Podiatrist has different prices based on insurance

[Brian Tymchak]

Went to a new podiatrist recently as my old orthotics have bit the dust. They offered 2 prices, one a lower "self-pay" and another higher if using health insurance. I've not seen that before. The orthotics self-pay price was about 25% lower than the insurance price. With my past experience with insurance coverage (or lack thereof) of orthotics, I opted for the self pay. They use this price model for all their services. I need a little PT for chronic plantar fasciitis. I had them bill the insurance for the first session to see what the difference will ultimately be.

Anyone else seeing this kind of pricing model? I wonder if this going to become a trend.

[Jeff Roltgen]

It's everywhere, and has been this way for a very long time. I've got friends who refuse to buy health insurance, and simply call accounting when bills arrive, declare they're not insured and proceed to negotiate the actual cost they will be paying the hospital, which is always a 40-60% reduction of what they'd charge the insurance company.

As a former insurance agent of a few decades ago, I can assure you, this is rampant in that industry. A local billboard advertises that your deductible will be waived for paintless hail dent repair. No, they simply fake a bill to the insurance company and bury the deductible in the invoice. It's called theft, but hey, we all hate the insurance companies, so when we get the chance, a person generally has no sense of remorse in being a party to the ripoff.

Then your next insurance bill comes, and then you scream, ripoff!
It's a vicious cycle.

jeff

[Patty Hann]

Went to a new podiatrist recently as my old orthotics have bit the dust. They offered 2 prices, one a lower "self-pay" and another higher if using health insurance. I've not seen that before. The orthotics self-pay price was about 25% lower than the insurance price. With my past experience with insurance coverage (or lack thereof) of orthotics, I opted for the self pay. They use this price model for all their services. I need a little PT for chronic plantar fasciitis. I had them bill the insurance for the first session to see what the difference will ultimately be.

Anyone else seeing this kind of pricing model? I wonder if this going to become a trend.

It depends on the doctor (or group).
I have had that exact "orthotics" situation that you describe.
When doing PT (for one thing or another *sigh*) I casually asked about pricing, even tho' insurance was paying for it.
Billing would be different (slightly lower) for those paying cash.

[Edwin Santos]

The next step in this phenomenon is those physicians or groups who simply don't take insurance. Some will reject all insurance except for traditional Medicare. This is because Medicare pays promptly and the billing process is fairly straightforward, meaning fewer hoops to jump through, not to mention fewer denied claims.
For most physicians, getting to the point of being able to do this is like the Holy Grail because it simplifies life so dramatically.
Even better are those doctors that are able to run a "concierge" practice. Under this model, patients pay something like a membership fee and in return the doctor will be more available because he/she presumably has fewer patients. My mother uses one, and indeed, she can call her doc on his cell phone, and when she was very ill he made a house visit.

There's an analytical measure called effective rate. Let's say the insurance company has agreed to pay a doctor $100/visit (hypothetical round number). But then they proceed to deny claims for prior auth, billing code, or some other finicky reason 20% of the time. At that point, the doc realizes he/she is effectively being paid $80 not $100. Then on top of that, let's say the insurance company is not paying in 30 days, but stretches payment out to 90, 120, maybe 150 days. They have models that show how much money they make by stretching the payment cycle.
Worst of all, let's say the insurance is increasing deductibles and co-pays on the insured, so now the doctor's office is in the business of collecting from the patient after the insurance has denied the bill for deductible reasons. So insurance means you will effectively be paid less, it will take much longer, and require more staff.
No surprise why cash paying would be attractive enough to offer a discount.

[Stan Calow]

and since all of this is well known to all the actors, one could infer collusion in the whole for-profit US medical system.

[Patty Hann]

It's everywhere, and has been this way for a very long time. I've got friends who refuse to buy health insurance, and simply call accounting when bills arrive, declare they're not insured and proceed to negotiate the actual cost they will be paying the hospital, which is always a 40-60% reduction of what they'd charge the insurance company.

jeff

How do your friends get service BEFORE paying anything?
In my experience if someone doesn't have insurance, (no card to hand over) they are basically shown the door right then and there.
I know people that negotiate costs PRIOR to ,say, entering the hospital (for elective surgery).
But without showing an insurance card are paying up front I don't see how they even get past the Glass window, unless it was an ER visit.

