mowkey
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Post by mowkey on Jun 9, 2017 7:24:37 GMT -6
@juliagulia Definitely interested when you have time!
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Post by dreadpirateroberts on Jun 9, 2017 7:25:31 GMT -6
Yeah I don't really understand why different people/insurance are charged different amounts. I mean when I go to target it doesn't cost different depending on which credit card I use. I know insurance companies negotiate for the cost but I think that's so stupid. It should be one price whether your insurance or Medicare/Medicaid is paying or you are paying OOP. Just to be clear pricing/charges is the same across the board (for each provider), but payment is what differs between payors. I have a tl;dr in my head on quick and dirty provider financing if people are interested. I just need to get to work and put my feet up first. 😉 I would be interested in that.
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kitchen
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Post by kitchen on Jun 9, 2017 7:27:55 GMT -6
"Medicare for all" doesn't work if Medicare reimbursement rates remain where they are today (Medicaid rates would obviously be a non-starter, but those would go away). Private insurance is subsidizing Medicaid and Medicare. That's why the Medicaid reimbursement for delivery is $Z and your insurance gets billed 3x$Z. Similarly, when someone arrives at the hospital in labor and has no insurance, your insurance is subsidizing that. That's what fucking infuriates me about the notion that "we can't afford to provide coverage for the uninsured". We're already providing shitty healthcare for them (catastrophic/emergency only) in an incredibly inefficient way that bakes in some profit for health insurers.
ETA: The extension is that if private insurance companies tried to offer Medicare rates they'd be laughed out of the building. Medicaid would be even funnier.
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Post by crimsonandclover on Jun 9, 2017 7:48:35 GMT -6
Similarly, when someone arrives at the hospital in labor and has no insurance, your insurance is subsidizing that. That's what fucking infuriates me about the notion that "we can't afford to provide coverage for the uninsured". We're already providing shitty healthcare for them (catastrophic/emergency only) in an incredibly inefficient way that bakes in some profit for health insurers. Thiiiiiiis! Thank you! The US spends so much more per capita on healthcare than any other developed country (look at OECD data). A major part of the reason is that hospitals have to charge more to the insured to recoup costs for emergency care for the uninsured. Do you have health insurance? Then you ALREADY ARE paying for the uninsured! Wouldn't it make more sense to pay for them to have insurance in the first place so they don't have to make use of emergency services as often? That will cut costs right there. I have lived in a single payer system for almost 15 years and have only had good experiences. For my 8-day hospital stay, c/s, and 2-week NICU stay for my DD1 we paid... wait for it... 10€ (about $12) as a standard co-pay (which has since been done away with, too). My premiums are a bit higher than those in the US (8% of my gross income, plus my employer contributes 8%), but I have no deductible and only minimal co-pays on some medications (up to a max of 10€). There are no co-pays for anything prescribed for children (18 and under). And I personally like knowing that with that small amount more than I would pay in the US, I know that every single child and adult in the country has access to the same level of care as I do (with standard urban/rural differences like you'll find anywhere).
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Post by Deleted on Jun 9, 2017 10:55:06 GMT -6
Ok so kitchen covered the main talking points of what I was going to say. I will preface that I have worked in hospital reimbursement for 17 years and now dabble a bit in physician reimbursement as well. I've worked for hospitals in about 20 different states. That's my background, but I'm obviously just one person with many opinions. 😉 So, hospitals get paid a variety of ways: Managed Care Insurance - they negotiate rates based on volumes. The bigger the insurance company, the better rates they get (because they provide more "business"). Rates are negotiated every couple years and range wildly. The negotiations are also fierce. Insurance companies don't play. They are secret amongst providers. The contracts are more than just rates but also what services are covered, how much hospital can raise their prices each year, and a lot of other provisions that govern how the provider and the insurance company do business together. Typically we get 35-55% of charges from insurance (so 50 cents on the dollar). However, in less competitive markets (like rural areas) they might get closer to 70%. That's across all payors. Medicare/Medicaid/tricare/workers' comp - no negotiations, fee schedule based reimbursement. Some differentiation in payments due to cost of living (to account for wages, etc) and for teaching hospitals/specialty providers. The rules are set, there is a lot of hoops to jump through, but payment is fast and accurate and the rules are clear. Government fee schedules tend to pay 30-35% of charges, Medicaid is 10-15% of charges. Self pay/charity/bad debt - uncompensated care is just that 0% of charges. This is either in the form of whole services being uncompensated or partially (like insurance pays and we can't collect the patient portion). Costs of providing care (all in) is typically 20-50% of charges. It varies a lot. A for profit system in a medium cost of living area will be in the 20-30% range, a rural hospital will be more like 40-50%. So, quick and dirty hospital financial strategy is to try to balance your payors mix so that you have enough of group 1 to keep your doors open for all three groups. Also, it's really important to keep that percentage of group 1 at a high enough