 1) The criminal justice system (which is appropriate), and 2) the imposition of an endless array of administrative review or prior authorization hurdles that sick people must manage to leap over before they can access the care they believe they need. See, e.g., "QualityImprovement Organizations" such as KePro (https://www.kepro.com/), which nominally exist to combat "waste, fraud, and abuse" but in practice exist to put hurdles in between patients and expensive care. As to #1, sure, give the DoJ all the funding it needs. The problem there (as the Rick Scott example illustrates) is that prosecuting big money provider-side fraud isn't an issue our current oligarchy cares about; the DoJ isn't getting the money it needs for this, and in many cases medical waste is even an avowed policy goal (again, see Rick Scott mandating Florida hire his wife's company to drug test every welfare applicant). To the extent that that's what we're talking about, sure, prosecute. From what I've seen working with MCO's and private providers, though, , in actual practice, most of the "fraud prevention" effort and administrative funding goes to #2, where it serves to save (usually private) insurers money by denying needed care to people who can't sufficiently navigate the prior authorization / approval maze. Insurers love this because it saves them money and on paper everyone's getting what they need, but in reality, it's just a pretext to deny care to those in need. So, as above: I'll start caring about medical fraud when we're putting Rick Scott's head on a pike -- that is, when there is a real clampdown on provider-side fraud. But any effort to cut access to services at the consumer side (i.e., "let's add three more levels of prior auth appeal review", which is the form "fraud prevention" often takes), strikes me as little more than a backdoor pretextual cut in needed services. Hieronymous Alloy fucked around with this message at 17:38 on Aug 30, 2017 |
|
#
?
Aug 30, 2017 17:35
|
|
|
patients attempting to defraud insurers or providers is almost nonexistent- this is true. financially speaking the opioid crisis' class of pill-seekers is a drop in the bucket! shame about the other costs, but hey, free market, we can successfully claim they are not the health system's problem, they are social services' problem now. hospitals "aggressively pricing" treatment, i.e. defrauding insurers, that's a genuine problem, and costs insurers an appreciable amount of money. insurers coincidentally deciding that the most expensive treatments, for the people least capable of contesting the issue, are the ones it's most profitable to deny coverage on? costs hospitals an appreciable amount of money. from both parties' perspective, the solution to their fraud problem is the other guy's fraud problem.
|
|
#
?
Aug 30, 2017 17:37
|
|
|
Hieronymous Alloy posted:Ok, now I'm not on a phone any more so I can go into a little more detail. I read the capitation arguments as arguments about how to align provider incentives with patient incentives, not about how to combat outright fraud. People act according to their incentives even if they're not intentionally defrauding people, and aligning incentives isn't really a fraud-fighting measure its more an efficient operation measure. When people's incentives are to do what you want them to do, they'll do it more often than if their incentives are to do something else. A big part of Obamacare was trying to reform incentives to cut the growth of medical costs. Because this isn't outright fraud you're combating it's not something that's appropriate to refer to the DoJ. That said, I don't view capitation models as inherently better incentives than fee for service incentives.
|
|
#
?
Aug 30, 2017 17:42
|
|
|
Ze Pollack posted:hospitals "aggressively pricing" treatment, i.e. defrauding insurers, that's a genuine problem, and costs insurers an appreciable amount of money. That's a good summary, actually. I'd argue that the Medicaid model (with, perhaps, some tweaks) can provide a good answer to both problems. Well, presuming we allow Medicaid to 1) aggressively negotiate prices (or even set prices via federal price controls!), and 2) provide assistance to patients denied care so that they can contest denials through the Medicaid Fair Hearing process (we'd have to strengthen and streamline it in a few ways, but that's getting into a level of granular detail beyond the scope of this thread).
|
|
#
?
Aug 30, 2017 17:44
|
|
|
Hieronymous Alloy posted:That's a good summary, actually. neither of those fixes a doctor being inclined to recommend the expensive treatment over the cheap treatment, even if the expensive treatment is fairly priced. i really think you're tilting at an argument nobody is actually making.
|
|
#
?
