It’s hard out there for a heath care profiteer:
The Senate Finance Committee is pressuring hospitals and insurers to follow the lead of the pharmaceutical industry and pony up to help pay for health reform, industry insiders say.
“They are shaking people down, and it’s fair to say that includes a broad range of health care stakeholders,” said a health care industry insider, who asked for anonymity to speak candidly without fear of retribution. “They’re playing hardball, and they’re serious about it.”
[…..]Policymakers are also considering costly administrative changes, such as forcing insurers to standardize enrollment forms and create a single portal for doctors to use when dealing with the industry’s many companies.
This amount of bureaucratic crap Americans have to go through to get health care sickens me. How on earth can anyone whine about government red tape when, right now, every fucking insurer and hospital has their own crazy set of forms you have to fill out (forms which usually only exist in hard copy or Microsoft Word form, btw)?
I’m less and less convinced that we’ll get anything decent passed this year. I think we’re looking at a 20-30 year fight to put American health care on a par with health care in other western countries.
Update. Commenter DBD has some interesting inside info on how the processing of claims and enrollment forms works.
Zifnab
Well,
JohnDougJ (*sigh*), that’s just the free market at work. If hospitals were meant to have simple forms and insurance companies were intended to have straight forward bureaucracies, the free market would provide. Clearly, the customers are demanding these conditions.BDeevDad
Insurance companies usually only pay 20-40% of any hospital bill. The system is so messed up right now and consumers are overpaying billions already because they can’t understand their own policies. At least one of John’s Senators is shedding light on this.
linda
if it doesn’t happen now, it will never happen.
Davis X. Machina
How on earth can anyone whine about government red tape when…
Because it’s government red tape. There’s a theological argument involved here — to wit, everything private is better than anything public — that cannot be refuted with evidence or subjected to rational debate. And the premise must be supported, if necessary, with your money.
It has taken 40 years to build this argument up to the status of revealed truth it has today, and I fully expect it to take at least that long to dismantle. At a minimum, most of the people who have been trained to believe it have to die.
For how long has the GOP been ‘the party of fiscal responsibility’ in the absence of any evidence for that contention?
Max Planck said of physics, “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it. ”
Politics works roughly the same way.
PeakVT
Won’t somebody please think of the CEOs! They might have to take a pay cut!
maya
The new Healthcare Industry Complex motto:
The only thing we need to reform is reform itself.
Dr. I. F. Stone
Where’s your factual support for the absurd conclusion that US health care ranks lower than that of other western countries?
tofubo
while the health care debate is taking place, all the DFHs can go galt, you don’t even need a plane
http://www.galtfestivals.com
Proportion Wheel
One aspect of this that I seldom see discussed is the fact that every large hospital or other provider has its own separately negotiated contract with each major insurer. What the provider gets paid for each of the gazillions of different procedures is controlled by these contracts, which are of course incredibly complex and full of intentional ambiguity. Often, and contrary to common myth, the contracted payments from private insurers are less than what Medicare pays.
Insurers employ armies of staff and proprietary software programs to find ways, within the letter of the contracts or not, to deny coverage or minimize payment for it. Hospitals employ armies of staff to try to get the most payment from the insurers. My wife spent many years as a member of one hospital’s reimbursement army. Our medium sized (around 500 beds) non-profit teaching hospital’s business office employs I would guess well over 100 people chasing insurance payment (I don’t know the figure but they fill a substantial 3-story office building).
This is a far bigger inefficiency than is commonly known.
gex
Oh goodie.
Zifnab
@Proportion Wheel: Hey, preach it brother. Half my job in IT is keeping the wheels greased on the Insurance Department. We produce new reports – not “new report” as in paper copy, “new report” as in completely automated report – on a near daily basis, just to stay ahead of the insurers.
Nothing makes our clients swear like the private insurance industry, and I can’t help but think their biggest dread in a public insurance company would be it having too many similarities with it’s private contemporaries – except, you know, bigger and more powerful.
DBD
We actually already have standards for every kind of transaction between providers (doctors, pharmacies, etc…) from submitting a claim, to inquiring about member and benefit status, claim status, etc… These standards are set by the government under the HIPAA standards. You could mandate tomorrow that all providers must submit their claim forms in the exact same format through one single portal and probably 90% could be doing it within six months. (it would mainly be a problem of changing computer code for where to send the transactions rather than how they are formatted)
The problem comes from the 10% of providers who don’t use electronic claim submissions. Many of these are small doctor’s offices and clinics. The insurance companies have been trying to force providers to use electronic submission forms, which all have to be HIPAA compliant, for years now because it’s so much cheaper. But many doctors either won’t, or can’t afford to switch.
I work in the computer department of a mid-sized, regional, not-for-profit health insurance company. We get 500,000 paper claims a month. Each one has to be scanned, OCR’d, checked against the image for errors, and then it can be put into our adjudication system. Some won’t work this way and have to be keyed in from paper, or from the image itself. As you can imagine, this takes a whole lot more people than a big old batch of electronic claims being submitted at once and handled automatically.
This 500,000 amounts to about 5-8% of our claims we receive each month. This costs a huge amount more than the equivalent number of electronic claims.
So, yes, if the government could mandate all claims must be submitted electronically through a single portal, it would cut costs in the whole system. It would also be a huge nightmare to figure out whose claim was whose and send the right claim to the right insurer. We’d also have to help smaller providers to switch over from faxing or mailing in paper claims to have them submit it electronically. (and no, faxing is not the same as electronic, we actually print out our faxes and then treat them as a paper claim. Don’t ask)
Personally, even though it may mean that my job goes away, we’ll never get the efficiencies we need until there is only one payer, and all providers take advantage of the speed and accuracy of electronic claims. And I don’t think we can afford to wait ten years. By then it will be too late and the US will be left behind as a second-rate country.
DBD
garyb50
@Davis X. Machina: Sad but true. Only death will set us free.
@Proportion Wheel: And multiply that by what? Ten Thousand hospitals? Fifty Thousand? What a freaking nightmare.
Edwin
@Davis X. Machina: Right on point. Conservatism has become a religion that ranks with Scientology in terms of irrationality and the zeal of its adherents. As bad as health care is today, I’m afraid it will have to get a lot worse before there is any meaningful change.
Davis X. Machina
Part of the public-option problem is the very word ‘public’.
“Public”is the ‘n-word’ of the Reagan-and-after era. It’s a dog-whistle. The right has spent a generation poisoning the very word.