level to subsidize your other populations. It's important to note that since the late 90s, Medicare has gone from a "cover your cost plus make a little money" to a almost not covering your costs. Payments used to go up a little each year to account for inflation, etc, but now they don't. When the government shut down happened, they took a 2% sequestration cut off payments that has never been given back. And then Medicaid does not cover costs, which is ok. But Medicare and Medicaid populations are increasing. So you have more of your patients on programs that barely or don't cover your costs and now the squeeze is on. What does this have to do with charges? Well, most managed care contracts pay based on formulas related to charges (unlike group 2). So, real simple example - payor A pays me 50% of charges. Now I need to get more money out of managed care to balance my payor mix/overall payment rates. One option (and really the easiest) is to increase my charges so that the 50% I get from payor A increases. The same charges will be billed to all 3 groups, but I only see a benefit from group 1. Sure there are other ways to fix my financial problem, but typically providers have to employ several of these strategies to keep things running. Cut costs, raise prices, negotiate new rates. So, I'm not saying charges are right. What I'm trying to say is that they are what they are because we are trying to live within the system as it stands and react to changes as they come (which is a problem - reactive solutions are hardly ever the best ones). For the $200 aspirin, we don't usually get paid for that. From anyone. But perception is reality and it doesn't look good that it's there. I see that. I have more thoughts on reducing costs in health care which are even more tl;dr. But one huge way, that relates to single payor is to reduce the cost to collect. Having the three groups makes more an extremely administrative heavy burden to just get paid for services that already happened. That eats up so much cost in the system and single payor fixes that. Ok, questions? 😉
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Post by Deleted on Jun 9, 2017 12:40:31 GMT -6
I didn't intend my long explanation to shut down the thread. Please continue discussion of the health care bill.
One thing related to heath care payments is that there are proposed changes to the Medicare payment system that will redistribute money from states that expanded Medicaid to states that didn't. (So blue to red states mostly). I need to read up more on it but my boss was filling me in on that today.
Also, the view on the CA single payor bill is that it is largely symbolic at this point. The real work needs to be done to actually write the details but they rushed this first part to show that CA is a leader and this is our long term goal.
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mowkey
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Post by mowkey on Jun 9, 2017 13:00:58 GMT -6
@juliagulia is there a difference between nonprofit, for profit and state hospitals in terms of operating costs? Is there a benefit to single payer to be in a state system only versus other types of institutions?
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amylou
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Post by amylou on Jun 9, 2017 13:10:01 GMT -6
@juliagulia,Thank you for taking the time to get break all of that down. I understand those paying for the services are carrying costs for those that cannot. It just seems like there has to be a better way that doesn't involve running three almost entirely separate systems. I also understand that healthcare is an extremely complicated issue (Who would have thought? ![O_o](//storage.proboards.com/forum/images/smiley/browraise.png) ) but everything you posted just seems to reinforce single payer as the best option.
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Post by Deleted on Jun 9, 2017 13:46:05 GMT -6
@juliagulia is there a difference between nonprofit, for profit and state hospitals in terms of operating costs? Is there a benefit to single payer to be in a state system only versus other types of institutions? That goes a little beyond my area of knowledge because I'm not in finance and the non profit versus for profit distinction is mostly for finance related matters (tax deductions and what not). As you may know, there has been a lot of changes that non profit hospitals are subject to now because previously there was discord about how much charity care non profits were really doing. So new charity reporting standards are in place and there is a focus on providers accurately capturing their charity care (whereas before a lot got written off and not appropriately categorized). My general understanding is that all hospitals get some "credit" for their bad debt write offs from Medicare. It's minuscule pennies on the dollar but it's something. Then non-profit hospitals prove their "status" by having enough charity care. Charity care is money you write off because the patient's financial situation meets the providers charity requirements (which is unique for each system). There are also laws about how to publicize your charity and financial assistance policies (needs to be highly visible and communicated and in multiple languages). In general a non-profit should have lower operating costs because of taxes and sometimes they get cheap land from the government to build or rent. But in reality they are facing the same pressures. And then they don't have "quick" ways to raise capital like a publically traded for profits. For the purposes of single payor, I don't believe that the financial type of the institution matters. All those types currently participate with Medicare and I would see single payor being built off of Medicare (or that's my hope anyway). Long term there will be some reconsideration of what it means to be a non profit hospital since the current standard is based on charity care, which would presumably go way down. And maybe that will all have to change.
