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Khisanth Magus posted:The reason medical costs have balooned so much is that both the medical providers and insurance both benefit from the increases. Insurance companies are only allowed to keep a certain % of the premiums they get, the rest must be paid in claims, and premiums are more or less automatically calculated as what is necessary to cover expected claims. So to increase premiums so that their flat % cut also goes up they need medical costs to go up. Which of course directly benefits the medical providers. That is not why medical costs have ballooned so much. Insurance companies are constantly negotiating lower rates in order to capture much greater market share. You have a warped view of the insurance market.
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Oct 25, 2017 18:53
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Khisanth Magus posted:Only to a degree. It really doesn't hurt them much to have medical costs go up because its not like people can go to a different company if their premiums go up. First of all, the other company's premiums are also going up, and second, most people are tied to their insurance through their employer. It takes a hell of a reason for a company to switch over to a different insurance provider. And rising premiums means the amount they can keep also goes up. A hell of a reason to switch such as - a lower premium from a different insurance company? Like do you seriously think that these companies are making contracts for millions of dollars and not going to market every once in a while?
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Oct 25, 2017 19:11
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Khisanth Magus posted:Unless it is substantially lower it is unlikely it is worth the costs associated with switching. And I rather doubt that the "negotiated" prices different insurance companies get with medical providers are really all that different. As someone who has been part of this decision making process many dozens of times, switching medical vendors can have a year 1 ROI of like 100:1. You 100% have no clue what you are talking about and are on the wrong side of the Dunning-Kruger curve here
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Oct 25, 2017 19:19
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Ze Pollack posted:and yet, you continue to post At no point is any of this a disincentive for insurance companies to slow their (very strong) efforts to cut costs
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Oct 25, 2017 20:00
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Ze Pollack posted:absolutely. that their most efficient way to cut costs is and remains finding ways not to pay for expensive people's health treatment ends up being one of the drivers of increasing costs is one of the bits of tragic hilarity in this whole story. The interplay of denials/upcoding/discounts/value-based-payments in the mix between providers and insurance companies is at worst, competitive jockeying independent of overall health care costs, and at best is has a downward impact on it. Do you honestly think provider prices would go down if they just dictated their own prices instead of having to negotiate them?
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Oct 25, 2017 20:17
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Ze Pollack posted:do you honestly think health insurer claim denial rates would go down if costs stopped rising No, and there's no reason for you to get that impression from anything I've said. You and I both know that You jumped into a discussion about a guy who said that insurance companies are colluding with providers to increase costs, appeared to post in agreement with him, then decided to keep throwing words at the thread that are either irrelevant to the point or directly against it. I'd say you were moving goalposts but I am unable to recognize any point from your posts that is more sophisticated than "insurance company bad"
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Oct 25, 2017 21:09
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Crashrat posted:A $600 fee from the IRS is a pittance in comparison to the savings of being on a CSR plan. The difference in deductibles, and especially OOP max, is *thousands*. I don't believe the feds claw back cost sharing reductions at all, even if you understate income - I could be wrong though. But yes the $600, if Trump decides to apply the law, is probably significantly less than the premium subsidy they get via lying.