Public transportation. They ride it — so we can’t expand it.
Public housing. They live there, ditto.
Public education. They use it — they screwed it up — must replace it.
Public works.They will get all the jobs, what with the affirmative-action and prevailing-wage and must-hire-union laws.
Public defenders’ office. Keeps them out of prison, on technicalities, mostly.
And so forth.
If, per Mencken, Puritanism is the haunting fear that someone, somewhere, may be happy, then modern American conservatism is the haunting fear that someone colored, somewhere, may be using something bought with my money.
(Public television is the only ‘public’ I can think of that’s poison because of (liberal) white people.)
Keith
Here’s my medical insurance story o’ the day: Last week I needed to see a doctor “tomorrow”, but I couldn’t find my insurance card. So I call Blue Cross, spend 15 minutes on hold, etc. to find that I’m not in their system – not by name, nor by SSN. They tell me because they are so big, I need to know the *specific* BCBS company that I’m with to find my info. So I call Blue Cross of Texas…same thing. Thinking “well, my company is HQed in Florida, so lemme try BCBSFL”. Same thing.
So by then, I call my company’s HR dept, and am given a phone number to call. Apparently, I *am* with BCBSFL, but they don’t have my info…some 3rd party admin’ing my group does. And I get my insurance info plus a replacement card mailed to me.
Next day, I get to the doctor AND LEFT THE INFO AT WORK. So I have the lady go to the 3rd party’s web site and call the only number on the site: their web site tech support line. As it turns out, the only way they’ll even give me the number to call to get the info again is if I register on the site and login (I already had, but the snail-mailed me the pin #).
When all was said and done, I paid the doctor’s bill out of my own pocket.
4tehlulz
This thread makes ADP sad; will no one
outside Congressthink of those dependent on the currentrotting carcasssystem?4tehlulz
@Keith: I believe the technical term for that at Blue Cross is “JUST AS PLANNED”.
Betsy
I made the mistake of reading Ruth Marcus’s piece about this in the WaPo this morning, and saw this:
Um, last time I checked, insurance companies were not members of congress. Why the fuck should their “line in the sand” make a damn bit of difference? In theory, at least, Congress doesn’t need their go-ahead to pass legislation. The fact that this might not be true in practice makes me sick.
The Grand Panjandrum
Your company gets 6-10 million claims per month?
PGE
@Dr. I. F. Stone: We’re ranked somewhere in the mid 20s. You can google it yourself. “You didn’t provide a link to some fact that’s completely non-controversial, except to wingnuts” isn’t an argument.
Leelee for Obama
If things are not settled in this political year, I think that health care should become Medicaid for all by Executive Order. Some of us will pay a premium, some won’t and we’ll wind up Single Payer by attrition. Please note that all of the people in this country will need some kind of health care sometime and as the costs escalate and the coverage shrinks, more and more people will qualify for Medicaid. Otherwise, Americans will start dying like flies from curable problems and the Marches on Washington will look like Tehran.
DougJ
Here’s one example.
I’m busy today but otherwise I could probably provide with you a few hundred other examples.
The Moar You Know
@PGE: 37th. Dead even with that bastion of advanced technology and human happiness, Serbia.
BDeevDad
What the health industry and members of Congress are failing to grasp is our current health care system makes our business’ less competitive. When industry starts lobbying Congress on the other side we might start seeing real reform because these international companies actually see the differences in their cost structures right now.
PGE
A co-worker told me this story a year or so ago: He needed to have something or other done, so called the insurer to make sure the hospital he was planning on going to was covered. He was told it was. To make sure he wasn’t talking to an idiot, he called again, spoke to someone else, and was told the same thing. Feeling confident he was covered, he went to the hospital. When he got the bill, he was charged hundreds of dollars because, of course, the hospital was part of the plan but the radiologist reading his xray wasn’t. Basically, the only way to protect oneself from this sort of thing is to spend a week investigating every single person who might be involved in your care. Before you know who they are. This sort of crap is one of the many reasons I’m in favor of single-payer.
Davis X. Machina
@PGE: 37th. Dead even with that bastion of advanced technology and human happiness, Serbia.
Yeah, but with our 15.2% of GDP — second only to the Marshall Islands among UN members — we’re not just buying an inefficient and incomplete health care system, we’re buying freedom!.
And you can’t put a dollar value on that.
PGE
@The Moar You Know: Cynical as I am, it’s never enough.
Jay B.
Moar,
Shit, wars have been started for less down around there. Serbia and Slovenia are two different places. And one is a nice little pocket-Alps and sea country without the martyr complex.
Svensker
@DougJ:
Yeah, right, WHO. An America-hating UN group. They just put France up first because they’re lefties. Everyone knows We’re Number One. Also.
Wolverines!
The Moar You Know
@Jay B.: Starts with an “S” and ends with an “A”, I don’t have to know this shit I’m an American!
Kidding, of course. The reason Serbia’s not on the list is because we’re tied with them. Forgot where I picked up that nugget of knowledge. Slovenia is one step below us and our pals in Serbia.
I know the difference, dated a Serbian girl for a while. They’re a little…nationalistic. And by “nationalisitic”, I actually mean “bat shit insane”.
slippytoad
@Moar
You forgot to mention that the US’ system is 2 steps ahead of Cuba. At least we’re still fucking better than Cuba at something.
The Moar You Know
@slippytoad: What’s killing me is that we’re one step below Costa Rica. Have any of you been to Costa Rica? It’s like Tijuana. Fewer Los Angeles gang members, but otherwise just like TJ. That a third-world shithole like Costa Rica has better health care than the United States is fucking humiliating.
grampyoe
It appears that many are stunningly superficially aware of the costs of health care, OR are blinded by isms. The right to health care is inherit in any modern democratic state. The ability to manage this right is the crux of the argument.
If you can argue that someone does not have the right to health care in any modern state – God love ya but you are an idiot. Most will say “how can we do this”?
Single payer – with continual voice of the people (aka: democracy) is the only real answer. All else is an expression of trying to put taxpayers money into the pocket of profiteers.
Ask yourself, “do you think it is reasonable to have a corporation (whose only desire is profit) making your health choice”?
A single payer option eliminates that. Only choice is what is right for your health between you and your doctor.
All other argument is banal reasoning to introduce greed into your health choice.
