Patterico's Pontifications

3/31/2012

The other side of the Obamacare bubble

Filed under: General — Karl @ 8:34 am

[Posted by Karl]

Like a number of others, I noted this week the bubble in which liberal legal analysts and pundits hid from how tenuous the claims are for the constitutionality of Obamacare.  It is also worth noting that conservatives and libertarians generally did not hide in a bubble of their own to ignore the proffered justifications for the law.

The Obama administration and its fellow travelers largely justify the mandate based on the supposedly unique features of the healthcare market, e.g., the general inability to “opt out,” legal requirements that hospitals provide emergency care, and cost-shifting related to uncompensated care.  Judge Roger Vinson addressed these arguments in his decision striking down the mandate; his arguments were generally accepted by the 11th Circuit Court of Appeals, creating the split with the 6th Circuit that essentially guaranteed Supreme Court review. (Again, liberal geniuses somehow missed this split as an indicator their case was not a slam dunk, even though these decisions have not always followed neat partisan lines.)  Judge Vinson’s decision was echoed in some of the skeptical questions raised by Chief Justice Roberts this past week, e.g., asking whether Congress could impose a cellphone mandate to summon emergency services.

Meanwhile, analysts like Avik Roy and Shikha Dalmia examined the free-rider and uncompensated care issues and found them wanting.  Again, their critiques were echoed by Chief Justice Roberts, e.g., asking how issues with emergency care are addressed by mandating comprehensive insurance coverage.  Although uncompensated care can be an issue in certain circumstances the $43 billion Congress claims affects interstate commerce amounts to only 3%-5% of total healthcare spending, roughly equivalent to the percent big law firms seek to provide as pro bono services.  Indeed, it’s only slightly more than the 2% average shrinkage in the retail sector.

Moreover, as John F. Cogan, R. Glenn Hubbard and Daniel Kessler note, peer-reviewed studies suggest cost shifting actually raises private health insurance premiums by a negligible amount, ($80 annually for the typical plan, far less than the $1,ooo Congress estimated):

Where did Congress go wrong? We traced its estimates of the magnitude of the hidden tax of $43 billion per year, or an increase in family premiums by an average of $1,000 per year, to two sources—the aforementioned Health Affairs study, and a non-peer-reviewed study commissioned by FamiliesUSA, a Washington, D.C., group long known for its advocacy of greater government involvement in health care. Yet Congress simply ignored the evidence in the Health Affairs study and failed to recognize the serious flaws in the FamiliesUSA analysis.

Specifically, Congress ignored the $40 billion to $50 billion that is spent annually by charitable organizations and federal, state and local governments to reimburse doctors and hospitals for the cost of caring for the uninsured. These payments, which amount to approximately three-fourths of the cost of such care, mitigate the extent of cost shifting and reduce the magnitude of the hidden tax on private insurance.

Moreover, the economics of markets for health services suggests that any cost shifting that may occur is unlikely to affect interstate commerce. Because markets for doctor and hospital services are local—not national—the impact of cost shifting will be borne where it occurs, not across state lines.

While taxpayers may not be thrilled at picking up the tab for uncompensated care, it is already being done.  Moreover, Cogan, Hubbard and Kessler make a point Roy also makes — Obamacare’s reliance on expanding Medicaid (which chronically under-compensates providers) is likely to increase cost-shifting, not decrease it.  Furthermore, as Peter Suderman notes, Congress purports to solve this supposed $43 billion problem with $200 billion in subsidies.

Nevertheless, even when fisking Linda Greenhouse, NRO’s Ed Whelan added his point “is not to maintain that any reasonable person must agree with the states’ brief,” while James Taranto noted it was quite possible Greenhouse would turn out to be correct in predicting a lopsided vote for Obamacare and that conservative lawyers he spoke with thought Obamacare would be upheld (which lefties see as an admission they are correct, rather than a recognition of a debate).  Despite the profound problems with the key justifications for Obamacare, folks on the right generally have not engaged in the level of dismissive denial the left has.

–Karl

329 Responses to “The other side of the Obamacare bubble”

  1. Ding!

    Karl (6f7ecd)

  2. I guess the same folks arguing this point will now come out and sing A-OK since karl wrote an article about it.

    Good article. The ER problem is nonsense and the amount taxpayers actually fund is miniscule as to be unimportant. (Para 3/4)

    I love the analogy to “shrinkage” in the retail sector. Excellent comparison.

    Our health care cost/financing crisis is a major fraud invented by those who want to drain more money from Payors or live off others.

    In fact, get Govt out of paying, make it harder for lawyers to file crazy suits and watch prices, service utilization drop like a rock — I would say about 30-40%. And the best part is outcomes would not change in terms of health.

    Bottom line is the increase in health and life expectancy can be traced more to Antibiotics, Vaccines and Clean Water more then anything else.

    And if you wish to improve those numbers, decrease caloric consumption and get more exercise. In fact, get more exercise with a smoke and some alchohol while you are at it if you need to indulge.

    Bill (af584e)

  3. I think we always knew it was going to be a fight to get the law overturned. That just because it should fall because it is far beyond the powers granted to Congress is no guarantee that it actually will be voided.

    Soronel Haetir (a4296a)

  4. This episode provides a fascinating look at the fantasy bubble the left lives in. Pelosi’s are you serious comment was genuine – a limiting principle does not exist in the bubble. Judge Kagan’s confusion about how heaping money on poor people could possibly be unconstitutional is similar. In the bubble, money plus government control solves every problem and is therefore understood to be sustainable almost by definition.

    The problem going forward if this is struck down is that the left will more aggressively assert extra-constitutional means of control. Given that these constitutional objections appear to be obscure and borderline anachronistic to the general public, I’d like to know how we can withstand the inevitable counter-stroke without fighting fire with fire.

    The left will not stop until the bubble is imposed on us all.

    Amphipolis (e01538)

  5. #4, Actually if struck down, the left will push for nationalized health care since that would be fine legally speaking.

    Bill (af584e)

  6. Bill (2),

    In the prior thread, you claimed, “Taxpayer dollars do not go to subsidizing pricing in hospitals. In fact, it is private insurers and self pays who do. They are the fools who over pay.” But according to the studies cited by Cogan, Hubbard and Kessler, taxpayers pick up about 75% of the cost.

    You did correctly note the cost-shift that comes from Medicaid and Medicare, but that does not seem to have been the point of contention in the prior thread.

    Karl (6f7ecd)

  7. Karl,

    “Specifically, Congress ignored the $40 billion to $50 billion that is spent annually by charitable organizations and federal, state and local governments to reimburse doctors and hospitals for the cost of caring for the uninsured.”

    Now, compare those numbers to the amount “subsidized” by private carriers who pay 20-40% more for all services then Medicare or Medicaid.

    Nonsense discussion.

    Bill (af584e)

  8. #7 let us not forget Pro-Bono which many MD willingly do even if complaining about it.

    … we are all taxpayers in some form but the Private market subsidizes this “writeoff” nonsense that most people rail about when trying to jam government care down our throats. Even those in Poverty pay sales tax.

    So if the word-smithing technocrats in all of us who never miss a chance to miss the point wishes to navel gaze for years on silliness … not much I can do. But all the hate focus on illegal aliens and the uninsured for this is ridiculous.

    In addition, when uninsured do pay their bills they pay upwards of $2 for every dollar Medicare pays.

    Where is that analysis of the cross subsidization of one uninsured for the other???????? I mean, would that not be a better analysis and intellectually honest to group properly the different market segments to compare profitability and true writeoffs.

    Bottom line — uninsured are the most profitable segment in medicine by far.

    Bill (af584e)

  9. Bill – If you take the time to actually read the links Karl embedded to support his argument, you will find yourself still as full of sh*t as on Thursday.

    daleyrocks (bf33e9)

  10. #9. Daley you are beyond ignorant on this discussion and have no reason to comment.

    Bill (af584e)

  11. Daley, you just want to beat up illegal immigrants so the narrative must survive.

    Bill (af584e)

  12. Unisured Patient Come into the Office.

    Avg Office Visit Price = $350
    Avg Payment = $200
    “Writeoff” = $150

    Oh the horror!!!

    Medicare Patient Comes into the Office.

    Avg Office Visit Price = $350
    Unallowable Price – $250.
    Avg Medicare + Patient Payment = $100

    … this is the bottom line for ER and MD Offices and Hospitals.

    Bill (af584e)

  13. Karl – One thing to note on the uninsured/uncompensated care data. The population of uninsured residents of the U.S., legal or illegal, is not evenly distributed geographically, which argues more for state-tailored policies or an EMTALA fix than a federal mandate. Just look at a high of Texas of around 26-28% uninsured to a low of Massachusetts pre-Romneycare of 8%. Part of that Texas rate is of course driven by policy decisions to restrict Medicaid access.

    daleyrocks (bf33e9)

  14. Unless you have run one of these enterprises and actually bothered to get past the horrid accounting reports most systems generate and actually do some analysis … you come to the wrong conclusion.

    But that MD and Hospitals use the “unsinsured crisis” to further their greed is undisputable.

    Might be a problem for the patient who is uninsured but not or the pocket book of the health care provider or facility.

    Bill (af584e)

  15. “#9. Daley you are beyond ignorant on this discussion and have no reason to comment.”

    Bill – That’s nice. You are continuing to cover yourself with glory on this subject. Carry on.

    daleyrocks (bf33e9)

  16. Most profitable Center we ever ran serviced 90% uninsured patients (mostly illegals). Generated $200 profit per year per square foot.

    Our other offices at around $50-$75 AT BEST.

    Bill (af584e)

  17. #15 You are a vile person Daley. It was you who said I was full of shit yet you provide zero in terms of analysis or facts.

    You also ignore the gist of the article is 100% consistent with the view point presented earlier by me.

    And yes, you are 100% ignorant on this issue as are most people. You know knowing about healthcare works or how it pays and where the money is. I do.

    Bill (af584e)

  18. You want to know another market segment which totally subsidizes MD/Facility Income. Medicare Advantage. What a great/lucrative boondogle for the Internist Community.

    Bill (af584e)

  19. “Bottom line — uninsured are the most profitable segment in medicine by far.”

    Bill – Even if they can’t pay? Really?

    daleyrocks (bf33e9)

  20. daleyrocks (13)

    I alluded to this in the post (“Although uncompensated care can be an issue in certain circumstances…”

    Bill (7),

    The inclusion of “charitable organizations” does not support the claim that the cost of uncompensated care falls on private insurers. That’s the point Cogan, Hubbard and Kessler — and the studies cited — are making.

    Karl (6f7ecd)

  21. Highest to lowest profitability by market segment

    1) Medicare Advantage
    2) Self pay
    3) Work Comp
    4) Private Insurer PPO
    5) Medicaid HMO PMPM
    6) All HMO non PMPM
    8) Medicaid FFS

    Bill (af584e)

  22. “Most profitable Center we ever ran serviced 90% uninsured patients (mostly illegals). Generated $200 profit per year per square foot.”

    Bill – Are you talking about Doc in the Boxes?

    daleyrocks (bf33e9)

  23. Isn’t there a significant difference between a doctor’s office in say family medicine, where the average uninsured patient can probably pay his bill, and a hospital?

    Anecdotal evidence sucks.

    Amphipolis (e01538)

  24. Karl,

    Listen up. It is a non-problem so far as subsidy goes. And specifically FEDERAL. Peanuts. Nothing. 5 fighter planes cost more money.

    The people who subsidize the healthcare system by logic are the one who pay the most for comparable services.

    And in every setting it is the uninsured who pay the most on a blended basis. Only exception is Outpatient Medicare Advantage at the PCP level which I put above since that is what I am most familiar with.

    Bill (af584e)

  25. #23, Hospitals collect tons of money from uninsured. To think uninsured simply don’t pay hospitals is a myth.

    Again, when looking at the difference between Billings and Collections on a per claim / per CPT basis per market segment. Uninsured yield the highest profitability by far.

    Might there be a border town hospital where illegals are conditioned not to pay by Social Services folks helping destroy the Hospital. Sure. Very very small.

    Bill (af584e)

  26. “Anecdotal evidence sucks.”

    Amphipolis – So far that is all that Bill, a senior executive in the field, is willing to serve up.

    daleyrocks (bf33e9)

  27. Good Allah. Bill and Random should hook up.

    JD (e5c06b)

  28. Amphipolis – That and the fact that some hospital advertise to improve capacity utilization and staff make jokes sometimes about over staffing apparently comprise proof of his arguments.

    daleyrocks (bf33e9)

  29. #26, yeah Daley, I am going to disclose confidential data on a message board. Anecdotal it is to you since you are clueless about this. Cold hard numbers above.

    $200 per square foot profitability at the ilegal alien health care center. $50 at the white shoe, lilly white, rich folks area.

    Keep talking smack all you want but I make a very very very good living doing this. Rest of you are amateurs playing with data you mostly don’t understand.

    Bill (af584e)

  30. #28 LOL. If ER lost so much money why would they advertise to get more money losing business?

    Bill (af584e)

  31. “Hospitals collect tons of money from uninsured. To think uninsured simply don’t pay hospitals is a myth.”

    Bill – I certainly made no claim that they did not. To make the claim that they are the most profitable patient demographic depends on how much is collected from what percentage of the uninsured percentage of the patient population. You may be talking about your personal experience, others have had different experiences and links which you have apparently not read are evidence of different experience. You should be cautious of how you frame your generalizations or present actual data to back them up. For a highly regulated industry, such data should not be hard to come by.

    daleyrocks (bf33e9)

  32. #28 Or for that matter, increase the size of the ERs, beds, etc ….

    Someone smarter then you once told me “look at what they spend money, not what say to raise money.”

    Bill (af584e)

  33. “$200 per square foot profitability at the ilegal alien health care center.”

    Bill – So you are talking about a stand alone facility rather than a hospital. Thanks.

    daleyrocks (bf33e9)

  34. #31, On this issue, I need no caution. And my generalization are 95% correct. Again, this is my life’s work and a very lucrative one.

    The folks writing about this subject are clueless and being manipulated by those who either a) don’t know or b) are getting very wealthy perpetuating the lie.

    … and there are both in the health care business.

    Bill (af584e)

  35. If a Hospital were to sell bricks of gold they would sell bricks at $1000 to the Uninsured, $200 to an Aetna Patient and $100 to a Medicaid Patient.

    They would “only” collect $500 from the Uninsured Patient. Claim they lost $500 on the Unisnured Patient. Go begging for money to make up the difference.

    On the Aetna and Medicaid Patient, they would adjust the $1,000 price to the $200/$100 contract price and no one would give a whits end about it the money “lost” since it was never lost because we signed a contract saying it was not.

    But taxpayer “subsidize” the uninsured. LOL. let the lie live.

    Bill (af584e)

  36. “Unless you have run one of these enterprises and actually bothered to get past the horrid accounting reports most systems generate and actually do some analysis … you come to the wrong conclusion.”

    Bill – I don’t claim to be any kind of expert or a senior executive in the field, but I have audited hospitals and conducted fraud examinations on them and I have a little familiarity with the insurance industry. It’s not hard to tell when somebody is blowing smoke when they won’t support a position with more than just anecdotal evidence, particularly when they’ve already been caught out wrong on their initial claims.

    daleyrocks (bf33e9)

  37. ==I make a very very very good living doing this==

    ==this is my life’s work and a very lucrative one==

    That’s what Bernie Madoff said too.

    elissa (a7f40f)

  38. You know who the taxpayer subsidizes? Medicaid Beneficiaries, especially kids. Now that is money.

    Bill (af584e)

  39. #36, What claim is wrong Daley? You throw out assertions with no analysis. Anecdotal or otherwise.

    Bill (af584e)

  40. #37 LOL. Another name caller with no substance on the issue. Anecdotal or otherwise.

    It really is difficult disabusing people of positions they hold to dogmatically and with religious fervor. Left or Right.

    Yes kids, those horrid illegals and uninsured are draining the health care system. Keep believing the hype.

    Bill (af584e)

  41. Did a comment get removed? Why does Bill keep replying to himself?

    #28 LOL. If ER lost so much money why would they advertise to get more money losing business?

    Comment by Bill — 3/31/2012 @ 9:46 am

    #28 was a comment by Bill…

    Ghost (6f9de7)

  42. Bill had a comment on moderation because he had cursed. It was put there automatically. I just released it.

    Patterico (f873f2)

  43. Karl – what I find amusing is how the left wails about free riders getting services in ER, but how little of what they have done addresses that. Or cost curves. Mandates for contraceptives, and preggers, etc … Do nothing to address free rider, which is the underlying claim cough cough BS cough cough.

    JD (e5c06b)

  44. The posters here sadly remind me of global warming enthusiasts. Pointing at all sorts of facts not bound by logic generating half ass conclusions and even worse courses of action.

    Then when you attack their methodology for compiling and analysing the data they recoil with no counter arguments, call names, and all the while pointing back to the flawed data and analysis along with the “expert” testimony.

    Same difference, different subject.

    Taxpayers don’t subsidize the uninsured. In fact uninsured as a class have some of the highest yields per any activity metric in healthcare. They are major money makers.

    Could their be a few places where uninsured get away with paying so little that it hurts. Yeah, can’t say every angle is explored. But again, as a class of people (market segment) no.

    ER, same story.

    Bill (af584e)

  45. Roses are red
    Violets are blue
    Bill is a mendoucheous twatwaffle
    And a blowhard too

    JD (e5c06b)

  46. #44, And on ER, at worst, they are loss leaders. Joint Commission looks down on hospitals seeking hospital status without one

    #42 Curse? Where was that?

    Anyway, have a great day guys.

