Map of life expectancy at birth from Global Education Project.

Monday, March 20, 2023

Why does health care cost so much in the U.S. part the infinity

I'm on a lot of email lists thanks to my profession. A message I got today is below. I won't make you read it before I explain that one reason medical services cost so much in this godforsaken country is that providers have to hire people to with specialized training and pay them salaries to deal with this crap. Keep in mind that they see people with multiple different kinds of insurance and they need to keep track of what insurance the person has, what it will pay for, how much, and how, based on manuals containing hundreds of pages of similar dreck. And if they don't get it just right, they won't be paid. In civilized countries, this doesn't happen.


When billing CPT code 99292 when you deliver critical care as a split (or shared) visit, an important correction has been made by the Centers for Medicare and Medicaid Services effective March 3, 2023.

According to Section 30.6.12.5 in the Medicare Claims Processing (MCP) Manual (Chapter 12), CMS changed the number of cumulative total minutes from 75 to 104.

This correction made to the MCP is effective 01/01/2023 and implemented 03/03/2023.  Please share this information to you coding, auditing and billing professionals.

“…. To bill split (or shared) critical care services, the billing practitioner first reports CPT code 99291 and, if 104 or more cumulative total minutes are spent providing critical care, the billing practitioner reports one or more units of CPT code 99292. Modifier -FS (split or shared E/M visit) must be appended to the critical care CPT code(s) on the claim.

The same documentation rules apply for split (or shared) critical care visits as for other types of split (or shared) E/M visits. Consistent with all split/shared visits, when two or more practitioners spend time jointly meeting with or discussing the patient as part of a critical care service, the time can be counted only once for purposes of reporting the split (or shared) critical care visit.”

MCP Chapter 12 Section 30.6.12.8 provides guidance on critical care documentation requirements.  This section was last updated in 2022, however, reviewing this information will assist in coding, documentation and billing compliance.  A few salient points to remember are:

  • Critical care is a time-based service;
  • Practitioners must document in the medical record the total time (not necessarily start and stop times) that critical care services are furnished by each reporting practitioner;
  • Documentation needs to indicate that the services furnished to the patient, including:
    • any concurrent care by the practitioner;
    • documentation of medical necessity for the diagnosis and/or treatment of illness and/or injury or to improve the functioning of a malformed body member
  • Services must be sufficiently documented to determine the role each practitioner played in the patient’s care (that is, the condition or conditions for which the practitioner treated the patient) upon audit

When critical care services are reported the same date as another E/M visit, the medical record documentation must support:

1) that the other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care,

2) that the services were medically necessary, and

3) that the services were separate and distinct, with no duplicative elements from the critical care services provided later on that date.

Sunday, March 19, 2023

Sunday Sermonette: Worst apostasy ever

The story of Ahaz is told in 2 Kings 16. Although the facts largely overlap, it's a completely different version of the story. It's basically the same old idea -- Ahaz forsakes Yahweh, worships Baal, and Judah gets trashed. Somewhat unusually, one of the instruments of the trashing is the northern kingdom. However, a prophet persuades the "people of Israel," oddly without mentioning their king or leadership, to release the Judean captives, essentially on the grounds that they have no right to enslave fellow Israelites.


Ahaz goes on to humiliate Judah before the Syrian king Tiglath-Pileser, by bribing him with some of the temple treasures and worshiping the Assyrian gods. He doesn't seem to suffer any consequences for this, however. Even though it's said to make God angry, God doesn't actually do anything about it. The reference in verse 3, "he sacrificed his children in the fire" is an issue that has come up before in the Deuteroomistic history. There is no evidence, archaeological or documentary, of human sacrifice anywhere in the Levant. This is probably either a reference to a purification ritual, or a slander.



28 Ahaz was twenty years old when he became king, and he reigned in Jerusalem sixteen years. Unlike David his father, he did not do what was right in the eyes of the Lord. He followed the ways of the kings of Israel and also made idols for worshiping the Baals. He burned sacrifices in the Valley of Ben Hinnom and sacrificed his children in the fire, engaging in the detestable practices of the nations the Lord had driven out before the Israelites. He offered sacrifices and burned incense at the high places, on the hilltops and under every spreading tree.

