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There’s a New Squid in Town: the view from the belly of the beast part II

In the first installment of my three-part series on healthcare, I covered the insanity of trying to get things covered by the private insurers.  Today I’m going to examine the second half of the problem: getting things paid.   If you are a healthcare consumer, you are likely at least a little familiar with the former, but not so much the latter. I know I’m spending a lot of time describing the problems with the system. But the thing is, we cannot adequately discuss solutions, or what proposed solutions will and will not work, and WHY, without having a very thorough understanding of just what the problems are from both the patient and the provider end.


I’ll first have to give a quick, VERY simplified primer on how medical services are billed.  Providers do not send a bill to an insurance company saying “20-minute office visit for diabetes and jock itch, $74.”  They use a system called CPT, or Current Procedural Terminology, that assigns a specific numerical code to everything a doctor does, from office visits to counseling to procedures. Office visits are rated from 1-5, depending on how complex the presentation, and how many medical problems were dealt with that visit. There’s a lot of these codes – the current CPT book is a good 4 inches thick. The codes are then fed into a computer, and the insurance pays accordingly, by a contracted fee schedule.   Diagnoses are entered via a separate set of codes, ICD, that must match up with and “justify” the CPT codes used. Got it?

I mentioned in part one the “perpetual adversarial chess game”, and it comes into play here.  The providers are always trying to figure out how to “correctly code” what they did, and the insurance companies are always trying to figure out ways to have the computer reject any given code combination.  Please keep in mind that because there are  so many similar codes,  the “game” gets interesting.  There may be 5 different diagnosis codes for a single illness, and THIS insurance company decides that they require you to use the second one, while THAT one kicks it out unless you use the 3rd one in conjunction with certain CPT codes.  Oh, and they change what will “kick out” all the time, so the code that resulted in your getting paid last month will not necessarily go through this month. Confused yet?

Here’s where it really gets interesting.  Matt Taibbi wrote his infamous article a couple of months ago, about the tentacled squid that is Goldman Sachs, and the questions over whether they have proprietary trading software that games the market in their favor.  Well, GS is not the only one who can play that game.  Insurance companies have been doing it for years.  Let me introduce you to some of these practices.

Bundling, downcoding, and black box edits:

Bundling is the practice of taking multiple procedures or codes that are billed, and deciding to proclaim by fiat, and with ZERO evidence, that they were not separate services at all.  For instance, let’s say a physician sees a followup patient with something like congestive heart failure.  So he/she bills for the CPT code associated with that service.  But on the way out of the room, the patient mentions that they have a skin lesion that is concerning. So the doc takes a look, and decides “Yeah, we’d better nip a sample and send it for biopsy”.  So he tacks on the procedure code for that entirely separate and unrelated bit of work, in addition to the heart problem visit he already did with the patient. Please note that he is NOT attempting to charge two duplicate office visits – merely an additional, usually modest fee for doing the biopsy/excision on top of a regular office visit.   The insurance company’s computer detects that two services are being charged, and “bundles” the two, paying only for the lowest-priced service. That’s bundling.

Let’s move on to downcoding.  It’s a pdf, so I won’t link it, but The Florida Medical Association has a good explanation of downcoding (emphases and brackets mine) :

What is “downcoding” of claims?

“Downcoding” occurs when an insurer unilaterally reduces an E/M [evaluation and management, i.e. a simple-to-complex office visit] service level. The typical scenario occurs when a practice submits a claim for a patient visit based on a CPT code definition (for example, new patient visit code 99204 — a “level 4”) and the insurer automatically “downcodes” the claim to a lower level (for example, new patient visit code 99203 — a “level 3”) and then reimburses at a lower rate. Typically, the physician receives no explanation for the change but simply receives lower reimbursement. Occasionally the EOB form might include an ambiguous explanation such as “level of service (or procedure) has been adjusted” but more typically the only way to detect that downcoding occurred is to be familiar with the fee schedule and compare that to the amount received on the EOB form.

Sometimes insurers downcode based solely on the diagnosis code. In other words, the insurer assumes (most likely through a software system) that when a patient presents with certain diagnoses, the clinical evaluation can never be more complicated than a certain E/M level, regardless of the specifics of the individual case. This assumption has no clinical basis. In order to appeal the decision, the practice is stuck with the administrative burden of having to submit additional justification for the level of service performed.