Aug 30, 2017 17:46
|
|
|
evilweasel posted:neither of those fixes a doctor being inclined to recommend the expensive treatment over the cheap treatment, even if the expensive treatment is fairly priced. Negotiated pricing or price controls under Medicare / Medicaid could absolutely address that issue (by reducing the number of expensive treatments; I would argue that almost no medical treatment, procedure, or device is currently "fairly priced" in America). For example, (edit: most state Medicaid programs have) Medicaid currently has a preferred drug list, and it's no coincidence that the preferred drugs are cheaper than the non-preferred alternatives. That's part of why Medicaid is so much more efficient than private insurance, and why simply moving everyone in the country onto Medicaid would do more to reduce wasteful spending than any other intervention you can come up with (including implementing any given proposed set of fraud prevention measures). We don't need to reinvent the wheel here, we have an automobile already. Hieronymous Alloy fucked around with this message at 17:59 on Aug 30, 2017 |
|
#
?
Aug 30, 2017 17:52
|
|
|
Medicaid is efficient because it pays half to three quarters of cost and shifts the rest to the private sector. Most Medicaid is also administered by private companies on top of that. Also Medicare already is price control by fiat. It hasn't stopped Medicare fraud.
|
|
#
?
Aug 30, 2017 18:02
|
|
|
Hieronymous Alloy posted:Negotiated pricing or price controls under Medicare / Medicaid could absolutely address that issue (by reducing the number of expensive treatments; I would argue that almost no medical treatment, procedure, or device is currently "fairly priced" in America). For example, Medicaid currently has a preferred drug list, and it's no coincidence that the preferred drugs are cheaper than the non-preferred alternatives. No, you're really just not getting the problem being discussed at all and keep spouting stuff that is about completely different problems. You go see a doctor for some problem, I don't know enough about medicine to come up with a reasonable scenario but this sort of thing happens all the time. There are two options: a low-cost option (say, a prescription drug) and a high-cost option (say, surgery). Or, even, they are the same price but for one of them the profit goes to the doctor, for a different one the profit goes to someone else. Both have risks and benefits, there is not an obvious answer that is simply "the correct choice" because it is better on all potential axes. Even if the doctor is an honest person, even if they're not trying to put their financial incentives on the line, test after test after test shows they will be biased towards recommending the option that is more profitable to themselves. Even if the other option is probably the better option. We are not talking bad people here: we all do it. That is why lining up a doctor's incentives with the patient's incentives is important: this bias exists, it won't go away, so you want it to work in the correct direction. "Fee for service" models bias the provider towards action: their financial incentives are to provide the most medical care. That is both bad from a cost perspective (spending more for the same or worse results) and bad in certain respects from the patient's perspective (in many cases the downsides to surgery or the like can make the expensive treatment worse for the patient). Capitation provides a different set of problematic incentives: you're paid by the patient so your financial incentive is to do nothing or to use the cheapest treatments, even if that's not in the patient's interest. This is more obviously problematic from a patient perspective, but also has some cost problems: if the patient will be discharged and someone else financially responsible for future care, preventative care may be underutilized. So, it's important to set up good incentives so that, to the maximum extent possible, the doctor's financial incentives are to do the best thing for their patient. Because that's going to lead to the best outcomes, and the most cost-effective outcomes. So how we set prices and incentives for the for-profit parts of medicine is still vitally important even if we have medicare for all, medicaid for all, what have you. Even if we have negotiated prices. What you are talking about are solutions to completely different problems. You're saying we don't need to reinvent the wheel here but not grasping this is not a problem to which a wheel is a solution. This is entirely different from fraud prevention stuff. This is entirely different from overpriced care, drugs, or devices. You're mixing up problems.
|
|
#
?
