Obama administration quietly approves new Obamacare loophole benefiting insurance companies.

[woo me with science]

http://www.commondreams.org/headline/2014/05/16-4

New Obamacare Loophole Shows Failure of For-Profit Health System: Critics
'This new rule to limit payments for needed medical procedures is a reminder of everything that is wrong with our profit-driven healthcare system.'

- Sarah Lazare, staff writer

The Obama administration earlier this month quietly handed the insurance industry another loophole in the Affordable Care Act—infuriating advocates for universal coverage who say this shows that an insurance-driven health system is doomed to fail.

Announced on May 2, the provision opens the door to "reference pricing," which allows insurance companies to set a price for medical procedures. If a patient receives a treatment that costs more, he/she will simply have to pay out of pocket. The measure is slated to apply to a majority of work-based health insurance plans and exchanges under the Affordable Care Act (also known as "Obamacare&quot , according to the Associated Press.

Many worry that reference pricing will force patients to bear the burden of a costly and difficult-to-navigate medical system.

"We don't need reference pricing—we need "right pricing" under a single-payer program," Don McCanne, M.D., senior health policy fellow at Physicians for a National Health Program told Common Dreams. "This is merely another way in which insurance companies are going to chisel down payment for care, shifting a greater share of the cost onto patients."

"This new rule to limit payments for needed medical procedures is a reminder of everything that is wrong with our profit-driven healthcare system," Jean Ross, RN, co-president of National Nurses United, told Common Dreams. "Rather than crack down on price gouging by hospitals—some of who set their charges as high as 12 times their costs — the administration is enacting a rule to ration care for patients."

Corporate-owned government in action...again. We need single payer. And we need corporate money out of politics.

[NJCher]

1. sad

but about what I'd expect.


Cher

[woo me with science]

2. It's often extremely depressing, with corporate-purchased government,

to find out what, "We'll fix it later" really means...



We must end corporate government. These are betrayals across party lines. We must be the 99 percent.

[billhicks76]

51. Obama Betrays Us Again

I remember calling Obama a corporate Trojam Horse and it being labeled as conspiracy theory by infuriated DUers who should've been directing their anger elsewhere...either at the administration or in the mirror. Obama's main task was foreign policy oriented with much of his domestic policy besides spying on the people or oppressing them with police as incidental. He gave "them" the coups the wanted in Honduras and Paraguay and Ukraine, the ongoing attempted coups in Venezuala and Syria and further wars in Libya and God knows what else is on the docket. The corporations are fleecing Iraqi oil finally and eyeballing Iran,Nigeria and anyone else with oil or oil routes.

[blkmusclmachine]

96. Nice to see the GOP still getting its way, all these years later.

To be an "Opposition Party," you have to do at least 1 thing ...


OPPOSE !!!

[billhicks76]

110. So True

These guys just want to be part of the Rich Mans club. They don't act like Democrats. They act like sell out corportists infiltrating our party on behalf of Wall St. They thought we wouldn't notice if our candidate was Black? Or a woman next time? We need to judge "our own" based on their actions and NOTHING else. Otherwise we are fools who deserve to be screwed over.

[pnwmom]

3. But we don't have single payer right now. We have a system under which the hospitals

can charge anything they want and the insurers, including Medicare and Medicaid, must pay their percent.

Why should hospitals in the same town vary so wildly in some of their charges? Shouldn't some pressure be brought to bear on those who charge excessive amounts?

[Fumesucker]

6. The pressure won't fall on the hospitals to cut costs as much as it will on individuals to pay up

For a lot of medical procedures it's not like the consumer has a great deal of choice in the matter.

[truedelphi]

17. Exactly.

There was a huge discussion over at Daily Kos about a year ago, about how when you go to a doctor, you think if the doctor is in "your plan" then the lab he sends your tests out to will also be within the same plan. But often it is not the case.

And monies you end up paying for the tests that were outside the plan do not even apply to your deductible.

[lark]

23. They are supposed to send the tests to contracted labs

We write off charges when one of our primary care locations sends the patients labs to the wrong place. Thought everyone did?

[hopemountain]

129. yes, my provider sucked up the cost when some of my

labs went to the wrong place and medicare did not reimburse.
in addition, one provider did not code the correct diagnosis for a test and it was also rejected - and the provider did not charge me, either.
those of us who are not too sick and who can - must continue to advocate for ourselves regrading extraneous medical costs because in doing so, we are also advocating for those who cannot.

let us not loose sight of the fight for single payer.

[lark]

186. Single payer is the answer

totally agree!!

[cui bono]

11. But this says it opens the door for insurance companies to set prices.

What the hell do they have to do with that other than attempt to cut their pay outs?

"Announced on May 2, the provision opens the door to "reference pricing," which allows insurance companies to set a price for medical procedures."

Utter and complete bullshit. This must not be done.

[pnwmom]

30. Why? If one hospital facility in a city charges $2000 for a colonoscopy

and another charges $8,000 for the same uncomplicated procedure, why should the insurers be bound to pay 80% of either charge?

http://www.nytimes.com/2013/06/09/opinion/sunday/the-weird-world-of-colonoscopy-costs.html

Colonoscopies are one of three standard ways to screen for colorectal cancer. So it is disturbing to learn that the cost of this routine procedure, performed on more than 10 million Americans each year, differs radically from state to state and even within the same metropolitan area.

As Elisabeth Rosenthal reported last week in The Times, the amount paid by a patient and the patient’s insurance plan for a routine colonoscopy can be as high as $8,500 in the New York area, compared with a high of $1,900 in Baltimore. The low price in New York was $740, less than a tenth of the highest price.

Variations like these are not limited to colonoscopies. Big price differentials occur in a wide range of procedures and services, including hospital stays, M.R.I. scans and artificial hips, among others. Bringing the highest prices down to more reasonable levels will be an essential ingredient in holding the nation’s health care costs to sustainable levels.

SNIP

[LiberalElite]

34. re: colonoscopy cost

My internist billed less than $2,000 for a colonoscopy performed in his office on the Upper East Side of NYC in 2010. Since then he affiliated with an "endoscopy center" in Midtown Manhattan just about 2 miles away. the amount billed my insurance company in October 2013 was $24,000.

[japple]

42. That is obscene. Hope your insurance company negotiated a more reasonable

settlement.

[LiberalElite]

45. I paid a couple hundred for the biopsy

the insurance company paid around $3,800.

I read in their literature while in the waiting room that increasingly procedures are being done in "endoscopy centers" rather than doctor's offices - which reminded me of reading headlines about rising medical costs.

[Ms. Toad]

58. Typically those are cheaper than hospitals -

one of the reasons to have them done there.

[pnwmom]

68. Wow. You've just demonstrated the problem. I don't know if reference pricing

is the answer, but something has to be done.

[Ms. Toad]

54. For one thing, all colonoscopies are not equal.

Most colonoscopies are looking primarily for polyps - or malignant lesions associated with polyps. Those are relatively easy to spot and most can even be spotted using a newer camera colonoscopy. I'd be just fine with those for my own screening. I get my colonoscopy at a stand-alone facility dedicated solely to doing colonoscopies - at the lower end of the pricing range - for my once every 10 years screening.

My daughter, on the other hand, needs someone who really knows what they are looking for for her annual screening. She is likely to develop flat lesions - which are much harder to spot. Worse still, she is likely to develop dysplasia before the lesions which is typically not visible to the eye. Her risk for colon cancer is approximately 50% by now (and will increase every year). She needs approximately 40 biopsies at ever colonoscopy - with the theory being that if they grab 40 snippets each year the odds of catching the dysplasia before it becomes malignant are much better even if they are just randomly grabbing snippets. She has hers done at a world class medical facility, by people who work specifically with her two-disease combination. The price for that is at the high end of the scale - both because of the specialists and because of the increased number of biopsies she needs. She needs to not be forced to a facility like where I have mine done because it would put her life at risk. And - because she already has far more medical expenses than most people every single year (because she will hit the out of pocket maximum every single year), forcing her to pay more merely to have access to quality of care she needs just exacerbates that discrepancy.

[pnwmom]

69. I'm talking about the price a hospital will charge for a standard screening colonoscopy.

The prices of those vary widely.

From what I read in another article, the idea of reference pricing is being used (at this point, anyway) on procedures that are fairly standardized and uncomplicated, like a routine colonoscopy.

I completely agree that any regulations should take individual health needs into account and pay for the care needed in situations like your daughter's.

[Ms. Toad]

73. Hers isn't labeled (or charged) any differently than a standard screening colonoscopy

aside from the number of biopsies.

It is just that given her high risk, I would not trust it to someone who is used to looking almost exclusively for polyps since that is what is most often found. And the places you find the folks who are more experienced a finding unusual things are not the cheap cattle call places.

So if there is a reference charge for a colonoscopy (and presumably separate reference charges for biopsies) - we will end up having to choose between paying out of pocket to pick the facility/doctors whose eyes are most attuned to the kinds of things that are riskiest for her - and hoping that the doc-in-a-box catches it.

[pnwmom]

74. Would it be possible to develop a system that assigned patients like your daughter

to the specialists most able to handle the colonoscopy?

[Ms. Toad]

76. This system right now is that we have selected a doctor

who is an expert (to the extent there is one) on the combination of her uncommon and her rare disease. As far as pricing, though, he doesn't work at a cheap facility. So if they are going to fix a price for a colonoscopy that is below the price her specialist/facility charges we'll have to choose (and we're not likely to sacrifice potentially life-saving expertise for a few thousand dollars - as long as there are a few thousand dollars in the bank).

But we are lucky in that - at least for the next few years we are unlikely to have to make that choice - I doubt our insurance company will stop contracting with the entity we use and they are big enough the entity is not likely to reject the contract rate. And I'll keep going to my little doc-in-a-box since I don't have any particular risk factors (even though I could go to her doctor and rack up the big buck charges).

But not everyone is so lucky - and I'm concerned about driving everyone (including those who need specialized care) to the one-size-fits-all places purely because of the perception that a $2000 colonoscopy (as an example) is always fungible with an $8000 colonoscopy.

[Doctor_J]

62. And why should getting medical care be like shopping for a used car?

Insurance companies are one of the very worst entities of life in America. Obamacare has made them a permanent half-trillion part of life. It may be the single most devastating blow ever delivered to the middle class.

[pnwmom]

72. It already is. I don't see how this would make it worse.

And I don't think the insurance companies are the only culprits.

For-profit hospitals and for-profit insurance companies are equally motivated to make money off the lives of sick people.

[burrowowl]

107. I agree!

[woo me with science]

84. [phone]. Note the blatantly false implications being offered in defense of this assault:

1) the attempt to imply that this move by the administration does NOT do what it clearly does, which is to transfer the burden of costs and pain from the insurance corporations to patients

and

2) the attempt to imply that this move by the administration does what it clearly does NOT do, which is stop insurance companies OR hospitals from price gouging.