What this last part essentially means is that the provider says he did X amount of work, and the insurer, with no basis whatsoever, simply says “No you didn’t.” Then he/she has to prove it. Sometimes he has to send the entire medical record, or large parts thereof to the insurance company, or at the very least go through more of that endless hoop-jumping, with more and more “justification” and “documentation” required to get paid for simple, everyday stuff. The insurers do not just do this on “fishy” claims, or on odd and unusual procedure combinations. That would be a pain in the ass, but not crippling to a practice. They do it across the board, on purpose, not just on a few but on hundreds and hundreds of perfectly ordinary claims, every damn day.

Please pay attention here: THE INTENT is to make it onerous.  THE INTENT is to overwhelm the billing office.  THE INTENT is to make it so difficult that the doctor will simply eat the loss on a certain percentage of denied claims, rather than go through the HELL of trying to meet the “requirements” and send them ever-increasing pieces of paper, only to have them ask for yet ANOTHER piece of paper, on claim after claim after claim.

And this is where the the proprietary software squid comes in, aka random claim-denial algorithms, aka BLACKBOX EDITS

A second common form of bundling is through “black box” coding edits. “Black box” edits refer to claims editing software that insurers purchase and then customize to automatically ignore certain modifiers or to group certain CPT codes together in a manner contrary to CPT instructions. The term black box comes from the fact that insurers consider these edits proprietary and keep them secret. The physician typically is reimbursed for just one procedure and receives no reimbursement for the second procedure.

Black box edits are very problematic because of the secretive nature of the edits. For example, some third-party vendors will customize surgical “packages” for insurers’ billing purposes. What services or procedures are included in the package are often unknown and may not be consistent with CPT.
Moreover, there are any number of idiosyncratic edits that are difficult to even decipher from an explanation of benefit (EOB) form. Sometimes physicians can only figure out certain edits after getting numerous denials or lower reimbursement for the same service or procedure.

So what we have here is a situation where physicians have no way of accurately predicting or knowing just what the coding and reimbursement practices are of any of the dozens of insurers they deal with. They have no idea HOW to get paid consistently. The insurers are not made to tell them. They do NOT disclose the secret “requirements” of these programs to the physicians. Ever. And they can change it at will, also with no consent from or even notification to the providers. These practices are fraudulent, and often violate the very CPT guidelines to which every insurer in the country is supposed and has agreed to adhere. And they know it. They pretty much do whatever the hell they want, and leave the providers scrambling to keep up, to figure it out. Forget practicing medicine, you need a huge staff devoted to nothing but poring over claims, and trying to figure out some sane pattern in how and WHY they are being denied (this week). And the providers do not have millions to invest in software to try to counteract the latest “black box” random-claim-denial algorithms of the insurers. The Squid has waaaaay more tentacles then they could ever hope to have.

Many of these practices are obviously fraudulent, so why don’t the docs fight back, you may ask? Well, there have been a few class-action suits, which the physicians have won, BTW. But getting the evidence together and filing one is very very difficult.

Part of the reason is that doctors are forbidden by law to share a lot of that type of information, because private practitioners fall under the anti-trust statutes. A doctor CANNOT just pick up the phone and talk to other docs in the area, comparing notes on who is getting paid what, or what claims what insurers are denying, and whether the fishy patterns she sees in her own claims are happening to others. It’s illegal to do so. Yes, the laws are subject to interpretation, and they can speak of the general problem. But the practical reality is that anytime a doctor does anything even approaching “colluding” with other doctors, or comparing specific insurance contracts or payment practices, he will get slapped with an anti-trust violation suit so fast it will make your head spin. So there is very little pushback, because collective bargaining or a unified front is not possible for doctors – it could and often has been considered “price-fixing” on their part.