A Mom Anon
@Dr. I. F. Stone:
It’s not the care itself,it’s the INSURANCE and the delivery of health care that’s at issue. We have a pretty good hospital/provider infrastructure. It’s having affordable access that’s at issue. No one should lose their home and any hope of a future because of illness or injury.
PGE
@A Mom Anon: While there’s a lot right with our healthcare infrastructure, one thing that’s declined significantly in the last several decades is our spare capacity. If we have a genuine pandemic or some such, we’re f**ked.
A Mom Anon
@PGE:
Is this because we have fewer people coming out of med school now? Too many specialists and not enough people going into general practice(where preventative care starts)? With fewer docs there’s no reason to expand the infrastructure. I know alot of places are underserved(rural areas especially),but I remember reading somewhere that we have fewer docs going into GP because the cost of medical school is insane and to pay off school loans it’s better to specialize.
A Mom Anon
And now I’m in moderation because of the word spec ial ist. This commenting software or whatever the hell it is blows large dino weenies.
ETA: never mind.
Edwin
@PGE: At my advanced age, I thought I had seen it all. But every day I plumb new depths of cynicism. At this point, I’m pretty sure that the “United States Government” doesn’t exist; it’s merely the PR arm of the banking and insurance industries. That’s why our elected representatives are more and more cartoonish – they’ve become the equivalent of Caligula’s horse.
Weedhopper
There are too few primary care physicians because they’ve been relegated to the far low end of the pay scale. A doc gets paid more for putting in stitches than for diagnosing a heart attack. It makes no sense for a medical student to leave school with crushing debts to be a family physician when she could make three times as much or more as a sub-specialist.
I know because I’m married to a family doc. She doesn’t do it for the money…
SGEW
Slovenia is a lovely little country, adorable even. I’d never been to a nation that could actually be described as “twee” before I went there (their national animal, however, is simply very very weird).
Serbia, on the other hand, has probably never been called adorable.
PGE
@A Mom Anon: Actually, I was talking about hospital beds, not MDs. The drive to make the whole system for-profit has virtually eliminated spare capacity. The invisible hand at work.
Jinka Jinka Jinkadoo
@A Mom Anon: Mom, I’ve talked to a few primary care docs when I was considering going to med school; all the factors you mentioned are true, but we can bring insurance companies into this discussion, too. If you are doing an open-heart surgery, you can charge a bundle of money, and you have to get clearance from the insurance company for ONE procedure. And since you aren’t doing that many of them a day, you have to get fewer approvals.
Now imagine you’re a primary care doc. You see maybe 30 patients an hour. You get paid almost nothing for seeing them, and everyone one of those patients is going to mean a fight with an insurance company. And lets say you order a test, which you get paid nothing for — you aren’t doing the work — but you are AUTHORIZING it, so you have to fight the insurance company for THAT.
Now imagine you’re out of medical school, you have a ton in debt. You can choose a specialty, which means you will spend more time practicing medicine, you will not have to work as many hours, and you will pay of your debt and make money. Or you can go into primary care, where you will spend half your time on the phone with insurance companies and looking at forms, and the other half with your patients, and the other half arguing with your spouse about when you’re going to be able to take a vacation and how much longer the civic is going to last. It’s an obvious choice.
Oh, and also… specialists tend to have newer procedures they can charge a lot of money for initially. The rate is set by how long it generally takes; as the docs get more efficient, they still collect the same rate as if it was taking longer. It takes a while for the reimbursements to catch up to the new way of doing things. So that’s a factor too.
I’m in Argentina right now, and all the doctors are educated in public university and have no debt when they come out. Being a doctor is still conseidered prestigious, but they work all their lives and relatively humble compared to their North American counterparts.
Martin
There’s a decent chance you work for my stepfather, who is a C-level at a mid-sized, regional, not-for-profit health insurance company. He describes exactly what you do, and notes that in his region, the problem is a bit worse than many regions due to it mostly being rural with a lot of local doctors who want nothing to do with a computer. Further, in some dustbowl town, that computer might be replacing a job for a town resident, which are hard to impossible to come by (though if everyone’s costs went down, maybe everyone could afford to employ some new services).
That said, computers are cheap. Get the government to cover the outlay based on income of the health provider (some are very low income – think of an at-home nurse in a rural area, who still needs to bill insurance) and provide some training. The economy would benefit, and it’d create some jobs and be an excellent stimulus move (since we still have unspent stimulus money). It’d be a move that would help the entire system – public and private.
My stepfather’s does. And he’s not in a large urban area, either. Think of one emergency procedure and how many different claims get filed – from the ambulance to the anesthesiologist. That could be 10-20 claims right there, depending on how things are set up. Every filled prescription is a claim. Every nursing/convalescent patient is a monthly pile of claims.
My aunt recently contracted west nile (she recovered fine) but she was laid up for almost 2 months before she could go home. Emergency room visit, spinal taps, zillions of tests, specialists, equipment, lots of meds, a few weeks in the hospital, more weeks in the nursing facility, walkers, gadgets to help hold off pneumonia and this and that, stuff she needed at home to continue the recovery for another 2 months before she could return to work. I wouldn’t be surprised if there were well over 100 claims filed just for her.
The reality is that patients really don’t have to deal with the crushing burden of paperwork. Your pharmacist has your insurance info and *they* do the paperwork, etc. It’s still too much for most people (when isn’t it?) and the paperwork often comes when you are least able to deal with it, or when family needs to do it for you, but the system has done quite a bit already to lighten the burden on the patient.
The flipside to it is that the system hasn’t necessarily made things more efficient in the process (it has, but not enough). What might have taken you 15 minutes to fill out, still takes someone else 10 minutes to fill out, but now you need to pay that someone else through your premiums, and for a lot of Americans, that someone else gets paid more than they do – so averaged out, they’re losing money which is why they probably don’t have health insurance – they can’t afford to pay someone else to spend that 30 minutes. HIPAA intended to fix that, and as PGE notes, that has happened to a certain degree, but the full savings won’t be realized until the providers can (effectively) shut down their paper operations entirely. HIPAA has failed on that front since that should have happened years ago but didn’t – too many hold-outs. The government needs a new effort here.
inkadu
@Martin: Why should doctors spend money so that insurance companies can save money? That, I think, is the only reason it hasn’t happened yet. Why can’t insurance companies mandate electronic forms? Is it illegal? And how many new doctors are refusing electronic filing? Is it just the old guys? Maybe, like conservatism, this will be solved with death. And if this is such a horror for insurance companies, why don’t they agree to provide the luddites tech support for a few years?