Aug 30, 2017 18:05
|
|
|
Xae posted:Medicaid is efficient because it pays half to three quarters of cost and shifts the rest to the private sector. "cost" as defined by the private sector. And yeah, as above, I'm also arguing against Medicaid privatization. Past that our laws against murder haven't stopped murder, either. "Bad thing still happens, sometimes" is meaningless.
|
|
#
?
Aug 30, 2017 18:06
|
|
|
Hieronymous Alloy posted:Negotiated pricing or price controls under Medicare / Medicaid could absolutely address that issue (by reducing the number of expensive treatments; I would argue that almost no medical treatment, procedure, or device is currently "fairly priced" in America). For example, (edit: most state Medicaid programs have) Medicaid currently has a preferred drug list, and it's no coincidence that the preferred drugs are cheaper than the non-preferred alternatives. Private insurance already does both those things - negotiated pricing and preferred drug lists. Medicaid programs also have significant utilization management and prior authorization programs, comparable to private insurance.
|
|
#
?
Aug 30, 2017 18:08
|
|
|
Hieronymous Alloy posted:"cost" as defined by the private sector. And yeah, as above, I'm also arguing against Medicaid privatization. You're really far out of your element and spouting a lot of word salad that has the right buzzwords but is utterly incoherent.
|
|
#
?
Aug 30, 2017 18:09
|
|
|
Here's an example of hard to detect fraud: There is a cancer drug Herceptin (trastuzumab) that comes in reusable vials each containing 440 milligrams. Herceptin is dosed according to things like body weight, so you would expect a relatively smooth distribution of billed service units (for Herceptin, one service unit = 10 milligrams). However, when looking at claims there were spikes in the service unit distribution at multiples of 44. What was happening was providers would bill Medicare for the full vial even though they only used part of the reusable vial. When this report came out I was asked to look at my employers claims and found a similar pattern in service units which was communicated to our fraud department. Because it's very difficult to prove intent with complicated billing practices like this, the providers will most likely end up paying back most/all of the overbilled amounts but not receive severe punishments if any at all. https://oig.hhs.gov/oas/reports/region5/51300024.pdf
|
|
#
?
Aug 30, 2017 18:11
|
|
|
Hieronymous Alloy posted:"cost" as defined by the private sector. And yeah, as above, I'm also arguing against Medicaid privatization. "your solution has been implemented, let us look at the results and compare to your suggestion of its effects" is not at all meaningless. it doesn't end an argument because there can be reasons it doesn't solve a problem entirely or it didn't work in other circumstances but it's extremely meaningful.
|
|
#
?
Aug 30, 2017 18:17
|
|
|
evilweasel posted:No, you're really just not getting the problem being discussed at all and keep spouting stuff that is about completely different problems. . . . . The problem I'm discussing is the "what health policy should we (i.e., national Democrats) propose: single payer or something else?" discussion from around the top of page 108. As I said above, it's not that I'm "mixing up" these discussions as that I see everything other than "pass Medicaid for all first" as utterly secondary, fiddling around the margins; the equivalent of arguing over the benefits of municipal vs. private wi-fi when you haven't gotten a public electricity utility set up yet. Medicaid and Medicare have problems and could be improved from a lot of different angles, but ultimately they outperform the other available current options so dramatically that there's no argument against expanding them till they serve the entire U.S. population. Furthermore, raising these ultimately peripheral quibbles (incentivization, fraud, etc), while perhaps interesting to discuss in the abstract, from a "what public policy should we advocate for" standpoint strikes me as getting in the way and confusing the issue, because in the political sphere those arguments are not usually raised in good faith, but rather as pretexts to deny care, cut benefits, or block needed expansions of care. esquilax posted:Private insurance already does both those things - negotiated pricing and preferred drug lists. Yes, I'm aware (as is literally everyone else). Individual private insurers don't have the same broad negotiating power that the government programs do, though (as you also know). There's also issues with it being much harder to contest denials by private insurance, and Medicaid patients having much stronger and more clearly established rights to contest denials of care (as per the Fair Hearing process I mentioned above, though admittedly that's a rights based objection to private systems not a cost based one). Hieronymous Alloy fucked around with this message at 18:32 on Aug 30, 2017 |
|
#
?