Therefore the Lord his God delivered him into the hands of the king of Aram. The Arameans defeated him and took many of his people as prisoners and brought them to Damascus.

He was also given into the hands of the king of Israel, who inflicted heavy casualties on him. In one day Pekah son of Remaliah killed a hundred and twenty thousand soldiers in Judah—because Judah had forsaken the Lord, the God of their ancestors. Zikri, an Ephraimite warrior, killed Maaseiah the king’s son, Azrikam the officer in charge of the palace, and Elkanah, second to the king. The men of Israel took captive from their fellow Israelites who were from Judah two hundred thousand wives, sons and daughters. They also took a great deal of plunder, which they carried back to Samaria.

But a prophet of the Lord named Oded was there, and he went out to meet the army when it returned to Samaria. He said to them, “Because the Lord, the God of your ancestors, was angry with Judah, he gave them into your hand. But you have slaughtered them in a rage that reaches to heaven. 10 And now you intend to make the men and women of Judah and Jerusalem your slaves. But aren’t you also guilty of sins against the Lord your God? 11 Now listen to me! Send back your fellow Israelites you have taken as prisoners, for the Lord’s fierce anger rests on you.”

12 Then some of the leaders in Ephraim—Azariah son of Jehohanan, Berekiah son of Meshillemoth, Jehizkiah son of Shallum, and Amasa son of Hadlai—confronted those who were arriving from the war. 13 “You must not bring those prisoners here,” they said, “or we will be guilty before the Lord. Do you intend to add to our sin and guilt? For our guilt is already great, and his fierce anger rests on Israel.”

14 So the soldiers gave up the prisoners and plunder in the presence of the officials and all the assembly. 15 The men designated by name took the prisoners, and from the plunder they clothed all who were naked. They provided them with clothes and sandals, food and drink, and healing balm. All those who were weak they put on donkeys. So they took them back to their fellow Israelites at Jericho, the City of Palms, and returned to Samaria.

16 At that time King Ahaz sent to the kings[a] of Assyria for help. 17 The Edomites had again come and attacked Judah and carried away prisoners, 18 while the Philistines had raided towns in the foothills and in the Negev of Judah. They captured and occupied Beth Shemesh, Aijalon and Gederoth, as well as Soko, Timnah and Gimzo, with their surrounding villages. 19 The Lord had humbled Judah because of Ahaz king of Israel,[b] for he had promoted wickedness in Judah and had been most unfaithful to the Lord. 20 Tiglath-Pileser[c] king of Assyria came to him, but he gave him trouble instead of help. 21 Ahaz took some of the things from the temple of the Lord and from the royal palace and from the officials and presented them to the king of Assyria, but that did not help him.

22 In his time of trouble King Ahaz became even more unfaithful to the Lord. 23 He offered sacrifices to the gods of Damascus, who had defeated him; for he thought, “Since the gods of the kings of Aram have helped them, I will sacrifice to them so they will help me.” But they were his downfall and the downfall of all Israel.

24 Ahaz gathered together the furnishings from the temple of God and cut them in pieces. He shut the doors of the Lord’s temple and set up altars at every street corner in Jerusalem. 25 In every town in Judah he built high places to burn sacrifices to other gods and aroused the anger of the Lord, the God of his ancestors.

26 The other events of his reign and all his ways, from beginning to end, are written in the book of the kings of Judah and Israel. 27 Ahaz rested with his ancestors and was buried in the city of Jerusalem, but he was not placed in the tombs of the kings of Israel. And Hezekiah his son succeeded him as king.

Footnotes

  1. 2 Chronicles 28:16 Most Hebrew manuscripts; one Hebrew manuscript, Septuagint and Vulgate (see also 2 Kings 16:7) king
  2. 2 Chronicles 28:19 That is, Judah, as frequently in 2 Chronicles
  3. 2 Chronicles 28:20 Hebrew Tilgath-Pilneser, a variant of Tiglath-Pileser

Saturday, March 18, 2023

Platinum Anniversary

As some readers know, for many years I maintained the Today in Iraq blog, during the U.S. occupation. The invasion of Iraq was an illegal war of aggression, and U.S. troops and mercenaries committed innumerable war crimes. The result was an indescribable catastrophe for Iraqis, with a conservative death toll estimate of 800,000 and most likely far higher, at least as many people injured, and entire cities destroyed. (Notably Fallujah and Mosul.) 