Mickey7
I’m inclined to agree with Linda above. If we can’t pass meaningful reform under the current circumstances, it is unlikely it will ever happen. What really bothers me is the lack of a strong, organized counter-assault on the fear-mongering about “national health care” coming from the other side. Let’s face it–the current system with no public option is nothing more than passive eugenics, selecting out the sick and weak for untimely death due to lack of access to care. Why we have continued to tolerate for so long is beyond me. I work with medical professionals from all over the world and have contact with sick individuals caught up in this mess every day. Our system is a shameful embarrassment. Period. I think we need to ratchet up the rhetoric and call our system what it truly is; private industry sponsored eugenics.
http://mickeymusing.vox.com/library/post/open-letter-to-tom-daschle.html
Iron-Ack-Ally
Sorry for the long post.
A while back, I worked for a software company dealing with electronic claims submission. In the 80’s, Medicare and Medicaid were swamped with insurance companies, clinics and doctors all using different formats, billing codes, and procedure codes on all their claims. This cost a fortune, so the feds developed the UB92 form (Universal Billing 1992), which standardized all the codes and format. The UB92 (since replaced, apparently, with the UB04) is kinda like the HUD-1 when you get a loan – all the numbered boxes are in the same place, representing the same thing no matter where in the country you are.
Standardizing the format allowed for electronic submission of claims, maximizing efficiency in itself but allowing for computerized troubleshooting of claims prior to submission (you’d be amazed how many times the hysterectomy procedure code pops up where “gender=male”), This prevented submission, rejection, and resubmission of the claims which drags on for months. My company charged on a per-claim basis for less than the cost of a stamp, and you get you paid in 2 weeks instead of 6 or 8.
If you tell doctors they will not get paid on any paper form they submit, only electronic, I bet most switch. If they can’t afford it, it seems to me insurance companies have an incentive to one-time buy the clinic/doctor a crappy $500 computer so they can, with the money coming from insurance company savings on (likely outsourced) scanning/OCR capability, manual key-(re)entry of the claim, etc. that DBD describes at hefty monthly costs. In the late 90’s, I was working with some of the biggest hospitals in Texas, and some of the billing departments – the financial engines of the whole enterprise – were running our software on 486 computers with no problem. All that’s needed in this case is a clerk, internet connection, and bookmark on the Claims Submission Portal page.
I fail to see how this is a problem. Texas and most other states have a webpage tracking the status of claim adjudication. When you log in, you are only shown claims related to the provider code of your login. It’s not rocket science; while DBD makes some good points, the 10% he’s referencing currently pay someone to fill a claim out longhand. Instead, this person is now required to submit through a single, standardized web portal. This person’s login automatically tells the system who is submitting the claim.
As a doctor or clinic manager, I can track how often my billing specialist enters the wrong insurance provider code, the resultant number of rejections, days(/weeks/months) in compensation delay, and the amount of money flat lost due to failure to bill the procedure within the required amount of time (usually 90 days, IIRC?). If my billing specialist sucks, I fire their ass and get myself who can read insurance provider code chart correctly, with 99% accuracy, and get myself paid weeks more quickly.
inkadu
@Mickey7:
I’m not so sure. This is the first serious policy discussion we’ve had about a public option that I can remember. Clinton didn’t try it, and I was too young to pay attention to Carter, so maybe you oldsters can refresh my memory.
What’s clear is that the public option has already won the public debate. Years of experience with the shitty private system has immunized most of the public to any fear of “government bureaucracy” and “government selecting your care.” They know that government can’t be much worse than their insurance company, and realize that the government plan isn’t going to drop them when they are sick.
What’s left, I think, is enough anger and grass-roots organizing (and Democratic house-cleaning) to overcome the substantial entrenched interest; the noise machine, for all it’s huffing, puffing, and disasterizing, hasn’t seemed to have had any impact on the pulic.
inkadu
@Iron-Ack-Ally:
Which is exactly why we should include a unionizing job-protection waiver to any electronic standardization bill.
KG
I still like the idea of Health Savings Accounts, but the advocates of that idea fucked it up, so I’m guessing it’s not going to see the light of day again. As for the current system, it’s also fucked, besides making a bet against yourself (that something bad will happen – and yes, I know that something bad can happen, but statistically, it’s still unlikely) and the house gets to determine if something bad happened to you, just how bad it was, and what the payout should be – all after the fact. The insanity of insurance schemes just baffles me. As for the public option, as long as it’s not mandated, and has to compete fairly (meaning compliance with the same regs as the private companies), I don’t see much of a problem with the government as market participant.
flavortext
The cynic in me remembered that the first attempt at creating at universal healthcare system in this country was in 1949 as part of Harrry Truman’s fair deal. It’s been 60 years already, what’s another 20-30?
Ron Chusid
“If they can’t afford it, it seems to me insurance companies have an incentive to one-time buy the clinic/doctor a crappy $500 computer so they can”
The computer hardware is a tiny portion of the cost of electronic billing. The real expense is the software and the ridiculous monthly charges for support. Fortunately I have enough computer knowledge that I have been able to survive for years without paying for support, but most doctors are not able to do this. I have also been able to keep the old version of my software going with some modifications, saving me the over $20,000 it would have cost just to update to a newer version.
While there has been more standardization of claims, the system has become more complicated in other ways. In the past I was able to submit electronic claims directly from my computer system. The vendor stopped supporting this function and it is now necessary to pay a clearing house monthly to convert the output from my computer system to the correct format and submit the claims electronically.
Someone might buy doctors “a crappy $500 computer” but this won’t be enough to enable them to bill electronically.
On the other hand, the idea of insurance companies buying doctors a computer is not at all far fetched. When Blue Cross set up a system to transmit prescriptions electronically they threw in a $500 computer to those of us who adopted the system. They also waived charges the first two years, but I wonder if they will recuperate their $500 or more when we have to begin paying to use the system.
Dennis-SGMM
…the house gets to determine if something bad happened to you, just how bad it was, and what the payout should be – all after the fact.
Some years ago my then one-year-old car was demolished (With me in it) by being rear-ended on the freeway by a one-ton truck whose driver hadn’t noticed that traffic was at a dead stop. The car was already paid for because I was making good money back then and I had full coverage insurance. Other than a sore back I was mercifully uninjured. The two insurance companies (Mine and his) concluded that what happened to me was worth exactly two thousand dollars – five hundred of it because I’d recently replaced the original equipment tires on the car and I still had the receipt for them. I realized then that the purpose of insurance is not to in any way make you whole or even make you better should Bad Things happen. The purpose of insurance is to make you think that you’ll be covered right up until the second that you actually make a claim.
inkadu
@KG:
I am more interested in your discussions on immortality than on health insurance.