Let's post again, for clarity:

"This new rule to limit payments for needed medical procedures is a reminder of everything that is wrong with our profit-driven healthcare system," Jean Ross, RN, co-president of National Nurses United, told Common Dreams. "Rather than crack down on price gouging by hospitals—some of who set their charges as high as 12 times their costs — the administration is enacting a rule to ration care for patients."

The assault here is on people, for the benefit of corporations. Again.

[davekriss]

86. You do understand what is being said here?

If the insurance company sets the "reference price" at $2,000, and you unknowingly go to a hospital that charges $8,000, the hospital pays up to $2,000 and you personally pay $6,000. Thereafter you're happily pursued by aggressive collectors and suffer a lien on your house (or similar consequences if you can't come up with the $6,000).

It's one thing to say the hospital can't charge more than the reference price. It's a wholly other form of screw the 99% when the hospital gets to charge whatever it wants and the insurance company gets to pay whatever it wants, and the unwashed masses with no say get to pay the difference.

(It is a good thing that the ACA forces the insurance company to pay out 80% of premiums on health care and will refund the difference to subscribers, but that's not helpful when you're the individual who still has to come up with the $6,000 beforehand.)

[pnwmom]

90. I think it would depend on how insurers are allowed to set the reference price.

I think our large group insurer has always set a price, but based on the average, not the lowest. And it would pay 80% of that average.

This doesn't sound like something new.

[merrily]

121. ACA was supposed to be something new--and more, well, affordable, not less.

I have been charged (on paper) thousands of dollars for tests for which my insurer has paid $100 or less--and my insurer has instructed me not to pay anything further.

I think it would depend on how insurers are allowed to set the reference price.

Sure, but do you know anything about that? If not, it could sound as though you are just throwing out stuff to make it sound as though the waiver is not a bad thing for us, after all, even if you do not actually know if it is or not. And why would someone affected by the waiver do that?

If there were mitigating circumstances, as you suggest there might be, the common dreams story would be very misleading if it failed to mention them. And I don't know of any reason common dreams has to mislead anyone about something a Democratic President did.

[pnwmom]

123. But we DON'T know how bad this is going to be, because, as I said,

the devil is in the details.

But we're progressives, so we'll always assume the worst.

[merrily]

124. All DUers are not progressives; and neither all DUers nor all progressives always assume the worst.

At least not without reason.

If this change is not better for insurers, why did they seek it? and if it hurts only medical providers, why did they not oppose it?

And, if it does not hurt anyone, why did the OP story not say so? And why was it done "quietly" and with no reassuring words from the Obama administration, which has not been shy with reassuring words, even when it should have been a lot shyer about that than it was?

And, if you don't know the details, why have you posted more than once that this is no change, at least no adverse change for patients?

BTW, I am not a progressive, nor do I have a clue what the word means these days. Both Obama and Clinton have described themselves as progressives and I have no clue what they meant. In fact, most New Democrats toss around the term "progressive" as though it were candy to the base.

If I had to choose any words to describe my political views, I would say I am the kind of Democrat that my parents assumed made up the entire Democrat Party. These days sometimes I say liberal, but that is not accurate, either. I never call myself a progressive.

[pnwmom]

125. The OP story is written by one writer with his or her point of view.

Don't you think we need more information than from a single story before we understand the ramifications of this?

[merrily]

126. Again, if no one understand the ramifications of this, why take any position at all?

And how about the other questions in my post?

For instance, if the American public cannot be expected to understand the ramifications of this, "this" being something so very important to them, where was the WH to announce it to Americans and explain it to them?

I am not saying that I am the smartest person or the best educated, but I ain't among the dumbest or least educated either. Or the least politically informed. If I can't possibly be expected to understand this with more detail, whose fault is it that the American people (for the most part) didn't know about it, let alone understand it?

[pnwmom]

127. I'm not saying that it's impossible to understand. I'm saying that this one Common Dreams

article doesn't tell us everything we need to know.

There is certainly reason to be cautious and skeptical about the effects of this decision. But everything is going to depend on how this is actually carried out and regulated.

We can't continue down the road of paying hospitals and drug companies anything they ever want to charge, whether it's $20K for a colonoscopy, or $300K a year for an orphan drug.

[merrily]

128. You said we can't understand it without more info. Whose fault is it that we don't have more info?

We can't continue down the road of paying hospitals and drug companies anything they ever want to charge, whether it's $20K for a colonoscopy, or $300K a year for an orphan drug.

No, that's obvious. And, as I posted before, that was what ACA should have addressed as well. It did to some extent, I guess, but not anywhere near enough.

[pnwmom]

131. Your fault,

in some small part, if you don't provide the public comment that the government is asking for.

This is all a work in progress, and they're asking for public comment. And they don't mean public comment on DU. Anyone who feels strongly about this should be submitting comments about this to the regulatory agency. That's how things work.

http://www.startribune.com/lifestyle/health/259489931.html

A recent policy ruling from the administration went to unusual lengths to acknowledge concerns, saying the pricing strategy "may be a subterfuge" for "otherwise prohibited limitations on coverage."

Nonetheless, the departments of Labor and Health and Human Services said reference pricing could continue. Plans must use a "reasonable method" to ensure "adequate access to quality providers." Regulators asked for public comment, saying they may publish additional guidance in the future.

HHS spokeswoman Erin Shields Britt said in a statement that the administration is monitoring the effects of reference pricing on access to quality services and will work to ensure that financial protections for consumers are not undermined.

[merrily]

133. Heroic try, but no, it's not my fault that the Admin did not inform Americans.

(You must have been really motivated to look all that up to answer my post at this hour, just to try to blame me for something that the Administration did not do.)

For one thing, educating Americans about the Administration's actions are my day job. People in the admin get paid with tax money I earn at my day job to do things like that. For another thing, I don't have the platform.

HHS spokeswoman Erin Shields Britt said in a statement that the administration is monitoring the effects of reference pricing on access to quality services and will work to ensure that financial protections for consumers are not undermined.

Wow. Words are always so impressive. And I expected them to say just the opposite, too: "Tough titties, America. We're here for the health insurers, not patients."

And, of course, I take this administration at its word and trust it fully to respond to comments from me every bit as much as they always have, which is zero.

But, what about subsequent administrations? Because this administration has set precedents that are not great.

Besides, my question was Whose fault was it that today, as we post, we did not have the info we needed to discuss this. And, no, that was not my fault, just as the final version of this and how it plays out in years to come won't be my fault.

[pnwmom]

135. This is a work in progress and the government depends on feedback

from people affected by its decisions. And this decision in particular is fluid, as evidenced by the fact that they're asking for feedback.

So give it to them.

[merrily]

136. Again that was not my question, but since you moved the goalpost to the future--

As my prior post indicates, I have given lots of feedback. Somehow, though, my feedback, even when solicited, doesn't count quite as much as the feedback that this administration and Congress and other administrations and other Congresses get from professional lobbyists.

As just one I gave feedback to both my Senators and the WH at least twice a week on the public option. So did over 70% of Americans polled, regardess of political party and in many more than one poll. Oops.

So, now, I stop pretending to myself and others that all our problems will be solved, if only we contact enough people in DC enough times. And, candidly, I suspect the good faith of those who do.

Do I still call in and email? Yes. Because that is part of doing whatever I can think of to do. But I don't kid myself or anyone else that its a be all and end all. Indeed, it's least effective part of what I do.

ETA. Not to mention counter-productive.

[pnwmom]

140. The Obama administration couldn't force Congress to pass the public option.

It barely was able to get through the ACA.

[merrily]

143. Highly untrue. The cake was baked before it ever got to Congress.

The lobbyists streamed to the WH as soon as Obama got in. (I would guess they were meeting with him even before that. Daschle sure was, but let's stick to the record.) The ACLU tried to show the public what was going on, given that Obama had campaigned on no secret negotiations of ACA--put it on C-Span, he said. And the WH fought the ACLU every step of the way, including moving the meeting out of the WH, to places that did not keep visitors logs.

People who make the claim you're making never point to all the efforts that Obama made to get Congress to pass the public option. Nor to any version of the bill that the WH sent Congress that included a pubic option. The Democrats had more than enough votes to pass the bill.

By the spring of 2009, Obama was not only not stumping to get people to cry out for the public option, for all the good that would have done--polls showed over 70% in favor. Rather, he was scolding those who were being activists for it.. A female doctor got detained by police for asking someone on the White House grounds to get a note to Obama about the public option. She was on Bill Moyers talking about it.

She was not the only one. Many were on TV at the time, complaining that only the anti-public option forces were welcome at the WH and only one view was welcome.

The delay was allowing Susan Collins and the industry to make the bill even worse than it was from the get go. And, when the WH really did not have enough votes--when Brown was elected--they went to reconciliation, which they could have done from the jump. Avoiding reconciliation from the jump was not about the law or the best interests of the American people. It was about Obama not wanting the Republicans to be able to claim that it was a partisan bill--which it was anyway, and which they claimed anyway.

Sorry, pwnmom, but the facts do not support your claim, even a little. Neither does the "he's not a king" bit.

P.S. Sorry, I have to break off for now and get to my responsiblities at home and on the job.

[pnwmom]

147. The Democrats did not have enough votes to overcome the filibuster.

When Ted Kennedy died, the possibility of a public option died with him.

[merrily]

137. Did they seek our feedback before deciding? Do you, even now, have

all the info you feel you need to comment intelligently? Or would you have to get a legal degree and go down to DC to see all the relevant info? And spend weeks off from your day job trying to inform yourself? Did special interests get consulted before deciding? You can bet they did. Did they get the info they needed? You can bet they did.

Do you relieve believe that your comments will now, or ever, have the same weight on this subject as the comments of an insurance company lawyer/lobbyist or a medical provider's?


I guess these providers and insurers form associations and hire attorneys and lobbyists for nothing? Because they are just as capable as I am of staying up to speed on this while performing their other duties at work and at home and calling the white house. And the white house is just as likely to respond to my voice as to the voice of their lobbyists, right?

And that is only one sub-issue of many, many important issues.

The reason we pay taxes and vote is because our representatives are supposed to look out for the public interest, not for the interest of special interest groups, like health insurers, to name only one. But, it doesn't work that way. And I am not the one that set it up that way. Only those who benefit materially and by getting power set it up that way. And no call from me will change that, either. Of course I could have tried to vote someone out of office, but then I'd get bashed for not voting Democratic. Because competing with the Democrats, if only to be fear of voters back into them, is also supposedly some kind of mortal sin.