The consequences for the U.S. were not as dire, but $8 trillion wasted and immense damage to the nation's international standing, along with 4,400 military dead and 32,000 wounded. (Mercenaries who were killed were often labeled by the corporate media as "civilian reconstruction workers," btw.) Alissa Rubin in the NYT gives an in-depth update on Iraq today. The country does have an independent press, and it has elections of a sort, but the result is not anything resembling democracy. The country is run by corruption and theft.  Most people live in poverty and squalor, despite the country's oil wealth it is economically backward, and there is no safety or security.


We're still arguing about why the U.S., along with Britain, invaded in the first place. Bush, Cheney, Powell and Blair ginned up a campaign of blatant lies to make it happen, that the corporate media swallowed without even chewing. A leading theory is that the real target was Iran. With the U.S. already occupying Afghanistan, by occupying Iraq we'd have them surrounded. Of course the exact opposite happened and Iran is now a dominant power in Iraq outside of Kurdistan, and occupies the country with Shiite militias loyal to Iranian leaders. 


The architects of this atrocity, and the vast ranks of their cheerleaders in politics and journalism, have paid no price at all. I do think some of them are chastened a bit -- reporters seem to be more skeptical of official claims, and the country as a whole no longer gets enthusiastic about military adventures. On the other hand that was true after Vietnam but it was soon forgotten, and neither disaster stopped the military industrial complex from continuing to bloat without apparent end or limit. 

 

When will they ever learn.


Friday, March 17, 2023

Death in Childbirth

I taught a course last year in global maternal mortality so I have some idea of what I'm talking about here. Childbirth is dangerous for women because, for one thing, thanks to evolution giving us big brains, the baby's head is too big for the birth canal. However, there are other complications of pregnancy that can occur. In Europe in the 19th Century, as it became common for women to give birth in hospitals, infectious disease killed a lot of mothers, thanks to the doctors transferring pathogens on their unwashed hands and unsterile instruments. Many a family was bereaved by maternal death, but it has become rare in most of the wealthy countries today. With, as I expect you have already guessed, one exception.


Maternal mortality in the U.S. has long been far more common here than in comparable nations, and this has in large part been due to a huge racial disparity. Black women are much more likely to die in childbirth than white women. But now it's gotten worse. I'm just going to post a press release I got this morning, and let it speak for itself.


Shocking Rise in Maternal Mortality, With Black Moms at Greatest Risk, Underscores Need for Congress to Pass Momnibus Act and Secure Access to Abortion Care

 

FOR IMMEDIATE RELEASE

March 17, 2023

CONTACT: Magen Eissenstat, 202/371-1996

 

Statement of leaders of MomsRising, the online and on-the-ground organization of more than one million mothers and their families, on the National Center for Health Statistics data released yesterday, showing a dramatic rise in maternal mortality and disparities in the United States in 2021:

 

“This is an emergency. Too many moms are losing their lives during pregnancy and childbirth in this country. Our nation’s maternal health crisis got appreciably worse in 2021, with huge disparities and Black women suffering the worst outcomes. Data released yesterday by the National Center for Health Statistics/Centers for Disease Control and Prevention shows that 1,205 women died of maternal causes in the United States in 2021, up sharply from 861 in 2020 and 754 in 2019. (Those deaths are among women who were pregnant or had been pregnant within the last 42 days, from any cause related to or aggravated by the pregnancy or its management.) The maternal mortality rate for non-Hispanic Black women was 2.6 times the rate for non-Hispanic white women.

 

“It is appalling that our already-high maternal mortality rate is getting worse, as are the disparities. It’s long past time lawmakers recognize this as the emergency that it is. The Black Maternal Health Momnibus Act will soon be reintroduced in both chambers of Congress, and its passage should be an immediate priority so we can provide more funds to strengthen federal maternal health programs, address social determinants of health, support diversification of the perinatal health workforce, provide grants to improve maternal mental health, support anti-bias trainings for health care professionals, and more.”