Ironic, huh? The huge corporations with the deep pockets are very obviously “price-fixing” and communicating with one another with impunity every day. It is uncanny how if ONE insurer begins some odious new denial or pre-cert or unfair practice, the others will follow suit pretty quickly. No one in our government bothers applying too much anti-trust scrutiny to THEM. But god forbid some pediatrician call around to other pediatricians to find out if BigMedPlan2 is reducing payment to all of them. Then you’ll have a hue and cry about the evil monopolistic greedy doctors wanting to defraud the insurers.

So, what to do? In parts one and two, I think I’ve laid out that the problem is leverage, and who has it. It’s not the patient. It’s not the providers. Almost all of the leverage to determine what is covered and at what cost in our system resides solely in the realm of the big insurers. What of Medicare? I’ll get to that. It’s much, much better, but not perfect. Whatever solution we propose HAS to deal with this issue of leverage, and where it resides. Is there a way to do single-payer and still put the leverage back where it belongs, with the patients and doctors, rather than just handing over complete and unthinking broad control to the government? I think so. If we do it right.

Stay tuned….

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66 Responses

  1. Excellent post, thanks.

    • Thanks. It’s way too long, but not a lot of time to edit between running after the grandbaby!

      I did want to cover some of this more “inside baseball” stuff, so that when people say things like “creating more competition” is going to fix this, one can understand just how ridiculous that statement is. No, that’s not going to solve it.

      • It wasn’t too long.

        One thing of note, though, is that health insurance companies do not provide the most challenging or interesting places to work. It’s tedious, and it must have taken managers too many years to work their way up, ’cause they are burned out and the environment is brutal.

        It is rapid turnover, so it doesn’t attract the brightest people. What I noticed is that most people who made it past 2 years most often made it to 20 years and those were people who were just fine with never having made it to management, or, if they made it to management, first line was as far as they went.

        It’s one of the few industries I’ve worked in over the past 2 decades where management is often trained on the job and has little or no college.

      • WMCB, first off, thanks for this piece, and the whole series! it’s really helped me see what’s going on.

        Secondly, you say that this idea of competition won’t do anything. I’ve been wary of that talking point myself, but i could never define why. Could you please explain what you mean? or will that come up in the next segment?

        • Kevin, I’m going to cover some of that in the next segment. There is just too much to cover – no way I could have done all this in one post!

          I’m all for free markets, where they apply. I’m no collectivist in general, nor do I think capitalism or profit is a dirty word. There are good reasons why they don’t really work for healthcare, that have nothing to do with ideology.

          • okay thanks.

            and i hope you didn’t take my post to insinuate that you are and anti-capitalist (is that a word?) or anything. poor word choice on my part, i assume.

          • Not a poor choice at all, Kevin – I didn’t take it that way. I’m just making a real effort here to explain my reasoning for wanting UHC in practical terms, not from a political ideology standpoint. I don’t want it because I normally or always think more govt intervention is a fine and great thing (as a centrist I really, um, don’t, not-so-much). I want it because I think it will work much better than what we have.

      • WMCB: It’s not too long at all. It’s concise and precise, especially considering the monstrous topic you’re tackling! Thanks again for taking the time to do this.

      • No way is this too long wmcb! But it is discouraging reading 😦 .

        Thanks so much for your effort, and … can I hope for an (just the outline) explanation of “single payer” in your next essay?

  2. Another superb diary, wmcb. Sounds like an opportunity for some really sharp programmer to come up with a program to help the doctors. Just keep sending the claims through with different algorithms until you defeat the insurance company’s program.

    Couple of observations on this. I used to have a skin doctor who prominently displayed a sign in his office that *everyone* paid cash for office visits. Whatever you got back from the insurance company would go directly to you. So if anyone was going to eat the non-reimbursement, it wasn’t going to be him.

    Also, from the other side of the aisle: I used to have a gynecologist who knew that I didn’t have insurance and would instruct the front office people what to charge me. That amount was always HALF of what people with insurance had to pay, because I was paying her cash at the time of the visit with no collection hassles. A figure of 30% administrative costs has been bandied about in terms of what private insurance eats up, but for a doctor’s office that figure is obviously greater.

    Anyway, much has been made of how those of us without insurance are costing money for those who do have insurance. Most of the time, the opposite is also true. My current doctor charges me the full rate for an office visit, even though she knows I don’t have insurance. So I’m having to pay the inflated prices of those who do have insurance, just because it’s such a hassle for doctors’ office staff to receive proper reimbursement. It works both ways.