[roger wiegand]

Though the billing to the insurance is higher, in all likelihood the reimbursement is much lower. It's extremely likely that your doc makes more money on the discounted cash price. People without insurance pay the highest prices in our wonderful system.

[Jeff Roltgen]

How do your friends get service BEFORE paying anything?

Just the way our local hospital does business, which I believe still is classified as a non-profit. And they are hurting, similar to the Denver system, who went in the red to the tune of many millions last year, based on caring for the huge volume of patients admitted who have no means to pay. My DIL , an employee in the local hospital's pharmacy, narrowly missed a layoff last week, due to this very problem, as they are trying to cut overhead to stay afloat with all the unpaid invoices, so naturally, they start whittling down the workforce.

Seems that, once people realize they can walk away (or again, negotiate a smaller invoice), why would they ever embrace the huge monthly expense of insurance, when they're convinced it's just a big rip-off? I hear it stated as such quite regularly by people of all walks of life.

So, those of us responsible enough to take care of ourselves and hemorrhage the crazy insurance premiums simply get hammered all the harder, as someone's got to pay enough to cover the shortfall, somewhere in the midst of it all. Doesn't seem to matter how much the Guv tries to leverage us all into paying. Just isn't worth it for most people who's salaries do not include healthcare. Lots of non-working poor in the local larger city create an immense amount of burden on the system. Our state has the embarrassing distinction of taking in $1.50 in federal aid for every $1 paid in. Not sure the local healthcare system could run as anything but a nonprofit.
Again, it's a vicious cycle.

[Patty Hann]

Though the billing to the insurance is higher, in all likelihood the reimbursement is much lower. It's extremely likely that your doc makes more money on the discounted cash price. People without insurance pay the highest prices in our wonderful system.

'Zactly....my doctor explained it to me (in detail).
Basically he inflates the price provided to the insurance company (including Medicare), because by the time he gets paid the amount is about equal to what the service "really" costs (and what he charges cash patients.)

[Jim Becker]

In addition to the wait time to get paid and the requirement to accept what the insurance pays, the cost of processing claims comes into play. It's often a full time employee or three that just processes insurance claims for a busy practice.

A doctor that was my primary years ago left the practice and started his own in a "premium service" system that doesn't accept insurance at all. You pay an annual fee to get a whole bunch of things for "free" and a doctor with a lower case load (he limits the number of subscribers) who has time to work with you and file for insurance reimbursement yourself.

Additionally, many practices sell out to corporations to get away from the whole insurance thing...the providers are "employees" of the bigger corporation and don't do anything relative to insurance coverage at all.

'Tis a very complex system that we've evolved to in the US and it should be no surprise that both providers and consumers are trying hard to find a way to make things work for themselves since the system is what it is.

[Ron Citerone]

Just the way our local hospital does business, which I believe still is classified as a non-profit. And they are hurting, similar to the Denver system, who went in the red to the tune of many millions last year, based on caring for the huge volume of patients admitted who have no means to pay. My DIL , an employee in the local hospital's pharmacy, narrowly missed a layoff last week, due to this very problem, as they are trying to cut overhead to stay afloat with all the unpaid invoices, so naturally, they start whittling down the workforce.

Seems that, once people realize they can walk away (or again, negotiate a smaller invoice), why would they ever embrace the huge monthly expense of insurance, when they're convinced it's just a big rip-off? I hear it stated as such quite regularly by people of all walks of life.

So, those of us responsible enough to take care of ourselves and hemorrhage the crazy insurance premiums simply get hammered all the harder, as someone's got to pay enough to cover the shortfall, somewhere in the midst of it all. Doesn't seem to matter how much the Guv tries to leverage us all into paying. Just isn't worth it for most people who's salaries do not include healthcare. Lots of non-working poor in the local larger city create an immense amount of burden on the system. Our state has the embarrassing distinction of taking in $1.50 in federal aid for every $1 paid in. Not sure the local healthcare system could run as anything but a nonprofit.
Again, it's a vicious cycle.

I am the ultimate suburban child, convince me that the country folk in rural areas don't cost me money. Blame it all on the evil cities if you want show me that rural areas don't cost me money..............show mw the data.

[Alan Lightstone]

In addition to the wait time to get paid and the requirement to accept what the insurance pays, the cost of processing claims comes into play. It's often a full time employee or three that just processes insurance claims for a busy practice.