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Oct 27, 2017 13:24
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paperwind posted:This is what HMSA offers: https://hmsa.com/health-plans/individuals-families/metallic-plans/ It's the Silver Plans that look out-of-whack compared to everything else. I'm guessing that when Trump eliminated the government subsidies for cost-sharing-reductions, it has a disparate impact on each of the individual silver plans. Because of the cost-sharing-reductions, the silver plans are a mix of people who get the cost-sharing-reductions and people that don't. So the "same plan" has a range of actuarial values between 70% (True Silver) and 94% (Extra-Platinum) depending on income level. The cost-sharing-reductions are still around - except they are paid for via higher premiums on silver plans instead of the government. If you are making more than 200% of the FPL, I would not recommend that you purchase one of the silver plans. Either way, I would recommend you talk with a health insurance navigator instead of us. esquilax fucked around with this message at 14:04 on Nov 2, 2017 |
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Nov 2, 2017 14:00
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Crashrat posted:
This isn't true - the Mental Health Parity Act of 2008 and the subsequent regulations make it so that mental health and substance abuse services need to have cost sharing that is no higher than the cost sharing required for other (non-MHSA) benefits. The testing for compliance with this is actually pretty onerous and strict
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Nov 7, 2017 21:59
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Annual Prophet posted:A question for Esquilax or others with some perspective on how plan provisions affect enrollment / pool characteristics: How much protection, if any at all, do open enrollment periods provide to avoid death spiral conditions relative to a mandate? Presumably you still lose the youngest and healthiest potential participants, but for those a bit further along who may feel a general need for insurance, could the temporal limitations on access (and hence the inability to enroll only upon negative diagnosis or condition) be expected, in some measure at least, to replace the incentive that the mandate provides? I seem to recall some speculation about this when the ACA was originally being structured and debated, but I can't recall any metrics or projections, or whether it was seriously discussed, etc. Those limitations are pretty much already in place. Limited open enrollment periods are currently the norm for health insurance (public and private) and are generally seen as important. I'd be surprised if the adverse selection impact on premiums from year-round enrollment was double-digits huge though - not even close to the selection impact of hypothetical "no-mandate" or "no-subsidies" changes. Despite the "low" impact, the practical impact on people who are doing what they should by staying continually insured is so minor that you'd be pretty irresponsible not to limit the length of open enrollment periods. There's probably a lower bound though, shortening the ACA enrollment period beyond the current healthcare.gov six-week window would probably not have a material impact on premiums. Side note: one interesting type of time-sensitive enrollment limitation are the ones used by Medicare. If you don't enroll when you first get the chance, you get a percentage penalty that lasts for the rest of your life. The longer you go without Medicare, the higher your penalty gets. I'm mostly speculating on the effects, there are probably others who are more qualified to answer specifically about pieces of these
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Nov 20, 2017 23:16
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PerniciousKnid posted:Today I learned that being in the 18mo COBRA eligibility people disqualifies you from subsidies. No it doesn't. Being enrolled in a COBRA plan means you can only switch to a market plan during open enrollment periods, but simply being eligible for coverage should not cause issues with subsidies or choosing a marketplace plan.
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Dec 3, 2017 14:47
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PerniciousKnid posted:Hm, then he got some information from, or was merely confused by what he heard from an advisor. He and I were very confused because healthcare.gov didn't show him getting any tax credits, but I eventually realized it's because he owed further information about eligibility because he told his advisor he didn't know yet if he was eligible for COBRA* or to buy into the plan at his wife's work (she works part-time at a school). I wonder if it's being potentially able to buy into his wife's plan that disqualified him, or if it's just that the advisor put in a TBD for those questions even though either answer would permit subsidies. I guess that he would have to send some kind of paperwork from both sources about what he's eligible for as part of his ACA eligibility form requirements. Even his advisor was surprised by the costs being shown. So - I was inexact before. Being eligible for COBRA could prevent subsidies, but only if the premium rates for COBRA are affordable based on his income. COBRA rates are generally unaffordable, so it usually wouldn't make a difference. But the possibility of this rare occurrence does mean that a "Yes I am eligible for COBRA" answer on that question might lead to a further question on whether the available COBRA coverage is affordable. Not familiar with the system they're using so I can't say for sure. The ability to buy into his wife's plan could also potentially make him ineligible for subsidies on 1/1/18. If her coverage through them is affordable based on their family income but his is not, he could be a victim of the "family glitch"
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Dec 3, 2017 17:11
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Twerk from Home posted:It's probably just negotiated network pricing. They're not going to cover cost of your treatment, but they're going to negotiate low rates so that you don't have to do it yourself. This usually the case. They are typically surrounded by marketing material that says something like "no deductibles!" or "no annual limits!" because they don't actually pay you any benefits. It could be a reasonable purchase if you don't otherwise have insurance, if it only costs a few bucks a month, and if the dentist you usually go to is in the network. Or you could just ask your dentist for a discount and they might give you one.
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Jan 25, 2018 18:45
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KillHour posted:Most people will buy whatever is the cheapest thing their employer offers. Employers are going to start offering these "plans" because of course they will. Nah it's usually a pretty complex choice environment and employees tend to choose the plan that offers the best value for their health. In 3 plan environments you'll often only get 10% enrollment in the cheapest plan
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Jan 27, 2018 21:41
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The last big expansion to Medicare was almost entirely Republican driven, and HIPAA and COBRA were both bipartisan. If a bipartisan work group offers a chance to make the R's behave like adults again then it's a shot worth taking.