    • Yep. The thing is, you have to set up your billing software to assign a fee for each code. Let’s say a procedure costs you $70. Let’s say you have a few insurances that will pay $120 for that, a bunch that pay $75, a few that pay $70, and a couple that pay $30.

      Where are you going to set the fee? You’re going to set it at whatever the highest schedule is, knowing full well that you won’t get that from most of your payors. Most doctors do negotiate a discount for cash patients, but some don’t bother, they just plug it in at whatever the pre-set fee schedule is.

      The entire system is so screwed up it’s not funny.

      • Your explanation is probably why my gynecologist had to verbally instruct those at the front desk what to charge me.

        • Yes, because it has to be hand-entered, you can’t just punch in the code like normal. MOST practices will do it, but many front-desk clerks forget to offer if you don’t think to ask.

          If you are self-pay, always ask.

          • It was my impression that passing on this savings to patients who pay cash is illegal. Is that only if the charge is less than what Medicare/Medicaid pays? I understood that this practice used to be more common, but that the insurance companies got legislation passed that prohibited doctors from giving a discount to people paying cash.

      • When I worked for Blue Cross recently, the dept I was in was “Provider Services”. One of my duties was to organize and take notes at the quarterly meeting where we had some 24 providers come in for 5 hours, learn the changes the company was making that they would be interested in, and listen to their questions and needs for future “fixes” to be put in place.

        I really found it entertaining. This company has been having 4 meetings a year for decades and the providers are still begging them to make the most basic, reasonable changes to the system so they can get paid accurately, and on time.

        The BC group I worked for customized their products for each employer, so just because one person on Blue Cross got their mole removed under their plan, didn’t mean the guy across the hall who worked for a different company and also had Blue Cross was going to get his covered.

  3. Excellent post, thank you WMCB !!

    Please pay attention here: THE INTENT is to make it onerous. THE INTENT is to overwhelm the billing office.

    Absolutely.That’s why I maintain any doctors office can handle the paper work of single payer…they have already gone though the paper work ringer!

    The simple fact is : We don’t need insurance compaines. It’s that simple and it’s why the whole of Washington’s beltway apparatus is defending these ruinous dinosaurs tooth and nail . If the government is will to spend hundreds of billions….what do we need insurance compaines for? To take 30-35 % of every dollar spent for their Kafka paper work? Somehow that doesn’t seem worth it

  4. I have a prescription for a condition that is a lifetime problem. It’s not curable, just treatable. Anyhow, every month the insurance company sends a letter saying I need my physician to very the “medical necessity” for payment. The physician gets the same notice and sends this information.

    Here’s the thing. If it’s a lifetime issue, the only way it becomes no longer medically necessary is if I’m dead. This is ridiculous and demonstrates the absolute waste in this unnecessary process. How stupid is that?

    • Sadly, SOD, there is a lot of fraud in the system. There are doctors requesting reimbursement for dead patients or people who are no longer patients of that particular practice. At least, we see a lot of that in Chicago. The doctors probably got the idea from the way our voting works here.

      • Yes, but the payment is not going to the doctor that has to verify medical necessity.

        • Same thing with re-certifying patients every 3- 6 months for a lot of things, from diabetic supplies to wheelchairs to medicines. You do it, but you don’t get paid a dime for it.

        • The doctor could easily have set up a phony address to receive payments–just saying. I agree that it’s stupid, and that the only thing that should trigger such a request is if the name or address changes for whom to send the payment to, not just because the six months is up.

    • Over here drug prescriptions are free. Basically you pay out of your own pocket for things that cost up to $10-15 (this isn’t hard and fast), such as aspirin, various ointments etc.

      However you are only allowed 2 packets of medicine for every prescription. I take blood pressure pills, I have to go to the doctor for a repeat prescription every 2 months. Usually I phone in and he leaves it out so I don’t have to wait. What drugs I take are all on the computer. What his assistant does is print it out and he signs it.