@Ron Chusid: When is the billing software going to be open sourced?
Martin
I agree. But if the government directed some stimulus money toward the effort at the same time they passed a public option, it’d work all-around.
No, and in fact, HIPAA comes close to mandating that they MUST use electronic forms. The problem is the long tail of the health care industry – consider a midwife in the middle of Alaska. She’d be better off working as a cash business than trying to plug into a national system if it’s an out-of-pocket expense. I’d argue that the public would benefit if he/she was plugged in and the govt. should help that along.
Some. Some too is that a lot of places are marginally profitable and some health workers make very little money.
Some do, but if this is their first computer you can imagine how difficult that support would be – might be better to stick with the paper. It’s a bit of a nasty problem. But for a government looking to give people work, it’s also an opportunity for them.
Martin
I might be more social!st than most, but I’ve never understood why the IRS would mandate that everyone submit a 1040, and then leave only companies like Intuit to make the software to submit the form that saves the IRS so much money in processing. Why the IRS didn’t just have their own web-based tax software from the outset strikes me as one of the stupider examples of how this government runs.
If HIPAA is mandating the format of the forms, and Medicare is out there and possibly a public option, again I don’t understand why the government wouldn’t become the provider of the billing software. If they wanted to preserve some degree of capitalism here, contract with 3 companies to produce the software and let doctors choose among them and have the government pay the companies based on utilization, like a utility.
Fulcanelli
Just as an example of the fraud and waste that existed in the past and may yet still exist…
In the early 1980’s I worked as a order filling clerk in the pharmacy department of the largest hospital in my small state. I would fill the daily orders of various IV solutions, dialysis fluids, etc. that were sent down from the floor unit secretaries who stocked the store rooms on the respective floors and the various ICU units. Each morning I was sent the orders for each floor, I’d fill them and deliver them on a cart to each unit. There were four units per floor (1N, 1S, 1E, 1W), and each unit had I believe 20 beds. Remember… 20 Beds = 20 Patients, right?
This was back in the days when patients were issued what was called an addressograph card upon admission. A stamped plastic plate with their name and address and an admission number was generated and was used to track the billing of meds, fluids and procedural equipment, etc. like the old credit card machines with the carbon backed slips.
Most 20 bed units would send just ONE addressographed order form per day. Just ONE patient account was used to replenish the entire 20 bed unit’s supply used from the previous day. This was often times GALLONS of IV solutions and dialysis fluids and dozens of individual, disposable procedure kits. All billed to ONE person’s account.
I brought this fact up to my supervisor and was told “don’t worry about it, it’s not your concern” and he quickly walked away. I never brought it up again. Draw your own conclusions.
inkadu
@Martin: Wow. A midwife in the middle of Alaska… I doubt she even has internet access… but that’s a rather extreme case. From what I’ve seen, individual, stand-alone medical practices are being replaced by group clinics. That helps. The only people I can think of that really can work alone without much equipment are mental health workers. They’d be tougher to integrate.
@Martin: Great questions, Martin, and great suggestions! I’ve often wondered the same thing around tax time; especially the one year I was a glorified contractor, but really I was just a temporary employee with even less rights than usual. I had to file my taxes quarterly, and because Quicken figured I must be a big-time businessman, the forms I needed were in the super-deluxe expensive package. Ugh.
Fulcanelli
Moderation Enema needed, #59 @4:06 PM, stat.
inkadu
Hey, I am in between dogs right now, so I have a lot of time on my hands.
tc125231
@Dr. I. F. Stone: Are you kidding? Krugman has regularly posted graphs on his blog showing the following:
1. Cost per capita is higher, and rate of increase in cost is higher –this is even with the large number of people not covered at all in the US
2. 3 key measures, among others are lower:
–Deaths per 1000 treatable illnesses are much higher than France, germany, or Sweden
–life expectancy is lower
–infant mortality is higher
Get off your butt and do some research idiot.
geg6
All I know is a mother fucking medical insurance company killed one of my former students this past week. Literally killed him. I hope every mother fucker involved in that company who had even a tangential connection to what happened to Greg never has a happy or peaceful moment of life until the day they die, hopefully in the most miserable and painful way possible. Fuckers.
Ruckus
@Dr. I. F. Stone:
I don’t need to regurgitate statistics – I am one. No health insurance, not old enough for medicare, VA far away and I’m over half way down the status list there. So it’s pay for everything, or ER and bankruptcy. What a country.
Anyone who does not think/see that the system we have is fucked up probably has a stake in the health insurance industry. Otherwise no amount of logic and actual thought gets you to where your statement leads. Unless you are a medical Dr. who thinks he/she is as much of a victim of the system as their patients, and not a participant.
As stated above some docs will not computerize. How do they do ongoing study and testing without a computer and it’s access to information? My personal primary care doc keeps her records on computer. She brings her laptop into the exam room and fills in my chart while I’m there. And this 3 doc office has more staff for insurance processing than medical staff. And when I pay for my visits I get a hand printed, ledger book receipt. Talk about waste of energy. And money.
I own a small retail store and use computers for inventory, billing, credit card processing, etc. so telling me computers are, oh what the hell if someone doesn’t want to use or be around computers just tell them to grow the fuck up and join the 21st century. They are tools, nothing else. They can be madding, throw them into the wall frustrating, but they are no more than tools to make some jobs easier and some even possible.
We need and deserve proper health care. And when insurance companies who we pay to provide that for us don’t do what we pay for we need to replace them. And even when we can not afford to pay for that we still deserve health care.
You know life, liberty and pursuit of happiness.
I even joined the military because I believed that I was protecting everyone’s right to have those things.
Oh the stupidity and righteousness of youth.
inkadu
Geg6 – Very sorry for what happened to your student; and your anger is completely justified. But if you want to talk about him or what happened, I’d be glad to hear you out.
Interrobang
DBD — Regarding “It would also be a huge nightmare to figure out whose claim was whose and send the right claim to the right insurer,” no, actually. I work for an Electronic Data Interchange company — sending electronic claims (and other documents) back and forth between thousands of trading partners is a large part of what I do all day. Not only would it be technically possible, it has been technically possible to do just that since the 1970s. The EDI field is about as low tech as high tech gets.