A doctor that was my primary years ago left the practice and started his own in a "premium service" system that doesn't accept insurance at all. You pay an annual fee to get a whole bunch of things for "free" and a doctor with a lower case load (he limits the number of subscribers) who has time to work with you and file for insurance reimbursement yourself.

Additionally, many practices sell out to corporations to get away from the whole insurance thing...the providers are "employees" of the bigger corporation and don't do anything relative to insurance coverage at all.

'Tis a very complex system that we've evolved to in the US and it should be no surprise that both providers and consumers are trying hard to find a way to make things work for themselves since the system is what it is.
Ah, retirement is wonderful.

As complicated as it is being explained above, it is in many ways far worse. And I could rant and rave about the evils of corporate medicine too.

Lots of evil in our system. Insurance companies, bloated hospital administrations making obscene salaries, big pharma charging US patients many multiples of the cost they charge other country's patients for medications (plus essentially no competition for all the biologic drugs. $90K a year for all the different medications to cure HepB from multiple companies??? How is that now illegal monopoly/collusion), insane HIPAA rules (try getting results from a practice without a fax machine. Yup, 1843 technology. Not able to e-mail you), lab companies charging massively abusive differentials for in and out of network care (try going to their competitor. They are both owned by the same company), and yes, doctors too.

Oh, did I mention how wonderful it is to be retired from my 100+ hour week job taking care of trauma patients and open-heart surgery? I miss helping people/saving lives. But the rest of the nonsense sadly outweighs all of that. :(

[Jim Becker]

Alan, it's sad to me that wonderful physicians like yourself can put your hearts into providing extraordinary and life-saving care and be so burdened by "the system". Something's got to give...

[Alan Lightstone]

Alan, it's sad to me that wonderful physicians like yourself can put your hearts into providing extraordinary and life-saving care and be so burdened by "the system". Something's got to give...
Sadly it will. And I don't think in patients' favor. Corporate takeovers of medical practices is evil. Plain and simple. Now being the patient, not the doctor is at times so sad. And I have wonderful hand-picked doctors I have gotten over the years, who I know are stellar, and I trust. Plus, no question, you do get a higher level of medical care as a physician for the most part. Like most professions, we protect our own, and I know the best questions to ask. Plus my physicians don't rush me. As I said, it's a higher level of care than many receive. And I worry about when they will retire and I will have to find new ones. Because they all will retire "early".

It really troubles me as a retired MIT graduate / Harvard Medical School resident and clinical fellow that 70% of Harvard graduates go into finance. That's what the best and the brightest in our country do. Just make money, and not benefit society. Just think of the advances we might have if our brightest students went into medicine. Didn't used to be that way. Sigh....

[Jeff Roltgen]

I am the ultimate suburban child, convince me that the country folk in rural areas don't cost me money. Blame it all on the evil cities if you want show me that rural areas don't cost me money..............show mw the data.

Terribly sorry Ron - thought I had done just that, but allow me to clarify:
That larger city I'm referring to is a mere 75,000 in population, so still, by most standards, a small town, and no way am I saying the "evil big cities" are being supported by us mid-westerners, as you appear to have interpreted it. A large concentration of the non-working poor are there, if for no other reason than easier access to a better hospital, assistance, but more likely to simply escape the depression and hopelessness of living on a reservation. You'd have to go to one to believe the destitution, regardless of the millions poured into upholding the Gov't promises to them. There are many diligently trying, but hopelessness is remarkably difficult to overcome, and clearly, money hasn't changed much of anything.

We, in our thinly populated, subsidized ranching countryside, along with the under-employed, are totally living off the Fed out here. Again, $1.00 paid in Federal taxation, $1.50 back in Federal funding, speaks directly to your demand for data. Not proud of it, but facts are what they are. So yes, you are perfectly correct, and as a resident, self employed, pay my way all the way business owner, I share in a fair bit of your frustration, while I'm living in the midst of it. We're not all living off the fed out here, but it is way out of balance, for sure.

Tourism is one of our biggest "industries". Fed by vacationers, like yourself, seeking a break away from the city, with fresh air, blue skies and prairie, and a nice little haven of the Black Hills to escape to. More evidence of you supporting country folk.