So, let's not try to kid ourselves or each other or anyone else that it's my fault or that a call or email from me is going to do squat.

[pnwmom]

139. This isn't a decision written in stone. It's a preliminary decision in an ongoing situation

and they're watching to see how it works out and they're asking for feedback.

And I have read public comments before. You don't need to have a law degree or even a B.A. to write one. But I suggest you read more articles than just the one in Common Dreams before you do so.

[Agony]

145. this is why I have proposed that any and all

communications between a paid lobbyist and an elected representative should be recorded and publicly available online in a searchable format.

At least the playing field would be slightly less inclined.

[Heywood J]

175. "why should the insurers be bound to pay 80% of either charge?"

Because the insurance company has a lot more clout to negotiate them down than you do.

[kelliekat44]

138. What do you mean by "oppens the door?" They have been setting prices all along nt

[cui bono]

221. I didn't write the phrase, it was in the OP. n/t

[merrily]

116. No, we don't have single payer, but what does that have to do with the waiver publicized in the OP

story from common dreams? Does that cut against what we supposedly do have now, namely an Affordable Care Act?

Shouldn't some pressure be brought to bear on those who charge excessive amounts?

Some pressure has been brought against them, by Medicare, by private insurers and by the Affordable Care Act. The last one could have, and should have done more in that regard. But, that's why representatives of medical providers, right along with private insurers and the pharmaceutical lobbies, were on the White House visitor logs early in 2009.

[pnwmom]

117. I think the waiver might possibly have been intended to let companies selling to individuals

on the exchanges do the same thing large group insurers have always been doing. We've had an employer based large group policy for twenty years. And before that, we had policies as state employees that worked the same way. Reimbursements are based not on 80% of whatever a hospital charges, but 80% of what is considered standard, based on a survey of the charges of all the hospitals (I forget what the terminology is).

In this sort of thing, the devil is in the details, obviously.

[merrily]

118. First, so? ACA changed what large group insurers have always been doing and that is exactly

what ACA was supposed to do.

Second, I don't agree that the waiver was intended to allow big private insurers to do what they have always done.

In many instances, they do not simply reimburse what is considered standard, then require the insured to pay the balance. Rather, both private insurers and Medicare routinely enter into agreements with providers up front: if you want us to cover your medical practice, hospital or whatever to any degree here is the deal: You will provide services to our patients. We don't care what you say you are charging, we will reimburse only X and you will not charge our insureds anything but the deductible, if any, that we require them to pay.

Then, the doctor or hospital has to decide whether it can survive without insured patients. If it does not think it can, then it agrees with the private and public insurers up front. Hence, statements from both the USG and private insurer insurers often tell the patient not to pay the provider more than the deductible for that service, if any.

The bolded language is, of course, key to very sick patients being able to afford care without bankrupting themselves. (And, as we know, even then, medical expenses, even for insureds, was the number one cause of bankruptcy in the US.) And that is what is missing here.

[Scuba]

149. "We have a system in which hospitals can charge anything they want ..." is laughably wrong.

Hospitals are reimbursed under a system of Diagnostic Related Groups (DRG's). This means that reimbursement is pre-set for a particular diagnosis and the hospital will receive that much reimbursement regardless of what they charge (or what their costs are).

This is true for Medicare and Medicaid by law, and commercial insurance companies have used this law to negotiate the same, or lower, rates. If a hospital doesn't go along, the insurance company will drop them from their "covered provider" list.

The DRG system was implemented in 1984.

[pnwmom]

154. Some hospitals charge ten times as much as others for a colonoscopy in the same city.

Please explain to me how that works, under the system you describe, and how it's justified.


http://www.nytimes.com/2013/06/09/opinion/sunday/the-weird-world-of-colonoscopy-costs.html

Colonoscopies are one of three standard ways to screen for colorectal cancer. So it is disturbing to learn that the cost of this routine procedure, performed on more than 10 million Americans each year, differs radically from state to state and even within the same metropolitan area.

As Elisabeth Rosenthal reported last week in The Times, the amount paid by a patient and the patient’s insurance plan for a routine colonoscopy can be as high as $8,500 in the New York area, compared with a high of $1,900 in Baltimore. The low price in New York was $740, less than a tenth of the highest price.

Variations like these are not limited to colonoscopies. Big price differentials occur in a wide range of procedures and services, including hospital stays, M.R.I. scans and artificial hips, among others. Bringing the highest prices down to more reasonable levels will be an essential ingredient in holding the nation’s health care costs to sustainable levels.

SNIP

[Scuba]

155. It doesn't matter what they charge - at least to Medicare, Medicaid and insurance companies...

They don't get reimbursed on what they charge. They get a fixed rate for colonoscopies.

Where charges do matter is the billing of private individuals with no insurance. This is where hospitals try to make up for what they lose on other reimbursement. So, yes, you will see different rates from different providers, but it matters not one whit to Medicare, Medicaid and insurance companies.

Here's a couple references that will help explain it all ...

http://en.wikipedia.org/wiki/Diagnosis-related_group

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html

[pnwmom]

189. If that is already the case, then why the uproar here over the "new" regulation? n/t

[Scuba]

190. Which uproar? What "new" regulation?

[Maedhros]

4. Slowly, one by one, the modest benefits of the ACA

are being stripped away, until all that will be left is the mandatory enrollment.

[Ed Suspicious]

18. Corporatist president run amok.

These stories are so damned tiresome. One hand giveth while the other hand taketh away. And it's done by a democrat so we get to say nothing of consequence about it.

Frankly, I'm getting sick of defending this asshole, my corporate-loving-president.

[Maedhros]

71. The ACA had two goals:

1. Earn Democrats some political capital that they could use to bludgeon Republicans.

2. Stave off real reform so the insurance companies could continue fleecing Americans.

[woo me with science]

93. Well said, except that I would qualify #2.

They did much more than merely *stave off* reform. They managed to *entrench* the profit sucking corporate middleman model into our system and mandated by law that *every single American citizen* participate with funnel in pocket.

They guaranteed obscene profits for the industry by writing them into law, and they politically camouflaged the entire scam by advertising subsidies for the needy.....but by ensuring that subsidies went TO the profitmongers from the pockets of taxpayers, rather than demanding that the profitmongers provide any part of them.

It was perhaps the most cynically brilliant corporate political scam in recent history, pulled off by a Democratic administration. And now we get to see what the promises to fix some things later really meant...

[merrily]

120. It was also to help medical providers, especially hospitals, and maybe

to throw a bone to the populace lest it revolt.

It is coming to be my theory that fear of public uprising played at least a significant role in the New Deal and the Great Society--and, in 2008, we were at 1929 levels of crisis, though all of us may not have been fully aware of it then. Between TARP and the massive foreclosures that were not fully underway in 2008, the PTB may have thought it needed to throw the rabble a bone. True, the pickin's on the bones they throw us nowadays are slimmer and slimmer, but they have less and less reason to think we'll actually revolt and more and more reason to feel secure that they can crush us if we do try it. But, that is only my theory. Back to topic.

Remember, hospitals-maybe others-- were required to render emergency treatment, even if the patient had no private insurance or Medicaid or Medicare. Hospitals--many of which overcharge and pay salaries and make profits that any mid sized corporation would envy--were fed up with that.

Requiring all adult Americans to have some kind of health insurance would help out providers considerably.

[grahamhgreen]

223. & give big crapsurance enough $$$ to lobby away any real reform in the ACA.

[grahamhgreen]

112. Ding ding ding! Exactly! They'll take their mandated trillions and 'lobby' away any good reforms.

[Shivering Jemmy]

156. Not really

[Maedhros]

188. Well, your superbly crafted argument has certainly quelled all of MY concerns. [n/t]

[SammyWinstonJack]

163. The way it was intended too be.

The healthcare insurance parasites loves 'em some ACA.

[leftyohiolib]

5. he really got me with that hope and change crap

[Fumesucker]

8. He probably would have got me but I was paying attention during the FISA vote

After that I knew it would be more of the same old same old..

[blkmusclmachine]

99. The more things "Change," the more THEY STAY THE SAME !!!

[woo me with science]

104. Or get much worse.

Surveillance state expanded. Secret laws, secret courts, indefinite detention, "kill lists," assaults on journalism, and establishment of a propaganda machine entrenched and defended. Trashing of public education in progress. Drilling and fracking strongly backed by a Democratic President. And now looking forward to the TPP and a corporate-controlled internet.

And this.

[Octafish]

7. One nation, under Wall Street...

...with Liberty for the rich and austerity for the rest.

[1000words]

9. What a boost for GOTV efforts!

Go Team!

[woo me with science]

87. See posts 63 and 81.

We have seen this game before, in 2010.

[1000words]

89. Good cop/Bad cop

[blkmusclmachine]

100. I'm not so sure the DC DEMS want to win in Nov. More DEMS could make "bi-partisanship" a harder sell

to the gullible DEM base!!!

[Hoyt]

10. I'm not sure this is bad if one is interested in reducing cost. Canada has used it

to control prescription costs.

http://www.boston.com/lifestyle/health/health_stew/2013/06/maybe_controlling_medical_prices_will_not_be_so_hard.mobile.html

Of course, it takes some consumer education, cooperation from docs and facilities, etc. It also takes employers ensuring the reference price is available. If Johns Hopkins charges twice as much for a routine hernia operation, I see no reason to pay more than what other quality facilities are willing to charge.

Reference Pricing - assuming all the above - gives the patient a choice of getting some coverage by going to what is essentially a non-preferred provider for the procedure, or getting full coverage by going to a "preferred" provider. The alternative is ever increasing premiums because provider prices and usage of higher priced providers goes up.

And yes, I can see some negatives. But we have to get control of costs - like Canada and Europe - if we expect a decent health care system.

I don't think this is the conspiracy theory some will make it. Canada and Europe know something about running health systems.

[Ed Suspicious]

20. Consumer choice in medical care is a myth. An illusion. Try to find the price of an MRI from your

hospital. Try to find it from an in network hospital. Try to find it from an out of network hospital. Try to find the cash price. It doesn't work. You will be sent though an un-navigable labyrinth of call transfers and disconnections and people who just don't know what to tell you or who to send you to who can.

[Hoyt]

43. It is really so much simpler than that. You guys are really making this more difficult than it is.

Pretty simple actually, under CalPERS (which has used reference pricing for several years), the insurers provide members with the hospitals that meet the reference price. A number of hospitals cut their prices to get on that list.

I suspect a member could also negotiate with other hospitals to meet the reference price. All of that will be layed out by HHS and insurers.

These are not just a couple of low cost/quality hospital. The hospitals on CalPERS' list performed over half of a common reference pricing procedure -- Knee and hip replacements.