    Bill (af584e)

  47. #45 Nice. LOL. Comes close to the amount of analysis and data provided to those who argue stuff they know ZERO about. And I mean ZERO like kelvin.

    Bill (af584e)

  48. Bill, can you point us to the other blogs and websites on which you have contributed and discussed your knowledge as a senior executive in the field? Or have you exclusively selected Patterico’s place for some reason? Since the commenters here are so stupid and unappreciative of your efforts, and it frustrates you so much, it’s difficult to understand why you keep trying.

    elissa (a7f40f)

  49. “The posters here sadly remind me of global warming enthusiasts. Pointing at all sorts of facts not bound by logic generating half ass conclusions and even worse courses of action.”

    Bill – Have you read the links embedded in Karl’s post? I already directed you to them because they contradict what you are saying. It’s great that you keep saying people are not presenting any facts by ignoring what people are saying. Winning!

    You brought up the billboard point, not me. I was in Florida last month for about 10 days but did not drive much on 95. I did not notice or pay attention to any hospital billboards of the type you described so I’ll have to take your word for it. To me, the services most worth advertising to fill beds in that market would be knee replacements, hip replacements, angios and the like. Have the patients convince their doctors to refer them to a given hospital that sounds nice.

    If you work for a freestanding urgent care center company I can understand your animosity to hospitals. Then again, you are also self-selecting your patient base because as far as I can tell most of them do not accept ambulance traffic, heart attack or stroke victims, or trauma cases. They also openly advertise payment terms on their websites creating the expectation of upfront cash or credit card payments, in effect discouraging walk-in indigent patients. I have no expectations the experience of this market segment would be similar to that of general hospitals. Common sense tells you that.

    daleyrocks (bf33e9)

  50. Bill,
    Your comment #17 had the dreaded “S” word.

    As for the rest of the argument… Maybe I missed the solution to what you say is the problem, but it appears that you’re exploiting the system, charging different prices to differently insured people for the same care, because you can just “write it off.” The English teacher in me is screaming about that runon sentence, but nevertheless, you seem to be bragging about gaming the system. That might explain the hostility towards you.

    Do you have a solution? Did I lose it in the sea of “LOL”s?

    Ghost (6f9de7)

  51. Bottom line — uninsured are the most profitable segment in medicine by far.

    Comment by Bill

    Here we go again. Broad generalized statement with nothing to back them up. Some uninsured do pay with barter. I had a lady cleaning my house for a year to pay for her mastectomy. And so forth… “bill “knows nothing about this. In fact, it is a felony for a Medicare provider to accept cash from a patient. That is one reason why doctors are abandoning Medicare. It pays poorly (about 20%) and slowly (about two years). The ones who are quiting are usually older and have paid their student loans.

    If Obamacare expands Medicare, as they plan to do, the trend of doctors leaving will accelerate and the issue than will be how to compel them to work for inadequate fees.

    Mike K (326cba)

  52. I meant to write “expand Medicaid…”

    Mike K (326cba)

  53. I really blew it Thursday night but didn’t find out ’til Friday AM. Rove spoke about a dozen miles away at a venue with like 3 entry/exits.

    In the bargain I wasted a great deal from Amazon: Buy one get one free, SuperSaver shipping on suicide belts. What a waste.

    gary gulrud (d88477)

  54. What ever you think about Rove (and I have no love for the guy)–Why fantasizing about blowing a “nobody” up when real people with actual power are destroying the western world (literally and financially).

    BfC (fd87e7)

  55. Sessions has picked through ACA with a calculator and found the overrun $17 Trillion over 9 years of regime results.

    With 70,000 codes to verify reimbursement, 4000 IRS agents to track down refugees, Swat teams to secure abortion services from conscientous objectors, etc., I believe him.

    gary gulrud (d88477)

  56. “Bottom line — uninsured are the most profitable segment in medicine by far.”

    Mike K – My understanding of Bill’s words is that he is speaking for his business, not healthcare in general. Based on the clues in his comments, centers they operate, etc., and his antipathy to general hospitals, my guess is he works for a chain of freestanding Urgent Care Centers.

    The business model for that type of company is no mystery, even imbeciles here can understand it. No huge bricks and mortar of an established hospital to maintain, no big overhead, no high risk patients, discourage people who cannot pay up front.

    Voila! Lower costs than general hospitals and profits. What’s not to like? Except ObamaCare frowned on certain conflicts in physician-owned arrangements. Don’t know whether Urgent Care Centers were one of them.

    daleyrocks (bf33e9)

  57. Bill should have just left a link to his company’s website in case anybody here needs medical care on their next trip to Florida since he was obviously pushing an agenda but was reluctant to reveal it.

    Bill post a link! Free advertising.

    daleyrocks (bf33e9)

  58. Avg Office Visit Price = $350
    Avg Payment = $200
    “Writeoff” = $150

    Oh the horror!!!

    Medicare Patient Comes into the Office.

    Avg Office Visit Price = $350
    Unallowable Price – $250.
    Avg Medicare + Patient Payment = $100

    … this is the bottom line for ER and MD Offices and Hospitals.

    Comment by Bill — 3/31/2012 @ 9:17 am

    Patrick, this guy is a fountain of misinformation. I go to a pain specialist for my back. An office visit is billed at $120. The Medicare EOB lists a payment of $11.40.

    The fellow bill has no knowledge and seem to be trolling you. I’ve heard from other regulars here who are tired of this.

    Mike K (326cba)

  59. http://www.usatoday.com/news/washington/2011-05-09-uninsured-unpaid-hospital-bills_n.htm

    So back of the envelope based on their facts and some basic assumptions ……

    1) Uninsured are charged $3 for every $1 charged insured.
    2) 12% uninsured pay bill (charges) in full. If you assume a little more then double that much pay nothing and the other pay 50%. 12% = 100%, 28% = 0%, 60% at 50% (play with this all day)

    CALC: Uninsured Yield = $3*.12*100% + $3(0% * .28) + $3(60% * 50%) = $1.26

    Insured at most equals $1.00 and is actually less b/c you never collect 100% of co-pays and/or deductibles. Likely closer to $0.90

    ….. and even better about uninsured. No wasted money doing insurance billing, no wasted money getting authorizations, no wasted money doing payment adjudication, no wasted money doing patient accounting entries.

    Uninsured are one of the most profitable segments in health care and even in hospitals with all those writeoffs (because adjustment for insurance contract pricing are not writeoffs according to hospital admin staff and MD).

    Again, look again at the issue with a fine tooth comb. Don’t trust the Hospitals or MDs. Rerun the numbers and get to my conclusion.

    Same holds true Aetna/BCBS versus Medicare and Medicaid for Hospitals. Bottom line is the private market segments (commercial, uninsured, work comp, etc) subsides the Government insurers.

    But they love to talk about writeoffs of uninsured — never contract adjustment for Medicaid or Medicare.

    LOL.

    Bill (af584e)

  60. #60, Cry poverty, get mo money mo money mo money.

    Bill (af584e)

  61. http://www.bizjournals.com/dallas/blog/2011/09/slideshow-who-are-the-highest-paid.html

    http://www.usatoday.com/money/companies/management/2009-09-27-nonprofit-executive-compensation_N.htm

    I could go on ….. it is good to be a Hospital Admin. But cease the poverty talk and complaint about write-offs for uninsured (who you make lots of money from).

    Bill (af584e)

  62. I really blew it Thursday night but didn’t find out ’til Friday AM. Rove spoke about a dozen miles away at a venue with like 3 entry/exits.

    In the bargain I wasted a great deal from Amazon: Buy one get one free, SuperSaver shipping on suicide belts. What a waste.

    Comment by gary gulrud — 3/31/2012 @ 11:01 am

    Woah, dude. That’s a little much, no? I mean, why kill yourself?

    Ghost (6f9de7)

  63. Roses are red
    Bill says things not true
    Bill is crazy obsessive like Random
    And eats glue

    JD (318f81)

  64. Bill,

    If I understand you correctly, you think most hospitals are doing okay financially. Is that correct?

    Also, was your hospital part of the American Hospital Assn or any other group that agreed on specific points regarding Obama’s health care reform? If so, why did your hospital agree and what’s your opinion about that?

    DRJ (a83b8b)

  65. DRJ,

    If I understand you correctly, you think most hospitals are doing okay financially. Is that correct?

    No. Only that uninsured patients are more profitable then most others as a market segment.

    Also, was your hospital part of the American Hospital Assn or any other group …

    I do not work for any hospital at this time in any capacity. I run an outpatient clinical services company. Well, I own most of it.


    or any other group that agreed on specific points regarding Obama’s health care reform?

    I hate Obamacare. In fact, the argument we need Obamacare for the uninsured and ER losses is counter intuitive to me knowing what I know. It is the BIG LIE in health care reform.

    If so, why did your hospital agree and what’s your opinion about that?

    Bill (af584e)

  66. DRJ,

    I have seen first hand for years how self insured patients are 100x more careful over what they consume then those that do not. I have also seen some go without care to their detriment and as professionals in this fields we something throw a bone around to help.

    But for us in the field to sit here an whine poverty over taking a discount here or there for uninsured patients knowing full well our revenue yields on these patients is much higher then those with insurance — well it is dishonest, immoral and unethical.

    And yes I charge most Health Care Administrators and MDs with being FRAUDS and OPPORTUNITISTS as it relates to this issue.

    They seek to serve those uninsured, get what they can at the highest prices possible and often beg people for money to cover their “writeoffs.”

    Meanwhile, these idiotic contracts they sign with Aetna, Medicare, Medicaid at these much lower prices …. they sit by passively and accept because “we need the volume.”

    So uninsured paying 3s times what insured pay does not constitute volume?

    Bill (af584e)

  67. Roses are red
    Bill knows more than you
    Tiffyosa buggers underage goats
    And Bill does too

    JD (318f81)

  68. This is like AARP going for Obamacare … in order to sell more UHC Supplemental Policies.

    This is like the AMA going for Obamacare … in order to protect its monopoly on CPT Coding and all the books and data they sell to support itself.

    It is beyond repulsive if you look at it from the stand point of “helping the people.”

    Bill (af584e)

  69. Bill,

    Uninsured patients may be able to pay in your city or state, especially for outpatient services, but at least one-fourth of the uninsured in my state can’t and taxpayers have to foot the bill. Can you see how that might matter to taxpayers in my state?

    By the way, your assumptions about this website may be a little off. I suspect very few (if any) people here support ObamaCare, but that doesn’t mean we can’t be rational when discussing it. What about thinking about what we say instead of reacting to it so quickly?

    DRJ (a83b8b)

  70. Also, do you really think Karl’s post supports your point? Because it doesn’t.

    DRJ (a83b8b)

  71. JD, if that is all you got then you lost the debate. Sadly, I think that is about the limit of your intellectual curiosity.

    Bill (af584e)

  72. #70 Yes it does. It supports it 100%.

    The fact most here know absolutely nothing about healthcare in any meaningful capacity as it relates to this discussion would yield that conclusion.

    If this was about criminal charges, I would not be so insistent.

    Anyway, go to post #59. Read, re-read, analyse, put a pen to paper and do some algebra. It is very helpful in framing the discussion so long as you believe others people generalizations.

    Bill (af584e)

  73. #72

    1) ER are very profitable in general and are at worst loss leaders for most hospitals.

    2) Taxpayers don’t subsidize the uninsured because the uninsured actually pay more then the insured.

    3) If the concept of a subsidy in Healthcare is money to offset the lowest priced payors — then in reality we are doing so for Medicaid beneficiaries since their yields are the lowest. And in reality the amount of cash is very low

    4) Obamacare will create more Medicaid beneficiaries because if all those uninsured go away, the margins will go down, utilization will go up, need for more capacity up and lower profits in the long run.

    Read up kiddos …. this is not $50 billion by the Feds. The rest is FQHC Grants et al which also benefits Medicaid and lots of other recipients.

    http://www.acep.org/content.aspx?id=37636

    Bill (af584e)

  74. Forgot link … this is the big money

    http://en.wikipedia.org/wiki/Federally_Qualified_Health_Center

    Bill (af584e)

  75. “1) Uninsured are charged $3 for every $1 charged insured.”

    Bill – There you go again. Illinois passed a law effective April 1, 2009 limiting markups to cost plus 35% for patients meeting certain income eligibility requirements.

    http://newsblogs.chicagotribune.com/triage/2008/06/uninsured-hospi.html

    daleyrocks (bf33e9)

  76. #75 I can’t believe you are a business professional b/c you never miss the opportunity to make an irrelevant, idiotic, tiny, point.

    1) Illinois is one state. 49 others
    2) Cost? Hmmmm, what is cost? That is interesting analysis. Full cost? How do you allocate over head? Please tell me how this is done because I have never really seen a good one in 25 years.
    3) Does cost include Hospital and MD charges or just Hospital? Outpatient as well as inpatient?
    4) Eligibility requirements are what? How pray tell are they proven? How is it done? After the bill is sent and collection efforts are tried or before?

    Please stop, you are totally ignorant on this issue. Ask questions. That is your best approach even if skeptical.

    Bill (af584e)

  77. California – 2006

    “A bill that becomes law in January prohibits hospitals from overbilling low to middleincome
    patients who are uninsured or have limited insurance.
    Under Assembly Bill 774, hospital charges for those patients can be no more than the
    highest rates charged by Medicare, workers compensation or other government programs
    in which the hospital participates.
    It prohibits harsh collection practices such as garnishing wages and putting liens on
    property. The legislation covers people with a household income no more than
    350percent of the poverty level, or up to $70,000 a year.”

    http://www.nonprofithealthcare.org/resources/California%20Law%20Passed%20on%20Hospital%20Billing%20and%20Collection%20Practices.pdf

    daleyrocks (bf33e9)

  78. Roses are red
    victims of auto-erotic asphyxiation are blue
    Bill is a pompous pedantic arrogant blowhard
    And is a taint snorter too.

    JD (318f81)

  79. Bill – Has Florida passed a law yet to stop people like you from ripping off uninsured patients?

    daleyrocks (bf33e9)

  80. As a young professional at Booz Allen and Hamilton years ago I went on a major Marketing and Channel Mgmt project.

    First day I was put as the Job Manager and I resented that some 67 year old guy was going to place with me on the project as an advisor. He was an old friend of the Senior Partner. John, had been with Booz Allen since the 50s in its hey day and had been a Senior Partner.

    John showed up and was a crusty, nasty man. I could not stand him. He sat around and lectured me and the two other associates for hours. He never even bothered to meet the Management or Ownership of this Company. He simply sat down and told us more or less what he thought was the problems in the Company and what they needed to do and what the value to the problem was.

    We were horrified. Who is he? What does he know? He did not even spend 1 minute doing any of the work?

    10 Weeks Later. John shows back up on site and he starts going through our work and well, John was right. All of it. Details somewhat off but so small as to be irrelevant.

    Point of the story. People with deep experience simply ow better than those. Even those with “all the data.” Their comes a point when you have seen the same thing so often that without knowing the data, you know the analysis, conclusion and solution. My anger at first came to great admiration.

    Turns out John cut his teeth helping companies like P&G, Colgate Palmolive, J&J build their strategy and marketing organizations for over 40 years. While I am not yet John, I am pretty close on this one.

    Simply put, we have no uninsured problem from a financial viability perspective anywhere in the health care system with the exclusion of some system near border towns or those over run with illegals. And the fact is, it would not be a problem even in these areas if Social Services, et al would stop telling people “you don’t have to pay” at the hospital.

    Look no further then Medicaid to find where the subsidies really go… assuming you subsidize unprofitable things at the expense of profitable ones.

    Bill (af584e)

  81. Last night on the PBS nightly news, Mark Shields said it was shocking to hear the justices parrot the lines of the Tea Party.

    AZ Bob (1c9631)

  82. i’d love to know what planet “Bill” is practicing medicine on because his numbers don’t match what i’ve seen…

    of course, if you are making things up, it’s easy to make them go the way you want. the only way to make a profit on medi/medi patients is to either commit fraud or cut corners and give sub-standard care, which is essentially the same thing.

    anyone who says otherwise is lying to you.

    redc1c4 (403dff)

  83. Bill – It seems like you are the greedy f*cker here, bragging about how you can operate without all the infrastructure of a general hospital and make the most money by billing uninsured patients 3x what others pay.

    How do you sleep at night?

    daleyrocks (bf33e9)

  84. #80 Florida?

    Bill (af584e)

  85. I guess the same folks arguing this point will now come out and sing A-OK since karl wrote an article about it.
    Comment by Bill — 3/31/2012 @ 8:43 am

    — That’s right, folks! The very first sentence My Boy Bill wrote in this thread was an ad hom attack on the poster. Not to worry, though. Certainly he followed this up with substantive arguments about how no hospital ER’s have ever been closed down, or something equally counter-factual.

    Icy (ab2a58)

  86. Roses are red
    Bill’s nads are clearly blue
    He is arrogant for no apparent reason
    Maybe because his nads are blue?

    JD (318f81)

  87. Bill:

    Taxpayers don’t subsidize the uninsured because the uninsured actually pay more then the insured.

    One of the links from Karl’s post contradicts this, and he even quoted it in his post:

    Specifically, Congress ignored the $40 billion to $50 billion that is spent annually by charitable organizations and federal, state and local governments to reimburse doctors and hospitals for the cost of caring for the uninsured. These payments, which amount to approximately three-fourths of the cost of such care, mitigate the extent of cost shifting and reduce the magnitude of the hidden tax on private insurance.