Anger does not help, and I'm sorry to have stirred it up in you. Hope this clarifies just how correct you are. But what to do?
We need to remain calm, and understand, regardless of who's feeding off of whom and for what reason, justified or not, how to strike a balance?
Plenty of us out here, exploring more ways to produce, be self-sufficient, and do our part to be contributors to this great nation. It's just not likely a perfect balance can be found, and you just have to trust that the vast majority of country folk (who all too often could be labeled the working poor) are doing their best to make good, and while not proud of it, appreciate the help we receive, when given.

jeff

[Brian Tymchak]

It depends on the doctor (or group).
I have had that exact "orthotics" situation that you describe.
When doing PT (for one thing or another *sigh*) I casually asked about pricing, even tho' insurance was paying for it.
Billing would be different (slightly lower) for those paying cash.

I was surprised at the difference in billing levels. My first reaction was to wonder if my podiatrist is overbilling the insurance company.

[Patty Hann]

I was surprised at the difference in billing levels. My first reaction was to wonder if my podiatrist is overbilling the insurance company.

If I remember correctly.... the "bill" for one pair of orthotics (paid by BCBS through employer) was $750.
If I had to pay [cash] for them because they weren't covered by insurance the bill would have been $395 or there-abouts ( I do recall thinking something like: wow...almost $400)

[Brian Tymchak]

If I remember correctly.... the "bill" for one pair of orthotics (paid by BCBS through employer) was $750.
If I had to pay [cash] for them because they weren't covered by insurance the bill would have been $395 or there-abouts ( I do recall thinking something like: wow...almost $400)

Wow, $750... My first pair billed to insurance would have been $495. The self-pay price was $350. I just ordered 2 more pairs. The insured price would have been ~$350 / pair. I self-paid $250. That HSA is coming in handy in retirement. ;)

[Jim Becker]

It really troubles me as a retired MIT graduate / Harvard Medical School resident and clinical fellow that 70% of Harvard graduates go into finance. That's what the best and the brightest in our country do. Just make money, and not benefit society. Just think of the advances we might have if our brightest students went into medicine. Didn't used to be that way. Sigh....

Professor Dr. SWMBO is out of Harvard School of Public Health with a D Sci in Epidemiology. She's about to retire from teaching for health reasons...and we have to do the whole insurance dance. She can stay on the university plan by paying the full, non-subsidized premium and will have to do that until she turns 65, more or less. I could stay on that plan, but it's most cost effective for me to "embrace my Medicare". The cruelty is with our younger daughter because the "retirement" version of the university health insurance only covers spouses, not kids under age 26 who are still on the parental unit's plan. So she's going to have to get insurance from the PA exchange 'cause as an independent contractor, she doesn't get benefits. Oy!

[Alan Lightstone]

Professor Dr. SWMBO is out of Harvard School of Public Health with a D Sci in Epidemiology. She's about to retire from teaching for health reasons...and we have to do the whole insurance dance. She can stay on the university plan by paying the full, non-subsidized premium and will have to do that until she turns 65, more or less. I could stay on that plan, but it's most cost effective for me to "embrace my Medicare". The cruelty is with our younger daughter because the "retirement" version of the university health insurance only covers spouses, not kids under age 26 who are still on the parental unit's plan. So she's going to have to get insurance from the PA exchange 'cause as an independent contractor, she doesn't get benefits. Oy!
Social Security Disability (which is amazingly hard to get if you have a pulse) isn't an option? That gives you the ability to get on Medicare before age 65, but bizarrely after a 20 month waiting period. I had to go through the insurance exchange thing after my COBRA ran out. Wasn't pretty, and was crazy expensive for mediocre coverage at best.

Love epidemiology. I love how the Freakonomics guys talk about what an improvement in math education would exist if we teach students how to analyze data instead of algebra, much less calculus. Read lots of epidemiology papers during the plague (I needed something to read that was scientific, not political). Also took courses at MIT on virology. Was stunned how much had changed since my biology degree there (although to be fair, that was 42 years ago - an eternity in science/medicine). Was brought back in time hearing a guest lecture from my college biology department advisor. Amazing to hear him again. And that he was totally up-to-date albeit so many years later (I guess that Nobel prize was pretty well deserved.)

[Mike Henderson]

If you go to a "for profit" hospital as a self-pay patient and you don't pay, many hospitals are now getting judgements against people and will file a lien against their house and garnish wages. And the amount is not the negotiated price, it's the full price.