Aug 30, 2017 18:23
|
|
|
Hieronymous Alloy posted:The problem I'm discussing is the "what health policy should we (i.e., national Democrats) propose: single payer or something else?" discussion from around the top of page 108. if you don't want to discuss more minor details then just don't, instead of suggesting that uhc moots them
|
|
#
?
Aug 30, 2017 18:32
|
|
|
evilweasel posted:if you don't want to discuss more minor details then just don't, instead of suggesting that uhc moots them Well, in the context of trying to pass policy, I'd argue that we should actively discourage those discussions. If the question we're trying to answer is "what policy do we propose," we want to propose Medicaid / Care for All and save the details for later. I mean sure discuss all you want in the abstract but, as you say, that's a different discussion.
|
|
#
?
Aug 30, 2017 18:40
|
|
|
Hieronymous Alloy posted:Well, in the context of trying to pass policy, I'd argue that we should actively discourage those discussions. Lol, what if a printout of a Something Awful politics junkie's post were to fall into the wrong hands? This type of thinking is really popular among many progressive posters on this board and, not only is it kind of delusional regarding the societal relevance of Something Awful, it also is totally contrary to the purpose of an online message board where people discuss and argue about politics.
|
|
#
?
Aug 30, 2017 19:22
|
|
|
Hieronymous Alloy posted:The appropriate litmus test isn't single payer it's Medicaid for All. Support any policy or politician that results in expansion of the fee for service Medicaid model. Do that and your work is done here. Any other changes you want to make besides striking "has attained age 65, and" from Sec. 226. [42 U.S.C. 426]?
|
|
#
?
Aug 30, 2017 19:47
|
|
|
Hieronymous Alloy posted:Well, in the context of trying to pass policy, I'd argue that we should actively discourage those discussions. If the question we're trying to answer is "what policy do we propose," we want to propose Medicaid / Care for All and save the details for later. Are you saying that SA is going to pass policy? Because those details are often pretty crucial in developing policy and can massively derail efforts unless you want to go hard anti-democratic and limit public participation, particularly in certain states where public comment (and mandatory response) is required. Like California.
|
|
#
?
Aug 30, 2017 20:15
|
|
|
Reik posted:Here's an example of hard to detect fraud: One problem is that stuff like this can simply be an error. In that case it isn't fraud. Medical billing is really complicated and the practitioners don't know much about billing while the billing folks don't know much about medicine.
|
|
#
?
Aug 30, 2017 20:26
|
|
|
hobbesmaster posted:One problem is that stuff like this can simply be an error. In that case it isn't fraud. Medical billing is really complicated and the practitioners don't know much about billing while the billing folks don't know much about medicine. I agree, but this also creates enough ambiguity to allow healthcare providers to knowingly bill incorrect amounts with the fallback of the system being complicated. People working in the system should be competent enough such that their rate of error is similar to any other system. You don't see engineers at Volkswagen saying "man, cars are really complicated these days" when they start cheating on emissions tests. Reik fucked around with this message at 20:41 on Aug 30, 2017 |
|
#
?