 

-Statement of Monifa Bandele, Chief Strategy Officer, MomsRising

 

“Certainly COVID is part of the reason maternal health outcomes in the United States worsened in 2021, but we had the highest maternal mortality rate of any industrialized nation before the pandemic struck. Enactment of the Black Maternal Health Momnibus Act, which will save lives and improve the health of mothers and babies, is long overdue.

 

“But there is more we need lawmakers to do. The shameful SCOTUS ruling in Dobbs v. Jackson Women’s Health Organization and the state abortion bans and restrictions it allowed are sure to exacerbate our already-devastating maternal health crisis. They have resulted in women being denied not just abortion care but also birth control, care for miscarriages, medications they need and have long taken, and other essential services. Low-income women and moms, women of color, young, rural and immigrant women, people with disabilities, and those who are LGBTQIA+ are suffering the most.

 

“America’s moms call on lawmakers at every level to prioritize maternal health and secure access to abortion care. Improving women’s health and addressing our maternal health crisis should be our highest priority.”

 

-Statement of Kristin Rowe-Finkbeiner, Executive Director and CEO, MomsRising

 

# # # #

 

Thursday, March 16, 2023

Reading the Entrails

I often come across arguments to the effect that humans aren't really unique or special, we're just one animal among all the others. I find this assertion, frankly, just silly. Every species is unique in some ways, of course, that's why we can classify them. But humans are highly unusual in very important ways. For example, the biomass of domesticated mammals exceeds that of all the other mammals on earth combined; and the biomass of domesticated poultry -- mostly chickens -- is three times the biomass of all other birds on earth.


This happened in part because of language, which is an absolutely unique human capacity that allows for an unparalleled degree of cooperation, and for the accumulation of knowledge and technological advancement over time. But what I want to talk about today is our very rich awareness of the future and out intense interest in it. We can't really say to what extent other creatures have foresight. Some mammals are affected by the death of relatives in ways that suggests they may be aware of their own mortality. Many engage in behaviors that are tied to future benefit, such as squirrels storing nuts, but whether there is any real awareness of the future associated with this we cannot say. 


Humans are entirely unique in the elaborate and flexible ways we plan for the future. Building a house requires the assumption that we're going to live in it, and we think carefully about the kind of environment we want to create, in the context of the expected climate, possible extreme weather or earthquakes, possible future children, and much more. Unlike birds or bees, we create an unlimited variety of houses depending on our individual desires, the available resources, and the future we anticipate.


But what struck me today is the problematic value of uncertain predictions. The prognosticators spent the past few days spouting alerts and warnings at us, even talking about roofs collapsing, because of a "high impact," "long duration," "powerful northeaster" with heavy, wet snow and screaming winds that was going to knock out power to tens of thousands of Connecticut customers. They did say that the deepest snow would be in the higher elevations of the northwest part of the state, but where I live they were predicting four to eight inches of snow and they stuck with that right to the end. The schools dismissed at noon yesterday because of the coming apocalypse. I just happened to need to go shopping and the grocery store was mobbed, people apparently fearing they would starve if they didn't strip the shelves of milk and eggs. Hundreds of events were cancelled, businesses closed, the snowplows geared up.


We got 12 hours of chilly rain. Total snow accumulation here was zero. No snow at all. There was a lot of snow farther north and  west, but they got the rain/snow line badly wrong. That we would get no snow at all was not within the range of uncertainty they presented. So the possible benefit of correct predictions has to be weighed against the harm that may come from wrong ones. 

 

The problem is compounded when predictions themselves affect the future.This is particularly evident in the economy. Investors are always trying to predict the future and obviously, many of their prophecies are self-fulfilling. If they think stocks will go down,  that's what happens. The reason for the recent bank failures is not, as Republicans ludicrously claim, because the banks had gay board members or diversity and inclusion policies, but because many of their depositors, all at once, started to fear that the banks might fail and went to withdraw their money. The banks' assets were illiquid, the result of incorrect predictions on the part of the bank managers, and they couldn't meet their obligations. 