So in that case, the self-pay person is paying the highest price - much higher than the hospital would get from insurance. But they have to pay to collect it.

Mike

[Edwin Santos]

If you go to a "for profit" hospital as a self-pay patient and you don't pay, many hospitals are now getting judgements against people and will file a lien against their house and garnish wages. And the amount is not the negotiated price, it's the full price.

So in that case, the self-pay person is paying the highest price - much higher than the hospital would get from insurance. But they have to pay to collect it.

Mike

Most "not-for-profit" hospitals are absolutely "for profit".
The "not-for-profit" designation gets the hospital certain reimbursement and purchasing advantages as well as marketing advantages. So it's great to have it, but also great to make money.

So how does a health system become not-for-profit-but-not-really?
Establish subsidiaries and related entities that are for-profit and direct income to those entities through intercompany transactions. A good example with be the affiliated real estate holding entity to whom the hospital will pay rent. Another example is ancillary service divisions that provide services and supplies to the hospital.
It can become a very complicated web but the idea is for the not-for-profit entity to be the jelly surrounded by a donut made of for-profit businesses.

[Jim Becker]

Social Security Disability (which is amazingly hard to get if you have a pulse) isn't an option? That gives you the ability to get on Medicare before age 65, but bizarrely after a 20 month waiting period. I had to go through the insurance exchange thing after my COBRA ran out. Wasn't pretty, and was crazy expensive for mediocre coverage at best.
We're familiar with SSDI as our older daughter qualified for it because of her own real disability. (surprisingly, got it first try which is HIGHLY unusual) For The Professor, it's not really worth the effort give there is only a year until her 65th birthday and it likely would take multiple tries with no assurance of getting it. SSDI Medicare benefits cost the same as normal Medicare, and there's a waiting period once you qualify as you mention, so there's little benefit in this case. There's no money issue with her paying for the retirement healthcare (identical to our current coverage other than loss of subsidy). As noted, it's just more complicated for our 24yo daughter who currently uses our family coverage.

Yea, Epi is kewel...I've learned a lot over the years from her. She did research for many years on liver cancer related to Hep-B including some association with Nobel Prize winner Baruch Blumberg and the Hepatitis B Foundation and Fox Chase Cancer Center (study populations in Senegal and China), but has been teaching Epi and related at a large university school of public health in Philadelphia. Interestingly, one of her colleagues and friends from Harvard is also in the program and will also soon be retiring. Her undergrad is from the University of Chicago.

[Jeff Clode]

I always find these (medical threads” interesting as they go in so many directions….I had a wonderful 45 year career in clinical medicine with some fascinating forays into administration and governance and I’d like to offer a couple of observations:


it’s almost impossible to understand charges, billings, collections etc as these have the transparency of a brick (for many reasons) and not affected by ordinary logic. Trying to understand will drive you mad.
there is little direct relationship between charges, payments and the cost of delivering a service. Lots of reasons for this also.
the medical system is Balkanized, fragmented, siloed (- pick your own word here-) into multiple semi independent parts - each it’s own financial and/or profit center.
this means terrible duplication of administrative functions, a lack of sharing savings and losses amongst the silos and therefore a lack of common goals (- if not competing goals).
the word “evil” is frequently used or implied when this system is discussed but in all my time in medicine I met very few folk to whom I would apply that term. I think it’s important to recognize that we get the behavior we reward the most highly and we’ve created a horribly complex system in which financial survival of each silo is the primary goal - “everybody’s got to eat”. That survival mode applies whether one is in charge of a hospital, a nursing home, a provider group, a pharmaceutical house etc. etc..
also realize no good deed or intention goes unpunished- for example, Medicare advantage plans were designed to reduce per capital costs but have done the opposite.
I don’t see much hope for substantial changes unless we actually have a national debate and decide whether health care is a right or a privilege- I don’t want to get political here but this is a fundamental question. If it’s a privilege, we can keep going as is, if it’s a right, then we have to figure out how to make this sucker more efficient and get it to all. As it is we have islands of brilliance in a sea of mediocrity. It is what we designed either consciously or not
End of rant

[Alan Lightstone]

We're familiar with SSDI as our older daughter qualified for it because of her own real disability. (surprisingly, got it first try which is HIGHLY unusual) For The Professor, it's not really worth the effort give there is only a year until her 65th birthday and it likely would take multiple tries with no assurance of getting it. SSDI Medicare benefits cost the same as normal Medicare, and there's a waiting period once you qualify as you mention, so there's little benefit in this case. There's no money issue with her paying for the retirement healthcare (identical to our current coverage other than loss of subsidy). As noted, it's just more complicated for our 24yo daughter who currently uses our family coverage.