Aug 30, 2017 20:38
|
|
|
silence_kit posted:Lol, what if a printout of a Something Awful politics junkie's post were to fall into the wrong hands? You cut out the part where I said "sure, discuss it, but it's a separate question." If we're talking about messaging -- which was the subject of the discussion I was responding to -- then the details are just a distraction. If we're just arguing on the internet sure go for it but (as Evilweasel had already pointed out) that wasn't the discussion I was having or responding to right then. karthun posted:Any other changes you want to make besides striking "has attained age 65, and" from Sec. 226. [42 U.S.C. 426]? It'd be a good start. We could also remove the income and asset qualifications from Medicaid, since there are things Medicaid covers that Medicare doesn't and vice-versa. Past that I don't care nearly as much. Theoretically it would need a funding mechanism but again whatever funding mechanism is most politically expedient (eat the rich, cut military spending, mint a trillion dollar coin, etc.) is fine. Zachack posted:Are you saying that SA is going to pass policy? Because those details are often pretty crucial in developing policy and can massively derail efforts unless you want to go hard anti-democratic and limit public participation, particularly in certain states where public comment (and mandatory response) is required. Like California. I'm not really sure that's the case. It's important that the people writing the policies understand what's in them, sure, but in terms of getting them passed, broad rhetorical strokes seem to make a much bigger difference than well-reasoned minutiae. In practice, I suspect that any major changes to the mechanics of the Medicare and Medicaid programs, beyond simply expanding eligibility, would be far more likely to derail the reform than to complete it. Medicare and Medicaid as they are now are the selling point: they're familiar, people understand what they're getting. Change those programs too much and you've lost the rhetorical selling point of "Medicaid / Medicare for All" because what you're selling is no longer Medicare / Medicaid but some other newfangled thing nobody trusts yet. (Quote: "What the gently caress is single payer?")
|
|
#
?
Aug 30, 2017 21:09
|
|
|
Hieronymous Alloy posted:Change those programs too much and you've lost the rhetorical selling point of "Medicaid / Medicare for All" because what you're selling is no longer Medicare / Medicaid but some other newfangled thing nobody trusts yet. If you can manage to weld healthcare for the old to healthcare for the young, the elderly won't vote against it because they will be killing themselves. This is how the NHS survives in the UK.
|
|
#
?
Aug 30, 2017 21:11
|
|
|
This had never been definitively nailed down, but it seems the parlimentarian has: if Obamacare repeal doesn't pass by September 30th, the reconciliation instructions expire: https://twitter.com/annaedge4/status/903674528018161664 That means that the GOP loses that reconciliation bill entirely. There was some talk that if Obamacare repeal died entirely maybe they scoop out everything but PP defunding and use it as a vehicle just to defund PP, but I doubt they can make that work in 30 days.
|
|
#
?
Sep 1, 2017 18:59
|
|
|
It's doubtful that they get the majority of PP defunding past the Byrd Rule, especially the part about preventing Medicaid patients from using their services. So hey Hieronymous Alloy if you want to see what happens when you run on vague platitudes while trying to crunch policy details live, look at the GOP losing their reconciliation bill this year.
|
|
#
?
Sep 1, 2017 19:46
|
|
|
The Phlegmatist posted:It's doubtful that they get the majority of PP defunding past the Byrd Rule, especially the part about preventing Medicaid patients from using their services. the difference between running on UHC without specific details and running on "repeal and replace" without specific details is democrats aren't lying about wanting to do UHC. republicans never intended to do any sort of replacement at all and got trapped by their lies.
|
|
#
?
Sep 1, 2017 19:54
|
|
|
The Phlegmatist posted:So hey Hieronymous Alloy if you want to see what happens when you run on vague platitudes while trying to crunch policy details live, look at the GOP losing their reconciliation bill this year. The GOP didn't run on vague platitudes, they ran on outright lies. Having to sort out the details of Medicare-for-All is not equivalent to figuring out how you're going to cut taxes and spending when you promised to also increase coverage and reduce premiums and deductibles.
|
|
#
?
Sep 1, 2017 19:55
|
|
|
evilweasel posted:the difference between running on UHC without specific details and running on "repeal and replace" without specific details is democrats aren't lying about wanting to do UHC. You might want to rethink this statement. The reason why it's okay for Democrats to support UHC is that nobody has made any concrete policy proposals or even estimated the effects of those yet. The reason why the GOP was okay with repeal and replace is that nobody had made any concrete policy proposals or even estimated the effects of it yet. Unless you want to somehow believe that Democratic legislators would be totally okay with trying to sell their constituents a massive tax increase, coinciding with a likely cost overrun (since UHC will be most expensive when first implemented) and also a net job loss since private payer jobs lost won't equal the jobs gained on the single payer side. I support UHC but I have no illusions about the fact that it will be loving rough to implement.
|
|
#
?
