Canadians are one in a million -- while waiting for medical treatment

[bcking 3,157]

2 minutes ago, Steeleballz said:

 

   Preventative is covered %100 for ours. The deductible applies for regular office visits (and even if you bring up too many issues at a preventative visit).  It's been a long time since I've seen an insurance that covers regular primary care visits at %100. We have a choice of Cigna, Kaiser and some other fly by night plan. They depend on what your employer wants to pay for though. A guy at work who came from New York said they still had a no deductible plan when he was there. They were unionized there  though, so they still had decent benefits. 

 

   For our over bill too, they never got back to us. Just that I knew it was wrong so I was watching the statements from the insurance company. We did have another one a few years ago where someone sent a check back because they billed us too much. I checked the insurer statement and they doctors office had issued the refund back a couple of days after they got reimbursed. Probably depends a lot on how on the ball the office staff are.

 

 

Ah gotcha, that's probably true. As I said I only have personal experience to go off for primary care, since all my patients are critically ill and hospitalized, so it works differently.

 

I'm definitely going to double check with my insurance company next time I pay a large deductible up front. I just assumed it went towards my deductible, because it made sense to me. It was an elective treatment for a specialist. For some reason my insurance provider decided it was covered under the "specialty care", and therefore I only needed to pay my "specialty co-pay", which is just 10 dollars more than my regular one. 40 bucks was definitely better than 800.

[Steeleballz 7,550]

11 minutes ago, bcking said:

Systems like Kaiser will always be easier since it is all one system. If you are part of Kaiser, you are in your own little "universal healthcare system" where provider and insurance are the same entity. 

 

Generally speaking medical care in the US is incredibly fragmented, which most of the time makes it far more complicated. Most doctors (myself included) can't really tell a patient anything about how much what they are doing will cost. In my case it's especially hard since we are talking about an entire hospital stay that is unplanned. These days some insurance providers are reimbursing based on a DRG, but your specific DRG adjustments may not be set until the hospital stay is over (depending on what complications develop during the hospitalization). Others will charge on a "daily" "fee-for-service" type system. Even in that situation most of what we do is bundled. They aren't going to see a bill for every single CBC we sent during the hospital stay, for example. 

 

In my view, for inpatient medical care, DRG-based payments are a significant improvement in the system assuming insurance providers create fair reimbursements. They reimburse for care based on "Diagnosis-related groups", based on what the primary reason for the care is (In my case something like premature infant born at 28 weeks, or something similar). The DRG can be adjusted based on complications (premature infant born at 28 weeks, complicated by NEC) and then the set reimbursement changes. It is then up to the hospital to provide care that is cost-effective based on what they are reimbursed. That puts more of the responsibility on us, which means we have an incentive to talk about issues like waste, over-treatment, over-diagnosis etc... Instead of just throwing the kitchen sink at everything knowing that we will generally get reimbursed for it.

 

  Yeah definitely that's true. I was just bringing that up to show that it's not absolutely required that a doctor has bill through insurance just because you have it.  I think with my current doctor, it's more likely an office policy or maybe the way they contract with my current insurance company.

[Voice of Reason 10,298]

This all reminds me of a convo had on this forum probably two years ago when talking about “free” health care in Canada.  I brought up the point that Canadians pay more in taxes to cover the cost of health care, and that it isn’t really free.  I was mocked, and told by some members “in the know” that their Canadian spouses didn’t get taxed any higher than Americans do (but NONE were willing to share a pay stub with us, not surprising at all).

Fast forward to this discussion, the realization that the health care in Canadia isn’t all the superior to ours, and add in my recent “gleaning” of Canadian taxes... my wife’s cousin showed us her pay stub, and the was taking home about 56~57% of her gross income.  That’s 43-44% of wages going to taxes & pre-paying for that “free” health care that they then have to wait a year or so for.

[Steeleballz 7,550]

2 minutes ago, bcking said:

Ah gotcha, that's probably true. As I said I only have personal experience to go off for primary care, since all my patients are critically ill and hospitalized, so it works differently.

 

I'm definitely going to double check with my insurance company next time I pay a large deductible up front. I just assumed it went towards my deductible, because it made sense to me. It was an elective treatment for a specialist. For some reason my insurance provider decided it was covered under the "specialty care", and therefore I only needed to pay my "specialty co-pay", which is just 10 dollars more than my regular one. 40 bucks was definitely better than 800.

 

  I've noticed with ours that some have direct access to the insurer (Cigna) and know exactly what we have remaining and others are just guessing what our deductible should be. I have just got in the habit now of calling Cigna before a procedure, then calling the physicians office, and if it doesn't agree, I have them talk to each other until we are all on the same page.