  5. I’m guessing that some doctors will instruct their billing clerks to “bill creatively” to compensate.

    For every action there is an equal and opposite reaction

    • Yeah, sometimes you take the “throw everything and see what sticks” approach. You file the exact same procedures coded 5 different ways, flag them, and see what comes back paid. For that insurance. This month. It will be entirely different in a few months, so you do it all over again.

      Most docs will not get too too creative, because the patient gets mailed a copy of that “explanation of benefits” as well. So if you are charging for stuff you flat didn’t do, or for diagnoses that are entirely fabricated, you’ll get caught really quickly. Outright fraud is truthfully not very common. It’s not like attorneys with hours billed – it’s harder to pad.

      Another thing that bundling does is force increased office visits. If the doc just doesn’t want to fight about getting paid for removing a wart when you came in for your diabetes checkup, he’ll tell you you have to make a separate appointment for that. The only sure way to defeat bundling is to make EVERYTHING a separate office visit. It sucks.

  6. All this bundling, down coding and black box edits sounds like a roll of the dice . Doctors are just guessing in many instances. When using the “roll of the dice” you can be a big loser. Are there times when you’re the winner? Doctors get what they deem as a fair payment, at least sometime. With my $5000 deductible, I was surprised to see that my office visit was $80 as opposed to the $105 that is normally charged. Even with the deductible, my office visit had to be turned in to the insurance company. (keeping tabs on my outlays, I suppose) Can’t wait to hear how Medicare works.

  7. Good post. I’m looking forward to part three.

  8. And then there are many of us who have just given up — in my area the doctors are not accepting new patients — and they haven’t for years. I’m not sure how their system works.

    The plan in this area is treatment by clinics — or walk in for “urgent” care. So you are treated via computer — plug in the symptoms and follow the directions. We’ve all been reduced to statistics and if you fall into the “norm” then you will do well in the clinic type system.

    I’ve heard of doctors who have had to declare bankruptcy because the state the are in uses an insurance company to handle Mediaide payments — etc. And the insurance company just wasn’t paying the doctors.

    Oh and then I have friends who live in the Caribbean — there are a lot of early retirements by Doctors. Meaning that a lot of MDs are just leaving the country. Could be that this is what doctors have always done — retired to the tropics OR this could be a new trend.

  9. All obama will do is outsource anyways. Just think about the all the lobbyists flocking to Washington DC because of obama’s reckless over-spending of $2 TRILLION in just 6 months, which alone is increasing the National Debt by 20%.

    Politicians take people’s money and reward the large corporations, in this case companies in the health care industry, since they have the money to more effectively lobby politicians. In the end smaller businesses will be hurt.

    Politicians will only reward companies that will be in their best political interest. Honestly, when can you really trust politicians since they are basically professional liars, and being president just means you are the best liar of the time. Why not just give the money directly from the people to the companies and take politicians in government out of the equation?

    obama is going to recklessly spend TRILLIONS of tax payers’ money just to give insurance to about 25% of those who do not have it. Over 50% of people’s income go towards taxes, just imagine how many more people will afford health care insurance if their income is almost doubled because of dramatic tax cuts.

    Competition is what is needed. It lowers prices of products and services, along with developing new innovations. All of which will benefit consumers. You need to remember that monopolistic tendencies can also apply to government.

    The reason why the cost of insurance is high is because politicians in government mandate insurance companies to increase their premiums to pay for ridiculous things. In addition, politicians put up regulations so that Americans are not allowed to get insurance from another state and use the coverage in their own state. This reduces competition making it more expensive for people to get insurance. On top of that medical professionals are not allowed to freely practice their profession in any US state without taking a long and tedious licensing process. This again increases the cost of medical insurance.

    In the end, the problem with most economic issues is too much government intervention of the economy by politicians, who will only tend to do things for political self interest. Just like how obama nationalized GM to pander to its unions. Politicians can barely run government, yet people think they can run a multi-national auto manufacturing company?

    The solution is SMALLER government, LESS spending, and LOWER taxes.

    • You really missed the part about us being “big government” liberals didn’t you?

      • I believe sammy has copied and pasted this exact generic response on several healthcare threads. Check, but I’m pretty sure.

        • Maybe he should go by the name Spammy instead of Sammy.