Prediction is very problematic in medicine as well. Physicians' prognoses determine people's decisions about painful or expensive treatments, or foregoing treatment at all. I've decided to have cataract surgery but it's entirely possible that I'd be able to get by just fine with glasses for years. We had to make a guess and act on it. Right now people are filling out their NCAA basketball tournament brackets and hoping to win a few bucks in the office pool, but in case you didn't know the odds of filling out a perfect bracket are 1 in a number that exceeds the number of stars in the universe. (Or something like that, it's a really big number.)


I'm not saying we shouldn't make predictions. We have to. But we should be very reluctant to do so and keenly aware of the possibility of error. I think people generally have a bias toward too much confidence in prediction. Trust Yogi Berra on this one.

Wednesday, March 15, 2023

Wednesday Bible Study: Hit the snooze button

Thank the Lord, we're almost through Chronicles. Just a few more chapters to go. Jotham is mentioned very briefly in the Book of Kings, so that is not the source referred to at the end here. What is odd, however, is that the Chronicler usually refers to what appear to be two separate books, the book of the Kings of Judah and the book of the Kings of Israel. Here he refers to a single book, but it can't be the canonical Book of Kings because that does not include any additional detail about Jotham.


Of course we get the usual absurd amounts of tribute.


27 Jotham was twenty-five years old when he became king, and he reigned in Jerusalem sixteen years. His mother’s name was Jerusha daughter of Zadok. He did what was right in the eyes of the Lord, just as his father Uzziah had done, but unlike him he did not enter the temple of the Lord. The people, however, continued their corrupt practices. Jotham rebuilt the Upper Gate of the temple of the Lord and did extensive work on the wall at the hill of Ophel. He built towns in the hill country of Judah and forts and towers in the wooded areas.

Jotham waged war against the king of the Ammonites and conquered them. That year the Ammonites paid him a hundred talents[a] of silver, ten thousand cors[b] of wheat and ten thousand cors[c] of barley. The Ammonites brought him the same amount also in the second and third years.

Jotham grew powerful because he walked steadfastly before the Lord his God.

The other events in Jotham’s reign, including all his wars and the other things he did, are written in the book of the kings of Israel and Judah. He was twenty-five years old when he became king, and he reigned in Jerusalem sixteen years. Jotham rested with his ancestors and was buried in the City of David. And Ahaz his son succeeded him as king.

Footnotes

  1. 2 Chronicles 27:5 That is, about 3 3/4 tons or about 3.4 metric tons
  2. 2 Chronicles 27:5 That is, probably about 1,800 tons or about 1,600 metric tons of wheat
  3. 2 Chronicles 27:5 That is, probably about 1,500 tons or about 1,350 metric tons of barley

Monday, March 13, 2023

Ruling out

People who, for ideological reasons,  don't actually want to do what is necessary to solve the problem of excessive spending  on health care often claim that the real problem is the cost of malpractice insurance. So they propose "tort reform" as the solution. The argument is that it isn't just the direct cost of insurance that's to blame, but also that physicians practice "defensive medicine," ordering unnecessary tests and procedures, to avoid possible liability.


First, let's just get the extent of the problem, if any, out of the way. The best estimate is that liability costs -- including both components, insurance premiums and any defensive medicine that may be happening -- account for 2.4% of health care spending in the U.S. Even if it were eliminated entirely, it wouldn't make a dent in the difference between spending in the U.S. and the rest of the world, but of course medical liability exists in every other country as well and people who are harmed by negligence, incompetence or malice should be compensated. 


So no, if this is a problem at all it is not a big problem, at least not compared to our other problems. That is not to say, however, that the status quo is ideal. Medical procedures sometimes go awry and people are harmed, but they can't get compensation unless they can convince a jury that a physician's negligence caused the bad outcome. (And no, "frivolous" cases don't make it to a jury. A judge will throw them out first and for that reason lawyers won't normally take them.) That means a lot of people who are seriously injured, even permanently disabled, can't get a dime. 