    In addition:

    A study commissioned by border counties in Texas, California, Arizona, and New Mexico found that about 25 percent of the uncompensated costs incurred by Southwestern border-county hospitals in 2000 resulted from medical treatment provided to undocumented immigrants without health insurance. The study attributes higher reported levels of uncompensated hospital care in border versus non-border counties to undocumented immigrants seeking emergency medical care.[25] The study also reports that in 2000, emergency health care to undocumented immigrants cost border-area hospitals $79 million in California; $74 million in Texas; $31 million in Arizona; and $6 million in New Mexico.

    [25]United States/Mexico Border Counties Coalition, Medical Emergency: Costs of Uncompensated Care in Southwest Border Counties, by MGT of America (Austin, Texas, September 2002), pp. iii-iv. Consultant’s report.

    [26]United States/Mexico Border Counties Coalition, Medical Emergency: Costs of Uncompensated Care in Southwest Border Counties, p. 30.

    Let me say this clearly: The hospitals did not get paid for these costs, which is why it’s called “uncompensated care.” Ultimately the taxpayers had to pay the bills or the hospitals had to close.

    For many reasons, Texas has a significant percentage of uninsured and has for some time. One way we coped with the burden this placed on hospital ERs was for Texas taxpayers to fund nearly 150 clinic sites across the state that provide primary health care services. I think it was money well spent but it’s still a significant, additional chunk of taxpayer money.

    I can tell you are concerned about what the future holds for you and your clinic, and probably with good reason. Good luck to you.

    DRJ (a83b8b)

  88. #84. LOL. Talk about a d-bag who fabricates things.

    You have been embarrassed by your ignorance and now you choose to simply make thing up which are untrue.

    So, do you know it is considered illegal to do what you suggest we do? Just saying.

    Bill (af584e)

  89. Roses can be pink
    Violets are blue
    Bill hates honesty and poor people and women and minorities
    And kittens and puppies and the elderly too.

    JD (318f81)

  90. __________________________________________

    conservative lawyers he spoke with thought Obamacare would be upheld

    Those lawyers perhaps are suffering from a form of battered wife syndrome, in which the current White House (and all its sycophants in the media and among the limousine-liberal elite in DC and Manhattan) is sort of the abusive spouse?

    Or maybe they’re full of squish, in which, when it comes to healthcare, those “conservatives” actually are closeted liberals. Maybe they privately welcome the idea of a big bloated healthcare bureaucracy, because they sense that will help grease the wheels for lawyers everywhere.

    Or perhaps they see all the socio-economic trends in Western societies like Greece, Spain and France, and the lazy socialism in nations like Argentina, Venezuela and Mexico, and figure that human nature is intrinsically devoid of common sense. Therefore, why assume that even the US Supreme Court — which already in too many instances tilts precariously to the left — will know which end is up.

    Mark (31bbb6)

  91. DRJ, #88

    Do you understand that uncompensated costs equals write-offs which for all uninsured are high?

    It would be like auto companies declaring discounts off MSRP “uncompensated” costs and asking Obama for money to cover the “losses.”

    Do you also understand that you are ignoring the hundreds of millions they did collect from uninsured at prices 3 times higher then insured payors?

    People here are so obsessed with illegal aliens and everything that comes with it that they can’t get past the fact that when it comes to healthcare — they pay more then you or I.

    Hate to use the “R” word but it is the only thing that comes to mind.

    Dude, just b/c they should not be here does not mean they “drain the health care system” as a class. And unsinured as a broader version of this.

    Bill (af584e)

  92. Anyone know the difference between AWP and contract pricing in Pharmaceuticals?

    Or are all of you just talking out of your butt about thing you have no clue about?

    Anyone here know what the Medicare Allowable is for a 99212 versus 213 and why use one of the other???

    Or are you all talking out of your ass quoting articles beyond your level of expertise to understand?

    Not stupid b/c that is not he case, just horribly misinformed and very prejudicial in your assessments.

    Bill (af584e)

  93. Health Care Collection Statistics – Much lower than Bill indicates in his “algebra” lesson.

    Average Recovery Rates

    Hospitals – 10.3 percent. (Source: ACA International’s Top Collection Markets Survey*, Jan. 1 – Dec. 31, 2010.)

    Non-hospitals – 17.8 percent. (Source: ACA International’s Top Collection Markets Survey, Jan. 1 – Dec. 31, 2010.)

    Uncompensated Care/Bad Debt

    U.S. hospitals provided $36.4 billion in uncompensated care in 2008, representing 5.8 percent of annual hospital expenses. (Source: American Hospital Association, “Uncompensated Hospital Care Cost Fact Sheet,” November 2009.)

    The national average for bad debt is 2.38 percent, 2.50 percent for charity and 4.88 percent for total uncollectable accounts. The Southeast region of the U.S. had the highest percentage of total uncollectable accounts at 6.88 percent. (Source: The Hospital Accounts Report Analysis on Fourth Quarter 2010.)

    http://www.acainternational.org/products-health-care-collection-statistics-5434.aspx

    daleyrocks (bf33e9)

  94. ==As a young professional at Booz Allen and Hamilton==

    OK, I can buy “young”. And that there may have been Booz(e) in the picture. But trying to sell us on the “professional” part is a real stretch, I’m afraid.

    elissa (a7f40f)

  95. Bill:

    Hate to use the “R” word but it is the only thing that comes to mind.

    Thanks for showing what you really think about people who disagree with you.

    DRJ (a83b8b)

  96. “People here are so obsessed with illegal aliens and everything that comes with it that they can’t get past the fact that when it comes to healthcare — they pay more then you or I.”

    Bill – Evidence please.

    daleyrocks (bf33e9)

  97. Why don’t Hospital talk about “uncompensated” losses from Contract Price Adjustments that can be as high as 66% off their MSRP???

    Anyone?

    Why are they focus on Writeoffs for uninsured which are usually less than 50% of MSRP?

    Anyone?

    Is there at least one health care professional with a clue about this issue?

    Please, amateurs need not apply. I want someone who actually knows something about this issue.

    Is there one person here who understands this issue from direct experience managing anything other then a lawyers office or a taco stand?

    Bill (af584e)

  98. I am more then happy to dialogue a professional in this area. Be happy to proved wrong too or corrected.

    … and MD need not apply unless they have actually run a financial organization in this area.

    Awaiting a professional ….

    Bill (af584e)

  99. “So, do you know it is considered illegal to do what you suggest we do? Just saying.”

    Bill – Excuse me, but as a Senior Executive in the Field, isn’t that exactly what you claimed to do in this thread. Are you admitting to illegal behavior?

    daleyrocks (bf33e9)

  100. Oh, c’mon, folks. Engaging this kind of insult-based screedfest? It’s like that cartoon Patterico posted a long time ago. In fact, here it is:

    http://imgs.xkcd.com/comics/duty_calls.png

    Me, I pay attention to Mike K. I have known him for years, and he has the background (not just an MD) to opine on this kind of thing. He also, um, doesn’t believe that his opinion constitutes natural law.

    Simon Jester (14c140)

  101. #97 None, supposition because clearly facts don’t seem to move the obsession folks have with “subsidizing the illegal aliens uninsured”

    Uninsured pay more, lots more for services. Why is it then that as a CLASS OF PAYOR they are being “subsidized?”

    If you can’t deal with this fact then I have to assume their is another agenda.

    Bill (af584e)

  102. elissa – BAH fits with the arrogant azzhole personality who knows everything but never ran anything in his life.

    daleyrocks (bf33e9)

  103. Yep. It’s Bill’s Place. He gets to set the rules for dialogue here. Good to know.

    elissa (a7f40f)

  104. Roses are red
    bill is a lying liar
    He reminds me of a saying
    Liar liar pants on fire

    JD (318f81)

  105. Algebra + Federal Programs + Uninsured Patients = Profits

    daleyrocks (bf33e9)

  106. Super high powered healthcare professionals sure do have sucky bad grammar.

    JD (318f81)

  107. Consultants, smartest people in the world and not afraid to tell you about it.

    daleyrocks (bf33e9)

  108. #100 No you d-bag. Not at all. That is what you fabricated in your small mind for purpose of smearing me since you have no facts, no knowledge and seem to love arguing things you know nothing of.

    And make no doubt, not one person on this board knows shit that amounts to useful manure about this issue.

    At least no one I have heard from yet. Awaiting a professional to discuss this. I am willing to accept the assertion you are as fact.

    [Found in filter.]

    Bill (af584e)

  109. Bill:

    I am more then happy to dialogue a professional in this area. Be happy to proved wrong too or corrected.

    If you are really an experienced professional, you should be able to explain what you know and back it up with links. In fact, it should be easy for you since you are so experienced and smart.

    FWIW, I provided information about illegal immigrant health care in Texas because that’s where the statistics are. I thought you wanted facts that I could back up with links, but it looks like you just want to call people names when they don’t agree with you.

    I really hope you will change your mind. If you are what you claim you are, you have a lot to add and you can help people understand your concerns. But that won’t happen as long as you act so antagonistic.

    DRJ (a83b8b)

  110. #108 An accountant talking smack about intellect.

    You are better at fabricating things about my positions then insulting me.

    Hurry back to your competency.

    …. long ago ex-consultant …..

    Bill (af584e)

  111. Roses are red
    Lilies grow fast
    Bill talks a lot
    Straight out of his @ss

    JD (318f81)

  112. awp, contract pricing, chargebacks, safe harbors, group purchasing… yeah, i know and understand the lingo from years of personal experience, as does HRH, which is why we’re laughing at “Bill”…

    fancy a55 bullschise is still just bovine excrement.

    funny how all he has is bluster when he gets called on it.

    redc1c4 (403dff)

  113. #110, I did post facts from articles. You ignored them.

    Bill (af584e)

  114. Consultants, make a bundle for validating management’s recommendations and bayoneting the wounded and avoiding responsibility for screwed up plan implementations.

    daleyrocks (bf33e9)

  115. #113, another person ignorant on the issue joining in.

    If you are a professional, let me know.

    Bill (af584e)

  116. Roses are red
    DRJ is honest and patient
    Bill insults everyone
    Because he is a taint snorter

    JD (318f81)

  117. The left will not stop until the bubble is imposed on us all.

    The court commands no armies, it has no money; it depends for its power on its credibility. The only reason people obey it is because it has that credibility. And the court risks grave damage if it strikes down a statute of this magnitude and importance, and stretches so dramatically and drastically to do it.

    Sen. Blumenthal
    http://tpmdc.talkingpointsmemo.com/2012/03/dems-warn-of-grave-damage-to-scotus-if-obamacare-is-struck-down.php

    Amphipolis (e01538)

  118. The court commands no armies, it has no money; it depends for its power on its credibility. The only reason people obey it is because it has that credibility. And the court risks grave damage if it strikes down a statute of this magnitude and importance, and stretches so dramatically and drastically to do it.

    That person was an Attorney General. F@ck the left. And bill.

    JD (318f81)

  119. ==I am more then happy to dialogue==

    ==I have to assume their is another agenda==

    Grammar police! Cleanup on aisle professional senior executive in the field.

    elissa (a7f40f)

  120. “Most profitable Center we ever ran serviced 90% uninsured patients (mostly illegals). Generated $200 profit per year per square foot.

    Our other offices at around $50-$75 AT BEST.”

    “So, do you know it is considered illegal to do what you suggest we do? Just saying.”

    Bill – How do you sleep at night?

    daleyrocks (bf33e9)

  121. Bill,

    I did not ignore your links. I read them and understand your point is that uncompensated losses are basically nuisance losses, like “shrinkage” in the retail sector — although daleyrocks analyzed your numbers and found they weren’t quite as good as you represented them to be. (That’s one reason it’s customary here to provide links and not just summarize the articles yourself.)

    I also understand you have basically admitted my point by acknowledging that we don’t have a health care problem “with the exclusion of some system near border towns or those over run with illegals.” My point is that the problem impacts at least 4 states — including two very big ones — and is spreading if reports like this are any indication.

    Finally, as I said before and will say repeatedly again, since you’ve now called me a racist, that this isn’t just about illegals. I’ve focused on them because there is data on them.

    DRJ (a83b8b)

  122. I get the feeling Bill did not last long at Booz Allen with his anger issues.

    daleyrocks (bf33e9)

  123. #109 and #111 are actually pretty ironically funny. It really is like this type of person doesn’t own a metaphorical mirror. I mean, you cannot complain that people insult you when you, well, insult people yourself.

    And angrily insisting that you Know All and No One Else Does is, um, not a road to convincing anyone, let alone inducing them to listen.

    It is, however, a road to encouraging a big giant argument, which is what trolls do.

    DRJ, once again, sets the bar for civility and professionalism.

    Simon Jester (14c140)

  124. let us not forget Pro-Bono which many MD willingly do even if complaining about it.
    — Yes, because the definition of doing something “willingly” is that you complain about it.

    In addition, when uninsured do pay their bills they pay upwards of $2 for every dollar Medicare pays.
    — And when they DON’T pay their bills they pay downwards of $0 for every dollar Medicare pays.

    Bottom line — uninsured are the most profitable segment in medicine by far.
    — By your own logic, those that pay their bills ARE, and those that don’t AREN’T. And your estimate of what percentage of the uninsured actually pay their bills is?

    Daley you are beyond ignorant on this discussion and have no reason to comment.
    — Yeah, daleyrocks. Stop wasting his time! He’s late for his MENSA meeting.

    Daley, you just want to beat up illegal immigrants so the narrative must survive.
    — Bill is an illegal immigrant?

    Unisured Patient Come into the Office.
    Avg Office Visit Price = $350
    Avg Payment = $200
    “Writeoff” = $150
    Oh the horror!!!

    — Okay, well, I don’t know about “Unisured” patients, but what I do know is that most doctor’s offices these days make uninsured patients pay up-front; and if that up-front payment is more than they would have received from insurance, then more power to them! ER’s don’t have the luxury of demanding up-front payments, however.

    Icy (ab2a58)

  125. #116: the very sequence that i typed the terms in is proof to anyone in the field that i am a professional in that arena, and at a high level.

    most people in healthcare have no idea where and how their supplies, equipment etc are purchased or even how they magically appear in their w*rk space to be used, other than sending a supply request slip in the inter-office mail

    that you pretend otherwise says that either you are not what you say you are, or that you are afraid i am what you asked for.

    either way, it sucks to be you. i know you’re wrong, others here have proved you wrong, and all you have left is histrionics…

    redc1c4 (403dff)

  126. Icy, I wasn’t sure what “Pro-Bono” meant. Liking “Sonny and Cher,” or enjoying “The Joshua Tree”?

    Simon Jester (14c140)

  127. “#108 An accountant talking smack about intellect.”

    Bill – Assumptions. Nicely done. Since you know nothing about me other than what I said about auditing hospitals and fraud exams. I will let you know I made it a practice to refuse to hire firms like Booz, BCG and Bain when I was in a position to do so because I thought they were a waste of money. You are perfect example of why and keep reinforcing to me that I made the right decisions.

    Many thanks.

    daleyrocks (bf33e9)

  128. Simon–yes there is some juvenile humor and school yard taunting going on. But “Bill” has done everything in his power to shut down discussion on this thread posted by Karl, and he also did the same on another one Karl posted here on a related subject two days ago. Bill obviously has an agenda at Patterico’s and I think we are starting to get to the root of it.

    elissa (a7f40f)

  129. ______________________________________________

    Hate to use the “R” word but it is the only thing that comes to mind.

    And you, in turn, are a wonderful, compassionate, humane, generous, sophisticated person? Perhaps a devout Democrat? Or a true-blue “centrist” who struggles not to be a do-gooder of the left?

    I don’t trust the sentiments of anyone who talks so idealistically about hospital emergency rooms being barely negatively impacted (if at all) by non-paying patients—legal citizens or otherwise. That makes me of all the two-faced, disingenuous people (particularly teachers who send their own kids to private academies or parochial schools) who say that public schools are so wonderful and sacred, and claim that if public schools aren’t already doing a bang-up job, it’s mainly because they’re underfunded. And, oh, isn’t it terribly xenophobic and racist to be leery of such schools merely because most of their students come from families that are the heaviest users of crowded hospital ERs. (And again: “It’s purely coincidental that I don’t want my own son and daughter attending such schools!”)

    Mark (31bbb6)

  130. Comment by Amphipolis — 3/31/2012 @ 12:59 pm,

    That’s a shocking quote from anyone, and coming from a lawyer and former Attorney General makes it even worse.

    DRJ (a83b8b)

  131. Comment by Amphipolis — 3/31/2012 @ 12:59 pm,

    That’s a shocking quote from anyone, and coming from a lawyer and former Attorney General makes it even worse.

    Comment by DRJ — 3/31/2012 @ 1:28 pm

    DRJ, I’d like to introduce you to Eric Holder…

    Ghost (6f9de7)

  132. Bill,

    I may be wrong but it appears you are so upset about ObamaCare (and I share your concern) that you’re trying to discredit everything that led to its passage, such as concerns about uncompensated care for uninsured patients. Thus, for example, you’ve argued that “taxpayers don’t subsidize the uninsured because the uninsured actually pay more then the insured.”

    If that’s really true, wouldn’t health care providers be better off if we abolished health insurance?

    It seems short-sighted to me but isn’t that partially why the American Hospital Assn supported Obama’s health care reforms, because it wanted to get rid of different levels of payment? I think it also reveals the fallacy in your argument. The prognosis is bleak for health care providers, even those who have achieved some kind of balance in their fiscal situations, because there are far more people who need services than are paying for those services.

    DRJ (a83b8b)

  133. Heh. Sad but true, Ghost.

    DRJ (a83b8b)

  134. Unless you have run one of these enterprises and actually bothered to get past the horrid accounting reports most systems generate and actually do some analysis … you come to the wrong conclusion.
    — Translation: You don’t know what you’re talking about; therefore, you cannot be a part of the solution. As an insider (and therefore, by definition, a part of the problem) I do know what I’m talking about . . . because we all lie about it . . . so trust me.