[bcking 3,157]

1 minute ago, IDWAF said:

This all reminds me of a convo had on this forum probably two years ago when talking about “free” health care in Canada.  I brought up the point that Canadians pay more in taxes to cover the cost of health care, and that it isn’t really free.  I was mocked, and told by some members “in the know” that their Canadian spouses didn’t get taxed any higher than Americans do (but NONE were willing to share a pay stub with us, not surprising at all).

Fast forward to this discussion, the realization that the health care in Canadia isn’t all the superior to ours, and add in my recent “gleaning” of Canadian taxes... my wife’s cousin showed us her pay stub, and the was taking home about 56~57% of her gross income.  That’s 43-44% of wages going to taxes & pre-paying for that “free” health care that they then have to wait a year or so for.

No healthcare system is free. The money has to come from somewhere. That should be fairly common sense. Not sure who was part of that conversation two years ago (certainly not me). That being said, countries like Canada do spend far less than we do per person for healthcare. Again that money ultimately comes from "the people" in both systems, but they are still requiring a lot less. Here is a reasonable summary - https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-start

 

Talking about what healthcare system is "superior" depends on how you measure "superior". Here is a good review of healthcare system comparisons - http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective

 

This particular thread is talking about wait times. Wait times in a universal healthcare system will ALWAYS look worse compared to the USA, because they don't ration based on cost of care like we do. They choose to explicitly ration via systems like waitlists. In the USA, lines may be shorter because we have less people in lines. 28 million people don't have health insurance. They won't be on any "list" to get a knee replacement because they likely can't afford one. Another significant number of people have health insurance that is adequate, and they STILL won't be able to afford "needed treatments" because they can't afford even their share of the responsibility. 

 

Of course if you compare outcomes/accessibility for people who have health insurance in the USA to everyone in Canada you may find a friendlier comparison for the USA. However, that isn't a fair comparison since it ignores all those who we don't cover in the USA. They still have healthcare needs, so you can't ignore them.

[bcking 3,157]

6 minutes ago, Steeleballz said:

 

  I've noticed with ours that some have direct access to the insurer (Cigna) and know exactly what we have remaining and others are just guessing what our deductible should be. I have just got in the habit now of calling Cigna before a procedure, then calling the physicians office, and if it doesn't agree, I have them talk to each other until we are all on the same page.

That may depend on the relationship the clinic has with the insurance provider. When an infant's parents have insurance that is directly connected to our hospital, my care managers can usually provide far more information far more quickly. They don't have to call the insurance company and ask questions. They have direct access. (Questions are usually about issues relating to length of stay, and justifying the need for continued hospitalization - It happens far too often than it should unfortunately)

Edited June 14, 2018 by bcking

[Steeleballz 7,550]

11 minutes ago, IDWAF said:

This all reminds me of a convo had on this forum probably two years ago when talking about “free” health care in Canada.  I brought up the point that Canadians pay more in taxes to cover the cost of health care, and that it isn’t really free.  I was mocked, and told by some members “in the know” that their Canadian spouses didn’t get taxed any higher than Americans do (but NONE were willing to share a pay stub with us, not surprising at all).

Fast forward to this discussion, the realization that the health care in Canadia isn’t all the superior to ours, and add in my recent “gleaning” of Canadian taxes... my wife’s cousin showed us her pay stub, and the was taking home about 56~57% of her gross income.  That’s 43-44% of wages going to taxes & pre-paying for that “free” health care that they then have to wait a year or so for.

 

  I said at the time, and I think I gave you the numbers, I got payed more in Canada last time I worked there, thus I payed more income tax, but the marginal rates were not different.

 

  How provinces fund health care is largely up to them. When I was in Alberta as a teenager, it was funded with revenue from oil and gas sales. Some provinces have higher premiums, some use more income tax and some use other taxes. It balances out with other things. Canada doesn't spend more on military than the next 10 highest countries combined. The USA does.  Other expenditures also comes from tax revenue. 

 

   Canada's higher tax brackets were a lot steeper than the USA when I was last there. I haven't checked recently though.

Edited June 14, 2018 by Steeleballz

[bcking 3,157]

I actually meant to provide this link from the Commonwealth Fund - http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017

 

Though the other one reports a lot of the same data.

[Steeleballz 7,550]

17 minutes ago, bcking said:

I actually meant to provide this link from the Commonwealth Fund - http://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017

 

Though the other one reports a lot of the same data.