        • I think he has. I’ve seen that same thing somewhere else. The point though is interesting. I generally believe that competition drives down prices, BUT I’m not sure that applies in this case, mainly because the insurance industry is so massively regulated AND because medical costs are not easily standardized or commoditized.

          However I find it a little hard to swallow that replacing massive private bureaucracies with a massive public one will solve things either, especially given our proclivity in the US to use every government program for political ends of rewarding certain constituencies and staying in power.


          • I understand your concerns, and I don’t scoff at them – I think they need to be firmly addressed in any UHC legislation. We’ll discuss how to do that in part three, so feel free to join in. 🙂

          • Health care does not respond to the normal competitive model. In the late 80s I used to read Modern Healthcare religiously because I worked for a firm that sold sw and data to healthcare orgs. I will never forget finding out that in our city, Philadelphia, Pa, medical cost were higher than the norm. We also have more hospitals than the norm, being a major hospital teaching center. The hospitals had to charge more because they were all still sharing the same number of people, so fewer people had to support more hospitals.

            At that time I questioned the value of hospitals spending a lot of money on marketing, which was the latest idea at that time. Most people do not get to choose which hospital to go to. It is either where their doctor is affiliated, where their insurance will pay or the nearest one. I don’t think people shop hospitals in most cases.

          • bc, on your blog you say it’s naive of liberals to have faith in the federal govt to not screw up UHC, but it’s not that we trust the govt–it’s that we trust the for-profit insurance industry less.

          • Wonk – thanks for visiting my blog. I don’t necessarily trust the for profit insurance industry either. There is a critical role for government in enforcing the moral restraint that is needed for the proper functioning of a free market system.

            The difference between private industry craziness and government craziness is that with private industry there is (ostensibly) another option. Government brings with it a heavy hand and police power; that is the full force of the law, around which no one can maneuver. And government can simply change the laws at any time and there is no recourse.

    • Go pick some more cherries and brew some more tea and say hi to Hannnity. Buh bye now.

      • My favorite is the part where He (She?) argues against licensure for doctors. I get that it’s an onerous process, and doctors (and dentists and lawyers and other professionals) all have my sympathy on that one. But I’m working on a doctorate in psychology, and knowing the kind of idiots who work in my field, I shudder to think who’d be practicing if they didn’t have to go through the licensure process.

  10. This is a Great post WMCB! Thank you.

    A colleague just left our house after a short meeting, but before he left I asked him “Craig as a Canadian, tell me ‘how bad’ the Canadian health system is.” He went on for an hour about the ‘baloney’ that is being pushed on the American people. In fact he said that if the system here doesn’t change he and his wife will probably have to move back to Canada as they won’t be able to live here (he’s 53 – she’s 56) he’s afraid of insurance costs and health care costs between now and when they are 65 will bankrupt them.

    Recently his wife was scratched by a neighbor’s cat – she went to a local hospital for a tetnus series – even with the insurance they have (BC/BS) it ended up costing them a little over $1000 for the care they received.
    “It would have cost us nothing in Canada”
    In response to some of our questions that have been raised by Repub friends: no, we never waited any longer than we’ve had to wait here – in fact, there have been times when we’ve waited longer here to be scheduled to see a doctor or for a procedure.

    Some people do go to the US for surgery – but only because they can afford to see a particular doctor much as some in the US go to other countries for specialists.

    “Health care in the US is insane. I can’t believe it. My wife works with a young woman who just had a baby and is beside herself because they can’t afford insurance that will also cover the baby. ”

    The Canadian system isn’t perfect but it’s far and away better than what we found here.

    And the fact that people believe what the media or politicians are telling them without checking it out for themselves is even more absurd. We need a single payer system with options.

    He simply confirmed what we already knew but I learned that he is willing to speak with “non-believers”

    • The biggest problem Canada has had, from what I can see, has been inequities by region. They are trying to fix that. Some of the “horror stories” you hear are indeed true, because waiting lists and access can vary greatly by province/city. You may get fabulously prompt care in one city, but have a shortage of particular specialists in another. Every system has flaws that need to be dealt with. They’re working on it.

      • Sounds like America. Try to get an appointment as a new patient with a specialist around my area….not easy I tell you. You have to go 150 miles for a Dermatologist just to get a screening.