    But that MD and Hospitals use the “unsinsured crisis” to further their greed is undisputable.
    — By demanding mandatory insurance, so they can (according to you) get paid less. Brilliant!

    Might be a problem for the patient who is uninsured but not or the pocket book of the health care provider or facility.
    — So we actually need the individual mandate in order to insure that the health care provider doesn’t get paid too much?

    The people who subsidize the healthcare system by logic are the one who pay the most for comparable services.
    — Logic don’t feed the bulldog! They should think about writing a check next time.

    Might there be a border town hospital where illegals are conditioned not to pay by Social Services folks helping destroy the Hospital. Sure. Very very small.
    — Did you know that voter fraud never takes place either? It’s a comditioned thing.

    Icy (ab2a58)

  135. Icy, I wasn’t sure what “Pro-Bono” meant. Liking “Sonny and Cher,” or enjoying “The Joshua Tree”?
    Comment by Simon Jester — 3/31/2012 @ 1:15 pm

    — Apparently, it means complaining about doing volunteer work. Sounds like something a lawyer would come up with during his off-hours.

    [BTW, saw U2 on their Joshua Tree tour. Excellent!]

    Icy (ab2a58)

  136. Nobody combines fisking and humor as well as Icy.

    DRJ (a83b8b)

  137. gee… he demanded credentials, yet when someone with then showed up, he disappeared…

    if i didn’t know better, i’d think he’s a troll.

    8)

    redc1c4 (403dff)

  138. redc1c4,

    I hope you will correct anything I’ve said that seems wrong because I like to know when I’ve gone off-track, and that you will address any part of this topic that you can.

    DRJ (a83b8b)

  139. Based on what I’ve seen of private pain clinics here in south Florida, it is not hard to accept that SOME make out quite well financially. Perhaps Bill’s acumen lies in that direction. Patients addicted to pain pills or making a living reselling oxy for big profit, usually pay cash and that si all some places will accept. The doctor examines them briefly and writes a Rx, which may be filled at their own in-house pharmacies. I had a friend who paid the doctor’s fee of $300 a pop and then paid additional at the drugstore. That is in addition to visits to other offices which took medicare/medicaid. And I knew of patients who would support some of their other habits reselling pills. That was a couple of years ago and I’m told the state of Florida has cracked down on these pill mills, but many people from around the country came for the easy docs and dangerous oxys. You could get an idea from a TV series like Justified, wherein dealers in Kentucky had people traveling by bus to South Florida for the controlled substances.

    Calypso Louis Farrakhan (d32e4c)

  140. Keep talking smack all you want but I make a very very very good living doing this.
    — Me only make a very (1 “very”) good living at me job.
    :(

    LOL. If ER lost so much money why would they advertise to get more money losing business?
    — Well, I’m one of those that know nothing about the medical field, but in my business we advertise to get more money in order to avoid becoming a losing proposition. But I’m sure that in your case it’s totally different.

    Someone smarter then you once told me “look at what they spend money, not what say to raise money.”
    — How ‘smart’ could someone that talks like that ^^^ possibly be?

    On this issue, I need no caution.
    — How about a “Do Not Enter” or “Wrong Way” or “Dead End”?

    And my generalization are 95% correct.
    — Oh, you’re giving Mr Limbaugh a run for his money!

    Again, this is my life’s work and a very lucrative one.
    — Well, if being wealthy proved you were right, then why don’t we just elect YOU president?

    The folks writing about this subject are clueless and being manipulated by those who either a) don’t know or b) are getting very wealthy perpetuating the lie.
    … and there are both in the health care business.

    — You’re manipulating us right now, aren’t you. Come on, ‘fess up you little dickens!

    Icy (ab2a58)

  141. http://www.accessproject.org/downloads/Hospital_Finance.pdf

    A bit old. Numbers have moved some. And it is from dreaded Harvard!

    This study says PPO and Self Pay are profitable in MA. HMO and Medicaid losers. So who subsidizes who? To quote …

    Self-pay Uninsured or self-pay patients pay whatever charges the hospital posts as their charge or price. In 1996, self-payers paid, on average, 87 percent more than what their care actually cost. As a comparison, private insurers paid, on average, 22 percent above the cost of
    their care.

    … again when people use these statistics on the uninsured they pick out the Doubtful Accounts (or equivalent)provision from a financial which has nothing to do with profitability or revenue by Payor Class (market segment).

    Financial Malpratice with an agenda for the most part.

    Bill (af584e)

  142. Did a comment get removed? Why does Bill keep replying to himself?
    — Ones own voice always sounds better inside an echo chamber.

    Icy (ab2a58)

  143. New York passed ceilings on billings to qualified uninsured patients. Yet more evidence Bill does not know his stuff.

    “Richard Kersch, executive director of Citizen Action of New YorkState, expressing support for the agreement said,New York patients will finally get relief from the nightmare of huge, unpayable hospital bills.Hospital patients will receive bills that are based on their ability to pay andbe charged no more than what hospitals would charge insurance companies.For the first time, hospitals in New York will be requiredto provide financial assistance to hard pressedhospital patients as a condition of the hospitals receiving $847 million in taxpayer funds to make upfor unpaid bills.”

    http://www.insurance-advocate.com/Protections-for-Uninsured-Hospital-Patients-Enacted-c42.html

    daleyrocks (bf33e9)

  144. The only person on this site who has posted anything meaningful data on this issue is a troll and the folks who sit around arguing data sources they don’t understand are enlightened.

    Sad group on this board.

    Bill (af584e)

  145. #144 And yet you have no clue how they dole out the money or what a sliding fee schedule is.

    But you “know” it is for uninsured who are money losing customers that taxpayers subsidize.

    You are a dense and idiotic fool. Again, is there a professional on this board or just a bunch of ignorant fools using data incorrectly?

    Bill (af584e)

  146. “If that’s really true, wouldn’t health care providers be better off if we abolished health insurance? “

    Yes they would be. Go ask an MD over 70 what it was like in the old days without ASSIGNMENT and pre-Medicaid.

    Bet you have no idea what that is…..

    Bill (af584e)

  147. Often we get Concerned Conservatives who are Recognized Experts in a Given Field.

    Seriously, it’s kind of entertaining to watch, as elissa suggested.

    Maybe this person is for real. Maybe this person is Yet Another Troll. But a Recognized Expert? Honestly, I doubt it. Real experts have little to prove, and don’t particularly care about “people who don’t know things.” And they are confident, not arrogant.

    The signifier, as always? People who are rude to DRJ. It’s okay to insult insulters, I guess. But look at DRJ’s posts. I think that this person has really not, um, covered himself with glory in that regard.

    But one things is for certain: this person is eaten up with anger and sophistry and the need to insult. Which is why is is teh funnee to watch him try to move goalposts and complain about a lack of experts and how awful it is to insult others.

    The bit about the troll is particularly precious.

    Simon Jester (c8876d)

  148. Maybe we could take up a collection to send this person a cleaning cloth for his computer screen. Lots and lots of flecks of spittle there, it would seem.

    Simon Jester (c8876d)

  149. #141, So ER needs to advertise to avoid losing money??? You are in Advertising?

    Can I ask Icy, do people go to the ER because they want to or have to? Because last I checked health care is a pure grudge purchase. Most hate going.

    So if an ER is advertising the purpose is not create demand but to try and monopolize demand. To so in order to cover fixed costs b/c variable costs are lower then the price of services. That is to say ER is profitable on a variable cost basis.

    But if the COST of servicing ER patients is higher then the revenue … why would want to monopolize demand and advertise????????????

    Pick a position b/c the one advocated makes no sense.

    People don’t advertise for purpose of selling an unprofitable product.

    Bill (af584e)

  150. Last bit:

    “…Go ask an MD over 70 what it was like in the old days without ASSIGNMENT and pre-Medicaid…”

    Well, I believe we have heard from such a person. And notice that anyone who disagrees with Bill is stupid, a fool, or ignorant.

    Anger is a not pretty, Bill. Neither is ranting in all caps.

    Simon Jester (c8876d)

  151. Bill:

    People don’t advertise for purpose of selling an unprofitable product.

    Actually, they do. TaxMasters, JK Harris and WaMu come to mind.

    DRJ (a83b8b)

  152. #151 The question is whether from a financial point of view MDs would prefer a world with no insurance versus one with insurance. The question is so simple to answer as it is asinine to ask.

    So Simon, ask Bill all you want but ask the proper question.

    Bill (af584e)

  153. Based on your personal style, sir, I really don’t trust the information you purport to provide.

    The ironic part is that you wouldn’t trust someone who acted, well, just like you do online!

    But that’s okay. It’s been fun to watch you show your unpleasant side so persistently.

    Simon Jester (c8876d)

  154. Taxpayers don’t subsidize the uninsured. In fact uninsured as a class have some of the highest yields per any activity metric in healthcare. They are major money makers.
    — Kinda makes one wonder why doctors and hospitals accept insurance at all, don’t it?

    Again, look again at the issue with a fine tooth comb. Don’t trust the Hospitals or MDs.
    — Well yeah. I mean, it’s not like the MDs and hospitals are demanding insurance in order to guarantee that they get paid something.

    I could go on …..
    — And you have. You could zip it, too.

    I do not work for am not a patient in any hospital at this time in any capacity. I run am an outpatient.
    — FIFY

    Read, re-read, analyse
    — Your Union Jack is showing, love.

    Awaiting a professional …
    — Ironically, the same thing his clients say.

    Icy (ab2a58)

  155. Bill:

    Go ask an MD over 70 what it was like in the old days without ASSIGNMENT and pre-Medicaid.

    Bet you have no idea what that is…..

    I remember those days! We had house calls and doctors got paid with cash, a check, or barter. For the most part, all the doctor did was tell us to take an aspirin, give us a shot, or both.

    I don’t mind going back to pay-as-you-go but I’m not sure how many health care providers would survive or what health care would look like. Pretty basic, is my guess.

    DRJ (a83b8b)

  156. #152, DRJ, companies advertise to sell money losing products and services? Let me give you the benefit of the doubt which no one else extends me …

    Are you trying to describe the concept of a loss leader? Because if you are then the purpose of advertising is not to sell the loss leader but to get individuals to shop at your business for other higher margin products. That is tosay they buy bananas at $0.39 per pound but walk out of the market buying $50 in groceries.

    Ergo my point that at worst ER play an essential role at filling up Hospital Beds — which is where they make most of their money.

    And most ER are not loss leaders either.

    Bill (af584e)

  157. @156 MD would love it.

    Bill (af584e)

  158. This thread is a lot of fun to read if you pretend Bill is Keith Olbermann.

    Dustin (330eed)

  159. I think some entities advertise hoping that volume will give them enough cash flow to stay afloat.

    DRJ (a83b8b)

  160. Again Icy go read

    http://www.accessproject.org/downloads/Hospital_Finance.pdf

    It clearly states what everyone in health care knows. Self Pay make money and are one of the most profitable Payor Classes (market segment)

    Bill (af584e)

  161. … and that seems to be what’s happening with many hospitals and ERs.

    DRJ (a83b8b)

  162. #160, ERGO that means the Contribution Margin on the services are POSITIVE, not negative.

    Guys, not looking to brawl but you are flat out wrong on this issue.

    100% wrong.

    Worst yet, this MYTH about uninsured draining the system only serves to strengthen to position of those who want single payer, nationalized health care.

    Bill (af584e)

  163. Bold and all caps really prove things. But I miss the random capitalization.

    And it has been a while since some self-puffery appeared.

    The Olbermann bit is apt, come to think of it.

    Simon Jester (c8876d)

  164. If Hospitals lose money, it is because their beds go empty. Having a kick arse ER helps solve that problem.

    Hospitals don’t lose money because the uninsured are consuming and not paying.

    In fact, few-to-no Health care Providers are going hungry or broke due to the uninsured. Most are actually making a pretty penny at it.

    Bill (af584e)

  165. #164 Educate yourself clown. Read some of the links and analysis I posted. You might learn something of use instead or eating more dog food on the issue.

    Bill (af584e)

  166. Read

    http://www.accessproject.org/downloads/Hospital_Finance.pdf

    [note: fished from spam filter. –Stashiu]

    Bill (af584e)

  167. “…You might learn something of use instead or eating more dog food on the issue…”

    Those are my choices? Oh, picking on your syntax is silly. But your superiority complex makes it pretty funny.

    Here is a thought: go for a walk. Call a loved one. Read a book. Try to smile a bit.

    And try—oh, yes try—not to presume that people with whom you disagree are stupid or bad.

    Simon Jester (c8876d)

  168. Bill #161:

    Your link does not say what you claim it says. It is a paper on evaluating how a hospital gets and spends its money, including the category of “Self Pay” patients (defined at page 4 of your link and discussed as part of the payment system at page 9). The charts on page 9 shows that Self Pay patients were 3% of gross patient revenues in 1997. The payment to cost ratio “for a sample of Massachusetts Hospitals” in 1998 was 1.13 — where “A payment-to-cost ratio of 1 means that the hospital is receiving payment that exactly covers its costs.”

    That was 15 years ago, Bill, in a sample of Massachusetts hospitals.

    DRJ (a83b8b)

  169. Bill,

    Your link also includes this:

    Wages and salaries paid to employees are usually the largest category of expenses for hospitals. In many hospitals, salaries make up about 60 percent of total expenses.

    That’s not surprising but it is interesting, since it shows the biggest cost a hospital has is labor. So putting patients in beds regardless of their ability to pay isn’t the goal, is it? You can always close a wing/floor and lay off staff, so the real question is how to balance staff, revenues, and the obligation to treat non-paying patients the law says you have to treat.

    DRJ (a83b8b)

  170. The inability to opt out is an artifice of other government regulation. The government says hospital emergency rooms must take everyone who shows up. Then having gotten the nose under the tent, it says well now everyone must buy insurance so there are no free riders. Well, change the law so emergency rooms don’t have to take everyone. Then the free rider problem is gone.

    JAY (c6d45e)

  171. Bill,

    One more quote from your link on Self Pay, uninsured, and uncompensated care:

    Self-pay Uninsured or self-pay patients pay whatever charges the hospital posts as their charge or price. In 1996, self-payers paid, on average, 87 percent more than what their care actually cost. As a comparison, private insurers paid, on average, 22 percent above the cost of their care. Self-pay also means uninsured, so much of a hospital’s potential self-pay revenue ends up as uncompensated care.

    By the way, the linked article states that as of 1997, there was no limit on what hospitals can charge indemnity insurance, PPOs, and Self Pay patients. I don’t think that’s true in all states now.

    DRJ (a83b8b)

  172. #169 Cutting staff in Hospitals is tough without simply shutting down an area. OB for example. Plus no one opens a wing for uninsured patients and another for insured. Either you are in the surgery business or you are not. ER or not.

    Playing with staffing levels can at the margin help profitability but whether you have 2 patients or 20 patients in the neo-natal unit is irrelevant to fact you need staff to be on duty 24 by 7 and that requires a nurse and a few helpers.

    By my estimates and analysis, the utilisation effects of volume on staffing is about 4:1. Growing by a factor of 4 grows staff by a factor of 1. Eventually utilization reaches 100% and you can’t fit more patients.

    At that point you start talking about benefit to scale but the risk is larger. Now you got 50 beds as opposed to 20. Where are the patients? You got tow nurses on duty, not one.

    Shit happens in acute care so you can’t just not be staffed.

    But this is why when folks (like harvard) do these analyses I am very very leary of them. It is butt tough to sit around and say this is variable and this is fixed in a Hospital. Then when you allocate the fixed costs to the analyses then what? Are all wings in the hospital geared to the same demographic and payer mix? No. So do you get real navel gazing and allocate different amounts of fixed cost per department per payer class??

    It gets insane fast and frankly it is useless analysis b/c end of the day — you gotta serve the customer regardless of their ability to pay.

    So …….. analytically you got to simple measures like Revenue per Encounter etc ….. which most folks mis calculate in medicine b/c they use billed charges as opposed to collections.

    Collections = Billed Charges – Contract Adjustment – Write-ofs = Actual Cash Received or in the real world of non-accounting, REVENUE. And revenue per uninsured is higher then not across all segments. The Harvard analyses shows that in essence.

    So when folks talk about subsidies to me what is subsidized is what loses the most first and that is Medicaid. As that study says, Medicaid loses nearly $0.20 on the dollar of spending for hospitals. It is 20-30% of business. Where do they make it up?

    First, commercial PPO as the study suggests since it is a large market segment with better revenue yields. Medicare also. Unisured too though volumes are lower so their net profit effect is low to overall size of the pie.

    Analytically, really fascinating stuff. Too bad many people don’t get into it enough to draw better conclusions.

    Bottom line, Medicaid is what is subsidized en masse as a patient segment. In terms of uninsured subsidies, check FQHC Clinics since uninsured represents a large part of their service pie then hospitals.

    Bill (af584e)

  173. “By the way, the linked article states that as of 1997, there was no limit on what hospitals can charge indemnity insurance, PPOs, and Self Pay patients. I don’t think that’s true in all states now.”

    It stands to reason that the vast majority of writeoffs come from uninsured but this number pales in comparison to Contractual Adjustments for players like Medicaid and Medicare.

    Bill (af584e)

  174. Before Bill highjacked this thread, the post was originally why the liberal legal analysts lived in the bubble not ever considering that the law was unconstitutional.

    Very simply 98% of the climate oops, I mean legal experts all agree the law is constitutional.

    joe (2d12c3)

  175. LOL. Wake up folks. No industry in the US is so poorly run, so filled with fraud, so large and so corrupt as the health care system.