Sep 1, 2017 20:40
|
|
|
The Phlegmatist posted:You might want to rethink this statement. the democrats passed obamacare knowing it was going to cost them elections (though it cost them a lot more than they expected) democrats believe very strongly in uhc, they may vehemently disagree on what can be done or what the best form of uhc is but they believe in uhc. that got obamacare across the finish line when it became clear it was the best that could be done, because democrats really, really believed in it. on the other hand (elected) republicans do not believe in "replace" and never did. they wanted to just go back to the status quo ante, without obamacare. but that was hideously unpopular so they had to lie. they believe that spending money on health care for poor people is bad/ their problem wasn't that they didn't come up with "replace" beforehand. their problem was there was no "replace" they could agree on: it was always a lie. coming up with "replace" beforehand would just have revealed the lie. The Phlegmatist posted:I support UHC but I have no illusions about the fact that it will be loving rough to implement. no dispute on this. but what i'm saying is that it wasn't an implementation problem that sunk trumpcare. it wasn't vaugeness. it was outright lies: republicans never intended to provide healthcare for people which is why they never had a plan to provide health care for people and when they were forced to make one, they couldn't. i mean i am also a strong supporter of the "uhc is hard and people who say it is easy are morons" party, but there's a meaningful distinction between being vague on UHC and being vauge on "replace" evilweasel fucked around with this message at 21:00 on Sep 1, 2017 |
|
#
?
Sep 1, 2017 20:58
|
|
|
I agree that telling the GOP telling their constituents that they had a replacement that would be better than ACA was an outright lie. But they did have a replacement. It kept sneaking into BCRA. That's what the whole association health plan thing was about. The House GOP has been pushing for that since...2003 I think? as a way to deregulate the insurance market and especially dodge any state regulations on insurance. I don't think it was any mystery for GOP legislators that repeal and deregulate was going to be their healthcare policy.
|
|
#
?
Sep 1, 2017 21:41
|
|
|
evilweasel posted:the democrats passed obamacare knowing it was going to cost them elections (though it cost them a lot more than they expected) no, honestly, really, we care about giving UHC to people, even though we nobly accept it will cost the people who deliver it elections in related news, I admit no knowledge of this "california"
|
|
#
?
Sep 1, 2017 22:15
|
|
|
Ze Pollack posted:no, honestly, really, we care about giving UHC to people, even though we nobly accept it will cost the people who deliver it elections Agreed, of course this logic means that Bernie Sanders also doesn't want UHC since he was against the rider added to the Obamacare repeal that had UHC. Right?
|
|
#
?
Sep 1, 2017 23:20
|
|
|
Peachfart posted:Agreed, of course this logic means that Bernie Sanders also doesn't want UHC since he was against the rider added to the Obamacare repeal that had UHC. opposition to a republican poison pill is exactly the same as a democratic supermajority immediately killing a bill it is fully within their power to pass good job gold star
|
|
#
?
Sep 2, 2017 01:44
|
|
|
Ze Pollack posted:no, honestly, really, we care about giving UHC to people, even though we nobly accept it will cost the people who deliver it elections Ze Pollack posted:opposition to a republican poison pill is exactly the same as a democratic supermajority immediately killing a bill it is fully within their power to pass The evil house in CA killed the senate UHC bill*. Bastards. *Bill didn't include funding mechanism, plan to comply with CA constitution, and was functionally identical to writing "single payer now!" on a napkin.
|
|
#
?
Sep 2, 2017 06:25
|
|
|
Should I be worried about not get my Obamacare renewal letter in the next few months?
|
|
#
?
Sep 2, 2017 11:05
|
|
|
|
| # ? May 15, 2024 04:12 |
|
|
Paracaidas posted:The evil house in CA killed the senate UHC bill*. Bastards. Bill also demanded that the Federal Government block grant Medicare.
|
|
#
?
Sep 2, 2017 22:34
|
|