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Post by Deleted on Jun 9, 2017 13:52:19 GMT -6
@juliagulia,Thank you for taking the time to get break all of that down. I understand those paying for the services are carrying costs for those that cannot. It just seems like there has to be a better way that doesn't involve running three almost entirely separate systems. I also understand that healthcare is an extremely complicated issue (Who would have thought? ![O_o](//storage.proboards.com/forum/images/smiley/browraise.png) ) but everything you posted just seems to reinforce single payer as the best option. After working in this industry for so long, I am a proponent of single payor. I would have to change my job, but I still think it's the best option. And, yes, it's complicated. Like apply what happens in healthcare to any other industry and it's laughable. Say you run a clothing store: customer comes in, picks out $500 of clothes, maybe pays $25, gives you a card for who to bill and leaves with their clothes. Then you bill another company and wait. The other company asks you some questions, maybe denies that they should pay for the clothes, "processes their payment". This takes 3 months. Then they send you a check for $200 and tell you to go get $75 from the customer. You send a bill to the customer (3 months after they came to your store) and they never call you or pay their bill. Oh and you, the owner, paid for the clothes before the customer came in. I mean, how do you run a business like that???
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amylou
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Post by amylou on Jun 9, 2017 14:00:10 GMT -6
@juliagulia ,Thank you for taking the time to get break all of that down. I understand those paying for the services are carrying costs for those that cannot. It just seems like there has to be a better way that doesn't involve running three almost entirely separate systems. I also understand that healthcare is an extremely complicated issue (Who would have thought? ![O_o](//storage.proboards.com/forum/images/smiley/browraise.png) ) but everything you posted just seems to reinforce single payer as the best option. After working in this industry for so long, I am a proponent of single payor. I would have to change my job, but I still think it's the best option. And, yes, it's complicated. Like apply what happens in healthcare to any other industry and it's laughable. Say you run a clothing store: customer comes in, picks out $500 of clothes, maybe pays $25, gives you a card for who to bill and leaves with their clothes. Then you bill another company and wait. The other company asks you some questions, maybe denies that they should pay for the clothes, "processes their payment". This takes 3 months. Then they send you a check for $200 and tell you to go get $75 from the customer. You send a bill to the customer (3 months after they came to your store) and they never call you or pay their bill. Oh and you, the owner, paid for the clothes before the customer came in. I mean, how do you run a business like that??? Yes, simplified to that extreme it makes even less sense.
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Post by Deleted on Jun 9, 2017 14:06:50 GMT -6
Why am I in this industry?
😳😂🤔
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Post by marshian on Jun 9, 2017 14:24:38 GMT -6
I would speculate that part of the reason healthcare costs have spiked is because the inclusion of preexisting conditions and 100% covered preventative care. Insurance companies have to recoup those costs somewhere. Also go ask your local hospital/Dr office how much they had to spend on electronic medical records and implementation. It is shocking how many millions hospitals have to spend on it. Most hospitals are non profit but they still should be breaking even or making a profit to reinvest in new equipment. EMR added to the payroll and budget but aren't necessarily brining in any more money. Also why can we not drop the 26 year old provision that adds a huge cost? Fix the college education system (which would benefit more than healthcare) and focus on a strong economy where people have jobs that pay more than minimum wage. Spending money on social and economic problems have more benefits than simply spending money on healthcare. Insurance companies recouping costs is not apples to oranges with rising health care costs in general. Insurance companies don't set the costs of goods and services. Though they do influence what the providers will charge for them. Like amylou was saying, just the basic cost of health care (the cost set by the provider) is insanely high. To fix that, we need to figure out why. I see multiple reasons (I'm sure there are more, people please chime in): 1. Actual increase in the cost of the physical goods the provider pays to the manufacturer 2. Providers being unable to determine how much it actually costs them to provide a service (e.g. 1 MRI = ??? They pay $XXX for an MRI machine, and estimate they'll do N number of MRIs per year, and the machine has a general life span, but none of that is set and they need to recoup the cost of the machine.) 3. Inflating the cost of the service/good because the insurance company won't pay the full amount so that way they actually get back a decent payment 4. Cost of dealing with ACA provisions These things can all be addressed. Would it be easy? Of course not. Is it the solution to all our health care woes? Nope. But I see it as one part of the bigger problem. We need to address the cost of health care, the power of the insurance companies (and the crappy things they do with it, like pull out of the exchange), and what legislation can do to help.