    I know. I am a Senior Executive in the field.

    I wonder if there has been such a relentless demand in Bill’s lucrative career for ethical compromise that, having looked the other way or pushed the envelope for so long, it has rendered him the angry, obtuse and frustrated man we see here?

    If so, I feel sorry for you, Bill. Nothing seems worth doing if it brings you nothing but contempt and impatience toward a smart group of voters who are very concerned about this health care debacle we’re facing yet pressing on to get the full picture and understanding of all that it entails and what its probable impact on us will be.

    Dana (4eca6e)

  176. Why, DRJ and Dana! He is a Senior Executive in the field! He knows better than you do.

    Even when the links he posts…well, don’t say what he claims they do.

    I think that the fellow needs a chipper for that shoulder of his, whether or not he is a Senior Executive or not.

    Simon Jester (c8876d)

  177. Bill:

    … but this number pales in comparison to Contractual Adjustments for players like Medicaid and Medicare.

    We agree, Bill! At least I think that’s true in some parts of the country, and it can hurt providers and patients.

    DRJ (a83b8b)

  178. I suspect, DRJ, you should change your terminology to Providers and Patients.

    Simon Jester (c8876d)

  179. #175 Dana,

    How condescending and ill informed. Thank you.

    #176 Simon,

    It stands to reason an expert knows more then one who is not. Unless that is you are on Patterico where a cabal of like minded people sit around kissing each other’s privates and claim some expertise in topics of which they know nothing. Like health care.

    Bill (af584e)

  180. He is a Senior Executive in the field! He knows better than you do.

    He may well at that, however, I’m now completely sidetracked and find myself more interested in what drives the bus – why so full of contempt and anger? Why the need to grind down others to build himself up…who’s he trying to convince? Clearly, he is not deriving any satisfaction from enlightening the thick headed masses here… perhaps its because we demand evidence more than heresy to convince? I don’t know.

    Dana (4eca6e)

  181. Bill,

    There are a lot of things that need to be fixed in health care, including cutting down on fraud and waste as you noted above. I favor policies that help to reconnect providers and patients, so patients have an incentive and ability to reduce costs. I also like tort reform, although my state has already done some of that, and changes that help people with pre-existing conditions.

    However, rather than manage these changes from the top down, I would like to try block grants to the states that let them figure out what works best, not only because each state faces different challenges but also because it makes it easier for the voters to choose what they like and don’t like.

    DRJ (a83b8b)

  182. @ 179,

    I certainly did not intend to be condescending at all (and find the irony in your comment amusing). Merely musing aloud on what has now become a distraction to me in this post. Maybe I’m ill informed, maybe not; the point is, you have been so full of contempt for commenters here, that one really wonders, why?

    Dana (4eca6e)

  183. Oh, Dana….you do not have to worry about being condescending in this context. At all. Ever.

    Which is why I find this person hilarious, the more I read his screeds. It’s like he doesn’t own a metaphorical mirror.

    So, yes, the reasoning behind all the posts and the venom is interesting. But we all know the answer.

    Simon Jester (c8876d)

  184. How is the health insurance market an interstate market?

    I am a licensed health insurance agent, and I kn ow that one can not buy insurance from across state lines.

    Michael Ejercito (64388b)

  185. Bill – I am waiting for an expert on health care to arrive to comment on the thread. So far none have appeared.

    daleyrocks (bf33e9)

  186. Oh, Bill. I thought we had made progress and were talking with each other, instead of attacking each other. Do you really think the people here are a “cabal of like minded people [who] sit around kissing each other’s privates and claim some expertise in topics of which they know nothing”? It is beneath you or anyone to say that, let alone someone who claims to be in the caregiving profession.

    DRJ (a83b8b)

  187. But Michael: you aren’t a Senior Executive. So you can’t know as much as Bill.

    Like I said, funny.

    Simon Jester (c8876d)

  188. And DRJ, I so wish you were a part of my family. You are calm and moderating and above all kind. I salute your approach to even the most irritating exchanges here.

    Simon Jester (c8876d)

  189. “He may well at that, however, I’m now completely sidetracked and find myself more interested in what drives the bus”

    Dana – We are not worthy.

    Don’t you know who Bill thinks he is?

    daleyrocks (bf33e9)

  190. summit nj

    elissa (cd1133)

  191. Michael Ejercito,

    I think they touched on your point in oral argument on the second day, and it’s a good question. I’m glad you raised it because it’s time for me to move on to another topic.

    On a related note, I’ve been pondering how liberals could be so surprised at how poorly the Obama Administration did in oral argument. There are many good explanations but I think one of them is that they never took the opposition seriously. Nancy Pelosi’s rhetorical question “Are you serious?” when asked if ObamaCare was constitutional is a good example.

    Appellate advocacy requires many skills but no matter how skilled the advocates, they still have to practice their presentations and arguments. Over and over again, both in court and in the media, liberal lawyers have treated opposing arguments like something to avoid rather than a challenge to confront. I suppose it’s good for those who oppose ObamaCare and it’s good because it forced the liberal Justices to step up and reveal their thinking, but it’s disappointing from a professional standpoint.

    DRJ (a83b8b)

  192. Thanks, Simon, but I’m actually selfish. I never know who might be reading this, and I don’t want anyone in my real life or my online life to think less of me.

    DRJ (a83b8b)

  193. “summit nj”

    elissa – He hasn’t mentioned Ivy League yet.

    daleyrocks (bf33e9)

  194. DRJ, I cannot tell you the number of people I know who have gotten themselves seriously into trouble via the Internet. Not due to someone “outing” them, but people writing very, um, intemperate things and *not* thinking employers or review boards would not check.

    Facebook is *not* private, for example. No matter what college aged students think. I have seen some good, good people damage their future prospects, and over petty silly things.

    The point: I appreciate your taking the high road as often as you do!

    Simon Jester (c8876d)

  195. Your point about the Left is great, DRJ: there is an awful lot of reasoning from the heart and not the head. Of course the bill is Constitutional—but not based on knowledge of precedent or the law…instead, based on what the person wishes to be real.

    I don’t know who said it, but I sure like it: the best and fairest law is one you do not mind in the hands of your bitterest enemy.

    Simon Jester (c8876d)

  196. If only we could get Bill to comment on which races are more likely to pay, it’d be like having a senior business executive random…

    Ghost (6f9de7)

  197. Michael Ejercito,

    I think there are 4 cases that are most relevant to the ObamaCare case: Wickard, Raich, Morrison, Lopez. The Washington Examiner summarized those 4 cases and 2 others here, and discussed how the Justices viewed those cases here.

    At some level, each case touches on whether something is part of interstate commerce and subject to federal regulation, or whether it is part of intrastate commerce and not subject to federal regulation. Some of the results are surprising. The one that matters to me is Raich. I’m not smart enough to know the answers, but I think Raich is an outlier and how it’s treated will tell us what happens to ObamaCare.

    DRJ (a83b8b)

  198. I would think Wickard was more relevant, as it’s closer to forcing someone into commerce. Why do you say Raich?

    Leviticus (870be5)

  199. Raich is brought up, because seemingly Scalia endorses the Commerce clause use, in it, the activity was already illegal, Lopez represents
    the other end of the continuum,

    james buchanan (7b583c)

  200. Leviticus,

    I think there are obvious similarities between Wickard and Raich, and both are distinguishable if you view ObamaCare as an attempt to regulate inactivity. But if the Justices aren’t willing to do this, IMO it’s easier to factually distinguish the Wickard case since Wickard was a commercial wheat farmer (so it’s easier to envision his production as having a “substantial economic effect on interstate commerce”) and at that time wheat farmers agreed to quotas through an annual referendum — quotas that applied both to wheat produced for sale and for home consumption.

    DRJ (a83b8b)

  201. “#175 Dana,

    How condescending and ill informed. Thank you.

    #176 Simon,

    It stands to reason an expert knows more then one who is not. Unless that is you are on Patterico where a cabal of like minded people sit around kissing each other’s privates and claim some expertise in topics of which they know nothing. Like health care.

    Comment by Bill ”

    DRJ I’m sorry to let you down. I have stopped reading the comments. I have several degrees in addition to an MD and am very interested in health care policy as you could see from my series on French health care. I have just gotten tired of debating with someone who knows nothing.

    Mike K (326cba)

  202. Mike K,

    You didn’t let me down, far from it. I needed direction and you gave it to me.

    DRJ (a83b8b)

  203. And if you haven’t done so already, I recommend everyone read Mike K’s link about what Anerica can learn from the French health care system.

    DRJ (a83b8b)

  204. As I wrote earlier, I’ll take Dr. K.’s commentary any day of the week. Also, I have heard Dr. K. openly state when he was mistaken, or rethought his position.

    He is honorable, and demonstrably knowledgable (I have learned a great deal from him over the past few years).

    This other person? Well, I think the record speaks for itself.

    Simon Jester (c8876d)

  205. You are a vile person Daley.
    Comment by Bill — 3/31/2012 @ 9:23 am

    I’ve been out for several days (hence the multitude of spam you’ve seen that I’m just now cleaning up) and still getting caught up.

    Stopped what I was doing to say this.

    Bill, tone it down or you will be moderated. From what I’ve seen so far, all you’ve offered is your opinion based on your supposed expertise. No links. Just unsupported assertions based on what you claim is your experience.

    Insulting others and trying to shut down their voice will not win arguments here. It will get you moderated. Understood?

    Stashiu3 (cd7afe)

  206. Bill and Random should hook up.
    Comment by JD — 3/31/2012 @ 9:39 am

    No, Random at least offered links, even if they were from bullshit sources.

    Stashiu3 (cd7afe)

  207. Someone smarter then you once told me “look at what they spend money, not what say to raise money.”
    Comment by Bill — 3/31/2012 @ 9:48 am

    *than

    Guess that makes me smarter THAN you, eh?

    Stashiu3 (cd7afe)

  208. Utilise
    Analyse

    JD (318f81)

  209. Stashiu3: I suspect that “I work here is done” will be the next step.

    Simon Jester (c8876d)

  210. I have seen first hand for years how self insured patients are 100x more careful over what they consume then those that do not.
    Comment by Bill — 3/31/2012 @ 11:52 am

    For someone so smart, this seems strange.

    Stashiu3 (cd7afe)

  211. Ah, now I’m seeing links. Obviously Googled links, but links nonetheless. I would think an expert, even self-styled, would have access to more credible information.

    I continue to catch up and await breathlessly what comes ahead. About 10 more pages of comments (and over 1,000 spam right now).

    Stashiu3 (cd7afe)

  212. Is there one person here who understands this issue from direct experience managing anything other then a lawyers office or a taco stand?
    Comment by Bill — 3/31/2012 @ 12:46 pm

    And again?

    By the way, insult DRJ again, that’s really winning you points here.

    Not really.

    Stashiu3 (cd7afe)

  213. Finding still more then/than. Not highlighting it anymore. Speaks to credibility in my mind however.

    Stashiu3 (cd7afe)

  214. And yet no one here has one piece of numerical analysis showing profitability by segment to disprove what I have written but I provided a Harvard study showing I am correct.

    Self pay are one of the most profitable segment of the medical market, though smaller slice of the pie then say other payor classes like Medicare, etc.

    Medicaid is by far the least profitable segment which is, by definition what gets subsidized first.

    The myth that self pay unisured are some how free riding the system and a root cause for Gov.t taxpayer subsidies is bunk. It is a tactic used by many in the industry to pan handle for cash in order to cover the low revenue yields from Medicaid.

    So if the pop psyc folks want to label that angry be my guest. Facts are facts and insuring the uninsured using Medicaid reimbursement models is financial lunacy for the industry.

    Mike MD, hope u retire soon because if this gets upheld your standard of living will be going to hell in a hand basket.

    Bill (af584e)

  215. Stashiu,

    No links? Read on.

    Also, limks are not a replacement for algebra or navigating financial statements.

    And understanding the impacts of accrual accounting in healthcare organizations along with their interpretation by many many financially un sophisticated readers also does not accrue with links to those very people who dont get it.

    Healthcare, as a field, is still stuck in the 1950s in so far as activity analysis, segmentation profitability, et al. At best, the smartest financial people in healthcare are in Yield Management, not FPnA or Strategy.

    Policy folks, plenty in the business but not financially sophisticated. Smart folks in their area much like MD on medicine. In fact teaching MD business while in med school is only beginning really. Hope they roll it out soon, be good for them to be grounded in management accounting and business law before they start cracking your ribs open.

    Bill (af584e)

  216. Bill,

    I’ve been a nurse for 20 years now, which does not always translate well into the administrative side because good nurses still focus more on care than the bottom line. We don’t treat healthcare as a business as much as others.

    That doesn’t mean we can’t smell BS a mile away. You came in as an arrogant and insulting brute. Keep it up and you’ll go out the same way. As Ryan just found out, I’m not in the mood.

    DRJ (although not from a medical background), Mike K., MD in Philly, red, daleyrocks, and several others have far more credibility here you have developed. Which is none. Check yourself before you wreck yourself.

    Stashiu3 (cd7afe)

  217. And yet no one here has one piece of numerical analysis showing profitability by segment to disprove what I have written but I provided a Harvard study showing I am correct.

    Hay Zeus effing krist. Did not not read, or not understand, the direct responses to the over 15 year old data you claimed to prove your point?

    JD (318f81)

  218. I think it has to do with algebra, JD.

    It reminds me of this Tim Allen quote:

    “…Men are liars. We’ll lie about lying if we have to. I’m an algebra liar. I figure two good lies make a positive…”

    Not that I am accusing anyone of prevarications, you understand.

    Simon Jester (c8876d)

  219. #216, like I care about posters names in terms of truth? Please, that tone is indicative of individuals who are protecting their egos more then interested in exploring for the truth. Take the issue seriously, not yourself. My points stand on merit. If this was a criminal law or constitution discussion I would try to listen and understand if the counter party happens to be a professional in the area, even if I dont like the cpclusion.

    Bill (af584e)

  220. Bill:

    And yet no one here has one piece of numerical analysis showing profitability by segment to disprove what I have written but I provided a Harvard study showing I am correct.

    This 2007 Thomson Reuters’ study (based on an analysis of 307 community facilities and the Thomson Reuters Top 100 hospitals) indicates hospitals generally have negative operating margins from Medicaid and Medicare patients, and positive operating margins from Managed Care, Commercial and Self Pay patients.

    So that offers support for your argument, although I suspect it is not representative of states with the highest uninsured populations. However, there is a caveat: The report also shows the operating margins for lower-profit hospitals are negative or flat for all but Self Pay patients. Thus, facilities that rely on Self Pay patients tend to be less efficient, lower-profit hospitals.

    DRJ (a83b8b)

  221. My points stand on merit.
    Comment by Bill — 3/31/2012 @ 9:43 pm

    That takes care of that then.

    Continue to insult people here, despite many of them being in the field (medical, not legal), and you will be moderated. Fair warning.

    Stashiu3 (cd7afe)

  222. C’mon, folks.

    “…Please, that tone is indicative of individuals who are protecting their egos more then interested in exploring for the truth…”

    That phrase, given the source, is laugh-out-loud funny. Tone? This has to be performance art!

    Paging Leonard Pinth-Garnell.

    Simon Jester (c8876d)

  223. DRJ’s grace and patience in the face of BILL THE SMART EXPERT’S JACKASSHATTERY is amazing.

    JD (318f81)

  224. Plus, Stashiu3, there was a bonus then/than sighting!

    Simon Jester (c8876d)

  225. 217,

    1, as opposed to no data to support the oppossite?
    2, the data is still consistent with pricing and collections in the marketplace

    I am sorry but you are simply wrong. You could care less what is presented. So no sense in speaking to a person who seeks not truth but convenience.

    And mind I add that Writeoffs for Uninsured have about nothing to with profitability relative to other payor segments.

    The entire industry unfortunately talks writeoff that while an uninsured issue ignores the fact they simplu pay lots more for the services they receive in comparison to say, Medicaid.

    Bill (af584e)

  226. It is easy to declare yourself a subject matter expert and dismiss any opinion that does not exactly mirror yours as stupid uninformed blah blah blah blah. Bill and Random deserve each other.

    JD (318f81)

  227. 220, at least I have opened someone to the possibility that what they have brain washed into believing is not true. My work is done. Thanks.

    FWIW, lots of changes in self pay segment last few years with the economy and yes self pat driven facilities have seen a biiger fluctuation of volumes than say a Medicaid shop. Also competition has picked up for the segment as MD have realised that you have no Stark limitations, no collections crap if you collect early, no need for billing staff and no authorizations, etc……

    Problem is that as a segment it is not big enough to make a real business from just serving them. They are not brand loyal, they price shop, they jump on Medicaid the minute they can.

    Bill (af584e)

  228. JD, I am an expert. Regardless of how often you say otherwise. Like Stephen Hawking talking physics to freshman engineers at MIT. Smart kids, heck might be even one or two smarter, but he has forgotten more physics in five minutes then they know at the time. .. not to say they cant one day be better but it takes some practice.

    Bill (af584e)

  229. What I suck at is typing and grammer. And being nice to fools.

    Bill (af584e)

  230. Bill:

    “My work is done.”

    I did learn from this so I appreciate that, but I don’t think a health care system built on the current version of Self Pay patients is a good solution. We don’t need a lot of inefficient, low-profit hospitals.

    But your quote made my day!

    DRJ (a83b8b)

  231. I bet you couldn’t pass a Daubert test.

    My work is done.

    That is so you, taint snorter.