 

   The biggest obstacle to change in the US health system is that it is such a money driven system. There are a lot of lobbies that don't want that to change, and I think we saw that with the ACA and how poor it turned out compared to what was first envisioned. Nobody wanted to lose their piece of the pie. A common example we see is for a company bringing a new drug to the market, there is a lot more money in treating sick people than in preventing disease.  All the money goes in that direction because that's how all the money comes back.

 

  Europe and Canada are much farther ahead in preventative care, IMO, and it's one of the reasons they get more bang for the buck out of their systems. Not the only reason, but a big one. I will probably end up off topic if I start getting into some of the others.

[Steeleballz 7,550]

4 minutes ago, Dee elle said:

Agree totally..

 

My take on meaningful reform is that it would end up with 7 out of 10 people currently employed in the health INDUSTRY losing their jobs.... mmmm  really not a good outcome for those workers and their families.. but that is what would happen if the multiple layers, players and stakeholders in the industry as a whole was realigned to provide good care at affordable costs, shared across the comunity, and available to all... 

Dont see too many politicians willing to face the next election on this outcome...but  anything less than this level of overhaul is simply tinkering at the egdes.. using a broken system to try and make a "healthy" one... just doesnt happen... 

 

   Depends on how you define health industry I guess. I can see whole sectors that reform would (or should) wipe out, such as the insurance industry, billing and a lot of that nature. Hospitals are also top heavy in management and that may change if and when the cash cow dies. 

 

   I'm not sure doctors and nurses and front line health care workers would have to worry. There are already shortages in those areas, and even in single payer systems like Canada, they can't keep up with the demand for doctors. I think a healthier population may at some point require less front line health care support, but I think that would be a long term goal at best. 

 

    

[TBoneTX 43,058]

We need more threads like this.

 

Question:  How much time is spent in

 -- medical school

 -- dental school

on the "business" side of these professions, such as establishing a private practice, dealing with insurance companies, and similar?  Is this training adequate, or must much or all of it be learned via mentoring or "the hard way"?

[TBoneTX 43,058]

Another question:

 

How much do ICD-9 codes affect patients' bills and insurance reimbursements?

 

(ICD-9 = International Classification of Diseases, 9th Revision -- a collection of diagnosis & procedural codes used to classify diseases and various signs, symptoms, abnormal findings, causes of injury/disease, and even social circumstances, to my understanding)

 

One example is what happened to a pal a few years ago.  His ears were plugged with wax, and he went to an Ear/Nose/Throat specialist at his clinic (covered by employment health plan).  Whereas previously this ENT doc had used a "vacuum" device to quickly remove the earwax, this time (post-Obamacare, if it's relevant) he laboriously used instruments for the procedure.  My pal's billing statement or explanation of benefits (whatever it was) said, "Surgery with instruments to remove earwax."  He had to pay not only his $80 specialist copay, but also nearly $400 for this "surgery."  Man, but he was hot.

 

He got even hotter when I told him that when I go across to Mexico, one doc charges $20 per ear and another charges $50 total for the selfsame procedure, cash money.

[bcking 3,157]

6 hours ago, TBoneTX said:

We need more threads like this.

 

Question:  How much time is spent in

 -- medical school

 -- dental school

on the "business" side of these professions, such as establishing a private practice, dealing with insurance companies, and similar?  Is this training adequate, or must much or all of it be learned via mentoring or "the hard way"?

I got Zero. Zip. Nada.

 

When I joined the group I'm at now they had just started rolling out training for the faculty to bill for themselves. Before that, they would bill a "proc 99" (generic code) and the hospital employer coders who would look at EVERY patient day and change it to the appropriate one. Now we actually do it ourselves (and it's not hard - there are like 9 options based on level of illness, weight of patient or amount of time spent).

 

6 hours ago, TBoneTX said:

Another question:

 

How much do ICD-9 codes affect patients' bills and insurance reimbursements?

 

(ICD-9 = International Classification of Diseases, 9th Revision -- a collection of diagnosis & procedural codes used to classify diseases and various signs, symptoms, abnormal findings, causes of injury/disease, and even social circumstances, to my understanding)

 

One example is what happened to a pal a few years ago.  His ears were plugged with wax, and he went to an Ear/Nose/Throat specialist at his clinic (covered by employment health plan).  Whereas previously this ENT doc had used a "vacuum" device to quickly remove the earwax, this time (post-Obamacare, if it's relevant) he laboriously used instruments for the procedure.  My pal's billing statement or explanation of benefits (whatever it was) said, "Surgery with instruments to remove earwax."  He had to pay not only his $80 specialist copay, but also nearly $400 for this "surgery."  Man, but he was hot.