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Post by morecoffeeplease on Jun 9, 2017 15:28:21 GMT -6
The break room tv was on Fox today, and the chryon said, "Most Americans do not support new health care bill". I was...surprised.
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LED
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Post by LED on Jun 9, 2017 16:03:04 GMT -6
Will this is comforting. 😥
“The outline leadership has presented isn’t Obamacare repeal, in fact it isn’t even reform. It’s a tax cut and a corporate bailout masquerading as health legislation,” said a conservative Senate aide.
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Post by rbgrocks on Jun 9, 2017 19:18:40 GMT -6
Women are really leading the resistance cases and point McCaskill right here. We have to stop this bill.
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Post by dreadpirateroberts on Jun 9, 2017 19:59:58 GMT -6
Women are really leading the resistance cases and point McCaskill right here. We have to stop this bill. At least one of my senators isn't a worthless pile of dog crap. 🙄
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LED
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Post by LED on Jun 9, 2017 20:56:07 GMT -6
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dc2london
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Post by dc2london on Jun 10, 2017 7:29:48 GMT -6
Honestly, I could afford to pay into single payer if I no longer had to pay over $5000 a year in premiums. That's all you pay in premiums? I haz the jealous.
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dc2london
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Post by dc2london on Jun 10, 2017 7:39:20 GMT -6
Not to get too personal, but we pay $1200/month in premiums and have $6500 per person deductible with a $12,000 family deductible. Our copays are $25/50 and our coinsurance is 80/20 on most things. The healthcare companies can get fucked, as far as I'm concerned. And no, I don't blame the ACA for that, bc we've been paying that for years and only just became ACA compliant in December. So even when we had those ludicrous premiums and deductibles, they covered NONE of my son's autism care, nothing for mental health, and they were even billing us for well visits.
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dc2london
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Post by dc2london on Jun 10, 2017 7:41:01 GMT -6
Sorry, thi sis why I have been staying out of this thread. It makes me too ragey. Partly bc it affects my family directly, but mostly bc of how inhumane it is to low income Americans. We're blessed to be able to afford it. Many people aren't.
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Post by crimsonandclover on Jun 10, 2017 7:50:03 GMT -6
Holy cow, dc2london. That is a lot. I thought we paid more compared to Americans, but it's less than 50% of just your premiums. O.O Do you know if that's standard in your DH's line of work? Or are their factors that cause your premiums/deductibles to be higher than a similar family with 3 kids?
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dc2london
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Post by dc2london on Jun 10, 2017 8:17:59 GMT -6
Holy cow, dc2london. That is a lot. I thought we paid more compared to Americans, but it's less than 50% of just your premiums. O.O Do you know if that's standard in your DH's line of work? Or are their factors that cause your premiums/deductibles to be higher than a similar family with 3 kids? My H works for a small-ish company. Without bringing a ton of buyers to the table they aren't able to negotiate great plans.
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kitchen
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Post by kitchen on Jun 10, 2017 8:42:34 GMT -6
Holy cow, dc2london . That is a lot. I thought we paid more compared to Americans, but it's less than 50% of just your premiums. O.O Do you know if that's standard in your DH's line of work? Or are their factors that cause your premiums/deductibles to be higher than a similar family with 3 kids? What she's paying looks pretty standard to me. That's the best plan we'd be able to get on our state exchange.
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kitchen
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Post by kitchen on Jun 10, 2017 8:43:49 GMT -6
dc2london my initial reaction to your premiums was shock and horror, but then I remembered that that's about on par with the family plans offered at pretty much every place I've ever worked. I'm so grateful my husband has always had a job with A+ insurance. I know we would struggle with that kind of premium/deductible and we are far from poor. Sent from my iPhone using Tapatalk This is exactly the crux of the problem - it's so hard to be okay with ANY change when you look around and know you'd be screwed if your specific situation changed. It turns the whole thing into a situation where we all have to take one giant leap of faith.
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athn64
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Post by athn64 on Jun 10, 2017 8:45:49 GMT -6
Honestly, I could afford to pay into single payer if I no longer had to pay over $5000 a year in premiums. That's all you pay in premiums? I haz the jealous. We live in a much LCOL area than you. And DH has great insurance options. I'm sorry your payments are so high.