The reference pricing only applies to a couple of hands-ful of costly procedures.

Further, emergencies aren't subject to reference pricing.

Complicated procedures that can vary widely in cost aren't included.

Point is, you guys are trying to make this much more difficult than it is.

[IronLionZion]

146. +1

Not sure why people spread false or misleading info about the health reform so much. I think people just like to work themselves up without getting the facts first.

[Heywood J]

181. I see absolutely zero reason why anyone should spend their precious hours

when they aren't working their three jobs to shop around for whatever hospital sixty miles away might give a bargain-basement price that's covered by their plan. I see absolutely zero difference between that and the same situation when the person was uninsured and paying out of pocket.

As to negotiating your own price with a hospital, good luck on that one. My equally-valid suspicion is that the hospital will laugh in your face and call security.

[woo me with science]

195. Well said. The mocking defense of this assault just shows

the utter contempt of the Third Way for sick Americans trying to battle our predatory health insurance system.

[Hoyt]

203. You don't have to shop around, your insurance company will tell you closest hospital that meets

requirements.

Actually, hospitals negotiate all the time. You call them up and say, my insurer's reference price for my knee replacement is $30K, will you do that or do I have to got to another hospital?

Truthfully, you and I have some responsibility in making health care affordable. Why not join in for the good of society.

[lark]

26. Hmm, this sounds a whole lot like the old "reasonable and customary" crap.

No dentist every charges anything near "reasonable and customary'. Sounds like they are using the same concept. It's not about reducing prices providers charge it's about blowing the amount we have to pay sky high. This is sickening, literally, especially in the south where Medicaid wasn't expanded! Guess I'll be paying my sons penalty for not having Obamacare because he can't afford it when he's barely able to have a roof over his head and food in his stomach now.

[Hoyt]

50. No, it's different because you'll have the tools to avoid paying extra out-of-pocket if you take

time to look.

See post #43 above.

As to your son, if he's not making enough to qualify for the exchanges, I agree that is tough in the South. I live here too, and curse the ignorant Republicans who are standing in the door-way blocking Medicaid expansion, and the fools that vote them into office. I hope you can find another option.

[Ms. Toad]

60. Actually - it sounds like worse.

Most insurance already uses UCR. If you stay in network, you never notice because your doctor has agreed to accept the UCR rate. If you go out of network, the first thing you pay is anything above UCR.

This sounds to me as if they would permit in network facilities to create a contract with insurance companies in which they no longer reduce their fees to the UCR. for covered patients.

ETA: I take that back - it is just UCR with a different name, applied to large group or self-insured plans. In that case, I'm not sure what the fuss is about. That is how every insurance plan I've been on for the past two decades has worked. http://www.dol.gov/ebsa/faqs/faq-aca19.html

[bvar22]

12. As usual, those who can afford it the LEAST...

...will be the hardest hit.

In most civilized countries, the term "Medical Bankruptcy" is unknown.
Here in the USA Medical Bankruptcy will STILL be Big Business as Usual as the Working/Middle Class
continues to be stripped of its assets by the already RICH and well connected.


[font color=firebrick][center]"There are forces within the Democratic Party who want us to sound like kinder, gentler Republicans.
I want a party that will STAND UP for Working Americans."
---Paul Wellstone [/font][/center] [center] [/font]
[font size=1]photo by bvar22
Shortly before Sen Wellstone was killed[/center][/font]

[RBInMaine]

13. Yes, we need Single Payer and corporate money out. How are YOU going to make that happen?

Do you vote? Do you run for office? Do you work for organizations trying to make that happen? Do you work for candidates trying to make that happen? Do you do all you can to unseat TeaPublicans so we can make those steps? How do you propose these things to PASS when Boehner is in charge of the House and there aren't enough Dems in the Senate? What do you propose to do to SOLVE it all? Talk is cheap. Action isn't.

[salib]

19. Yes.

I vote,
I support very progressive candidates who run for office, most local, most trying to unseat very conservative types.
Always work for orgs and candidates to make many liberal things happen.
"All I can"? I think so.
Boehner, are you kidding me? This is not Boner doing this one. It is in fact Obama.

So, I do all that, work as hard as I can to get Kerry, then Obama elected. Then again in 2010, 2012. Now 2014.

All that.

BTW, talk is indeed cheap. Medical expenses bankrupt.

To me, as my wife just texted, "that just pretty much negates everything obamacare was supposed to do."

Doesn't mean I will stop any of what I am doing. Does mean I will try to be more creative about it.

However, it still is a VERY VERY bitter pill to swallow.

I had thought, well at least Obamacare is there and I do not have to worry so much about bankruptcy from med expenses. Well, lost that one.

So, cheap enough talking for ya?

No need to slam someone for pointing out the hurt. Sit down, shut up, recognize that we are being hurt by this, and get back to work. OK?

No need to slam someone for pointing out the hurt.

[Divernan]

44. This was an Obama admin. on the sly/back room deal with Big Insurance

Contrary to your vacuous post, IT WAS NOT SOMETHING WHICH HAD TO BE RAISED AND VOTED ON IN THE HOUSE, I.E., PASSED BY BOEHNER. AND NO "TEAPUBLICANS" HAD ANY SAY IN THIS SHADY DEAL.

Perhaps YOU never took a basic civics course or understand the division of powers in our government. See, we speak of the Obama ADMINISTRATION because Obama is the administrator of his vaunted Affordable Care Act. It's getting damned unaffordable with this latest development.

How much more could Obama suck up to Big Insurance than letting them change the terms of the policies, ex post facto?

What's next? Insurance companies allowed to decide "you are too old, so you are not eligible for that" rationing in the name of cost savings?

[Phlem]

185. ....

I've heard this toothless argument before. It's fail on top of fail. Obama got elected twice because we were all sitting on our asses?

but no, we're not doing enough.

What about when he asked us to hold his feet to the fire. Are we not supposed to do that?

Ridiculous.

Working 2 jobs isn't enough? I've go on the campaign trail too? Just for more of this bullshit? Where does sleep and time with my family come in. Oh I've got to sacrifice all that so I can get shit on again?

I knew during Obama's acceptance speech he was not honest. Every fricken day he proves me right.

What did he say, "I'm a new Democrat." Tell me that doesn't raise a flag.

[pa28]

208. Here is what Obama's nominee for HHS thinks about single payer.

(Reuters) - U.S. Health Secretary-nominee Sylvia Mathews Burwell sought to allay a major Republican worry about Obamacare on Thursday, telling lawmakers that President Barack Obama's reforms would not lead to a government-run single-payer healthcare system on her watch.

http://www.reuters.com/article/2014/05/08/us-usa-healthcare-burwell-idUSBREA4703L20140508

Implying that activists just aren't working hard enough is BS. Our own leadership doesn't want single payer and is willing to say so in broad daylight.

[Demeter]

14. I expected nothing more

Just less and less for people, everything for the insurance biz.

[Hoyt]

27. It's more likely the employer in short run, and society in long run, will benefit.

Canada and Europe use this method to control costs. There are also requirements which will ensure availability of quality providers.

http://www.detroitnews.com/article/20140516/POLITICS03/305160048/Cost-control-plan-health-care-could-cost-you

[Doctor_J]

98. Canada and Europe did not make middleman part of the system by law

Any comparison between us and then is based on fantasy

[Hoyt]

114. I would suggest you look up drug coverage in Canada and how private insurance

fits into health coverage in Europe.

I'd also suggest you read a little bit more on the OP misrepresentations.

[blkmusclmachine]

102. "ObamaCare" was originally a Republican-hatched WET DREAM out of the Heritage Foundation, circa

1996.

[EEO]

15. This country should be ashamed of itself for not having universal healthcare.

Sadly, most Americans are so ignorant they have no idea what socialism is and how they benefit from it every day.

[Javaman]

38. This country should be ashamed of itself for a great many things. nt

[Whisp]

206. And for a great long time. Some seem to think the shame all starts with this President. n/t

[AAO]

85. Nice user name.

[salib]

16. This could really hurt my family

We have major health issues and have so far navigated the worst of it.

Try paying for a heart transplant if the insurance companies decide it is too expensive at the nearest (and in may ways designated) hospital. We rally have no choice. It is the only one within 3 hours.

I even avoided the company offered plan until Obamacare kicked in and pre-existing conditions could no longer be an exception. Again, try a heart transplant as a pre-existing condition.

Now, we have to worry that any emergency treatment (most everything is an emergency when you are immunosupressed and it is your heart that is rejected) will only be covered for a portion. So, if the "hospital of [no] choice" is charging what the insurance company sees as "excessive", maybe by 12 times, we then have to pay 11 of 12 of the cost.

There are many scenarios where we cannot do that. So, we just find a place that is cheaper? How? It's an emergency!

I am sure there are all sorts of feel good exceptions which claim to cover you when you have an emergency. It is bullshit. You know it is. That is the worst time to claim caveat emptor.

[truedelphi]

21. A lot of us here tried to put up a good fight for people in

The situation you describe.

But we were told we were Obama haters or worse.

And meanwhile, many here also praise the notion of MediCaid for All. The difference between MediCaid for All and Single Payer Universal HC is a vast difference. Under Medicaid for All, should your health ever cost the system any sort of money, you end up losing your home or modest savings to the state you live in; while under Single Payer your kids still get a chance to inherit a modest amount. (And some here are infuriated by the idea that someone on MediCaid should leave their small home or small savings to their kids. But apparently the fact that the execs at Big Insurers will leave huge estates and dozens of car, and summer homes etc to their kids doesn't seem to bother them at all.)

[salib]

29. I see your point. However, I have really never heard may say "Medicaid for All".

I researched just now (Google, of course), and did see a little about it but seems like a right-wing strawman, or only there as a last resort (as was its intention).

What most talk about is MEDICARE for all. That is not losing ones assets.

To bring up Medicaid for all seems like a red herring?

Tell me it ain't so.

[krawhitham]

24. This does not change your out of pocket max

Once you hit it, you're still done paying

[salib]

32. From what I read in the DOL reference from the Article, I STILL HAVE TO PAY

http://www.dol.gov/ebsa/faqs/faq-aca19.html

See "Limitations on Cost-Sharing under the Affordable Care Act" section:

"Q4: If large group market coverage or self-insured group health plan has a reference-based pricing structure, under which the plan pays a fixed amount for a particular procedure (for example, a knee replacement), which certain providers will accept as payment in full, how does the out-of-pocket limitation apply when an individual uses a provider that does not accept that amount as payment in full?

Reference pricing aims to encourage plans to negotiate cost effective treatments with high quality providers at reduced costs. At the same time, the Departments are concerned that such a pricing structure may be a subterfuge for the imposition of otherwise prohibited limitations on coverage, without ensuring access to quality care and an adequate network of providers.