For example, I’m in the middle of doing a back-end setup for transferring transactions between a buying group (the middleman), their seven suppliers, and their 124 members, which will take me maybe twelve hours all told — and that’s a small group, compared to some of the multi-thousand trading partner groups we handle.
And we’re a tiny EDI company — we only have 15 people on staff. This is not rocket science, which is actually pretty frickin’ simple as technology goes.
I don’t guess implementing a system that had to handle four times our document flow (we do a little more than a million transactions quarterly) and maybe 100x the number of trading partners would be a piece of cake exactly, but it’s certainly within the realm of possibility. The company I work for could probably implement such a system, given money enough and time, just by scaling up what we’re already using.
geg6
inkadu: Greg was a quadriplegic from an auto accident. If you know about quads, they suffer from numerous complications: infections, pneumonia, bed sores, organ failures, etc. Greg had had a bad year, in and out of hospitals and nursing homes and rehabs. He had actually just spent the first extended time at home in months and was starting to get back to relative health when an infection in his trach sent him back to the hospital where he went into kidney failure. In the midst of this battle, he was informed that his coverage had run out and to continue treatment, his wife would have to sell their home and the three rental properties that were their only real income so he could qualify for Medicaid. He chose to go home and die so his wife would have a roof over her head and some way to support herself. He died two days after he was sent home. Fuckers.
SGEW
O god, that’s just the worst fucking thing.
I’m often startled by the fact that health insurance executives aren’t murdered by grieving families.
inkadu
geg – How old was Greg? How did you guys keep in touch after he graduated?
The system is very, very screwed. It sounds like a horrible choice for anyone to make — get medical care or sentence yourself and your wife to poverty. It’s really sick. I can’t even imagine what kind of hell his wife is going through.
I think old folks transfer their assets to their children just to be prepared for this kind of thing… but, christ… how do you dump what is essentially your life’s financial work in 12 hours to get medical care … it’s just wrong on every level imaginable.
Have a Wild Turkey on me.
jcricket
The point made about how the public buys the public option and knows the system is broke – yet our politicans act like the insurance company is who we have to cater to – shows what the problem is.
You can’t normally get 72% of the public to agree on anything – and that’s one reason legislation is so hard to pass for meaningful yet “complicated’ issues.
This is a no-brainer. Ignore the Republicans, ignore the insurance industry, fuck the AMA. Hammer the “moderate” Democrats and maybe a moderate Republican or two. Pass the best bill with a public option + increased regulation (eliminate recession, charging more for sick people and pre-existing condition clauses) you can. Make sure you improve the public/government’s ability to negotiate with pharma/providers (i.e. fix Plan D).
And when this isn’t perfect in 3 or 5 years, do some more.
If Republicans and the insurance industry continue to resist, they will eventually get crushed, because they are on the wrong side of history.
Democrats need to understand the only thing they have to fear on this issue, is fear itself (to steal a line).
inkadu
sgew – ditto. i used to temp at an insurance company (facilities) and I was always worried about security — not so much that I would get shot, but that a perpetrator would bring an extra gun for me to use. Working at a health insurance company without health insurance gave me a clarity of mind.
geg6
Greg was 43 and was my student about 15 years ago, just about 2 years after his accident. I live in the same town he does and would see his wife around town. In addition, when he was getting his MBA, my sister was one of his professors. Then, a few years ago, I broke up with my long time SO and moved into my current apartment. Their home is on the next block and I’d stop and chat if I saw him sitting outside. His poor wife and kids are just devastated, but furious. I’ve never been at a funeral that was more dominated by anger than sadness. They were realistic and knew quads don’t last forever or even a normal lifespan. But he had recovered from worse episodes in the past. This didn’t have to happen.
gex
@inkadu: Hell, you’re not even supposed to have counter tops, much less a home, if you want health care in this country.
Iron-Ick_Ally
@Ron Chusid, no offense, but it sounds like your vendor sucks, though you may not have many alternatives in your area. As I mentioned, our pricing model was completely different, with an upfront installation fee and per-claim pricing. (One of the value adds we touted for our software was the ability to error-check all claims and flag faulty ones before submission, valuable for large hospitals.) This model would not encourage us to support small clinics, obviously, which leads to a point I was trying to make and Martin was brushing against: quite honestly, no software is needed at all.
Anyone can go to amazon.com or eBay and buy anything they want by filling out an encrypted webform with various information. Amazon has millions of products for sale, but it doesn’t have any trouble figuring who ordered what, it mails a given person the random book they ordered to the address they entered into the form. It charges the right person’s card the right amount advertised for the book. If you don’t enter your last name in the credit card number field, or a Montana ZIP code to a Boca Raton FL address, you’ll get your stuff. All you have to do is fill out the form right.
What specialized software do I need to place an order with amazon, exactly?
For claims submission, the webform is already dictated by UB04 standards. Send large care providers who submit large claim volumes in bulk to one website; send individual doctors and small clinics to another where, ad hoc, their billing specialist fills out and submits a secure, online UB04 instead of spending the same amount of time doing it on paper.
Perhaps a monthly subscription fee for the doctor or Alaskan midwife might be in order, offset by faxing or mailing costs and enhanced by quicker repayment (or the threat of never getting paid for paper claims). This site can also be underwritten by the insurance companies who, I suspect, realize giant savings by shuttering the departments currently needed by each company to scan, OCR, review, and submit paper submissions. As noted by DBD, These submissions already require a disproportionate amount of resources for their volume.
There is no software required for this process. As I said earlier, all that’s needed in this case is a clerk, internet connection, and bookmark on the Claims Submission Portal page.
Dennis-SGMM
@geg6:
Stories like this one are one of the reasons that I finally gave up TV news, papers and even most blogs. Every time some jerk reared up and said “We have the best health care system in the world” it made me want to see how long it would take the best health care system in the world to get him over a #12 ass-kicking.
Ruckus
@geg6:
Sorry for the loss and grief.
This is a most monumental tragedy and it would be unthinkable if it was the only time this kind of crap had happened. But of course it’s not, as any reading of the bolgosphere would tell you.
We would be bad though if we did not acknowledge that not all health care stories are bad, even if the ending is not what we wanted.
My sister passed away a year and a half ago, after battling breast cancer for 6 years. Her care was as good as it gets and her end of life care in the hospital was, for all the sorrow and pain, amazingly humane.