Yea, Epi is kewel...I've learned a lot over the years from her. She did research for many years on liver cancer related to Hep-B including some association with Nobel Prize winner Baruch Blumberg and the Hepatitis B Foundation and Fox Chase Cancer Center (study populations in Senegal and China), but has been teaching Epi and related at a large university school of public health in Philadelphia. Interestingly, one of her colleagues and friends from Harvard is also in the program and will also soon be retiring. Her undergrad is from the University of Chicago.
It's great having a spouse who's really smart/talented and in a totally different field of work than you. But I don't have to tell you that. In my case she's an award winning pastel artist. Me, I can't draw a stick figure at gunpoint, but logistics, numbers, pattern recognition, multitasking - that's what benefitted me in my career. The woodworking just came later as a fun hobby.

[Lee DeRaud]

My dentist has a variant of that system for uninsured patients.

There's a yearly subscription fee which is roughly his "retail" price for two cleanings. It covers those two cleanings, a set of xrays, and 20% off all other work.

[Curt Harms]

[COLOR=#000000][FONT=UICTFontTextStyleBody]I don’t see much hope for substantial changes unless we actually have a national debate and decide whether health care is a right or a privilege- I don’t want to get political here but this is a fundamental question. If it’s a privilege, we can keep going as is, if it’s a right, then we have to figure out how to make this sucker more efficient and get it to all. As it is we have islands of brilliance in a sea of mediocrity. It is what we designed either consciously or not
End of rant
[/LIST]

A very difficult topic indeed. If health care is a right, it seems like there'd have to be some sort of rationing, society can't afford unlimited care to every sick person. Talk about a difficult/uncomfortable topic.

[Mike Henderson]

A very difficult topic indeed. If health care is a right, it seems like there'd have to be some sort of rationing, society can't afford unlimited care to every sick person. Talk about a difficult/uncomfortable topic.

Any service that's free will generally be over used. To limit utilization some type of rationing is required. Today, we ration by cost. If you can't pay for service, you don't get any.

Incidently, that's somewhat a problem with Medicare. Once you pay for your Part B and supplemental plan, you have no incentive to limit your utilization.

Mike

[Malcolm McLeod]

... medical system is Balkanized, fragmented, siloed ...


I saw a long and fascinating discussion (debate?) about what the delivery of health care would look like without insurance. Insurance industry would clearly fight it. Most patients would say they would just have to die, since they couldn't afford it. And providers would thus all go out of business.

Or maybe look at changes in the price and downtime of a woman's 'enhancement' procedure over the last couple of decades?

What's that old saying about compromise? ...Everyone is unhappy?

No citations on this either, so maybe I just made it up??;)

[Malcolm McLeod]

Any service that's free will generally be over used. To limit utilization some type of rationing is required. Today, we ration by cost. If you can't pay for service, you don't get any.

Incidently, that's somewhat a problem with Medicare. Once you pay for your Part B and supplemental plan, you have no incentive to limit your utilization.

Mike

Media (probably 60Minutes?) did a segment about retirement center in FL - busing residents to the doctor's plaza. Asked do they need to go? Paraphrasing, "I paid my money, so I'm going."

It was treated like a trip to a shopping mall or the zoo. Que sera. And this is probably 10-15 yrs ago.

[Bruce Wrenn]

My last pair of diabetic shoes were about $375 (four years ago,) with my share being $74. Recently wife went to New Balance store to buy a pair of their "Roll Bar" shoes, which are the same model as my diabetic shoes. Cost directly out of pocket, $140. Remember this is four years later, so prices have definitely increased. To get a prescription for another pair, I would have to pay a $40 deductablele, plus 20% of the cost of shoes, which most likely would exceed the $74 dollars I paid four years ago. Based upon old pricing (four years ago) I would only pay $26 more than using insurance (Medicare Adv.)

[Lee DeRaud]

Media (probably 60Minutes?) did a segment about retirement center in FL - busing residents to the doctor's plaza.
Any retirement/over-55 housing that doesn't provide that service deserves to go out of business.