Accordingly, the Departments invite comment on the application of the out-of-pocket limitation to the use of reference based pricing. The Departments are particularly interested in standards that plans using reference-based pricing structures should be required to meet to ensure that individuals have meaningful access to medically appropriate, quality care. Please send comments by August 1, 2014 to [e-mail].

Until guidance is issued and effective, with respect to a large group market plan or self-insured group health plan that utilizes a reference-based pricing program, the Departments will not consider a plan or issuer as failing to comply with the out-of-pocket maximum requirements of PHS Act section 2707(b) because it treats providers that accept the reference amount as the only in-network providers, provided the plan uses a reasonable method to ensure that it provides adequate access to quality providers."

So, I guess I must "comment" and await "guidance" to be "issued and effective".

No, according to the above, if It costs $500K for the procedure and hospitalization and the insurance company has decided (maybe just last week for all I know) that it should only cost $50K, then I still owe the provider $450K and none of the $450K come out of my max. I would certainly hit my max, but I still owe the provider.

[krawhitham]

41. Q2, Q3, & Q4 are all listed under Limitations on Cost-Sharing under the Affordable Care Act

Which states

Public Health Service (PHS) Act section 2707(b), as added by the Affordable Care Act, provides that a non-grandfathered group health plan shall ensure that any annual cost-sharing imposed under the plan does not exceed the limitations provided for under sections 1302(c)(1) of the Affordable Care Act. Section 1302(c)(1) limits an enrollee's out-of-pocket costs.(4)

All exchange plans are non-grandfathered

You mentioned

Until guidance is issued and effective, with respect to a large group market plan or self-insured group health plan that utilizes a reference-based pricing program, the Departments will not consider a plan or issuer as failing to comply with the out-of-pocket maximum requirements of PHS Act section 2707(b) because it treats providers that accept the reference amount as the only in-network providers, provided the plan uses a reasonable method to ensure that it provides adequate access to quality providers.

That states that in-network providers accept the reference amount, which is the way it has always been, Out of Networks has always been outside they out of pocket limits.

Now it sounds like you can go to Out of Networks and only pay the difference they charge and the reference amount, where before if you had a HMO you had to pay 100%

[salib]

47. I really wish that your conclusions were true

I really do.

However, it appears to me that it would be easy for an insurance company to argue that the "limits on enrollee's out-of-pocket costs" could easily be interpreted as the difference between the reference amount and the amount paid. HMO or not.

Emergencies are often "out of network".

No, this is a huge loophole. Wishful thinking (even on my part) will not make the difference.

[Hoyt]

56. CalPERS has been using reference pricing for several years. Emergencies don't fall under RPricing.

I suspect -- obviously don't know for sure, but I'm going to assume this is not a conspiracy -- the same will hold true here.

And, reference-pricing only applies to a limited number of procedures with relatively easy costs to predict.

I think it is a good move, provided insureds know hospitals meeting reference price; reference price is sufficient for participation of quality providers of the procedures in question; and the like. I think that will happen, but I understand your concern.

[Ed Suspicious]

25. I feel your pain. It's a disgusting system designed to confuse. The consumer was never meant to

shop based upon price. Maybe on outcomes, but most likely on who's in network and who is closest.

[woo me with science]

106. "It is bullshit. You know it is."

Succinct and true. Thank you for cutting through the garbage and the talking points and saying clearly what needs to be said: that this is yet another vicious, indefensible assault on human beings for corporate profit.

[Cal Carpenter]

22. It sounds like this goes above/beyond deductibles and annual OOP limits?

Can anyone confirm?

Either way, disgusting.

[zeemike]

28. All the good stuff is quietly approved.

And that is some good stuff for the "free market"

[woo me with science]

31. Note the absurd attempts to spin this already.

Funny how the road to a more liberal and compassionate future, according to corporatists, always involves necessary incremental steps that transfer the burden of costs and the pain from corporations to ordinary people.

[salib]

33. Yes, absurd.

I do want want to walk "down the road" when it means stepping all over others who fall to this farce.

[zeemike]

35. And when you go far enough down the road you get to the crossroad

Where they sell your soul to the...well you know.

[blkmusclmachine]

103. Once everything good has finally been taken out of ObamaCare, all that'll be left is the TAX.

[Sheepshank]

216. the absudity comes for the many ASSumptions

your are pounding....starting with the title of the OP

[smallcat88]

36. Still pissed

at Obama for caving on the public option. Single payer would have been better but at least a public option would have been a good compromise. Instead we got Romneycare. That's why I voted for the Green candidate in 2012. Figured I live in Illinois, the electoral college in my state was going for Obama anyway. I know it made no difference, but it made me feel better.

We need to get rid of the charge master system of billing in this country. Hopefully time will help - as people get used to the healthcare system they'll make greater demands for improvements. Doesn't help anyone burdened by the system right now - all the more reason to get your stories out there!

[oneofthe99]

37. How come the Obama can never do wrong crowd are always absent from these threads

I guess it's more important to talk about how beautiful Michelle's dress looked or how cool Obama looked walking off Air force one.

[McCamy Taylor]

40. Michelle does look beautiful.

[Cha]

92. Michelle Obama is an intelligent caring woman who is the First Lady of the United States

unlike your graphic which is dull and insipid.

[Hoyt]

59. Actually, like most of these Obama-is-out-to-screw-us-threads, those in the "know" come along later.

If you'll notice, there are a number of posts and posters with the truth on reference-pricing showing up.

[L0oniX]

199. LMAO Jeeze.

Obama-is-out-to-screw-us-threads, those in the "know" come along later

Pathetic that all threads that bring up supposed problems with Obama's actions or lack there of are "Obama-is-out-to-screw-us-threads". I think you can do better than that. I suppose we can trust - those in the "know". So we don't need to be concerned or even bother to look at what's going on. Is that what you are saying? IOW if it looks like Obama is doing wrong don't bother to bring it up ...cause you're wrong and we don't give a shit what you think. We'll keep that in mind. Thanks.

[Hoyt]

202. Have you researched this issue, or are you just going along with the he's-screwed-us-again-crowd?

[Tarheel_Dem]

65. Perhaps you stopped reading too soon? Read on, oh wise one, read on!

[Number23]

79. So this is where the Obama Can Do No Right crowd is? No wonder the other thread

took this one's lunch and threw it under the bleachers http://www.democraticunderground.com/10024968196

[Cha]

97. "Obamacare saved consumers billions, new report finds" which doesn't interest those

who only want to whine about the President and post stupid graphics that says more about them than anything else.

[Number23]

119. Well, they've rallied up the Truthiness Crew and the recs are a'pouring in now!

Proving to the world a) exactly who Counterpunch's core constituency is and b) why they have no clout.

[Tarheel_Dem]

178. I think they're pissed cuz the rally was a big fail!

[blkmusclmachine]

105. Administration sock-puppets to explain how down is up in 3 - 2 - 1 ...

[Tarheel_Dem]

179. Explain to who? I don't count you.

[woo me with science]

78. The propaganda brigade typically ignores OP's about Democratic betrayals until about 35-40 recs,

probably to keep from calling attention to them and hoping they sink on their own. After about 40 recs, they get to work.

You can see they are swarming now and making deliberately absurd and belligerent claims that the article has been "debunked."

[1000words]

101. It takes a little time for the PM "phone tree" to get going.

"Tsk, tsk" talking points need to be dreamed up, too.

[joshcryer]

109. "woo" doesn't provide constructive debate.

I've stopped trying to actually have a discussion with them before because they just paste a wall of links and scurry off whenever their disingenuous posts get called out.

At least Manny replies constructively when I go dig out the information.

The fact of the matter is the Common Dreams article is out of touch with reality, does not recognize that this is a WIP in order to reduce costs, and that in fact the rules "invite comment on the application of the out-of-pocket limitation to the use of reference based pricing," "should be required to meet to ensure that individuals have meaningful access to medically appropriate, quality care," "provided the plan uses a reasonable method to ensure that it provides adequate access to quality providers."

So, in short, they're trying out "reference-based pricing structure" but it's not set in stone, and if it fails to meet the stringent quality standards required by the ACA, it will be changed. I swear, some people need to dig out a book on administrative law sometime and just learn something.

[McCamy Taylor]

39. This is how it already is with private insurance. Indeed, they can decide after the surgery to pay

nothing. I had a patient who got his brain tumor removed on a weekend and the insurance used that as an excuse to avoid paying for it for over a year. As if they were ever going to say "No, we don't think that tumor that is causing pressure on the brain and seizures needs to be taken out" (Note, I am not talking about a pituitary adenoma which is the straw man they usual bring up when talking about refusals to cover care for "brain tumors", this was a real though not malignant tumor that was doing real pressure damage).

Some of the "outrage" is over real stuff and some of it is over just ordinary stuff. This does not strike me as outrageous. For example. I took my son to an ER for a single albuterol updraft treatment because I was out of town and did not have his inhaler. The charge? $5000. The insurance would not pay. Of course they wouldn't pay. Who would pay that much? A whole nebulizer machine only costs about $150. Do you really want your ACA insurance to be required to pay $5000 for a single nebulizer treatment because some crazy hospital ER thinks it can get away with charging that much?

Story has a happy ending. I did my residency there. I called the billing office, reminded them I did my residency there, suggested $5000 for an updraft was too much and that they really wanted to write that one off for an alumnus. But imagine what they are doing to people who did not do a medical residency there? Eeks!

[Egnever]

48. The reporting seems to be confused

this story is based on a FAQ addressing private employer based plans. There was no change just clarification on the rules regarding plans you seem to already be aware of.

[Doctor_J]

49. Yes, private insurance sucks. We know that. That's why making them a permanent part of

the government was the absolute worst thing that could happen. Duh

And as to your post right above this?

[Egnever]

46. Hey look it's dishonest reporting again..

surprise surprise.

I never would have expected it.

This woo article is based on a FAQ put out by the Department of labor http://www.dol.gov/ebsa/faqs/faq-aca19.html

Which is addressing employer based plans that were in effect before Obama care. It is clarifying how these older employer based plans re affected by the ACA.

There is no rule change.

I don't expect this will effect the woo at all.

Que the corporate toady garbage.

[Divernan]

53. It IS honest & dated May, 2014.

Headline: Cost-control plan for health care could cost you

From The Detroit News: http://www.detroitnews.com/article/20140516/POLITICS03/305160048#ixzz327ExpmcM

The Obama administration has given the go-ahead for a new cost-control strategy called “reference pricing.” It lets insurers and employers put a dollar limit on what health plans pay for some expensive procedures, such as knee and hip replacements.

