what are your thoughts?

[SANE-A30]

So today while studying for my exam tonight, my test is based on HMO's PPO's insurance in the healthcare setting etc... Then came the topic of medicare / medicaid and it's function. Every diagnosis is based on a code and depending on the code that is how much money the facility gets reimbursed for services rendered...blah blah..I'm not a very political person but I have to question the fact how can they determine how much a preventive/ curable measure will cost when illnesses have advanced over the years or improved. a cardiac catherization procedure is different then what it was ten years ago heck even five... the actual cost of the procedure .. just makes me curious how they have these set codes ( DRGS ) in place when things flucuate through out the years...this really hit home for me b/c I work at a facility that has ALOT of medicare patients and I have relatives on medicare, If the system was revamped would it improve the status of our healthcare system? Is the government paying to little or to much for these codes? I found it to be pretty interesting and it made me curious.

* maybe they have to do it in a code form b/c we would go broke if they based how much they paid on the actual cost of a procedure. I still think someone is getting jipped whether it be the facility or the government only b/c things change so much the cost of supplies procedures etc.. how can it possibly be accurate. if you fall within this category you get reimbursed for this amount and then the poor patients that have to use these services ( THE ELDERLY not the crackhead ) suffer b/c noone wants a medicare patient b/c they don't get paid...

[retdetsgt]

How do private insurance companies determine the amount of payment? Don't they use codes too?

[SANE-A30]

How do private insurance companies determine the amount of payment? Don't they use codes too?

I'm not sure if they do or not..is'nt it based on your plan HMO vs PPO how much you have to pay? With private insurance I think you go in for a procedure and they go by the actual cost of the procedure b/c when you see it on your bill your procedure was 1,000$ your part is 400$ with medicare....Your procedure falls under this code the government only pays x amount back to the facility it's similar in a sense but different as well. maybe the codes are the cost range for each procedure? but still the cost of procedures change on a yearly basis...do they change the codes every year? with every advancement of technology?? I don't think they do....I think the Hmo & PPOs are more accurate b/c with them you actually see what the facility is being charged for they break it down in a sense with a code a person receiving a heart transplant should not fall under the same code as someone having a kidney stone removed the procedures are total different as well as the expense.. Not sure if that is the case or not but it just seems fishy to me how they keep the cost so accurate but then again the facilities are being REIMBURSED so maybe they do pay what is rightly owed after services are rendered..I just think it's odd that they say ok your diagnosis falls under this code we will be reimbursed this amount....lol it's way over my head but it did make me think about it.....

[SHH 1313]

How do private insurance companies determine the amount of payment? Don't they use codes too?

Yes they do..My girlfriend worked for a doctor in AZ, those codes are a b*tch to learn because there are so many and also many different codes that can be substituted to make costs higher or lower.That is why some hospital bills are so astronomical. Then imagine the sheer volume of the audits when they get around to checking into fraud.

[JoetheGI]

If the system was revamped would it improve the status of our healthcare system?

Absolutely.

However, due to the fact that government programs are largely dictated by budget, as opposed to results / profit, efficiency and effectiveness are not as significant of a factor when compared to private organizations.

Private organizations that fail to make a profit go out of business. Government organizations only have to concern themselves with how many tax dollars they will be allocated, as it takes legislation to put them "out of business".

Even if leadership within a government organization attempts to streamline the organization to save cash, unless mandated by legislation, they are liable to meet with resistance by legislators when jobs are cut within a congressional district, or when business opportunity is reduced or eliminated. More often than not, significant change, for the better, will only come about as a direct response to some kind of major crisis.

Is the government paying to little or to much for these codes?

There is no doubt in my mind that many, many, government funded costs are inflated in some way shape or form. A lot of this has to do with what you observe concerning the changing costs of procedures and resources. They can't, or choose not to, keep up with the changes, because they generally don't have to in order to "stay in business". It all comes down to the budget, and businesses that provide goods and services know this and are willing to take advantage of exorbitant and unrealistic compensation for the goods and services they provide. While there are goods and services purchased at reasonable costs, many are not.

Throughout my service career, I witnessed countless examples of government waste in the form of overcompensation for goods or services rendered, however, more often than not, there is always some measure of plausible deniability that precludes calling such transactions "fraud" in the legal sense. I'd be willing to bet a keg of beer that my experiences and observations would be easily recognizable in the health care sector as well.

[retdetsgt]

There is a lot of government waste. I read once that 40% of all money in government programs goes to administrative costs and I believe it.

That being said, the money paid by Medicare and Medicaid isn't generally up to standards. Many doctors refuse to see Medicare patients because the money they pay is too low for them to break even. Medicare costs taxpayers a fortune, but it's mostly in administrative costs. Doctors that do see Medicare patients try to make it up in what they charge private insurers.

Add to the mix lawyers, malpractice insurance and fear of being sued. My doctor told me once that he ran me through a battery of unnecessary tests just because his malpractice insurer required it. Of course, that cost my insurance company.

[sparrow803]

I worked in a hospital for twenty years....I was there when all the HMO's started. Wasn't long after that we had layoffs, a lot of layoffs. And, private sector insurances such as bc/bs will base their contract amounts with the doctors and hospitals on what Medicare/Medicaid pays. Can't really blame them....why should they pay more than the gov't? Healthcare has been dismall since then...doctors have to see twice as many patients to make their money and hospitals have to cut costs by any way they can.

Back in the day....when I first started we didn't have the major outbreaks of staph and other infections hospitals have now......just sayin.....cutting of costs will always in some way mean the customer/patient gets it in the hiney.

[retdetsgt]

The only HMO I've ever dealt with is Kaiser. When I was on it in the 70's, it was terrible. I had it because the other choice was Blue Cross which had horrible co-pays. At that time, Blue Cross wouldn't pay more than $900 for a pregnancy from first pre natal exam until the birth and the doctor and hospital cost for just the birth was nearly $1500. And most of the doctors had English as a second language. But Kaiser had a co pay of a dollar then. They were also worse than the Army as far as getting people in and out, getting personal treatment and keeping costs to a minimum. As soon as my kids were old enough to not need much medical attention, I dumped them.

I went back a few years ago because the other alternative health insurance I can buy through the city's premium was going up 20% a year and I couldn't afford it. (We have to buy our own insurance after retirement) Kaiser has totally reinvented itself and it is great now. My doctor is very responsive and they give me the best health care I think I've ever had in my life. If I want something, I get it. I can email my doctor with a question and she gets back to me within a couple of hours. My other private physician was never that accessible and they will refer me to a specialist over the slightest thing. Getting my other insurance to do that was like pulling teeth. Also, there's an advice nurse available 24-7 if I have a concern about something. They're a great HMO now.