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kitchen
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Post by kitchen on Jun 10, 2017 8:45:50 GMT -6
Another thought: I worked in HR consulting when the ACA was passed. I know that the healthcare consultants absolutely billed it to their clients as an opportunity to make changes that would increase employee cost sharing and blame it on Obama. Some of the shit employers did was pre-emptive "well, obamacare!!!" either as a preventive measure under the assumption that costs would go up more, or just because they're assholes. #blameobama extends outside of government.
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Taitai
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Post by Taitai on Jun 10, 2017 8:56:52 GMT -6
+1 to what dc2london said. The healthcare system in America is inhumane and flawed on so many levels - I can't really even discuss it with many people without banging my head against a wall. I'm American (with a degree in Insurance and Risk Management) - and I will say this - so many Americans I have spoken with about the U.S. healthcare system are incredibly arrogant and ignorant on this topic. It's astounding. There is zero willingness to educate themselves on why virtually every other single developed country in the world has adopted a single payer system. The insistence that the U.S. can't learn from what other countries have figured out decades ago is really disheartening. When I try to have a calm and rational conversation with anti-ACA people about this, they tend to start lashing out at me personally and revert to off-topic rhetoric/talking points. This typically happens once they realize they are out of their depth on the subject or feel they are "losing" the argument. Older conservatives and Trump supporters in particular will spew their hatred for ACA and universal healthcare...but then in the same breath say they love their Medicare, and how dare you even suggest we do away with it. Head --> Desk. Medicare IS a single-payer microsystem. If Medicare covered ALL Americans at the macro level, the U.S. Government would have much more leverage in negotiating reimbursements with healthcare providers, which would significantly lower/control healthcare costs and increase administrative efficiencies throughout the entire U.S. health system. Plus - as @juliagulia has already explained - people with insurance are ALREADY subsidizing the costs of the uninsured/underinsured, via higher premiums and higher payments to healthcare providers to make up for the deficit from those who cannot pay or are bankrupted by their healthcare bills. You'd think these arguments would appeal to a supposedly fiscally-focused demographic, but no. Rush Limbaugh and Breitbart said Universal Healthcare will destroy America, so I'm going to stick with what they told me. On a moral/ethical level, the total and complete lack of empathy for people with who have to choose between groceries and healthcare/medication for themselves and their children really sickens me. I live in Asia, in a country that is not first world. The healthcare here is world class and affordable. I actually receive better care here than I do in America, at a fraction of the cost. The healthcare industry doesn't have to be the way it is in America - but unless a big chunk of the population actually realizes how the rest of the world works and realizes how truly broken/inefficient the U.S. system is, I unfortunately don't see this problem being resolved anytime soon. It really is a willful ignorance.
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Post by Deleted on Jun 10, 2017 9:15:50 GMT -6
The for profit insurance companies make me ragey. I feel that the fixes involving the ACA center around their participation. That's where the ACA didn't go far enough IMO. Like ok insurance company, you want to sell group health in a certain state, you need to sell on the exchange too. And everyone calls the subsidies that the government pays a help for consumers, but if you look at it another way, the government is paying the insurance companies. So who is winning here? Ugh. I can't think about it too much because I see red and it's outside my sphere of influence.
That's why I focus on cost control so much because that's what I can impact. I'm also working on a project right now to help patients to our health system understand their financial liability BEFORE they have services (this is for non medically urgent services). Most of these patients are insured but their insurance won't pay for them to come to our system. The insurance company does not do a good job explaining that at all and patients get treatment and end up with huge bills. For us, we look at that and say, well, we treated the patients physical health, but now we've doomed their financial health (which in turns affects their health), so are we really treating the patient well on a holistic level? So we are implementing ways to educate and communicate with our patients before they schedule so they can make decisions based on all the information. It's interesting work but it's really hard. And it's hard to see people with insurance owing so much money after their treatments.
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Post by Deleted on Jun 10, 2017 9:19:04 GMT -6
I see you've spoken with my H's grandma re: Medicare Taitai! She is totally against the ACA (Obamacare to her) or single payor, but loves her Medicare. She called an ambulance that she totally didn't need a couple years back and Medicare denied it. She was screaming "I deserve this. How can they do this to me? I worked for this." And I'm thinking, yeah, and so did everyone else in our country. 🙄
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