A better way is to create a pool of money to compensate people who suffer iatrogenic harm (i.e. harm caused by medicine) and to set up a separate procedure to decide whether a physician bears responsibility and some action should be taken. That could range from retraining, to restricting scope of practice, to delicensure. Of course, if wee had universal health care people's medical expenses would be taken care of anyway so we'd only be talking about compensation for other losses, such as lost income or the need for supportive services. Again, this wouldn't save much money, if any, but it would take money away from lawyers and give it to people who need it, and it would be more fair and constructive.


But you know, socialism.

Sunday, March 12, 2023

Sunday Sermonette: Do not mess with the guys who wrote this

The story of Uzziah, including his transgression and consequential leprosy, is told briefly in the Book of Kings, embedded in a much longer discussion of goings on in the northern kingdom at the time. The Chronicler as usual has no interest in the northern kingdom, but he has a great deal of interest in the prerogatives of the priesthood so he makes that the focus. There have been instances in the past when the priests have put kings in their place, although in the early part of the Deuteronomistic History kings sometimes made sacrifices and apparently it was okay.  The Chronicler wants to be very clear that kings cannot get away with usurping the role of the priesthood, even by burning incense, and that Yahweh agrees. The point is all the sharper because Uzziah gets a big build up to that point -- he's the most successful king since Jehoshaphat. But that doesn't earn him any slack when it comes to the temple.

The reference at the end is not to the canonical Book of Isaiah, which only mentions Uzziah in passing, but to some lost book. Since the existing Book of Isaiah was written much later than these events, perhaps around the same time as Chronicles, it could not add any historical reliability. I should mention once again that "leprosy" does not refer to the disease known by that name in modern times (now called Hansen's disease) but to what are probably understood to be several different dermatological conditions today. 


26 Then all the people of Judah took Uzziah,[a] who was sixteen years old, and made him king in place of his father Amaziah. He was the one who rebuilt Elath and restored it to Judah after Amaziah rested with his ancestors.

Uzziah was sixteen years old when he became king, and he reigned in Jerusalem fifty-two years. His mother’s name was Jekoliah; she was from Jerusalem. He did what was right in the eyes of the Lord, just as his father Amaziah had done. He sought God during the days of Zechariah, who instructed him in the fear[b] of God. As long as he sought the Lord, God gave him success.

He went to war against the Philistines and broke down the walls of Gath, Jabneh and Ashdod. He then rebuilt towns near Ashdod and elsewhere among the Philistines. God helped him against the Philistines and against the Arabs who lived in Gur Baal and against the Meunites. The Ammonites brought tribute to Uzziah, and his fame spread as far as the border of Egypt, because he had become very powerful.

Uzziah built towers in Jerusalem at the Corner Gate, at the Valley Gate and at the angle of the wall, and he fortified them. 10 He also built towers in the wilderness and dug many cisterns, because he had much livestock in the foothills and in the plain. He had people working his fields and vineyards in the hills and in the fertile lands, for he loved the soil.

11 Uzziah had a well-trained army, ready to go out by divisions according to their numbers as mustered by Jeiel the secretary and Maaseiah the officer under the direction of Hananiah, one of the royal officials. 12 The total number of family leaders over the fighting men was 2,600. 13 Under their command was an army of 307,500 men trained for war, a powerful force to support the king against his enemies. 14 Uzziah provided shields, spears, helmets, coats of armor, bows and slingstones for the entire army. 15 In Jerusalem he made devices invented for use on the towers and on the corner defenses so that soldiers could shoot arrows and hurl large stones from the walls. His fame spread far and wide, for he was greatly helped until he became powerful.

16 But after Uzziah became powerful, his pride led to his downfall. He was unfaithful to the Lord his God, and entered the temple of the Lord to burn incense on the altar of incense. 17 Azariah the priest with eighty other courageous priests of the Lord followed him in. 18 They confronted King Uzziah and said, “It is not right for you, Uzziah, to burn incense to the Lord. That is for the priests, the descendants of Aaron, who have been consecrated to burn incense. Leave the sanctuary, for you have been unfaithful; and you will not be honored by the Lord God.”