Some experts worry that patients could be surprised with big medical bills they must pay themselves, undercutting financial protections in the new health care law. That would happen if patients picked a more expensive hospital — even if it’s part of the insurer’s network.

The administration’s decision affects most job-based plans as well as the new insurance exchanges.

From The Detroit News: http://www.detroitnews.com/article/20140516/POLITICS03/305160048#ixzz327ESzKZz

[Hoyt]

57. You left out some good quotes from your own link.

It’s been pioneered in California by CalPERS, a giant agency that manages health and retirement benefits for public employees. CalPERS started with knee and hip replacements in 2011, steering patients to hospitals that had been vetted for quality and charged $30,000 or less.

Ann Boynton, the agency’s health benefits director, said the program has been a success, with patients able to choose from about 50 hospitals. “People do not feel like we went to bargain-basement hospitals where the quality is not good,” she said. “The quality is the same, and in some instances, better.”

Economist James C. Robinson of the University of California at Berkeley studied the CalPERS experiment and found not only that many patients shifted to lower-cost hospitals, saving money, but that expensive hospitals responded by cutting their prices. . . . . . ."

From The Detroit News: http://www.detroitnews.com/article/20140516/POLITICS03/305160048#ixzz327HmeiUB

[davidpdx]

130. Glad to see someone digging for the truth in all the bitter screaming

[woo me with science]

83. Another transfer of cost and pain from corporations to ordinary people.

Third Way spin and denial, though predictable as sunrise, cannot whitewash this.

[Sheepshank]

214. OP is dishonest.

implying Obama conspired to hand something to insurance companies. The fact is more like the insurance companies are exploiting a loophole and there is no evicdence whatsoever that Obama approves or is unwilling to address and make changes.

NOT ONE person ever said that ACA was rolled out in it's one and only format and changes would never have to be made. In fact clearly and repeatedly, the opposite has been addressed. It just doens't happen to fit the current narrative.

Gawd the woo here is irresponsible.

[ProSense]

61. Of course it's "dishonest reporting."

It's like the administration improving the rule to allow appeals. This is an existing rule, and the administration is working to clarify and strengthen patient access to services.

Do you notice that some people only pay attention to the negative spin (the stuff that's not real), but ignore the good things the law is doing? More rules approved in late April/early May.

New price transparency rules for hospitals
http://thehill.com/policy/healthcare/204868-new-price-transparency-rules-for-hospitals-under-o-care

Employers Must Notify Laid-Off Workers of Health-Care Options, New Rule Says
http://www.democraticunderground.com/10024910841

Then there is this.

"Obamacare saved consumers billions, new report finds"
http://www.democraticunderground.com/10024968196

[Egnever]

64. Yea I know

Don't know why I bother people even here don't seem to ever read past linkbait headlines

[Number23]

80. Why read anything when you can just label EVERYTHING that disagrees with your ill informed

and preconceived perceptions as propaganda and the folks that don't swallow your story whole and unquestionably as "propagandists?"

The beauty of burning calories convincing yourself that the world is out to get you is that you don't have to actually listen to any of it when it disagrees with you.

[SidDithers]

91. Shocked. Shocked I am...nt

Sid

[joshcryer]

111. "adequate access to quality providers"

That's the key wording there, it means the HHS can change the rule at any time if it is not assuring quality providers. There's a discussion up thread about different procedures and pricing, and it's clear to me they will be watching this very closely. So that either 1) the lower quality providers raise the quality at the same price benchmark or 2) the higher quality providers lower the price to reach a middle ground.

[Egnever]

201. Yup

I agree with your reading of it. It is also something they are watching closely to ensure what the OP claims WILL happen does not happen.

[Whisp]

207. SURELY YOU JEST!!!!

The great sin of asking for opinions! omg. what a Bush!

Times are tough for the cat food commission believers so an OP that misleads again to bang and bash the President is there just as a release valve, I'm supposing. Maybe Obama can also take the blame for some of those strange medieval medical practices, like Boar Bile Enemas and Hot Irons for Hemmoroids. Hmm, why not.

[ramapo]

52. I would think this is for out-of-network coverage

I have a PPO but most all providers that I use are in-network. I don't see how this could affect in-network coverage since rates have been negotiated. Now if I want to go out-of-network I can almost understand the insurance company using reference pricing. Not that I like it but it is not completely unreasonable.

Now if this somehow affects any and all provider pricing, then this is horrible.

[Kablooie]

55. Sounds like a loophole the GOP could exploit.

[Doctor_J]

63. Obama doesn't care. He seems to be campaigning for a Republican congress anyway

this clusterfuck, the Walmart photo-op, the school corporatization, toll roads, net neutrality...all designed to depress turnout by real Dems this fall.

[woo me with science]

81. I suspect that's exactly what they are doing. It's worth reposting this:

Last edited Sun May 18, 2014, 11:03 PM - Edit history (1)

The two corporate parties work very hard to maintain the numbers for and the illusion of gridlock, even though they share the same goals in virtually every policy area important to the One Percent.

A party with strong majorities cannot continue to claim to be unable to respond to the will of the People.

http://www.salon.com/2010/02/23/democrats_34/

Tuesday, Feb 23, 2010 11:24 AM UTC
The Democratic Party’s deceitful game
They are willing to bravely support any progressive bill as long as there's no chance it can pass
By Glenn Greenwald

Democrats perpetrate the same scam over and over on their own supporters, and this illustrates perfectly how it’s played:

.... Rockefeller was willing to be a righteous champion for the public option as long as it had no chance of passing...But now that Democrats are strongly considering the reconciliation process — which will allow passage with only 50 rather than 60 votes and thus enable them to enact a public option — Rockefeller is suddenly “inclined to oppose it” because he doesn’t “think the timing of it is very good” and it’s “too partisan.” What strange excuses for someone to make with regard to a provision that he claimed, a mere five months ago (when he knew it couldn’t pass), was such a moral and policy imperative that he “would not relent” in ensuring its enactment.

The Obama White House did the same thing. As I wrote back in August, the evidence was clear that while the President was publicly claiming that he supported the public option, the White House, in private, was doing everything possible to ensure its exclusion from the final bill (in order not to alienate the health insurance industry by providing competition for it). Yesterday, Obama — while having his aides signal that they would use reconciliation if necessary — finally unveiled his first-ever health care plan as President, and guess what it did not include? The public option, which he spent all year insisting that he favored oh-so-much but sadly could not get enacted: Gosh, I really want the public option, but we just don’t have 60 votes for it; what can I do?. As I documented in my contribution to the NYT forum yesterday, now that there’s a 50-vote mechanism to pass it, his own proposed bill suddenly excludes it.

This is what the Democratic Party does...They’re willing to feign support for anything their voters want just as long as there’s no chance that they can pass it. They won control of Congress in the 2006 midterm elections by pretending they wanted to compel an end to the Iraq War and Bush surveillance and interrogation abuses because they knew they would not actually do so; and indeed, once they were given the majority, the Democratic-controlled Congress continued to fund the war without conditions, to legalize Bush’s eavesdropping program, and to do nothing to stop Bush’s habeas and interrogation abuses (“Gosh, what can we do? We just don’t have 60 votes).

The primary tactic in this game is Villain Rotation. They always have a handful of Democratic Senators announce that they will be the ones to deviate this time from the ostensible party position and impede success, but the designated Villain constantly shifts, so the Party itself can claim it supports these measures while an always-changing handful of their members invariably prevent it. One minute, it’s Jay Rockefeller as the Prime Villain leading the way in protecting Bush surveillance programs and demanding telecom immunity; the next minute, it’s Dianne Feinstein and Chuck Schumer joining hands and “breaking with their party” to ensure Michael Mukasey’s confirmation as Attorney General; then it’s Big Bad Joe Lieberman single-handedly blocking Medicare expansion; then it’s Blanche Lincoln and Jim Webb joining with Lindsey Graham to support the de-funding of civilian trials for Terrorists; and now that they can’t blame Lieberman or Ben Nelson any longer on health care (since they don’t need 60 votes), Jay Rockefeller voluntarily returns to the Villain Role, stepping up to put an end to the pretend-movement among Senate Democrats to enact the public option via reconciliation.

Of course it's deliberate. A string of ostentatious, highly publicized betrayals of Americans, combined with a propaganda machine working overtime to insult and alienate Democrats. Also note recent polling showing Democrats doing quite well, at least compared to Republicans.

This is your party in corporate collusion.

[Enthusiast]

150. I cannot see it any other way.

One can only bury the head so deep.

[yodermon]

177. It's even simpler than that: Dems are fine losing midterms so they can use repuke congress as a Foil

in the presidential.

"shellacking" nudge wink grin.

Then of course they blame the dirty fucking hippies for "not voting".

We'll see how/if OFA cranks up anything even remotely close to their presidential levels of operation. They slept thru 2010 and then proceeded to hippie-punch us.

Hillary will be more than happy to run against the horrible horrible no-good do-nothing repuke-controlled congress of 2014-2016

[SidDithers]

66. Spin it!!...

Sid

[WinkyDink]

67. Culling the herd.

[Cali_Democrat]

70. Thank you to all the people who debunked this OP

[Enthusiast]

151. There was not a single post that successfully debunked the OP.

There were a few ineffective blah blah blah attempts to debunk. But no substantive refutation.

[msanthrope]

187. Actually...this thread has not only been debunked, it's now great flypaper for determining

who understands things like math and economics.

[sobenji]

75. Every single insurance policy sold have these

Reference pricing, reasonable and customary, usual and customary, allowed amount....

Not a big deal if you use an in network provider. Bigger deal on out of network expenses. Has been around for 25 years.

[Jesus Malverde]

173. In the past they negotiated rates with health care providers.

Now they have no incentive to negotiate rates because they are passed on to the consumer and do not apply to the out of pocket maximum, It's complete madness.

[sobenji]

220. Of course they are still negotiating rates

I've worked in the individual health insurance market for 27 years and I have no clue what you're talking about.

[UTUSN]

82. That Woo-Democratic President!!!1 n/t

[Jesus Malverde]

88. The insurance racket is now a partner with government and is too big to fail.

If we lose the middleman who would pay the bills....

[bornskeptic]

205. If the insurer pays $1000 less for a procedure, $800 goes to the policyholders

in either reduced premiums or rebates, except in large group policies, where $850 goes to policyholders.
Do the people demanding single-payer really think the government would pay whatever the most expensive provider decided to charge for a procedure when other providers would do it as well for a third the price?

[Jesus Malverde]

217. This regulation change applies to even private employer insurance, not sure what the government

Paying has to do with this, insurance that previously was covered is not now, and it doesn't apply to the out of pocket max.

[blkmusclmachine]

94. This seems to be part of the plan. It's not a "mistake," or 11-dimensional chess. It's something

much worse...