[Scott Winners]

I agree that healthcare as a right v- privilege is a fundamental question, but it isn't the entire problem.

What about (sorry) the responsibility of each individual to pursue a healthy lifestyle?

I have 27 years as a bedside RN. I came "home" to general unrestricted med-surg 6 months ago. The first thing I noticed, in about two hours on the floor since last working general med/surg around the turn of the century, is you lot as a group have gained about 75 pounds, each, since I saw you last.

I can look at a chart for a new admit coming up from the ER, see dilated cardiomyopathy, diastolic CHF with stage 3 kidney disease; and I don't have to look at the urinalysis to know I am about to be handling a methamphetamine addict, again.

But beyond street drugs (bad), alcoholism (bad) and smoking (really bad, I mean come on, really? You are still smoking in 2023?!?) where do we draw the line between right and privilege? It is a slippery slope.

What about folks addicted to sugar? What about folks addicted to their smart phones, doesn't matter if it is boys addicted to internet pron or girls addicted to social media, these folks are all addicted to either dopamine hits or running from reality. Do you want to pay for that, knowing no amount of $$$$$ is going to change the outcome without patient buy-in and participation/ownership?

What about the folks addicted to caffeine?

I am in favor of universal USA coverage for stuff like flu shots and broken bones. I am opposed to the same universal coverage paying for stuff like cosmetic implants or babies born with transposition of the great vessels. Where the line is between those basics should be publicly debated and publicly decided. Professional deference, professional courtesy, requires those decisions to be made by John Q Public, with the implicit understanding that if you ask too much of me I will quit my job.

Two of the cornerstones for a solid foundation of good overall health are good mental health and good nutrition.

The American stigma related to pursuing good mental health needed to end somewhere around 1968. When did you last stand up in airport and deliver standing applause to a returning home active duty soldier? Did you also vote in favor of the congress person who sent that young person on a futile mission for a repeat term?

At the end of the day, big pharma CEOs are responsible to the share holders for paying dividends. To do that they need to come up with pills you take over and over for the rest of your life. Insurance companies are in it for the money, not for your personal health outcomes. Have you heard the one about the health insurance executive who talks his way into heaven, but Saint Peter tells him he can only stay for three days?

Have you seen the current TV advert where serious athletes on bicycles ride fast over a brutal desert in pursuit of a boxcar load of soda pop as a reasonable serving size for a group of four?

The third cornerstone of basic good health is physical activity. I do know folks who could sprint a mile over a hostile desert on a bicycle, but none of them drink any sodapop at all. How many brand names does Coke/Pepsi actually own?

The American healthcare system is broken. I do not know how to fix it. Besides the right/privilege question, we will need to address the folks who want to have their cake and eat it too.

Gaming the existing system with billing tiers is par for the course, I think.

[Patty Hann]

^^^^^ This ^^^^^

[Bill George]

I agree with Scott mostly, but one way or another we are All paying for the folks who abuse the system we have now, druggies and all.

[Jeff Clode]

“Two of the cornerstones for a solid foundation of good overall health are good mental health and good nutrition.”
To this I would add good solid education. A child not reading at grade level by the third grade is many times more likely to have subsequent issues with drugs, alcohol, early pregnancy, delinquency, incarceration etc.. All of this directly impacts our medical system which has to try and pick up the pieces
(We are on the same side in this discussion Scott)
Jeff

[Malcolm McLeod]

Any retirement/over-55 housing that doesn't provide that service deserves to go out of business.

^I agree.

But the bus wasn’t really the point of my post.

[Lee DeRaud]

^I agree.

But the bus wasn’t really the point of my post.
And my point is that most elderly and chronically-ill people don't go to the doctor as a recreational activity or just because it's "free".
A media outlet looking hard for a sound-bite can always find people willing to tell them what they want to spin.

[Mel Fulks]

Don’t think the law is going to stop anyone from charging by the foot, well established in structural stuff like arches. The Doc’s
lawyers are on their toes and will bring butt- inskees to heel and nail them.

[Malcolm McLeod]

And my point is that most elderly and chronically-ill people don't go to the doctor as a recreational activity or just because it's "free".
A media outlet looking hard for a sound-bite can always find people willing to tell them what they want to spin.