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Feb 7, 2018 21:55
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Hieronymous Alloy posted:COBRA was 1985 and HIPAA was 1996. Not exactly modern era Republicans. The MMA was 2003, and McCain actually had a rough health policy during the 2008 election. The current rot in the Republican party on health policy really started in opposition to the ACA and does not have to be permanent - it's something that other R's can try to fix. Frist for example voted to expand medicare entitlements to cover prescription drugs for seniors.
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Feb 7, 2018 22:19
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joepinetree posted:Frist also proposed the medicare premium support amendment that would transform medicare into a subsidy that people use to buy private insurance. It's aimed at moderate republicans and moderate democrats, and it's certainly easier for both of them to buy into the conclusions and not get primaried out if they have the cover of "bilateral" or "policy over politics" or whatever. And I haven't checked the ideological purity of all 52 founders but just last page there was an exchange about a bunch of people angry at noted M4A advocate Jon Favreau. I realize that this is somethingawfuldotcom and the inclusion of republicans or any private company ever automatically poisons the well, but there is discussion about health policy in this country that's a little more tactical than "M4A when?" It's becoming more widely recognized that the health system in this country is broken and that's why these workgroups like Unites States of Care and Amazon/Chase/Berkshire and the Health Transformation Alliance are starting up. And getting some republicans on board with actually trying to solve the problems the country is facing - even if we don't agree with their solutions - is a good goal.
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Feb 8, 2018 23:54
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The Phlegmatist posted:I'd rather have bad legislation that can pass through Congress (like PPACA) that actually helps people instead of screaming bernie sanders would have won into the ether for all eternity while people loving die because these groups don't pass your purity tests. The big issue is that the republicans proved that being "just say no" babies about health policy is an effective strategy that leads to electoral success, if not legislative success. There's a real danger that the democrats will copy them.
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Feb 9, 2018 00:09
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Willa Rogers posted:If there's an upside, it's that this group is bound to fail--not only because people immediately saw it for what it was and called it out, but because there's nothing else left to do wrt our healthcare system than either work toward radical reform or continue to prop up the status quo. Radical reform doesn't necessarily mean socialized medicine. As just one example, all payer rate setting is a great cost control method that is budget neutral by design that would maintain private insurance and the current employer cost contributions, and could potentially gather support from parts of the insurance industry and from employers. However it's vulnerable to attacks from both the right and the left and from the provider side, and is too wonkish to gather grassroots support. So it needs a few years in the incubator before it can be rolled out - someone needs to work on the politics of it to see if it's plausible to roll out on a state-by-state or nationwide basis, or even at all, and also find a way to make it palatable to both parties. E.G. to appeal to R's they start talking about the need for price transparency and responsible consumers of healthcare. For D's they can emphasize patient savings and the use of medicare as negotiating leverage against drug companies. Someone needs to actually work at it though. That's the type of fundamental reform that this type of group could be working towards. If all they come up with is more of the same garbage then yeah it's nothing worth going into siege mode over.
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Feb 9, 2018 07:28
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Reik posted:They 100% determine preferred drugs within a therapeutic classification code based on which manufacturers they can negotiate a better price with, but these aren't really kickbacks because the PBMs are set up to pass these rebates to the insurer, leading to a reduction in overall costs which will translate in to lower premiums. There are definitely some kinks in that pipeline that need to be fixed, but for the vast majority of cases that is how PBMs work. With no real regulation on drug prices, we have placed the burden of keeping down drug costs on PBMs and/or health insurers, and it has the negative side-effect of having PBMs and/or insurers toeing the line of practicing medicine. The PBM often ends up retaining a lot of the rebates. When contracting with self-insured employers the amount of rebates that the PBM passes along is part of the bid, and it's often opaque as to how much the PBM end up retaining and how much they pass through. I wouldn't consider them kickbacks, but the whole rebates-instead-of-prices negotiation paradigm is ridiculous and doesn't really benefit anyone other than the PBMs. If there's a benefit I can't see it.
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Feb 15, 2018 18:27
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Reik posted:Wellness incentive programs are dumpster fires that almost always ending up costing more than they save. Generally the value prop for those types of programs rely heavily on savings due to reduction in absenteeism and presenteeism and the benefits of employee engagement. It's rarely the (more easily measurable) hard dollar impact on health insurance costs that drives those decisions from an employer standpoint.
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Mar 7, 2018 18:56
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Reik posted:That would make more sense. We don't really have access to absenteeism/presenteeism data on our end, so I guess they just do those studies internally or with their consulting house? Generally, but only the largest employers really have large enough numbers to give the results any kind of statistical plausibility. Other employers tend to be followers.