[Skip Intro]

95. Why the outrage at the insurance companies? The Obama admin did this. The ACA did this.

It was part of a pre-arranged deal, clearly. Don't know how that could be missed. It is obvious. Possibly some failure to deliver the right mix of newly insured, thereby triggering some action like this. Some might say it is a backdoor bailout of the insurance industry.

Not sure what color the sky would be in a world where everyone was blind to, or refused to see, such a glaring reality.

But the thing is, the insurance industry is out to make a profit, as some hospitals are. The government, the Obama admin, who created the context and then handed this loophole to the insurance companies, is supposed to be out to help us.

[DeSwiss]

108. K&R

[woo me with science]

113. +100000 "...As is most of the population."

That's the key phrase there. We have much to agree on, even across party lines. Number One being that our elections and our representation have been stolen from us by corporate thugs.

Their biggest fear is that we will find that agreement...realize that they deliberately play us against each other....and realize that, together, we vastly outnumber them.

[nationalize the fed]

122. +a billion

Great post. Trying to get people to focus on the big picture can be infuriating, can't it. You're doing a super job, and it's not much fun.

[DeSwiss]

134. Their fear is that we'll wake-up one day.....

...and realize that we had the power all along.

- Literally, to make them stop we have to stop first.

''When the taste for physical gratifications among them has grown more rapidly than their education . . . the time will come when men are carried away and lose all self-restraint . . . . It is not necessary to do violence to such a people in order to strip them of the rights they enjoy; they themselves willingly loosen their hold. . . . they neglect their chief business which is to remain their own masters.''

~Alexis de Tocqueville, Democracy in America - Volume 2

[Enthusiast]

152. Plus one a whole bunch.

[L0oniX]

200. Double K & R

[merrily]

115. "this shows that an insurance-driven health system is doomed to fail."

It didn't take exceptions to figure that out. The left called it before the bill even went to Baucus. Only with exceptions granted by the Executive branch alone, and long after Lieberman's long overdue (IMO) retirement, the standard excuses don't work anymore. Not that they ever did.

The real question back in 2009 was not whether Obamacare was really about health care or affordable health care, but rather what would happen in the years after people ceased to think of it as the Affordable Care Act or as health care legislation?

Will we continue to limp along under Obamacare as before, with families going bankrupt because of illness, even when both spouses are insured? Or, will Obamacare be improved over time? Or will Obamacare be dismantled over time, like the New Deal and the Great Society, and used by the right as yet another of their examples that the federal government can't do anything that works as intended?

We shall see.

Whatever happens, I hope the part about kids under 26 and pre-existing conditions survive and are not "waived" anywhere. Social Security and Medicare survived, even after other New Deal and Great Society strides bit the rightist dust. And that ain't nuttin'.

[davidpdx]

132. I believe South Korea uses prices that are fixed for procedures as well

Though the actual health care company is quasi-governmental given it is a national healthcare program.

I find it interesting that people are still ignorant enough to believe the OP after it has been debunked. Progressives my ass....

[Jesus Malverde]

218. Some experts are concerned.

"The problem ... from the patient's perspective is that at the end of the day, that is who gets left holding the bag," said Karen Pollitz of the nonpartisan Kaiser Family Foundation.

Previously a top consumer protection regulator in the Obama administration, Pollitz said the administration ruling amounts to a substantial change for consumers.

http://www.startribune.com/lifestyle/health/259489931.html

[madfloridian]

141. With emergency surgery, no time to check out prices. This is indefensible.

Yet it is being defended.

[951-Riverside]

142. Thanks to Obama care...

I pay nearly the same rate as before for insurance and the state pays the rest. Before I paid $104 for the same coverage, today I pay $98 and the state pays the $140 increase from the insurance company.

Talk about a win/win.

[woo me with science]

148. The subsidies are paid by taxpayers to the corporate profitmongers.

The subsidies allow the insurance cartels to continue looting the country in a slightly more politically palatable way.

The middleman corporations are *guaranteed* their outrageous profits for merely standing between Americans and their doctors through mandate that every single American must purchase their outrageously overpriced product. By design, assistance to individuals is paid for by the people rather than demanded from the insurers. Their obscene profit margins are codified into law and guaranteed by ensuring that taxpayers are forced to make up the difference for those who cannot pay, rather than forcing the insurance cartel to offer an affordable product.

The mandate was the goal all along, designed by the corporatists who designed the program.

We need single payer.

[IronLionZion]

169. Thanks to Obamacare, I was turned into a newt.

I got better.

I find it hard to believe you have the same coverage as before.

Nothing has changed for your coverage or caps? Which state are you in and have you shopped around?

[Enthusiast]

144. I agree. We must have single payer.

We need a system that includes zero corporate influence. We need a system that is made up of advocates for humans, not advocates for profiteer pirate corporations.

We know what we want. A majority of the American people want this. Why can't we have this? Max Baucus for one. We can have single payer, still.

[cantbeserious]

153. The Oligarchs, Corporations And Banks Own And Control The Politicians That Own And Control Us

eom

[heaven05]

157. I am beginning to

wonder at the agendas of the MANY people on this site that continually snipe at the POTUS, and no I don't agree with everything this administration has done. Constantly the president is made the bad guy. He's not anywhere near as bad as the bushmonkey administration and I venture that he is somewhat better than billyboy clinton was. Yeah, I agree, we need a single payersystem but good luck on getting that passed with the clowns currently in charge of the legislative section/arm of our government. Just not realistic. But I find a lot on this site ignore the political/racial/corporatel realities of politics in this country in 2014 in all areas of discussion on this board. Get money and corporate influence out of our political system? NO POTUS or their administration will EVER be able do that without getting assassinated or at the least, impeached. Get real!

[DeSwiss]

159. My agenda?

Life, liberty and the pursuit of happiness.

Because I prefer not giving my power away TPTB, nor do I prefer for everything and everybody to remain in stasis. I would expect that a person who willingly runs for public office of their own volition, to fulfill the promises they make to get elected. But as in this case, they always seem to give to the common good with the large print, and then steal it back for the 1%ers with lawyers, fine print and loopholes.

As for the prospect of being killed: Firemen face that prospect every day, but still answer the bell. And if a person doesn't want to take that kind of risk, then maybe they should study history a little better. This isn't a new concept. Even Shakespeare wrote a few things about it. However, I realize that lying is now SOP in The New Oligarchy, so we've come to expect the lies from our candidates, and no real results from them that changes our lives for the better. But we like to see an effort.

That way we can show incredulity and outrage when articles (as per above) like this surface. Once again we have been betrayed. So what else is new? And why should we expect any better? Obviously we aren't worth it or they'd have fixed at least some of it by now. It only gets worse with these guys, you notice that?

- Oops, I forgot. ''Get real,'' right? Well, for me, I'm with Bartleby who said: ''I would prefer not to.''

[center]

[/center]

[heaven05]

161. I have no problem with the oligarchy

Last edited Mon May 19, 2014, 11:34 AM - Edit history (3)

statement. When the influence that corporate money wields in our political system is eradicated, our 'leaders' MAY be able to effect change as they promise. Until then, we cannot expect change in our, the 99%, favor. I said I question the agenda of those who constantly snipe and whine about our present POTUS without acknowledging the reality that change is only possible, at the behest of any president, only with the okay given by the real PTB, bankers, corporations and RW and some democratic party louts in congress on their payroll. You want to put it out there that you are paranoid about your agenda? I can't do anything about that. I agree with you that we are currently living in an oligarchy with a POTUS that might have been idealistic enough to believe that he could change things for the better for the 99%ers during his campaign. We'll never know. But to get real, it's not all his fault that he could not live up to all his campaign promises. I have watched our political system for the last six years and it's a crying shame what scum has crawled out from under the rocks, in the swamp of racial monied politics, to thwart someone I think has a good heart. You can blame BO, I don't. That's agenda.

[DeSwiss]

164. I don't blame him either.

But neither will I try to deflect or obscure the truth. Omission, commission, a lie is a lie.

For example: I'm not judging Obama for curtailing due process by creating kill lists and circumventing the courts and not allowing a citizen to defend himself in court and to be judge by a jury of his peers. But that has happened and I assume is still happening. This is not a lie. This not blame. This is fact.

No matter who initiated the idea, or compelled him to go along with it, or even if he dreamed it up all by himself. He owns it, because it's his presidency. And he's also tried to justify the need for it and assure us it wouldn't be abused.

So if we won't even acknowledge the truth of our reality, how can we ever hope to change it?

- Lies just begets more lies.......

[heaven05]

170. no deflection or obscuring intended

I have not agreed with all this administration has and is doing at the behest of the PTB. I voted for BO in hopes of being part of change. If he had another term I would vote for him again. Now you want pick out assurances by our POTUS that he hasn't, according to link, lived up to. Fine. Truth is truth. Where ever and on whomever it is placed. My president still has done more in six years in helping the everyday joe and josephine than all of our POTUS since Carter. That's the truth I acknowledge. You want real change? Get big money out of our political system and we'll have change. Until then all administrations will be limited by who they owe and for what reason(s). RW administrations because they pursue and grovel at the feet of big money, and democrats because overall we are too cowardly, and to be specific, in the halls of congress, to demand change. When OUR PARTY starts fighting for REAL change maybe we have a chance at change. The corrupting influence of big money, corporate or otherwise, in politics, is the devil to be dealt with. That's reality. BO can be the focus of failure for the whiners and detractors, to me he is a good POTUS limited by the system we have allowed to become reality. My opinion only, not trying to speak for anyone else.

[IronLionZion]

168. Some people think attacking these reforms will somehow bring us single payer

while failing to even consider the fact that reference pricing is used by many single payer programs as a way to have some transparency and fairness in the pricing of standard procedures and reduce costs. They refuse to even try to understand what the reforms are, or the possibility that it may be a good thing. They always assume its bad.

And of course there is the ever-present irrational accusation that "someone is getting something they don't deserve". On our side its insurance/hospital profit. On the GOP side, its patients are getting more benefits than they deserve. And they just assume that its bad for these people to get something, and falsely assume all of us should agree with that notion.

[heaven05]

171. thanks for the lucid clarification

[raouldukelives]

158. All of our forward momentum was wasted.

Or better yet, diverted to corporate interests. The people at the top in this country saw what was coming down the pike. The years of stories of health insurance nightmares and of people unable to afford any coverage. The film Sicko raised national debate to sky high levels on the issue. People were pissed, they had enough and were rallying to fix it.
But, instead of allowing the peoples voice in the matter, only the insurance corporations were allowed to speak.
None of this was by accident. It was, in essence, the very least that could be done while still being able to say, we did something.
We had two ways to go. More corporate or less corporate. There never really was any question on what they wanted to happen. The profits are protected, are now institutional. The battle to get everyone health insurance has been won.
The battle for health care still rages, only the momentum has abated.