    JD (318f81)

  232. Did I say “paging Mr. Leonard Pinth-Garnell”?

    This fellow actually likened himself to Hawking (Lucasian Professor of Physics at Cambridge) talking to engineers at MIT. To quote Jerry Seinfeld: Really?

    Yes. He. Did.

    Applaud wildly: “Horrifically bad…couldn’t be worse…”

    http://www.dailymotion.com/video/xkuff1_saturday-night-live-bad-conceptual-theater_fun

    Simon Jester (c8876d)

  233. #230: the “grammer” bit was precious, as well, DRJ.

    Simon Jester (c8876d)

  234. I was in rehab with a “senior health care executive”. He was a buyer for a hospital – medicines to floor wax. He was an opiate addict. He had diverted every opiate, and the prescrition pads too, for his use. It could be Bill.

    nk (dec503)

  235. : Mr. Bill – what you’ve just said is one of the most insanely idiotic things I have ever heard. At no point in your rambling, incoherent response were you even close to anything that could be considered a rational thought. Everyone in this room is now dumber for having listened to it. I award you no points, and may God have mercy on your soul.

    JD (318f81)

  236. What I suck at is typing and grammer. And being nice to fools.
    Comment by Bill — 3/31/2012 @ 10:04 pm

    Yeah, I have trouble with the being nice part sometimes, the spelling and grammar I do fairly well. You can join Ryan in moderation and ponder who is the real fool… someone who argues their position effectively and respectfully, or the ass who poisons any actual points they have by calling everyone with a contrary opinion a fool and other things.

    FWIW, I don’t concede you’re an expert, although I am willing to believe you work as you say. Your points are self-serving without any acknowledgment there may be a conflict of interest. Plus, your links don’t always say what you contend they say. The mark of a bloviating blowhard.

    My work here is done. Priceless!!!! 😉

    Stashiu3 (cd7afe)

  237. nk, I don’t think I have formally said that I have my fingers crossed for your recovery and better days ahead. Agree or disagree, I often learn things from your posts. Plus, you make cool cutlery.

    As for this “Bill” fellow, c’mon. He was playing games. He actually claimed to be as brilliant as Hawking, in his own area of expertise. There isn’t a word for such arrogance.

    Except…wait…maybe he is like Hawking, in one way:

    http://www.nypost.com/p/news/national/renowned_physicist_hawking_regular_usOh44cqUIkishSkhXbdXI

    Or not.

    Simon Jester (c8876d)

  238. Bill, discussing Self Pay patients:

    Problem is that as a segment it is not big enough to make a real business from just serving them. They are not brand loyal, they price shop, they jump on Medicaid the minute they can.

    You know, Bill, that seems at odds with your earlier comments about the benefits of Self Pay patients and, as far as I recall, you never admitted taxpayers pay for health care (other than to claim it is so “miniscule as to be unimportant”).

    I opened my mind to your concerns and even researched them for you. You never did the same for me, did you?

    DRJ (a83b8b)

  239. He is too busy with being as brilliant as Stephen Hawking, DRJ. That takes time, and effort. Cut him some slack.

    Simon Jester (c8876d)

  240. nk, I don’t think I have formally said that I have my fingers crossed for your recovery and better days ahead. Agree or disagree, I often learn things from your posts. Plus, you make cool cutlery.
    Comment by Simon Jester — 3/31/2012 @ 10:17 pm

    I endorse this 100%. I hope you (nk) are getting better by the day and that life treats you well.

    Stashiu3 (cd7afe)

  241. You know, nk, there’s a lot of sympathetic pains here for you. Plus, we’re getting old so some of those pains are real.

    DRJ (a83b8b)

  242. I’m always glad to see folks here wish each other well, independent of agreeing with one another on oh-so-important political folderol.

    We are only on this planet a short span of time, and shouldn’t waste it on hatred or nastiness (like the Breitbart vileness from some—not all—people on the Left).

    Simon Jester (c8876d)

  243. Thanks, Simon. I’m fine. I walk just fine with a cane and ankle brace. Life happens. Hephaestos and Weyland were lame too. 😉

    Might take a while, but I will be posting a push dagger I made, and a curved knife my father made out of a straight razor if I can find it.

    nk (dec503)

  244. Thanks, everybody. I post slow, so you posted while I was replying to Simon. What I said is true. I only have a lame left foot.

    nk (dec503)

  245. Jerry Pournelle used to carry a sword cane, nk. He told the story of someone with a knife trying to hold him up. “I’ll see your four inches,” he claimed to have said, “and raise you sixteen!”

    Doubt it happened quite like that, but it was a cool cane.

    I’m glad you are doing well. My kids have been learning a lot of Greek and Roman mythology from the Riordan kids’ novels (the Percy Jackson series).

    Simon Jester (c8876d)

  246. My fourth-grader (just turned ten) is on book number seven (?), The Son of Neptune. She chose that for her book report. 500 pages.

    She had read the first books, independently, in second grade. I bought her Riptide and she brought it to school for show it and tell. I gave it to the teacher, to permit it at her discretion, and the teacher was cool with it.

    nk (dec503)

  247. Comment by Bill — 3/31/2012 @ 12:06 pm

    1) ER are very profitable in general and are at worst loss leaders for most hospitals.

    Another way of putting this is that ERs are already a form of cost shifting!

    If they appear to lose money, it is only because too much overhead is assigned to it. They are, probably, assuming you are right, just about the least unprofitable part of a hospitals operations, with the exception of the daily inpatient rate for room and board.

    What percentage of hospital expenses would you say is overhead? And there’s probably different kinds of overhead. Overhead just to not to go bankrupt, overhead to maintain a hospital, overhead to run an emergency room for one night, etc.

    2) Taxpayers don’t subsidize the uninsured because the uninsured actually pay more then the insured.

    In other words, the cost shifting goes the other way: from the insured toward the uninsured.

    This is because, even though a lot of the billed charges aren’t paid the list price uninisured patients charged is so much higher. On balance, therefore, hospitals make a bigger profit on uninsured patients than insured ones.

    This is, of course, if you count Medicaid as a form of insurance. Now, if anyone is plausibly (who subjects them to an IRS audit??) poor enough to qualify for Medicaid, the hospital is better off getting that person on Medicaid and they do, but as a class, uninsured patients pay more.

    This is so true, that one piece of advice is to get a high deductible insurance policy, but run everything through the insurance company, even though it will never reach the deductible and pay except in a very extreme circumstance. It will not pay, but you’d get the advantage of the lower rate.

    A lot of the argument for what was passed is premised on the market working in a way any person could tell it is not
    .
    Fifty years ago, poorer people used to be charged less or get charity care and even though a legal obligation to offer financial aid continues, it is not done. (In fact the New York Times ran a front page story about how hospitals were routinely violating a rule to give charity care – Obamacare actually can get those hospitals in trouble so a lot are trying to reform before it hits. (The law may not be all bad)

    Study Finds New York Hospitals Flout Charity Rules by Nina Bernstein, published on the Internet on February 12, 2012, and printed on the front page of the Monday, February 13, 2012 New York Times:

    The study found that some hospitals did not provide financial aid applications at all, and that many made impermissible demands for irrelevant documents or failed to supply key information, like eligibility rules for big discounts required by state law in 2007. Data reported to the state was obviously faulty, it found.

    Yet even hospitals that reported they had spent nothing on financial aid, or had filed hundreds of liens against patients’ homes, were allowed to collect without questions from the charity care pool, which distributes more than $1 billion a year.

    Hospitals are not legally barred from seeking judgments or liens, but must first offer an aid application, help the patient complete it, and wait while it is pending. Instead, many hospitals turn to collection agencies, and sue when that fails. The unpaid bills — typically reflecting much higher rates than what insurers pay — are then treated as the equivalent of charity care.

    Change is now urgent, health care experts agree, because the state pool stands to lose hundreds of millions of federal dollars in 2014, when provisions of the health care overhaul will no longer treat so-called bad debt, based on uncollected bills, as if it were charity care.

    ….Court records abound in judgments against patients who say they had little or no chance to apply for help. A couple fighting foreclosure in Elmont, Nassau County, has a $41,000 default judgment from NYU Langone Medical Center for emergency surgery on their disabled adult son in 2007, when their insurance unexpectedly dropped him. He was eventually approved for Medicaid, but it would not pay for the surgery retroactively.

    The New York Times links to the study at cssny.org

    Sammy Finkelman (32408d)

  248. nk, from whence did you obtain Riptide? You must know Chiron!

    Simon Jester (14c140)

  249. Comment by Bill — 3/31/2012 @ 3:25 pm

    If Hospitals lose money, it is because their beds go empty. Having a kick arse ER helps solve that problem.

    It makes the most money from the daily capitation tax on patients because the marginal cost for room and board is very low. Is that rate at least the same for insured and uninsured patients.

    I see what you say now – an ER leads to admissions.

    Sammy Finkelman (32408d)

  250. Wake up folks. No industry in the US is so poorly run, so filled with fraud, so large and so corrupt as the health care system.

    I know. I am a Senior Executive in the field.

    From the Nina Bernstein New York Times article:

    http://www.nytimes.com/2012/02/13/nyregion/study-finds-new-york-hospitals-flout-charity-rules.html?_r=1&sq=charity%20hospital&st=cse&scp=2&pagewanted=all

    But a new study of New York hospitals’ practices and state records finds that most medical centers are violating the rules without consequences, even as the state government ignores glaring problems in the hospitals’ own reports.

    “The entire system is corrupted, and it isn’t working for patients,” said Elisabeth R. Benjamin, vice president of health initiatives at the Community Service Society of New York, a nonprofit antipoverty group, which is releasing the two-year study on Monday.

    The state’s Department of Health acknowledges systemic problems, including the need for better reporting and enforcement, a spokesman, Michael Moran, said. A group of patient advocates and hospital administrators is being convened to develop a better system, he said, and the department is engaged in “a comprehensive data integrity project that will include the retention of an outside auditor.”

    Sammy Finkelman (32408d)

  251. Two comments to the New York Times article (there is this bias in many comments that universal health care would prevent this or it’s the bad insurance companies but there is valuable anecdotal information there too:

    A few years ago, while in NYC, I was rushed to the C/P ER twice. I had insurance, which covered a bit, but the bills were broken into sub-sections by department, and each department billed separately. Luckily, I heard three people at a support group meeting tell how even with insurance, if they contacted the hospital (any publicly supported hospital) the hospital had to help them.

    I embarked on the laborious, tedious and almost impossible task of applying for help. When I’d call each department for clarification, I’d get a different response depending on who I was speaking with on any given day. Most (but not all) the financial people were rude or gave me information that later turned out to be inaccurate.

    Anyone going through this should write times, dates, and first and last names of everyone they speak with, and a brief note of what the person said.

    I was tenacious, something I’m sure many cannot manage if ill or injured. The hospital wanted mountains of paperwork to verify all kinds of stuff – worse than the IRS. Eventually, I was granted lower payments and allowed to pay as little as $10.00 to $25.00 per department per month. Some parts were entirely “forgiven.”

    While I eventually prevailed, the system is awful and needs to be fixed.

    ——————-

    As a ‘victim’ of New Jersey’s charity care system, I can tell you this is not limited to NY State.

    I am on SS Disability. I go to Somerset Medical Center. After I get discharged, I don’t hear anything from them for 9 months. Then some collection agent calls me up and starts demanding personally identifiable information, which I refused. They persisted, I demanded they send me an application for charity care. I never heard from them. NJ has a website about their charity care applications – it is beyond complex; but, it is clearly states the hospital must help you fill out the application. Somerset ignored that too.

    Then they sold the account to another collection agency. I persisted in demanding a charity care app and help completing it. Still no response.

    Then they sold the account to a third collection agency who just ignored me, entirely.

    I wrote to the hospital administrator and asked them if they knew what their collections department was doing.

    Within a week, I got a letter from the administrator saying they were going to write off the balance. And I got a weird letter from a woman in the collections department, asking me not to blame her for what happened…

    Charity care is a travesty. The current system doesn’t work.

    —————–

    As a doctor I am not surprised by all this. Insurance companies and medicaid are looking for all sorts of loopholes and technicalities to avoid paying, even in one of your examples in this article. If we just ignore this and allow medicaid and insurance companies to gouge us without a fight then no one will solve this problem. A lien on peoples’ houses and seizure of their inheritances should bring this issue to the attention of the nation. People without insurance are a different matter entirely, but aggressive collections when insurance denies payments due to technicalities and “lapses” (usually after medicaid has told us the insurance is valid) is the only way to make people take notice. If enough people complain then perhaps medicaid and other insurance companies will start acting in good faith and paying the bills. Aggressive collections is the only way to bring this problem to the forefront. Notice that the most aggressive collections are from state institutions, the ones who deal the most with medicaid.

    Sammy Finkelman (32408d)

  252. 17. Poor Libtards, the Marxists have had their May Day and all they got was a lousy hoodie.

    gary gulrud (d88477)

  253. Making all the money Bill does, I hope he is paying his share.

    sickofbill (44de53)

  254. I am willing to accept the assertion you are as fact.
    — Okay. I assert that I are as fact. Accept me!

    You are better at fabricating things about my positions
    — Oh no, YOU’RE better! Don’t sell yourself short, dude.

    another person ignorant on the issue joining in.
    — It’s kinda bad form to dance with oneself in public, don’tcha think?

    If you are a professional, let me know.
    — And if you do pro-bono work, hurry on over! Bring commitment papers.

    Financial Malpratice with an agenda for the most part.
    — Catchy, but you should probably go with something different on your business card.

    Sad group on this board.
    — We’re having fun. Aren’t you?

    ask Bill all you want but ask the proper question.
    — “I’m speaking to the person inside of Bill now. If you are there, you too are hypnotized and must answer all my questions. Come forward and answer me now. Are you the person inside of Bill? Who are you?”

    Icy (1acc20)

  255. #141, So ER needs to advertise to avoid losing money??? You are in Advertising?
    — Advertising attracts business; business makes money; money covers operating costs; loss avoided. Sounds like a plan, Stan. And NO, I’m not in advertising, but I am in business.

    Can I ask Icy, do people go to the ER because they want to or have to? Because last I checked health care is a pure grudge purchase. Most hate going.
    — Last I checked most people go to the ER for non-life-threatening injuries. Time always provides a consumer with choice, even when making a “grudge purchase”.

    So if an ER is advertising the purpose is not create demand but to try and monopolize demand. To so in order to cover fixed costs b/c variable costs are lower then the price of services. That is to say ER is profitable on a variable cost basis.
    — it doesn’t really matter whether you perceive it as covering fixed or variable costs; they all need to be covered. And if they aren’t? That’s when the variable costs of labor and medical supplies for running an ER must be redirected to cover the fixed costs of maintaining the facility . . . and the ER closes.

    But if the COST of servicing ER patients is higher then the revenue … why would want to monopolize demand and advertise????????????
    — Because once you have enough paying patients to cover the fixed costs, then you have achieved relative stability because, as YOU said: “[the] ER is profitable on a variable cost basis.”

    Pick a position b/c the one advocated makes no sense.
    — I picked only one position: the one that makes sense.

    People don’t advertise for purpose of selling an unprofitable product.
    — Who said that it was impossible for this to be profitable? Certainly not you! ‘Do not worry about the providers; they make their money.’ Right?

    Icy (1acc20)

  256. nk, from whence did you obtain Riptide? You must know Chiron!

    Comment by Simon Jester — 3/31/2012 @ 11:11 pm

    I’m sorry, Simon, I never got the lady’s name at Toys R Us. 😉

    Bill had some good points, too bad he was so intemperate. My wife is part of a university hospital. She has to bring in three times her salary. One third goes to the overall budget of the university, another third to the overhead of her department. She engages in a great deal of research, much of it funded by NIH grants, private philanthropy, and medical publishers and suppliers, so she helps support the research lab. Her patients will require additional services, such as physical and occupational therapy, provided by other departments. She does not do direct admissions so her patients go into the hospital through the ER or the medical teams. There is a lot of one hand washing the other.

    nk (dec503)

  257. #254, Uhhh, too much.

    But I find funny that multiple posters who can’t understand the concept of uninsured subsidizing insured via higher effective (net) prices descend to a) name calling, b) alleging illegalities in my conduct with no basis in anything c) I would surmise trying to shut down a discussion they are losing b/c they simply are not versed in the subject.

    #256 No Icy, your position if I understand it makes no sense. You claim ER advertise to get patients in spite of losing money. I pointed out a) they make money, and b) at worst they are loss leaders for hospital. Try getting a license to be a hospital (or recertify) from the Joint Commission. try filling hospital beds without an ER as a point of entry for customers.

    Again, frankly you are out of your element in this discussion and I would suggest all who truly are interested do more homework on the issues at play. They are vitally important b/c this uninsured issue is used as a wedge for Govt to take over the health care sector. And that is a bigger disaster then 30MM uninsured.

    #252 I would never use the Times as a source for fear of their political orientation. But in the NY Metro, the graft and corruption in the non-profit healthcare arena and Medicaid is breadthless. Second only to Miami Dade in fraud by both MD and Operators.

    My favorite in NY is Pedro Espada and his Soundview Healthcare Clinic. Non profit of course. Purveyors of goodnes too. Or even better the Russian/Hspanic MDs, DDS and Medicaid abuse. Just today the NY Post did an article on an MD who received over $500,000 in charitable giving and was nowhere to be found at the site where allegedly she works.

    Just horrible how often, and unnoticed, the blatant cases such as these occur. But if there is one thing non-profits in healthcare are great at is PR.

    And this is the purely legal, then get into the barely legal activities like the Marijuana docs or the Orthopaedic Surgeons and Workplace Injuries or Auto Accidents.