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Mar 7, 2018 19:57
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More developments in PBM/insurer consolidation: Cigna to Buy Express Scripts in $52 Billion Health Care Deal With this and Aetna/CVS, there won't really be any more large independent PBMs.
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Mar 8, 2018 19:17
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Malcolm XML posted:Everything shares the same drug coverage after the deductible. The drug coverage is copay based yes. People are better consumers of healthcare when in high deductible plans, so companies often give greater subsidies to those plans than to PPO plans. It's very possible that the HDHP is your best option, especially when you consider that you can pay your premiums AND out-of-pocket payments pretax through your HSA (whereas under the PPO only the premium is tax advantaged)
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Apr 12, 2018 17:05
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Peven Stan posted:Hahah this is demonstrably false. Then reword it into "significantly reduce their health care spend under an HDHP plan"
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Apr 12, 2018 17:16
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Malcolm XML posted:Health insurance companies are mandated to run at cost-plus so they have no interest in reducing costs. Volume matters and purchasers are extremely price sensitive so insurance companies do a ton of cost containment. Like negotiated discounts, narrow networks, high deductible plans, care management, claim denials, etc. They have a huge interest in reducing costs and their efforts toward it are obvious.
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Jun 12, 2018 13:50
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Malcolm XML posted:They are required to maintain a loss ratio greater than 80% and also required to generate increasing profits for shareholders. Heath insurers have also been merging rapidly. Which is why they are focused on cost-saving measures. Economies of scale is another example of this, as it leads to higher volume which increases profits. How do you look at everything that health insurers do that you hate and come to the conclusion that "yup they don't care about costs at all"
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Jun 12, 2018 14:18
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Malcolm XML posted:
No I'm not agreeing with you. The fact that you can't see that is telling. They account for the expectation of cost-reduction activities to determine how to much to charge in premiums. Which allows them to charge lower premiums. Which allows them to increase the number of policies sold. Which allows them to increase profits.
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Jun 12, 2018 14:37
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youre agreeing with me
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Malcolm XML posted:Being less glib: They lower plan costs so that they can charge lower premiums and still be profitable and meet loss ratio requirements while increasing total volume. Cost reduction strategies are decided in advance, like premiums. Why are narrow network plans on the marketplace? Lower costs Why are high deductible plans? Lower costs Why do insurers negotiate provider discounts? Lower costs Why did they used to exclude preexisting conditions, including in states with loss ratio requirements predating the ACA? Lower costs Why did they used to do medical underwriting to make sure no high-cost people joined the plan, including in states with loss ratio requirements predating the ACA? Lower costs Why do they deny claims? Lower costs If your mental model of the health insurance marketplaces concludes that health insurers must hate making money, then you should probably rethink it. esquilax fucked around with this message at 15:28 on Jun 12, 2018 |
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Jun 12, 2018 15:26
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Malcolm XML posted:ACA adjusted MLR will take into account efforts to increase care quality so this poo poo pays for itself, but on the whole if the cost of a procedure or drugs increases 10% that cost is directly recovered from premium payers, and causes an increase in revenue as premiums increase. But when they deny claims it reduces their costs, and they wouldn't get their 1/80% load on that so by your reasoning denying claims leads to less profit for them so why would they ever deny claims?
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Jun 13, 2018 17:12
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Reik posted:Health insurers are incentivized to reduce systematic costs. They are trying to change health delivery via value based case reform. Are you guys trying to move to upside/downside on everything or do you view upside-only or downside-only as desirable models long term?
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Jun 13, 2018 17:32
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Malcolm XML posted:You deny claims to the 80% mandated MLS then hope that the systematic costs (so you can ratchet up premiums) rise. Claims are costs, revenue is premiums. The industry-wide effort towards value based care is literally systematic cost reduction Which is why the effort that US private insurers are doing in value-based care has direct analogies in US Medicare, Canada, the UK, and other countries "The minimum MLR requirement is causing problems by making insurers avoid reducing costs" is just not something that is true
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Jun 13, 2018 18:00
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Malcolm XML posted:Premiums in Aca So then do you think that 2018 premiums would be lower if the regulatory oversight/rebate program around minimum loss ratios didn't exist at all? And that in the absence of this regulation, insurers would not have raised premiums as much as they did?
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Jun 13, 2018 18:55
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