[humbled_opinion]

160. Is Obama intent on making sure

That the talking points of the rightwingers regarding the ACA come true? Rationed care? Only the rich will receive the necessary medical treatments? We should be calling writing and forcing our reps to "crack down on price gouging by hospitals and Doctors"...

[Jesus Malverde]

162. The new strategy works like this: ...

Your health insurance plan slaps a dollar limit on what it will pay for certain procedures, for example, hospital charges associated with knee and hip replacement operations. That's called the reference price.

Say the limit is $30,000. The plan offers you a choice of hospitals within its provider network. If you pick one that charges $40,000, you would owe $10,000 to the hospital plus your regular cost-sharing for the $30,000 that your plan covers.

The extra $10,000 is treated like an out-of-network expense, and it doesn't count toward your plan's annual limit on out-of-pocket costs.


That's crucial because under the health care law, most plans have to pick up the entire cost of care after a patient hits the annual out-of-pocket limit, currently $6,350 for single coverage and $12,700 for a family plan. Before the May 2 administration ruling, it was unclear whether reference pricing violated this key financial protection for consumers.


http://www.startribune.com/lifestyle/health/259489931.html

WOW OMG!

[SammyWinstonJack]

166. WOW OMG! is right!

And the screwing over of the 99% by the 1% continues.

[ProSense]

172. Very misleading

Say the limit is $30,000. The plan offers you a choice of hospitals within its provider network. If you pick one that charges $40,000, you would owe $10,000 to the hospital plus your regular cost-sharing for the $30,000 that your plan covers.

From the same article:

It's been pioneered in California by CalPERS, a giant agency that manages health and retirement benefits for public employees.

CalPERS started with knee and hip replacements in 2011, steering patients to hospitals that had been vetted for quality and charged $30,000 or less.

Ann Boynton, the agency's health benefits director, said the program has been a success, with patients able to choose from about 50 hospitals.

"People do not feel like we went to bargain-basement hospitals where the quality is not good," she said. "The quality is the same, and in some instances, better."

What the snip at the top doesn't mention is that this is about going out of network.

[Jesus Malverde]

176. Sorry prosense this is about IN NETWORK providers.

Your full of spin. It's terrible and puts the burden on the consumer to negotiate with the hospitals.

By not applying to the out of pocket max, this change, will bankrupt thousands.

There is nothing in the change that distinguishes out of network providers.

It also affects all the existing employer provided plans. This is a billion dollar subsidy for the insurance companies. It's disgusting.

[woo me with science]

191. This is horrifying, and the article clearly states that it applies in-network.

Thank you for putting this link here. I think it should be an OP. This has the potential to bankrupt millions.

[Maedhros]

193. The true measure of the success or failure of the ACA

is not enrollment numbers or premiums.

The ACA will succeed or fail based upon whether actual health care is affordable or not.

Right now annual health care costs account for 17.6% of the GDP, or $8,233 per person. This is the highest in the world. For the ACA to be considered effective, we should expect a significant drop in this number - maybe to 12%, which would put us in a tie with the second-place country, the Netherlands. If we continue to spend more per person per year on health care costs than anyone else, the ACA will clearly have fallen far short of what is needed. Only time will tell.

(http://www.pbs.org/newshour/rundown/health-costs-how-the-us-compares-with-other-countries/)

Medical bankruptcies are another, related problem that is out-of-control.

The implementation of the Affordable Care Act might not significantly offset the number of patients who struggle paying for medical care.

This finding was part of a report by NerdWallet Health, a division of a price-comparison website NerdWallet. The report said unpaid medical bills are the biggest cause of U.S. bankruptcies, affecting 1.7 million people this year. Three in five bankruptcies are due to medical bills, according to NerdWallet.

The report predicted that about 20% of adults — 56 million under 65 — will have problems with health care bills this year. NerdWallet based its report on data from the U.S. Census, the Centers for Disease Control and Prevention, a Commonwealth Fund report and academic studies.

NerdWallet's conclusion that the ACA might not make a big dent in that number comes from the fact that about 10 million adults with year-round health insurance coverage are expected to have medical bills that they can't pay off in 2013. Many of the 14 million newly insured patients expected in 2014 as part of the ACA could struggle, because health plans continue to raise premiums and deductibles. For example, the American Medical Association's National Health Insurance Report Card, released in June, found that 23.6% of the amount of pay for doctors, as set by insurers, was paid out of pocket by patients.

(http://www.amednews.com/article/20130708/business/130709932/6/)

One thing is certain: adding additional out-of-pocket expenses related to "reference pricing" will NOT help alleviate either of these problems.

[woo me with science]

196. [phone]

[Maedhros]

197. The ACA is emblematic of the failings of the Democratic Party on a wider scale.

When crafting legislation, the Democrats prime concern is "what will the corporations allow us to do?" That relationship is the exact opposite of what it should be.

[davidthegnome]

165. Greed, money, politics...

I don't know about the rest of you, but this sure isn't what I voted for.

This last year I've been working my butt off to try to get out from under some debt, maybe think about going back to school some day. It's all rather funny, in a sad, twisted sort of way. Eight dollars an hour pays for the car and for dinner most nights, but it doesn't pay for much else. Most of the plans under Obama-care have such high deductibles (to me, at least) that I just kind of chuckle at the irony when I look at them. I wanted health insurance, well, now I've got it... just can't afford to use it.

Granted, 500 bucks isn't a lot of money for some people. For some people, 5,000 isn't a lot, for me, either number is beyond my means. I can't afford to put away more than 20 bucks a week for my son to (hopefully) go to college one day. Debt collectors from student loan companies and collection agencies holding my medical debt are sending me all sorts of love notes. It's laugh or cry. I'd rather laugh at the absurdity of it all.

If I get sick, I will not go to a hospital - I can't afford it and I refuse to let my family bankrupt themselves paying for my care. So in the event that I get some sort of serious illness, I'll do what I can to manage it myself, failing that, I suppose I'll die quietly.

I don't really blame Obama, but I do laugh at the idealistic naivete I used to cling to. That this administration, this brave man with the audacity to hope, was going to fix things. Frankly, I think they're beyond fixing.

Too much money, too much power in the hands of the very few - and the rest of us are too tired from working to pay for their corporate welfare, working for the very same people our tax dollars benefit the most.

I'm overworked and underpaid - which is the same sad story that most of us have. We're not going to get single payer, or an increase to the minimum wage, or any of the things we want, until enough of us get angry enough to stand up to the rich pricks who have everything. This little policy here? This little loophole? I expect that it's a sign of things to come. They're not going to stop until we're all working 80 hours a week without benefits, until none of us can retire anymore, and are forced to work for them until we die.

I'm tired of voting for rich people and working for rich people. When we give them what they want, they squeeze even harder.

[cbdo2007]

174. This is all alarmist conjecture, and is really no different than the way the system is now.

Good job getting everybody all worked up again over nothing.

[Jesus Malverde]

180. It's very different

Insurance companies can claim to include hospitals in their network, without having to negotiate rates.

It applies to all plans, ACA or private employer provided.

It does not go towards the out of pocket maximum. This change will bankrupt families with insurance.

The health care provider has no incentive to cut rates because they can go after the individual consumer for the uncovered difference.

[Maedhros]

194. Exactly: the ACA is really no different than the way the system is now.

And the way the system is now is despicable.

[JEB]

182. Too much bullshit to endure.

If you don't die of disease, you'll die fighting your way through a corrupt, greedy and malicious health system. Fuck it, I'll live till I die.

[Romulox]

183. Obamacare both guarantees 20% margins to the for-profit insurers AND $2500 savings to each American.

But in the case both of these objectives cannot be achieved, the latter will have to go.

[IronLionZion]

198. No it requires that 80% be paid out for care or paid back to the customer.

The 20% includes operating/admin costs. Profit doesn't mean jack to non-profit co-ops btw.

Reference pricing is an attempt to have transparency in the costs of routine procedures so patients can compare providers.

And either way, no matter what flaws are in the PPACA, none of it will get amended without the Dems retaking congress.

[woo me with science]

219. Yes, this has been extensively discussed here. They have *guaranteed* their obscene profits

by writing them into the law.

[BlueJac]

184. Fucking thank you Obama..

who the fuck do you work for....shit I lost my mind for a second. Big business of course. Yes we can.........ROTFLMAO

[woo me with science]

192. PLEASE DO NOT MISS POST 162 by Jesus Malverde.

The example is horrifying, and the linked Star Tribune article clearly states that the rule applies in-network.

[GoneFishin]

204. Screwed again.

[pa28]

209. No single payer according to Obama's HHS nominee.

(Reuters) - U.S. Health Secretary-nominee Sylvia Mathews Burwell sought to allay a major Republican worry about Obamacare on Thursday, telling lawmakers that President Barack Obama's reforms would not lead to a government-run single-payer healthcare system on her watch.

http://www.reuters.com/article/2014/05/08/us-usa-healthcare-burwell-idUSBREA4703L20140508

[woo me with science]

210. They've got the corporations' backs.

Not to worry.

Too bad ordinary Americans can't buy that quality of representation.

[pa28]

212. To me that looks like the end of the state single payer waiver.

Which was suppose to be a sneaky trojan horse proving Obama had *our* backs by allowing states to create their own single payer system.

What I'm clearly getting from her statement is that she has no intention of renewing it for legislation after 2016.

This administration is really just hired management for corporate interests in case anybody out there has not figured that out yet.

[woo me with science]

213. "has no intention of renewing (the state single payer waiver) for legislation after 2016."

I believe you are correct about the intentions of this administration.

[Blue Owl]

211. Blessed insurance...

[colsohlibgal]

215. Just Another Betrayal

For profit healthcare is a travesty. You really need another overhead cost to hire a few office workers and a boss or 2 making more than they do but not 300 times more. In other worse they way it used to be not so long ago.

Oh - and colonoscopies - and I was amazed to learn this - if you have a polyp removed, no matter how small -even if your insurance covers this 100% you'll be on the hook for this going forward because from then on they'll term it a medical procedure - even though it's the same test exactly. This happened to someone in my family and also to another acquaintance. Unbelievable and this move by Barry just moves more cash from those who often can't afford it to billionaire CEOs.

[alarimer]

222. We need price controls for everything in medicine.

Limits on what any hospital/doctor/clinic can charge for anything. It needs to be standardized across the country.

And doctors should not be able to refer patients to hospitals, clinics, surgical centers in which they have a financial stake.

[ProSense]

224. What an

embarrassing thread.

The misleading information about the "reference pricing" rule.
http://www.democraticunderground.com/10024972599