 

He got even hotter when I told him that when I go across to Mexico, one doc charges $20 per ear and another charges $50 total for the selfsame procedure, cash money.

It can, just like the example you showed.

 

It does partly depend on how the insurance company is reimbursing. DRG based payments are becoming popular (I've heard more so in adults, but it's coming to us in peds). In that system a hospital (or clinic) gets paid a set amount for a set primary diagnosis. The amount can vary based on additional factors (diabetes can be the primary diagnosis, diabetes complicated by diabetic neuropathy could be a subdiagnosis). I don't believe things like type of procedure used in that case would make the doc more money. They would have been billed for the problem, not for what they did.

 

In the fee-for-service world, which is still probably the most common system, then it makes a huge difference. iCD-10 offers a lot more specific details for a lot of things (and sadly no detail in many cases where it matters). We are asked to change the ICD-ap diagnoses (add more, if they are applicable) all the time by our coders. I assume for to best "capture" all facets of care for reimbursement.

 

Physicians can bill procedure time, even in a DRG based system, however.

[yuna628 9,528]

7 hours ago, TBoneTX said:

Another question:

 

How much do ICD-9 codes affect patients' bills and insurance reimbursements?

 

(ICD-9 = International Classification of Diseases, 9th Revision -- a collection of diagnosis & procedural codes used to classify diseases and various signs, symptoms, abnormal findings, causes of injury/disease, and even social circumstances, to my understanding)

 

One example is what happened to a pal a few years ago.  His ears were plugged with wax, and he went to an Ear/Nose/Throat specialist at his clinic (covered by employment health plan).  Whereas previously this ENT doc had used a "vacuum" device to quickly remove the earwax, this time (post-Obamacare, if it's relevant) he laboriously used instruments for the procedure.  My pal's billing statement or explanation of benefits (whatever it was) said, "Surgery with instruments to remove earwax."  He had to pay not only his $80 specialist copay, but also nearly $400 for this "surgery."  Man, but he was hot.

 

He got even hotter when I told him that when I go across to Mexico, one doc charges $20 per ear and another charges $50 total for the selfsame procedure, cash money.

Many doctors have no clue about codes. Honestly, in my sister's experience, everything is relied upon the training and experience of the medical billers and other staff. There are sometimes employees that make critical mistakes with codes, which results in denials... and there are also some doctors who put in the codes themselves... who have little experience either. My mom's PA, has little clue. There's a test he's wanted her to have for months, and it is not covered by medicare unless a specific code is put in. My sister's practice is well experienced in what codes need to be put into the system for desperate patients (and frustrated doctors) to get around insurance stonewalling. Every time my mom is denied, my sister gets more and more frustrated with the PA.

 

She was talking about recently new guidelines regarding colonoscopies in advising people to get screened much earlier than first thought. She's had some people call up wanting to do that.. but the fact is, insurances are going by the old guideline which narrows the screening window to an older age.. so all these people calling up? They aren't going to have it covered. Even in younger patients it can be difficult, because they have to fight with insurance companies to prove the patient might be at-risk.

[Neonred 3,446]

7 hours ago, TBoneTX said:

We need more threads like this.

 

Question:  How much time is spent in

 -- medical school

 -- dental school

on the "business" side of these professions, such as establishing a private practice, dealing with insurance companies, and similar?  Is this training adequate, or must much or all of it be learned via mentoring or "the hard way"?

We did get a little.....very little.

 

One of the problems with dentistry is that every year there are new procedures and new materials to learn.  Even years ago it was felt that 4 years of dental school (after 4 years of undergrad) was not enough to learn all of the clinical skills needed.  As more is added to learn, something gets cut.

 

 

44 minutes ago, bcking said:

I got Zero. Zip. Nada.

 

When I joined the group I'm at now they had just started rolling out training for the faculty to bill for themselves. Before that, they would bill a "proc 99" (generic code) and the hospital employer coders who would look at EVERY patient day and change it to the appropriate one. Now we actually do it ourselves (and it's not hard - there are like 9 options based on level of illness, weight of patient or amount of time spent).

 

 

Dentistry has a very long list of procedure codes.  I have a large book to refer to.  Used to be the ADA updated the codes every 5 years.  Now they are updating yearly.  Lists of deleted codes as well as new codes.  New materials and new procedures require new codes.

 

Every once in a while I get a request for a medical code......I have NO IDEA about them and don't want to even try to understand