    People simply don’t know and given the “technical nature” of the purchase by patients — they never will.

    Bill (af584e)

  258. … then, than, whatever but that is what “los pallazos” will harp on or the fact I lack a 100 page screed from the American Enterprise Institute to support reality.

    Bill (af584e)

  259. Bill:

    FWIW, lots of changes in self pay segment last few years with the economy and yes self pat driven facilities have seen a biiger fluctuation of volumes than say a Medicaid shop. Also competition has picked up for the segment as MD have realised that you have no Stark limitations, no collections crap if you collect early, no need for billing staff and no authorizations, etc……

    Problem is that as a segment it is not big enough to make a real business from just serving them. They are not brand loyal, they price shop, they jump on Medicaid the minute they can.

    If you’re still around, you don’t have a monopoly on thinking about our health care system and the value of Self Pay patients. We’ve been talking about this for at least 2 years.

    DRJ (a83b8b)

  260. NK,

    Ask your wife if her Hospital could actually function well without an ER …..or if they would risk sending patients to another ER and possibly “lose” the patient?

    Also, ask her why she feels (feels) that Hospitals are aggressively buying Outpatient Centers and Physician Practices? Or for that matter exploring ACO Models with CMS in preparation for 2014.

    I realise that while research is isolated in Teaching Hospitals from the competitive landscape, she still must over hear a great deal.

    Be very curious the answers.

    North Carolina by the way?

    Bill (af584e)

  261. #260, DRJ,

    People have been incorrectly diagnosing health care finance for years. So with respect to my thinking (you are implying) I have a monopoly on thinking … uh no. Lots of “thinking” going on. Most of it not of high quality.

    But I would suggest (modesty never a strong suit) I am one of a select few professionals who not only understand the system as it is but also what makes the different actors tick.

    And the whole “we love our patients and want to cure sick people” drives a select few who have the luxury afforded by someone else’s money or lots of their own.

    Fear and greed are as much a part of medicine 2012 as it is on Wall Street.

    Bill (af584e)

  262. If Hospitals lose money, it is because their beds go empty. Having a kick arse ER helps solve that problem.
    — Does anyone have some reliable statistics as to what percentage of ER patients get admitted to hospital?

    Hospitals don’t lose money because the uninsured are consuming and not paying.
    — At our local Piggly Wiggly they invite the homeless in to sample all of the grapes they want. Awfully sporting, I say.

    In fact, few-to-no Health care Providers are going hungry or broke due to the uninsured. Most are actually making a pretty penny at it.
    — Is it shiny and new?

    You might learn something of use instead or eating more dog food on the issue.
    — Isn’t it bad enough to eat dog food? Not quite cricket to make one eat it on “the issue”. Eww!!!

    Read
    — Think!

    Icy (1acc20)

  263. For those who wish to assail another point about fraud and abuse being rampant, if putting aside illegal activities which are gigantic, let me outlined the “legal” but not ethical practices … always justified as being cautious and a “higher” standard of care ….

    1) Rampant, irrational checking in for over night observation of Medicare patients
    2) MDs acting as both outpatient and inpatient providers and over using the inpatient system b/c it is very lucrative
    3) Hospitals requiring diagnostics be done on campus for any procedure performed on campus. That is to say, they don’t want to use diagnostic reports from outpatient facilities.
    4) Shot gunning blood draw / labs
    5) Ridiculous standards of care pushed by the AMA and the Specialty Boards.

    Smart insurers are actually tackling this issue. Humamaa for example has recently stopped contracting outpatient MDs to be Hospitalists. In order to eliminate the incentive to check in patients.

    Humana also recently acquired Concentra in order to provide walk-in medical care and avoid unnecessary ER visits. Huamana exerts a great deal of control over its MDs in general. With Concentra they are beginning to really push this ER lite solution. Nationally, large MSO are starting to explore this business model too. Fits neatly into the ACO concept being pushed out of CMS.

    Some insurers are starting to encourage MD practice better rounded health care in the Outpatient setting in order to avoid unnecessary specialist referrals and hospital visits. That is to say going back to old school medicine where only the truly grave see specialist care. Issue here is how do you pay MD to take on the additional burden when they have been on a hamster wheel last 30 years simply burning through lots of patients to make that Medicaid $37 rate “profitable.”

    Bill (af584e)

  264. #263 you are posting nothing in terms of facts or evidence of anything to support whatever it is you purport to believe.

    This is faith to you (and many).

    This is business to me.

    Bill (af584e)

  265. http://health.usnews.com/health-news/managing-your-healthcare/healthcare/articles/2011/05/18/health-buzz-number-of-emergency-rooms-declines

    … so I would surmise given this is a fixed cost business that profits are up … again, they are $$$ makers not they were in the 1990s lest anyone harp on that incorrect interpretation of the statements made.

    http://californiawatch.org/health-and-welfare/chain-profits-admitting-er-patients-11561

    … more interesting is the fact a few other hospitals were doing the same …. and this list goes on and on.

    Lots of work to do in the business to clean it up.

    Bill (af584e)

  266. I found a report concerning Self Pay patients in LA public and private hospitals that found the distribution of Self Pay patients has changed and self pay patients have been redirected from public hospitals to the private sector for their emergency care and admissions. It appears the report was motivated by hospitals that view Self Pay patients as more of a burden than a boon.

    Reading that report made me question my support for Bill’s claims about the benefits of Self Pay patients, because it’s not clear how these studies define “Self Pay.”

    The LA report linked above states the “study uses the Office of State Health Planning and Development’s definition of ‘self pay,’ which includes those without insurance who are expected to pay the majority of the costs of their care …” (Footnote, page 1) The Office of State Health Planning and Development defines Self Pay as follows:

    Self Pay. Payment directly by the patient, personal guarantor, relatives, or friends. The greatest share of the patient’s bill is not expected to be paid by any form of insurance or other health plan.

    However, Self Pay does not include persons covered under County indigent programs or other indigent charity programs. Apparently, indigents and charity patients are not considered as Self Pay patients for the purposes of California health care reports. In other words, Self Pay statistics do not include the very patients I’m concerned about, e.g., those who cannot pay their bills. Presumably the taxpayers or charities are paying for them.

    I can’t tell if this is peculiar to California reporting or if it’s an industry standard definition that applies to my Thomson Reuters’ link, above. I couldn’t find a definition at Thomson Reuters but if it does apply, I withdraw my limited support for Bill’s claim.

    DRJ (a83b8b)

  267. But I would suggest (modesty never a strong suit) I am one of a select few professionals who not only understand the system as it is but also what makes the different actors tick.

    Good Allah.

    JD (c73bec)

  268. #257: heck, nk, I thought you bought the real thing…or made one!

    Simon Jester (14c140)

  269. “This is business to me.”

    Bill – That’s is very clear. Your business model is very simple to understand as is your vaunted algebra. You can make a ton of money charging triple cost to uninsured patients as long as enough of them full pay or partial pay as a group to make up for your full costs.

    Your blind spot is in your commenting fury you have ignored evidence presented that collection experience is different than that you have presented overall, that the uninsured population may have different income characteristics in other geographic areas and that lawmakers have implemented laws in different jurisdictions which make the triple charging approach problematic.

    It’s also easy to understand how by avoiding surgery and traumatic patients you avoid big ticket bad debts as a way of minimizing your risks, but also limit your overhead.

    Your concepts are not difficult to understand. Your tunnel vision with respect to what any one says is, but that is usually the case with egomaniacs.

    daleyrocks (bf33e9)

  270. I’ve been looking at the Thomson Reuters’ website to see how Thomson Reuters defines Self Pay. It’s not clear to me but I think Self Pay + Charity/Indigent/No Charge = All Uninsured. I also found another Thomson Reuters’ report that expands on the point daleyrocks made in his comment 94:

    Charity Care Deductions as a Percentage of Gross Patient Revenue

    Differences in patient mix between nonprofit and public hospitals are reflected in charity care and bad debt deductions and expenses. Charity care consumes slightly more revenue in public than in nonprofit hospitals (2.88% vs. 2.47%), but overall accounts for a small, but growing, percent of total revenue.

    Bad Debt as a Percentage of Net Patient Revenue

    By contrast, bad debt exceeds 10% of net patient revenues in public hospitals, but only about 6% in nonprofit hospitals. Expanded Medicaid eligibility and increased access to private insurance under healthcare reform may reduce the percentages of charity care and bad debt.

    There are charts at the link that make these numbers easier to see but the trend is one of ever increasing non-payment of hospital bills, especially in public hospitals where the total uncompensated care was 13% in 2009, and is almost certainly higher now.

    Perhaps this is what’s bothering Bill. He must know the trend is not good for hospitals and that opens the door for solutions like ObamaCare. However, we do agree ObamaCare isn’t the answer.

    DRJ (a83b8b)

  271. As someone who makes no claim to being an expert in either the medical or legal fields there are a few things in this thread that puzzle me.

    1) Does everyone agree the real problem with our medical care system has to do with medi/medi bankrupting the country rather than whatever the problem with the uninsured happens to be?

    2) Isn’t everyone aware hospitals really do charge an astonishing amount on their “MSRP” for their services compared to what they charge for their contract prices with insurance companies? I’m no expert, but I did have to have surgery a couple of years ago, and the reduction for the contract price of my hospital visit (+20k down to ~4k for the hospital) blew my mind (and made no difference to my cost, since I overran both the deductible and copay that year).

    3) Isn’t clumping the “uninsured” all together in terms of whether hospitals make money from them kind of missing the point? Rich people tend to be uninsured. Many in the middle class who are uninsured also end up paying. Hospitals making a net profit on uninsureds by charging unlucky uninsured young people up the yingyang to make up for their losses on poor people in the country illegally doesn’t really mean hospitals and ER’s aren’t hemorraghing money on people in the country illegally. They are different groups, with one getting shafted while the other rides free. If you are one of the shafted ones, you might see this as a problem.

    As I said, I am not an expert in these things, so maybe someone who is an expert can enlighten me?

    Roland (5ff18d)

  272. I’m not an expert, Roland, but I agree the main problem is entitlements like Medicaid and Medicare. However, I’m not sure we will resolve that anytime soon so it’s easier to work on other issues.

    I also agree that there is cost-shifting that puts more burden on some patients than others, although I disagree the rich tend to be uninsured. Of course, some wealthy people may choose other vehicles, like health savings accounts.

    Finally, I agree that people who are bearing the weight of this cost burden might feel aggrieved. To me, the main group that fits that bill is taxpayers.

    DRJ (a83b8b)

  273. Does everyone agree the real problem with our medical care system has to do with medi/medi bankrupting the country rather than whatever the problem with the uninsured happens to be?

    Price controls can fix that, although there may be some side effects.

    Michael Ejercito (64388b)

  274. _______________________________________________

    If Hospitals lose money, it is because their beds go empty. Having a kick arse ER helps solve that problem.

    The assertion that struck me as ridiculous on its surface is the conclusion that emergency rooms heavily used (and sought out) by non-paying, uninsured patients aren’t necessarily draining the system (or a particular hospital) of support. That seems so counter-intuitive as to be ridiculous. After all, any business won’t do as well if far too many of its customers are getting free goods and services, and the provider, in turn, has to beg and cajole third-party sources in order to make up for that.

    Those who want to rationalize away the negative impact of ER patients getting services and treatment for free can also state that while shoplifting and pilferage are rampant in the retail industry, that, by itself, isn’t forcing store X, Y, Z to shut its doors. But it sure as hell isn’t helping the bottom line.

    Mark (31bbb6)

  275. Michael:

    Price controls can fix that, although there may be some side effects.

    Actually, I think the problem is that effectively we already have price controls, because Medicare and Medicaid are paying less than their share of costs, and that is skewing the entire health care market.

    DRJ (a83b8b)

  276. _____________________________________________

    Price controls can fix that, although there may be some side effects.

    Sort of parallel to that, I wonder how much of the “SUV” mindset makes a bad situation worse and can be applied to the issue of healthcare? I’m referring to all those in the public who will happily and nonchalantly buy a big gas-guzzling vehicle just for the hell of it. So even though they’ll be paying more for gasoline, even though they may not need a larger vehicle, they still — for any number of reasons — want a SUV to drive around town in. I read that sales of SUVs are on the rise again, even with the increase in oil prices.

    These probably are the same type of people who will overuse visits to the doctor and nonchalantly take too many prescription medicines. That, in turn, is then exploited by those in the healthcare industry (doctors, medical staffers, pharmaceutical companies, and makers of high-tech hospital equipment, etc) who’ve got skin in the game. So everyone has a “let’s buy a big ol’ SUV!” mentality.

    Where there’s money to be made, lots of folks will try to grab their share of the pie.

    Mark (31bbb6)

  277. Mark,

    We used to call that “I want it all” attitude pursuing the American Dream. It was a good thing, as long as you paid for it yourself. Now it’s sinful.

    DRJ (a83b8b)

  278. Finally, I agree that people who are bearing the weight of this cost burden might feel aggrieved. To me, the main group that fits that bill is taxpayers.

    The main impact on taxpayers seems to be from medi/medi rather than the uninsureds, since costs appear to be being shifted from the illegals to the legal uninsureds, although I do not know if illegals are getting on medicaid (I would guess they often are, but I really have no idea). There are other costs to taxpayers from illegals, like education costs, but this is a health care thread.

    Roland (5ff18d)

  279. “By contrast, bad debt exceeds 10% of net patient revenues in public hospitals, but only about 6% in nonprofit hospitals.”

    DRJ – Those ranges would not be out of range with the figures I post from the credit agency association.

    What Bill ignores is the facts posted about the use of taxpayer funds used to compensate hospitals for uncompensated care in at least three states, originally dismissing the information as only coming from one state, a state incidentally 50% larger than Florida’s. He then turns around to hang his hat on a study using 16 year-old data from one state only one-third the size of Florida and ignores legislation implemented in three states limiting reimbursement rates of hospitals from uninsured patients. Yet we are asked to take on faith that the algebra presented by Bill is a representation of something, perhaps how his small segment of the market works, where a change in one or more of the variables could move the profitability of uninsured patients into the red. Again, no explanation was given for what the formula given represents except perhaps a hypothetical.

    Yes, Bill is not selective in accusing people of cherry picking information but very selective in doing in doing it himself. He started with a lack of good faith and just continued down that path.

    daleyrocks (bf33e9)

  280. With 250 comments, half of them by “bill”, is too much to wade through. You have your “expert” Has he yet explained what he does in health care ? I’ve got better things to do.

    Mike K (326cba)

  281. Mike K,

    I think this conversation is winding down — frankly I’m the one keeping it alive now — but Bill said this about his work in comment 65:

    I do not work for any hospital at this time in any capacity. I run an outpatient clinical services company. Well, I own most of it.

    DRJ (a83b8b)

  282. daleyrocks,

    I realize the data isn’t in the same range. It shows much larger bad debt numbers, right? But I thought it might be because it covers a different, more recent time period.

    DRJ (a83b8b)

  283. “Where there’s money to be made, lots of folks will try to grab their share of the pie.”

    Mark – That is exactly the way Bill appears to be looking at it, from a collection or credit perspective rather than a medical perspective. No harm in that, but it explains his constant references to how lucrative his model is.

    It reminds me of two other businesses that crashed and burned spectacularly after people figured them out. A company called URCARCO and another one called Mercury Finance, both in the used car business. Both sold used cars to people with less than stellar credit at big mark ups and financed the purchases with loans at rates as high as they could get away with under usury laws. The theory was that collections from the people actually paying would offset the deadbeats, plus they had the collateral, which had been marked up to begin with. Both companies predictably flamed out spectacularly, with bad debts higher than claimed or expected and the value of repossessed collateral lower than promised. URCARCO was much earlier than Mercury Finance, but people had forgotten about it when they decided to make Mercury Finance a high flyer.

    The other analogy is to subprime lending, where the default rates blew away assumptions because there was nothing to model them on and the collateral couldn’t save the lenders from significant losses.

    Just food for thought.

    daleyrocks (bf33e9)

  284. “I realize the data isn’t in the same range.”

    DRJ – I thought the overall 6% was in the same range?

    daleyrocks (bf33e9)

  285. DRJ – I think Bill has limited himself to a discussion of a particular geographic market with which he has experience, while you and I and others have been providing information about other areas and the country as a whole which he just willfully ignores.

    daleyrocks (bf33e9)

  286. daleyrocks,

    I goofed that comment up.

    I think the private hospital numbers are in the same range but the public hospital numbers are significantly larger. Under our theories, it’s not surprising that public hospitals might have larger bad debt write-offs, but it could also be that the statistics I linked cover a different, more recent time period.

    DRJ (a83b8b)

  287. Actually, I think the problem is that effectively we already have price controls, because Medicare and Medicaid are paying less than their share of costs, and that is skewing the entire health care market.

    Comment by DRJ — 4/1/2012 @ 10:14 am

    I agree. However, I do not see any other path. Price controls do not control costs, but they will drive down the availability and quality of service. So the country will be saved from bankruptcy by greatly reducing the availability and quality of service to anyone not rich enough to opt out of the system in which the prices are controlled (primarily Medicare).

    We cannot afford to fulfill the country’s promises to the masses, so we have to figure out the most politically viable way to cheat them out of what they have been promised.

    The Left wants to do it with socialized medicine. That can work. Long lines reduce costs as people die off.

    We need a politically viable alternative, but the best we seem to have is to stay the course and let the whole system grind down, adapting however it can outside of the growing medi/medi debacle, using draconian price controls on medi/medi to keep from bankrupting us all.