A friend of mine has many disabilities, mostly genetic in cause and was hospitalized about 6 months ago. She was in intensive care for a week before her problems settled down and she could go home. Once again the care she got was great, the doc and nurses did a great job.
Both of these cases would have been massively worse except they were both able to fit into the crappy safety net that is out there. Sometimes a person fits into the net but most of the time not. And to take it further my sister did not have insurance when she found out about her cancer and that’s why it was not found as soon as it could have been. She may have been able to survive. My friend, because she has genetic medical problems manages to fall within some of the safety nets that do exist. But she is very afraid that with the Govinator trying to cut all those services she will no longer have anything.
What a great country. Health care as a crap shoot.
inkadu
Geg – What did Greg do after his accident? I would probably just hook up Dragon Naturally Speaking and spend all my time on here arguing with Bob. At least you got to spend some time with a former student (which in my life is pretty rare; i haven’t seen any of my teachers, high school, college, or trade, since I left), and you were there for his family during the funeral. Having people support you, even if it’s just being at the funeral, can make a big difference.
geg6
Ruckus: So sorry about your sister. I agree with you about the caregivers. We have some wonderful, caring people who try their best within the shitty system they have to work in. My mom battled breast cancer that spread to her bones and died in 2001. Before she finally refused any more chemo and went to hospice, her insurance wouldn’t cover her chemo meds and her oncologist would hoard and beg samples to give her. He, his staff, and the hospice workers were heroic on her behalf, IMHO. All of them attended the funeral. Meanwhile, the insurance company wanted us to pay for the morphine they forced her to get in a 30 day supply and of which she had only used 2 days worth. The pharmacy had agreed to accept the unused doses back but the insurance company made us pay anyway. I hate insurance companies with a white hot hate.
Leelee for Obama
@geg6: Sorry , geg, that’s a damned shame and shameful as well. I hope his wife can find some peace. And you as well. This debacle will kill more rather than less until we insist on a better system.
geg6
inkadu: He ran an eBay store. He really was an amazing guy. Never let his problems stop him. Got his BS in business when I had him and went on and got an MBA. And then started his own business. Before the accident, he’d been big, burly guy who worked as a union iron worker. Spent his time dangling in the air building bridges and sky scrapers. Like I said, an amazing, fascinating guy. He was a pleasure to have known.
Wile E. Quixote
One reform I’d like to see enacted is what I call “one price for everyone”. Right now your insurance company negotiates with providers on how much they’ll pay for a specific procedure. When you get your statement of benefits you can see how much the provider billed and how much the insurance company paid. Sometimes the provider charges you the difference, sometimes not. Of course if you don’t have an insurance company you’re fucked, the provider charges you full price for the procedure.
Now, this is bullshit, if we can codify medical procedures to the point where we can describe them with a coding system then it should be easy enough to assign a dollar cost to each one of those procedures, and once that cost is assigned that’s what everyone pays, regardless of which insurance company they have or whether or not they have insurance at all. As much as they might bitch hospitals and doctors do not lose money on procedures because they’re not being compensated enough by the insurance company, because when hospitals and doctors decide that an insurance company isn’t paying enough they drop that insurance company, which has happened to Medicaid patients all over the country and which is also happening to some fairly large insurance companies. So if a provider can cover their costs and make a profit by providing service X for cost Y to Premera Blue Cross then there’s no reason why they shouldn’t be able to do the same for everyone else. As it is right now people without insurance are paying higher costs to subsidize the lower costs paid by insurance companies, and dealing with insurance companies is an expensive pain in the ass versus just sending someone a bill and telling them to pay up.
I’d also like to see the government mandate the publication of a cost schedule for hospitals and doctors. There is a lot of non-emergency medical care that patients do have the option of shopping around for, but just try and get cost information from a hospital. Two years ago I had surgery on my left wrist to install a pin in my scaphoid bone. The surgery wasn’t an emergency, I had been walking around with a broken wrist for six months thinking that it was just a severe strain (and two sets of X-rays found no break) before I said “Damnit, this should have healed by now” and went to the hospital. So this was a simple day surgery, I went in at 11 and was out by 5PM. The total cost: $16,000, which was covered by insurance. As much as we bitch about insurance companies, and I can tell you my horror stories, hospitals and doctors are also part of this problem and also need to be held to account. If a doctor or hospital is charging more money for a procedure or set of procedures and their outcomes are no better than those of providers who are charging less then patients need to know about this.
I think that even if we had single payer insurance the latter reform would still be valuable. Most people I know don’t like spending money unless they’re getting something for it, and under single-payer we’d still be spending our money for health care, only via our taxes instead of via the byzantine system we have today.
PGE
@geg6: A cousin of mine was a quad for 30+ years; he just died within the year. Knowing his story, and all the times he was hospitalized like your student (for all the same types of reasons), I was somewhat shocked when I looked up the lifetime maximum on my coverage. I work for a large company (not quite Fortune 100, but close) with “good” coverage, but a catastophic injury like his could easily run up expenses that hit the lifetime max in 5 years. With our current insurance system, we’re ALL one accident away from being in your student’s position.
inkadu
Geg6 – He sounds like a fantastic guy; no wonder you kept in touch with him.
Mnemosyne
@Wile E. Quixote:
The really sad thing is that sometimes you’re better off being uninsured than underinsured because you can negotiate with the medical provider ahead of time. Since they want at least some money and know they can’t get blood from a stone, oftentimes they’ll be willing to cut you a deal.
However, if you have crappy insurance, or if your insurance gets cut off partway through treatment, you’re totally fucked because you will then get charged the MSRP for each and every goddamned thing.
Mnemosyne
@inkadu:
The husband of one of my cousins was diagnosed with multiple sclerosis and I strongly suspect that one of the big reasons behind their divorce was that he wasn’t going to be able to get the care he needed as long as he had a working wife. Once they were divorced, he could be indigent and go on Medicare, but as long as she was working and had some form of health care, they were expected to completely impoverish themselves to care for him.
inkadu
@Mnemosyne: And a lot of people get married in order to get on their partner’s insurance plan.
Funny, I don’t see how getting married and divorced because of insurance fits into the right wing’s plan for individual freedom.