      • You can even have very differing experiences in the same facility, depending on several factors, such as how busy it was at the time. I worked in two different ER admissions and it struck me that some people were happy and well served and others had less satisfactory experiences. There are so many variables. And I am talking about many years ago. There is even more variation now, I think.

        I live in a metropolitan area and one hospital near me (where I was born and worked as a candy striper) was shut down a few years ago. Those people now have to go elsewhere, putting more burden on other area hospitals. The quality in the place we have gone for 20 years has really fallen off due to financial problems. Of course, they had to pick up the slack from the closed hospital. It is a mess.

      • yes, our friend said that they are building hospitals and incentivizing medical groups in the regions that don’t have ready access. Canada’s big – he said that even those he knows in outlying areas get serviced within a normal waiting time for procedures – but they have to travel to hospitals outside of their regions – heck we do to if we want specific docs.

      • Yes. That is exactly it. In Canada there is some inequality by region, and it is something we’re working to fix.

  11. For those of us who have high deductibles, that bundling could get expensive. For those who don’t, that process cost someone, be it doctor or repeat expense to the insurance company. Either way, it doesn’t sound efficient to me.

  12. Anonymous White House Aides Attack Advocates Of Public Health Care Option


    • Oh how courageous he’s going on an Obama-can’s radio show, but he won’t talk to the “little single payer people.” Real bold president we got there.

  13. New post up.

  14. That’s the thing about a system such as Canada’s…however “bad ” it is, you don’t lose your house while fighting to stay alive. If I had to choose between the bad we got and bankruptcy and the supposed bad they got with solvency….hmmmm seems the personal solvency pic would be best.

    • Agreed!

    • Agreed 2!

    • And babies are insured. All babies.

      You don’t just have a baby and then can’t afford the insurance.
      Tell that to the fetus fetishists who believe that government should have a moral role and do nothing.

      The point about Canada is that it’s enormous in size and some areas are very out of the way places, with sparse population.

      • What I mean is it’s difficult to find doctors who’ll stay.

        • I think we’ve mostly curbed the brain drain now. But I think a federal debt forgiveness program wherein your debt was forgiven faster if you’d work in remote areas (like isolation pay) would be ideal. It’d get doctors where they’re needed, cut down on the massive student debt, and keep doctors in Canada, because they A) get debt forgiveness and B) can start earning money right away.

  15. Super excellent, thanks.

    It seems like the patient or patients could get together to help. After all, they hire the insurance companies and hire the doctors, and there is nothing wrong with lots of patients getting together. So perhaps some patient rights organization could work with patients of many doctors, and through them get bills and other paperwork (after all, it’s their heart that was operated on, shouldn’t they get any relevant paperwork), and pool that knowledge and publish something that, oh, say, those various doctors could get copies of. After all, you can’t have a anti monopoly problems about the customers.

  16. Thank you for this post. Very helpful for those of us who are trying to understand what all the “fuss” is about. I have lived half my life in the UK and half in NZ, both of which have nationalised health care. I have used both the NHS and private health care in the UK and in MY experience the standard of both is excellent. In NZ health care is subsidised – yes we pay, but not much, and what we pay is adjusted for our age (cheaper the older you are) and the area you live in (medical practices in lower socio-economic areas charge less). I have been reading up on the various options – very complicated (to me). I would definitely be for single payer.

  17. Excellent post.

    What saddens me is that doctors study so hard to get into their profession, and run up such large student debt. And then they run into this kind of paperwork.

  18. Thank you again. I look forward to your next post.

  19. I think we should have heavily subsidized health care education—for doctors, nurses, physician assistants, lab techs—it should be on some kind of a sliding scale so that the more remote or distressed the area in which you practice, the less “co-pay” for your medical education bills.

    If we are going to have health care for all, we have to do something about medical education. We have a huge shortage of such people now and if it were not for the infusion of talent from all over the world, we would be in dire straits.

    Thanks WCMB. Your posts are really excellent in their detail and in presenting us with some reality. I appreciate that you stick to “information” that can help us see more clearly what the problems are and do not try to sell us a solution.

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