    Roland (5ff18d)

  288. Different hospitals have different protocols for their ERs. A major trauma center decided it would no longer have a comprehensive ER. A very big Catholic order with multiple hospitals is actively reaaching out to the neighborhoods with walk-in clinics. A not small consideration is tax exempt status. It is not enough for an institution to be a not-for-profit, it must qualify as religious, charitable or educational. Here in Cook County, where commercial real estate taxes are based on 40% of the property values, that can be a big bite, for one example.

    nk (dec503)

  289. daleyrocks,

    Bill’s claims were based on his experience, so it stands to reason they would be limited to experience where he runs his business. Ultimately, he also seemed to recognize health care markets in border towns might not perform consistent with his experience. But, overall, it was my impression that Bill believes his experience and opinions translate to the entire American health care market.

    DRJ (a83b8b)

  290. “But, overall, it was my impression that Bill believes his experience and opinions translate to the entire American health care market.”

    DRJ – Exactly. I have no problem seeing the composition of the uninsured patient population in a rural Texas county, not necessarily a border county either, being different from that of inner city Chicago, Southern Illinois, or rural Lake County north of Chicago along the Wisconsin border in terms of willingness and ability to pay health care bills. I have a strong feeling Bill would disagree based upon his strident comments.

    daleyrocks (bf33e9)

  291. Roland:

    We cannot afford to fulfill the country’s promises to the masses, so we have to figure out the most politically viable way to cheat them out of what they have been promised.

    Our political leaders could fool us or cheat us, as you suggest. Or, faced with the inevitable fiscal trainwreck, the American people can deal with it like adults and make the necessary changes. ObamaCare was one solution but it’s expensive, unpopular and may not be legal. That means we have to find other solutions, and whether or not ObamaCare is ruled unconstitutional I think the GOP needs to step forward.

    We can do it now or we can wait until we’re Greece, but ultimately that’s the way free countries work.

    DRJ (a83b8b)

  292. DRJ – Also, with patients going into a hospital setting where it has been engrained in segments of the uninsured population that you have to be treated no matter your ability to pay, I would intuitively expect different payment patterns than similar patients walking into a clinic setting.

    daleyrocks (bf33e9)

  293. Yes. Where I live, getting free health care is as ingrained in some as getting a free attorney after being arrested. I’m not suggesting they are the same people, only that it’s as if some patients have been given the health care equivalent of Miranda warnings. And frankly, having been to the ER and hospital several times, they do make a point of telling every patient that they can be seen even if they can’t pay. So it’s no surprise that many patients don’t pay.

    DRJ (a83b8b)

  294. Comment by DRJ — 4/1/2012 @ 10:50 am

    Which is why I mentioned his undisclosed conflict of interest. You think he might have an agenda to push his point-of-view here?

    I do.

    Stashiu3 (cd7afe)

  295. Daley and DRJ–

    I just want to say that I admire your persistence in trying to understand Bill’s frame of reference by asking good questions of him in your attempts to verify his claims and assumptions. You are better people than I. And smarter too. From the moment Bill sprang into Patterico’s site on the earlier thread (over three days ago) I never did get what his goals were or what his reason for even being here was. Frankly, I admit I still don’t know what he wanted us to do with the information he brought, why he chose this particular blog, or why he was so overtly hostile from the get-go. Tis a puzzlement.

    elissa (c9d3f1)

  296. Our political leaders could fool us or cheat us, as you suggest. Or, faced with the inevitable fiscal trainwreck, the American people can deal with it like adults and make the necessary changes.

    The same American people who elected Obama and the Democrats in 2008 and who still look to be reelecting Obama are going to be adults when being told they will not get what they were promised with regard to issues of life and death medical care?

    I was not suggesting our leaders will cheat us. I was pointing out they have to cheat us out of what we have already promised ourselves. The money necessary to pay for the care we have promised ourselves simply is not there. You have seen what the projected debt looks like 50 years out. That is mostly the medi/medi monster.

    Roland (5ff18d)

  297. There’s an element of self-interest in almost everyone’s decision-making, but help me understand the conflict. Is it that he may need referrals or orders from hospitals for his business? Or that it’s better for his business if things stay the same?

    DRJ (a83b8b)

  298. Roland,

    I’m sorry to put words in your mouth, and thanks for clearing that up so kindly.

    First, I don’t think anyone is being cheated when it comes to entitlements. Despite rhetoric to the contrary (including the way I hear seniors talk about their entitlements), entitlements aren’t contracts between government and citizens and they can be changed.

    Second, I hope many of the same voters who supported and elected Obama have learned a good lesson. The hardest lessons in life are often the best ones, and in that sense this one has been especially “good.”

    DRJ (a83b8b)

  299. Is it that he may need referrals or orders from hospitals for his business? Or that it’s better for his business if things stay the same?

    He could be having something traumatic going on in his life that is entirely unrelated to the issues here, and he is taking it out here.

    Or it could be he is just an ass.

    Roland (5ff18d)

  300. elissa,

    I don’t get Bill’s hostility, either, but a wise man we all know says anger comes from fear. Thus, I can speculate that Bill fears what ObamaCare will do to his business. I fear ObamaCare, too, but my livelihood isn’t totally dependent on how healthcare works. If it were, I might be as angry and afraid as Bill.

    DRJ (a83b8b)

  301. OT:

    I encourage everyone to give a warm welcome to Morgen from Verum Serum, whose first post (hopefully of many?!) is here.

    Patterico (ce48b8)

  302. First, I don’t think anyone is being cheated when it comes to entitlements. Despite rhetoric to the contrary (including the way I hear seniors talk about their entitlements), entitlements aren’t contracts between government and citizens and they can be changed.

    Good point, DRJ. I was speaking of the way the masses will feel about it rather than the way it actually is, and I should have said that. I certainly do not think the people will be being cheated when the entitlements get adjusted to fit reality.

    Roland (5ff18d)

  303. “Tis a puzzlement”

    elissa – Bill is a vulture feasting on the fat carcass American health care system and he does not want anybody to move him off his meal.

    daleyrocks (bf33e9)

  304. DRJ– You are probably right about “Bill” fearing certain impacts from ObamaCare to his business interests and finances. It would seem though that there might be other avenues for him to take, or other venues in which to make his case, that would be more logically suited than this blog.

    elissa (c9d3f1)

  305. Comment by Bill — 4/1/2012 @ 6:21 am

    Her department’s protocol is to advise the patient to dial 911, which means they will go to the nearest ER. Many patients are from far away towns and even out of state. But many prefer to be privately driven to her hospital’s ER where their history is known and they will be seen by a doctor they trust.

    Cook County, Illinois.

    nk (dec503)

  306. The left will not stop until the bubble is imposed on us all.

    An opinion striking down the mandate would go beyond the outer limits of the Supreme Court’s legitimate authority, and responsible legal officials should treat the opinion as a bad joke–not funny and not law.

    Andrew Koppelman, Northwestern University School of Law
    http://lsolum.typepad.com/legaltheory/2012/04/koppelman-on-frivolous-opinions.html

    Amphipolis (e01538)

  307. nk–

    It’s not always at the patient’s choice, either. I was talking to a doctor at Sroger (at a 4th of July party.) He was telling me how indigent patients get transported/dumped there in Cook Co. from all the collar counties. (Lake, Will, McHenry, DuPage etc). I know I shouldn’t have been, but I honestly was shocked.

    elissa (c9d3f1)

  308. Oops – I think I fell for an April Fools joke, negate that last post!

    Amphipolis (e01538)

  309. ___________________________________________

    We used to call that “I want it all” attitude pursuing the American Dream. It was a good thing, as long as you paid for it yourself. Now it’s sinful.

    That’s the irony of an increasingly secularized, liberal society. More and more people chastise others for being greedy — but in a way that fits within the framework of liberalism (ie, a two-faced approach) — yet they have no less of “I want it all” attitude. Combine the two and you end up with the essence of the increasingly common mentality of self-entitlement.

    I can never forget Obama back in 2008 or 2007 giving a speech on the horrors (!) of global warming, which was held at a location he drove to in his SUV. A vehicle that his handlers at the time tried to pass off as actually being environmentally friendly, when a closer look revealed no such thing. Or his touting the virtues of Obamacare while handing out waivers to his biggest supporters.

    Both sold used cars to people with less than stellar credit at big mark ups and financed the purchases with loans at rates as high as they could get away with under usury laws.

    It would be interesting to know the politics of the people behind those ventures. It’s very possible they’re quite similar to the crowd that created Solyndra. Or they may be peculiarly apolitical types, but in such an amoral, graspy way, they’d still be more of the left than the right. IOW, they would be similar to ambulance-chasing trial lawyers and bosses of big unions. A bit of George Soros mixed in with a dash of Warren Buffet. I wonder if that fits the profile of Bill?

    Mark (31bbb6)

  310. I’m not going to wade through all the points here re Bill’s original comments. But I will note this re his comments about uninsured patients being profitable, though this point might have been raised by others.

    I think part of the confusion is the idea that all “uninsured” patients are unable to pay, and are therefore “uninsured.” In fact, in my experience, there is a significant number of “uninsured” patients who are really “self-insured”, meaning they have sufficient wealth to pay for their medical care and forego paying the premiums of health insurance policies. I know, for example, a very famous individual was treated for a coronary condition in my local hospital and wrote a check to cover the cost of the in-patient care. He didn’t get the benefit of discounted prices negotiated by health insurance companies as part of their contracts with providers, so he likely paid a multiple of what an insurance company might have paid for the same procedures.

    I doubt this is a large segment of the uninsured population, but I suspect it is bigger than most imagine.

    shipwreckedcrew (e57b7e)

  311. I’m not going to wade through all the points here re Bill’s original comments. But I will note this re his comments about uninsured patients being profitable, though this point might have been raised by others.

    I think part of the confusion is the idea that all “uninsured” patients are unable to pay, and are therefore “uninsured.” In fact, in my experience, there is a significant number of “uninsured” patients who are really “self-insured”, meaning they have sufficient wealth to pay for their medical care and forego paying the premiums of health insurance policies. I know, for example, a very famous individual was treated for a coronary condition in my local hospital and wrote a check to cover the cost of the in-patient care. He didn’t get the benefit of discounted prices negotiated by health insurance companies as part of their contracts with providers, so he likely paid a multiple of what an insurance company might have paid for the same procedures.

    I doubt this is a large segment of the uninsured population, but I suspect it is bigger than most imagine.

    shipwreckedcrew (e57b7e)

  312. Cutting staff in Hospitals is tough without simply shutting down an area. Plus no one opens a wing for uninsured patients and another for insured
    — Ya know what they call the wing for the uninsured?
    The waiting room.

    Playing with staffing levels can at the margin help profitability but whether you have 2 patients or 20 patients in the neo-natal unit is irrelevant to fact you need staff to be on duty 24 by 7 and that requires a nurse and a few helpers.
    — Fewer helpers if you have fewer patients. My mommy, the career hospital nurse taught me that one.

    By my estimates and analysis, the utilisation effects of volume on staffing is about 4:1. Growing by a factor of 4 grows staff by a factor of 1. Eventually utilization reaches 100% and you can’t fit more patients.
    — All of that “growing” and ‘utilizing volume’ stuff . . . sounds dirty!

    It is butt tough to sit around and say this is variable and this is fixed in a Hospital.
    — Not only “butt tough” but also “meaningless”.

    Then when you allocate the fixed costs to the analyses then what?
    — Punt!

    “How condescending and ill informed. Thank you.”
    — That would be the blurb to leave OFF of your book cover.

    It stands to reason an expert knows more then one who is not.
    — Have you found one yet?

    Unless that is you are on Patterico where a cabal of like minded people sit around kissing each other’s privates and claim some expertise in topics of which they know nothing.
    — Sir, I will have you know that we DO NOT kiss each other’s privates around here!

    And I sure wish that Dustin would stop asking for permission to “go hog wild”. It’s kinda embarrassing.

    [I keed! I keed!]

    Icy (1acc20)

  313. DRJ, I came by and saw you were still commenting.

    “Mike MD, hope u retire soon because if this gets upheld your standard of living will be going to hell in a hand basket.

    Comment by Bill ”

    I retired in 1994. Then I went to Dartmouth for another degree in medical outcomes research. I kind of shot my bolt on numbers in the Dartmouth Atlas, I’ve been studying health care policy since then and doing consulting for insurance companies.

    What is it that gives you you great expertise ? I’m afraid I have trouble seeing it.

    Mike K (326cba)

  314. I also blog at ChicagoBoyz and some is on health care.

    Mike K (326cba)

  315. The myth that self pay unisured are some how free riding the system and a root cause for Gov.t taxpayer subsidies is bunk.
    — That’s the second time you’ve typed “unisured”. Are you really so lazy and arrogant as to not realize that good spelling and grammar works to focus people’s attention on the point you’re trying to make?

    It is a tactic used by many in the industry to pan handle for cash in order to cover the low revenue yields from Medicaid.
    — So, you’re saying that they NEED to cover the low revenue yields from Medicaid?

    So if the pop psyc folks want to label that angry be my guest.
    — We label you Rooty Tooty, Fresh & Fruity.

    Also, limks are not a replacement for algebra or navigating financial statements.
    — No, but they’re tastier, especially with some eggs & hash browns.

    like I care about posters names in terms of truth?
    — FIFY

    So no sense in speaking to a person who seeks not truth but convenience.
    — Who here was speaking to Sandra Fluke? (Oh, snap!)

    at least I have opened someone to the possibility that what they have brain washed into believing is not true. My work is done. Thanks.
    — Get it right, grammarian! It’s “I work here is done”. Sheesh!

    Icy (1acc20)

  316. shipwreckedcrew,

    I agree there are uninsured who are Self Pay who pay more than insured patients with negotiated rates, but paying and non-paying patients aren’t equally distributed across the United States. For example, border states probably have higher percentages of uncompensated care than high income urban areas, so they need different solutions. One thing I objected to in Bill’s arguments is that worrying about those differences is unimportant.

    DRJ (a83b8b)

  317. DRJ, I stopped by again and will try to make a point or two. “Self pay” and uninsured are not the same group. Doctors who are Medicare participants are barred by law from offering discount prices to patients who offer to pay cash. What is happening now is that many doctors are dropping Medicare and accepting cash payment. One such group is the “retainer practice” model who charge a monthly fee and provide outpatient care for that fee. Another is the pure cash practice model that is being accepted by many surgeons. For example, the busiest hip replacement surgeon in Newport Beach CA accepts only cash. His fees are about what Medicare actually pays (around $1750 for a total hip) and eliminates the overhead of the billing staff. Similar programs are adopted by primary care docs, but the surprise, as I began to research this, is the surgeons. This has nothing to do with “bill’s” theories as these are all doctor’s fees and not hospital charges. It does bear some similarity to the French system.

    Anyway, all the best.

    Mike K (326cba)

  318. Mike K – A patient who doesn’t pay, whether on his or her own, through Medicaid, Medicare, or private insurance is still an unprofitable patient. Masking the fact by saying “hey, but we charge other patients without insurance 3x what Medicaid pays” and some of them actually pay full freight does not alter those facts. All it does is call attention to the broken pricing structures within our health care system.

    daleyrocks (bf33e9)

  319. What I suck at is typing and grammer. And being nice to fools.
    — But you’re good at selling yourself short.

    #256 No Icy, your position if I understand it makes no sense. You claim ER advertise to get patients in spite of losing money. I pointed out a) they make money, and b) at worst they are loss leaders for hospital.
    — I said that hospitals advertise the ER in order to generate revenue that minimizes losses, be they in the ER or elsewhere in the hospital. Why do YOU think that hospitals advertise their ERs?

    Try getting a license to be a hospital (or recertify) from the Joint Commission. try filling hospital beds without an ER as a point of entry for customers.
    — Is this another denial that hospitals have been closing their ERs while keeping the rest of their facilities open? About time to raise the white flag on that one, I’d say.

    Icy (1b5e18)

  320. I’ve always hated wallpaper.

    [me too, that’s why it’s gone. 😉 –Stashiu]

    Icy (1b5e18)

  321. Again, frankly you are out of your element in this discussion
    — Pretty sure I wouldn’t want to associate with your element.

    … or the fact I lack a 100 page screed from the American Enterprise Institute to support reality.
    — To support YOUR reality you’d better co-opt 4 or 5 screeds.

    People have been incorrectly diagnosing health care finance for years.
    — Cle . . . . . . . . . . . . . . . . . . . ver.

    But I would suggest (modesty never a strong suit)
    — In your case it’s not even a blip on the radar.

    #263 you are posting nothing in terms of facts or evidence of anything to support whatever it is you purport to believe.
    — I learned from the best.

    Icy (1b5e18)

  322. דיווחי תנועה…

    you don’t have to choose!
    you’ll learn more and work out more!
    it’s two sites in one!

    Colonel Haiku (322895)

  323. 313. When a niece, now employed at Heritage, visited Dartmouth on a vacation to PEI I happened to notice the average SAT scores of incoming frosh were, oh, roughly 184 points above mine.

    Bill, a man’s just got to know his limitations.

    gary gulrud (d88477)

  324. Dartmouth was my safety school.

    daleyrocks (bf33e9)

  325. English, motherf**ker, do you speak it?

    Ghost (6f9de7)

  326. Ghost . . . duuude. Quit harshin’ your own mellow. Just ’cause they told you that green stuff in your Easter basket was “grass” doesn’t mean you should smoke it!

    Icy (ce8ca9)

  327. Oh god… I wasn’t supposed to smoke that?

    Ghost (6f9de7)

  328. Its such as you learn my mind! You seem to grasp a lot approximately this, such as you wrote the guide in it or something. I believe that you just can do with some % to drive the message house a little bit, but other than that, that is great blog. A great read. I will definitely be back.

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