^ Again, we agree. And (‘All’ - ‘most’) = ‘Some’ who will abuse any system. And leads back to Mr. Henderson’s assertion:

Any service that's free will generally be over used. To limit utilization some type of rationing is required. Today, we ration by cost. If you can't pay for service, you don't get any.

Incidently, that's somewhat a problem with Medicare. Once you pay for your Part B and supplemental plan, you have no incentive to limit your utilization.

Mike

Quick 2min lunch search of 60Min archives didn’t find the story I referenced, but did pull up a 2009 story of $60B Medicare fraud (centered in FL). Not a good tie-in to this thread, but easy to find, if interested.

[Mike Henderson]

I would advocate that all Medicare physician encounters have a co-pay. It should be graduated based on income, but everyone should have to pay a co-pay. That would get people to (at least) think about whether they need the service. This would probably not be popular with Medicare patients, and probably not with the doctor's staff (who have to collect it).

Today, the major thing that limits Medicare utilization is the inconvenience of having to go to a doctor's office and the time it takes.

Mike

[Jonathan Pace]

I don't think this is related to just podiatry, and it seems like the whole health/medical industry, paired with the insurance industry, on a global scale, functions and operates like this.

[Perry Hilbert Jr]

There was a wonderful and very humble Vietnamese Doctor in Falls Church Va, who maintained a low cost clinic as a form of giving back to his adopted country and it's freedoms. He worked full time for the VA, IIRC, and did this 5 evenings and half days on Saturdays. He took no insurance. $25 a visit. His wife was his office staff. His waiting room was always crowded. For the couple years that my wife and I did not have health insurance, he was a God send. The other thing, was that you didn't have to wait three weeks for an appointment. The Washington Post did one or two articles about him. He was often there from 5 pm until midnight to see everyone. I once counted 37 people waiting to see him. That meant he was taking in over $1,000 a day. almost all in cash. Not bad even by today's standards. I never felt rushed, but he didn't waste time either. He didn't do some of the more simple things like vaccines, and diagnostic tests, those he referred patients out for. There were no drugs anywhere in the office. He also owned the office building and I heard he opened a discount pharmacy a year or two after we moved away, where he continued helping people with no insurance.

[Kent A Bathurst]

So - basically the point here is that the podiatrist changes the cost of service depending on who is going to foot the bill.

I’m here all week. Remember to tip your server

[Ken Fitzgerald]

Insurance companies like to play games. They try to get reduced costs. So if you pay it may be one price, if the insurance company is paying they may call the provider and ask for a discount. The provider can give them a discount and the result is they pay what you would. Dealing with insurance companies is seldom fun as an insured person or a provider.

My neighbor was a partner in a local gas station and repair shop. The vehicle leasing company for the corporation I worked for wanted me to use their service/repair shop. I asked my neighbor's partner about the reduced prices and he chuckled. He then told me that if I paid it was one price. If the leasing company paid, it was another price and if they called requesting a discount, they paid what I did.

[Bill Howatt]

I've been told more than once, if you are getting body work done on your car to ensure you tell the shop that you are paying for the repair yourself, not an insurance claim.

[Scott Winners]

“Two of the cornerstones for a solid foundation of good overall health are good mental health and good nutrition.”
To this I would add good solid education. A child not reading at grade level by the third grade is many times more likely to have subsequent issues with drugs, alcohol, early pregnancy, delinquency, incarceration etc.. All of this directly impacts our medical system which has to try and pick up the pieces
(We are on the same side in this discussion Scott)
Jeff



My family happened to move across state lines the summer between second and third grade for me. Of all the new kids I got to know that first year, I think there is an enormous amount of validity here. There was a group of kids who were yawning because our classwork was so easy, there was a group of kids who were working to be current, and there was a group of kids who were not current.

I suspect Jeff has some expertise in this area, but my own life experience (to recall while I was changing the oil in my lawn mower, Gerald Ford was in the White House when I was in third grade), my recollection is in fourth grade we started reading chapter books with no pictures in them, and reading expectations from faculty just went up and up and up from fourth grade through college. The kids/peers I remember as not being caught up on reading by the end of third grade just got further and further behind, I has in the same school system through the end of 8th grade.

I accept, and welcome, a solid basic education as a cornerstone of good health.

Total I am up to four corner stones, there may be more. Right now I have good mental health, good nutrition, fundamental education, and physical activity.

Thanks for the input Jeff.