19 Uzziah, who had a censer in his hand ready to burn incense, became angry. While he was raging at the priests in their presence before the incense altar in the Lord’s temple, leprosy[c] broke out on his forehead. 20 When Azariah the chief priest and all the other priests looked at him, they saw that he had leprosy on his forehead, so they hurried him out. Indeed, he himself was eager to leave, because the Lord had afflicted him.

21 King Uzziah had leprosy until the day he died. He lived in a separate house[d]—leprous, and banned from the temple of the Lord. Jotham his son had charge of the palace and governed the people of the land.

22 The other events of Uzziah’s reign, from beginning to end, are recorded by the prophet Isaiah son of Amoz. 23 Uzziah rested with his ancestors and was buried near them in a cemetery that belonged to the kings, for people said, “He had leprosy.” And Jotham his son succeeded him as king.

Footnotes

  1. 2 Chronicles 26:1 Also called Azariah
  2. 2 Chronicles 26:5 Many Hebrew manuscripts, Septuagint and Syriac; other Hebrew manuscripts vision
  3. 2 Chronicles 26:19 The Hebrew for leprosy was used for various diseases affecting the skin; also in verses 20, 21 and 23.
  4. 2 Chronicles 26:21 Or in a house where he was relieved of responsibilities

Friday, March 10, 2023

Why we don't get what we pay for

Before I take up the subject of this post, a note about commenting. I wish I could publish more comments but most of them are ridiculous or off topic. For example, I wrote a post about Kanye West. He was the subject of the post. It was about him. And I get a comment to the effect of Why won't I talk about Black antisemitism? WTF? I post about the high cost of health care in the U.S. and I get a comment about total federal revenues and the federal budget deficit. BTW, obviously federal revenues will generally increase over time because the economy and the population grow. Also you have to adjust for inflation. But that's all irrelevant, it isn't what we're talking about right now. You can see in the side bar that off topic comments will not be punished. I'm actually fairly liberal about that, but if you're deliberately being off topic just to be annoying it ain't gonna happen. Also, if you're banned, you're banned, so give it up.


To understand why we pay more for medical services than the rest of the world, and why we get less for it, we need to take both sides of the question separately. We pay more because of the way we finance the industry. Here are the major bullet points.

1.      Administrative costs: The U.S. healthcare system has a complex administrative structure, which adds to the overall cost of healthcare.

2.      Fee-for-service billing: The U.S. healthcare system often uses a fee-for-service billing model, which incentivizes healthcare providers to order more tests and procedures, thereby driving up the cost of care.

3.      Limited competition: In many parts of the U.S., there is limited competition among healthcare providers, which can lead to higher prices for services.

4.      Drug prices: The high cost of prescription drugs in the U.S. is a major factor driving up the cost of healthcare.

 

These moving parts work together. Health care in the U.S. is paid for by innumerable entities, mostly private insurance companies. (Even public funds -- Medicare and Medicaid -- are usually passed through private insurance companies that actually pay doctors and hospitals.) That means there are high administrative costs on both sides. The insurance companies pay profits to their shareholders, big salaries to their executives, and spend money on marketing. Traditional Medicare, in which the government reimburses providers directly, is much more efficient - only 2 or 3% in administrative costs, compared with 15% or more for private insurers. On the other side, providers need to spend a lot of money figuring out to bill many different payers, that have different rules about what they will pay for and pay different amounts. They also spend money figuring out how to game those systems and squeeze the most they can out of the various payers.  

 

Fee for service billing means that providers get paid to do things to you, not to get results. Since they're the experts, and you don't know what you really need, their bias is to just do more stuff, even if it's low value or even probably bad for you. But that also means they have to do the above, i.e. figure out who to bill and how to bill them for the most. And in many parts of the country, there just isn't a lot of choice of hospitals or providers, which means the payers don't have a lot of leverage. Drug prices are higher in the U.S. than in the rest of the world because the pharmaceutical industry is politically powerful and they have gotten politicians to create a regulatory system that restricts competition and let's them charge as much as they can get. If there's only one manufacturer, and you need the drug or you'll die, and they're charging a quarter of a million dollars for it, they're often gonna get that much.


None of this pertains in civilized countries. Next up: why we're healthy, why we're sick, why we live and why we die.