Wile E. Quixote
@PGE
The thing is you’re still going to have lifetime maximums under single-payer. Lifetime maximums are a form of rationing, nothing more, nothing less. Now, those lifetime maximums might be different under a single-payer system, but you’re still going to have to have them and other forms of rationing. Now, rationing is a scare word that conservatives like to use when they talk about single-payer, and the British have done a fantastic job at implementing rationing in a spectacularly boneheaded fashion, thus providing plenty of scare stories for conservatives to tout, but regardless of who ends up paying at the end of the day we’re still going to have rationing, it’s just that we’re going to change who makes those rationing decisions.
monkeyboy
@Ruckus:
The other force against change is essentially racist – mainly white people who are mostly not rich but oppose anything that might aid their perceived inferiors (mostly Blacks and Mexicans these days) and diminish their superiority over at least someone.
These same people will also dismiss the US’s low international ranking in international health statistics by blaming it on Blacks, Mexicans, and other moral degenerates such as homosexuals and welfare recipients. If the US could only eliminate such not-true-Americans then USA would be #1.
whatsleft
So sorry to hear about your loss geg6.
I recently had to have some tests done to find why I’m still having problems after major surgery in March. My surgeon had ordered a CT, and then my GI ordered another about 10 days later. My insurance denied the second test, which my GI had done anyway. My GI told me that in order to get that second CT, she had to personally talk to the gatekeeper, who was fresh out of med school and was on call on his cell phone to “evaluate” these situations.
Fortunately, the doctor’s group had made the decision to pay for the CT themselves if my insurance company continued to deny.
I know I am so lucky to even have coverage, but since my unexpected, nearly emergency surgery cost over $100,000, and my oldest daughter has had hospitalizations in the past two years for strep throat (throat swelled up and nearly killed her), kidney stones that needed surgery, and then a stay at the mental hospital, believe me, I am (especially as a former insurance agent and underwriter) having dark thoughts about possibly reaching that lifetime maximum limit. Of course these were just the hospitalizations – doesn’t include emergency room visits for concussions and possible broken bones for my other two athletic kids!
pseudonymous in nc
@geg6: my condolences.
Let’s just say it straight-up: for all the talk of “rationing care”, a healthcare system elsewhere in the developed world would not have given up on Greg. (I’m not saying that the doctors gave up on him here — that was the rent-seeking bastards — but there are so many scare stories about universal healthcare leaving the sick and vulnerable to die in ditches.)
Those damn clipboards that get thrust at you when you walk into a clinic symbolize everything that’s screwed up about the US healthcare “system”.
Ruckus
@monkeyboy:
Monkeyboy, you’re
probablycorrect, I have tried to forget that there are fucked up racist people in this world, or at least in my small corner of it. But I keep getting reminded of it when I read about, well life in this country. (and many other countries) I must be a DFH because I just don’t get why people have to makea bigany kind of a deal because someone doesn’t look like them. Or act just like them. Or believe the same things. Or……I mean at least we’re not politicians /snark.
PGE
@Wile E. Quixote:
Well, “rationing” is a loaded term, with negative connotations. Which is why it’s been inserted into the debate by defenders of the status quo. Of course, in a system with finite resources, limits of one sort or another are going to exist. But I’m inclined to think (hope) that a single payer plan, by virtue of the pool size, and by being answerable to political forces, would be able to minimize the impact of those limits on individuals, including including lifetime maximums. (I presume Medicare would be eliminated as a separate program, so the need to become a pauper to qualify would also be eliminated.)
WereBear
@geg6: I am sick at heart at your story. If a mugger killed him accidentally it would be felony murder; if a large corporation does it, it is business as usual.
I do wonder why no one has lost it on a high rankIng insurance executive. Part of it is keeping it together for the survivors, but all it would take is someone with nothing more to lose…
Ivan
There’s a perfectly good solution for bypassing scanning out in the marketplace, it’s not new (2004 vintage in fact) and it’s not all that expensive: PDF Barcoded Paper Forms. This allows someone to fill out a PDF form file on a computer, and as the information is typed in the computer encodes it onto a 2-D barcode on the form itself. The form can then be printed out and faxed or mailed, and the barcode scanned into a computer to reproduce the data. It’s incredibly robust.
Mandating either electronic or machine-readable forms submission should be a no-brainer.
mclaren
Linda remarked:
There. Fixed that for you.
Health care will eventually get fixed in America, but only after we get a massive pandemic resulting from the fact that essentially no non-wealthy Americans can afford health care. At that point, things will change, but after the latest H5n1-variant killer influenza epidemic leaves 50 or 75 million of us dead, it won’t be an America anyone will want to live in.
slightly_peeved
No you don’t. Australia, for one, has no lifetime maximum. If the government covers an operation or treatment, it’s covered for everyone eligible for Medicare. The government doesn’t go around discriminating on who should get the operation; that’s part of the reason single-payer has less overhead. You make decisions on allowable care at a nationwide level, rather than scrutinising every single patient request.
In fact, in Australia, they have the reverse of a lifetime maximum; a yearly safety net. Some parts of the medical system, such as some doctor’s visits, are a co-pay rather than being fully covered by Medicare. But once you spend a certain amount in a year, the co-pay increases to 100%.
You want a full description of the system? Go here. Note the complete lack of mention of any lifetime personal limit on care.
I’m pretty sure the NHS has nothing of the sort either; I’ve never heard of anyone being left out to die because they reached some lifetime maximum of treatment. It’d be a national outrage. What they have is waiting lists on elective surgery, government decisions on what care is available, and some issues with finding the care you need in the part of the UK you need it – the “postcard lottery” as it’s known there. But no lifetime maximum.
Sui Generis
@PGE:
Please all, get straight:
Medicare is for the >65 and has no means testing. NONE! It is all paid by the Feds, virtually all from our prepayments (payroll taxes) and premiums. It has no lifetime limits.
The so called Advantage plans are privatized Medicare plans to which the Feds pay the average per capita Medicare costs for the region plus 14-18%. They are supposed to provided extra benefits and save by – whatever they want; essentially limiting providers and procedures and all the games HMOs play.
MedicAID is for poor, actually destitute people and requires assets be below a certain line. You are supposed to be able to keep and not count a home, a car with value not more than about 2k above what is owed, and about 2k.
Since it is for the poor it is, of course, rather shXtty. And it pays providers the least so it is not much accepted.
Medicaid is also some 51 separate systems. Since it is partially state paid it is state run. The states vary in a lot of ways in the limits for eligibility, how often you get dumped (does the budget need balancing?) and other things.
When will we treat the “least of these” the same way we would like to be treated?
When you mix up the terms you give some people arguing points. And confuse others.