[Grissler] has even seen the list in years. So I’m not sure why you care.”
Orstad also refused to comment on any of the specifics in Janice S.’s bill, including the seemingly inflated charges for all the lab work. “I’ve told you I don’t think a bill like this is relevant,” he explained. “Very few people actually pay those rates.”
Very few people? Actually, it’s only people who pay those rates – the uninsured and under-insured. The big insurance companies certainly don’t. They pay negotiated, much lower rates. Although some negotiate down from the chargemaster rate, most prefer to negotiate up from the Medicare rate.
. Insurers with the most leverage, because they have the most customers to offer a hospital that needs patients, will try to negotiate prices 30% to 50% above the Medicare rates rather than discounts off the sky-high chargemaster rates. But insurers are increasingly losing leverage because hospitals are consolidating by buying doctors’ practices and even rival hospitals. In that situation — in which the insurer needs the hospital more than the hospital needs the insurer — the pricing negotiation will be over discounts that work down from the chargemaster prices rather than up from what Medicare would pay. Getting a 50% or even 60% discount off the chargemaster price of an item that costs $13 and lists for $199.50 is still no bargain. “We hate to negotiate off of the chargemaster, but we have to do it a lot now,” says Edward Wardell, a lawyer for the giant health-insurance provider Aetna Inc.
Medicare has a pretty sophisticated method of determining what it will pay for procedures, hospital and doctor visits.
By law, Medicare’s payments approximate a hospital’s cost of providing a service, including overhead, equipment and salaries.
[the hospital send the patient’s] bills to Medicare electronically, all elaborately coded according to Medicare’s rules.
There are two basic kinds of codes for the services billed. The first is a number identifying which of the 7,000 procedures were performed by a doctor, such as examining a chest X-ray, performing a heart transplant or conducting an office consultation for a new patient (which costs more than a consultation with a continuing patient — coded differently — because it typically takes more time). If a patient presents more complicated challenges, then these basic procedures will be coded differently; for example, there are two varieties of emergency-room consultations. Adjustments are also made for variations in the cost of living where the doctor works and for other factors, like whether doctors used their own office (they’ll get paid more for that) or the hospital. A panel of doctors set up by the American Medical Association reviews the codes annually and recommends updates to Medicare. The process can get messy as the doctors fight over which procedures in which specialties take more time and expertise or are worth relatively more. Medicare typically accepts most of the panel’s recommendations.
The second kind of code is used to pay the hospital for its services. Again, there are thousands of codes based on whether the person checked in for brain surgery, an appendectomy or a fainting spell. To come up with these numbers, Medicare takes the cost reports — including allocations for everything from overhead to nursing staff to operating-room equipment — that hospitals across the country are required to file for each type of service and pays an amount equal to the composite average costs.
The hospital has little incentive to overstate its costs because it’s against the law and because each hospital gets paid not on the basis of its own claimed costs but on the basis of the average of every hospital’s costs, with adjustments made for regional cost differences and other local factors. Except for emergency services, no hospital has to accept Medicare patients and these prices, but they all do.
Go figure. There is a rhyme and a reason… and they’re both reasonable! So, why is Medicare the biggest driver of the deficit?
Our laws do more than prevent the government from restraining prices for drugs the way other countries do. Federal law also restricts the biggest single buyer — Medicare — from even trying to negotiate drug prices. As a perpetual gift to the pharmaceutical companies (and an acceptance of their argument that completely unrestrained prices and profit are necessary to fund the risk taking of research and development), Congress has continually prohibited the Centers for Medicare and Medicaid Services (CMS) of the Department of Health and Human Services from negotiating prices with drugmakers. Instead, Medicare simply has to determine that average sales price and add 6% to it.
Similarly, when Congress passed Part D of Medicare in 2003, giving seniors coverage for prescription drugs, Congress prohibited Medicare from negotiating.
Nor can Medicare get involved in deciding that a drug may be a waste of money. In medical circles, this is known as the comparative-effectiveness debate, which nearly derailed the entire Obamacare effort in 2009.
Doctors and other health care reformers behind the comparative-effectiveness movement make a simple argument: Suppose that after exhaustive research, cancer drug A, which costs $300 a dose, is found to be just as effective as or more effective than drug B, which costs $3,000. Shouldn’t the person or entity paying the bill, e.g. Medicare, be able to decide that it will pay for drug A but not drug B? Not according to a law passed by Congress in 2003 that requires Medicare to reimburse patients (again, at average sales price plus 6%) for any cancer drug approved for use by the Food and Drug Administration. Most states require insurance companies to do the same thing.
Huh? We thought Congress was there to protect us, not the big corporations. Why would they do such a thing? Just follow the lobbyist money!
“…the drag on our overall economy that comes with taxpayers, employers and consumers spending so much more than is spent in any other country for the same product is unsustainable. Health care is eating away at our economy and our treasury.
The health care industry seems to have the will and the means to keep it that way. According to the Center for Responsive Politics, the pharmaceutical and health-care-product industries, combined with organizations representing doctors, hospitals, nursing homes, health services and HMOs, have spent $5.36 billion since 1998 on lobbying in Washington. That dwarfs the $1.53 billion spent by the defense and aerospace industries and the $1.3 billion spent by oil and gas interests over the same period. That’s right: the health-care-industrial complex spends more than three times what the military-industrial complex spends in Washington.
I decided to go to my favorite expert on the ills of our health “care” system. Wendell Potter, who rose to prominence when his conscience got the better of him and he quit his high-paying job as the VP of Communications for insurance giant Aetna, testified in front of Congress and wrote the sad but true book, Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care and Deceiving Americans, joined me on the show this morning to discuss the article and how little has changed.
Tomorrow morning, I’ll be joined by Congressman Alan Grayson. In his last stint in the House, he introduced the “Medicare You Can Buy Into” Act, and just authored a letter to the president saying that he will vote against any compromise on the sequester that cuts benefits from Medicare, Medicaid or Social Security.
Today, is Tuesday, so I was joined in hour two by Gottalaff of The Political Carnival, who brought us these stories today:
(turns out he has quite a history… )
And I shared this one with her.. the Jesus bird poop. Here’s the picture:
It looks more like a dog to me…