[Retric]

> part of the healthcare system that is moderately competitive.

That’s only half the story though insurance companies also try and reject way more claims, cover fewer people, and are just harder to get money from than Medicare.

This means hospitals can’t afford to give them cheaper rates as they just require vastly more work from staff for the same procedure.

The industry isn’t blind to this effect, but has little reason to change.

[phil21]

Hospitals and clinics can only take so many Medicare patients as a ratio to private pay because it’s very well known that Medicare and Medicaid is often provided at below cost. It’s of course area and demographic dependent but as a rule any private clinic has a cap on these patients they will accept overall. Hospitals cannot cap it realistically speaking, so looking at clinics is a good proxy.

Private insurance subsidizes Medicare and Medicaid even after you add in admin overhead.

[rexroad]

The MLR incentive question is one I'm digging into for a future issue. The short version: the ACA's 80/85% MLR floor was supposed to constrain overhead, but vertical integration changed the math. When UnitedHealth's Optum division provides services to UnitedHealthcare's members, those internal payments count as "medical expenses" for MLR purposes. The money stays in-house but reports as care delivery. On the denial rate point: 15-17% initial denial rate, 80%+ overturned on appeal, but less than 1% of patients actually appeal. That gap between the overturn rate and the appeal rate is where the profit lives. If you deny 100 claims and only 1 patient appeals, you've effectively reduced payouts on 99 claims at the cost of processing 1 appeal. I'll have the numbers on this in a later issue.

[lotsofpulp]

> That gap between the overturn rate and the appeal rate is where the profit lives.

Or doesn’t live.

https://www.macrotrends.net/stocks/charts/UNH/unitedhealth-g...

All the other managed care organizations have similar 2% profit margins.

It is funny seeing complaints of excess profit margins from businesses earning 2%, that compete against non profits, from people on a forum composed of employees of tech businesses earning 20%+ profit margins. I wonder how much Epics’s profit margin is?

And then there is also pharmaceuticals, also earning double digit profit margins. And then the law firms in medical malpractice suits, who I imagine are not working for 2% profit margins either.

[Retric]

Profit margins are difficult to compare across industries, game developers on average have great profit margins in part because all the studios that fail quickly stop counting.

Grocery stores on the other hand are a known as a low margin business, but as people constantly need more food every month it can be really stable. Further as most stock turns over multiple times a month your return on capital can be extremely high. Even better during a downturn when people buy 20% less food you also need to buy 20% less stock and employ fewer people to stock shelves etc, which makes your profits far more resilient.

Suddenly grocery stores are looking like a much better investment than making games.

[lotsofpulp]

The point of a profit margin is to be able to compare a seller's pricing power across industries. It invalidates attempts to claim the seller is able unilaterally act in their interests without the customer having recourse. For insurers, not only do customers have a choice to switch to a different insurer, but insurance prices have to be approved by government employees.

And total returns are the end all, be all for measuring investment performance. Just because some volatile video game businesses go bust does not make the grocery business or insurance business attractive. I could just as easily put my money into SP500 and earn far more with far less (almost zero) risk.

[Retric]

> It invalidates attempts to claim the seller is able unilaterally act in their interests without the customer having recourse.

By that logic the cap’s on annual profits by insurance companies suggest significant pricing power by insurers.

As to S&P vs a grocery store, there are grocery chains in the S&P there’s nothing wrong with the business model. As always the arguments for starting a business are more complicated than the alternatives due to the amount of leverage you can get etc. Further a weekly turnover at 2% is a rather insane annual ROI, we’re talking 100% return on investment though obviously actual business don’t just concern themselves with groceries, labor, and rent.

[nradov]

That's true to an extent, and those minimal controls are why Medicare also wastes billions on paying fraudulent claims.

https://relentlesshealthvalue.com/episode/ep502-how-some-pre...

[Projectiboga]

Yes but the Medicare and Medicaid reimbursement rates are below breakeven so cash and insurance rates have to be above provider breakeven. The main cost frictions are administrative costs for billing on both the insurance and provider sides.

[nradov]

That's true to an extent, but some provider organizations manage to survive with patient populations that are almost entirely Medicare / Medicaid. Many provider organizations are just badly managed and haven't taken steps to optimize their finances through automation or participation in value-based care programs.

[lupire]

See the above comment about fraudulent billing for non-existent illnesses that don't need treatment.

[apical_dendrite]

I'm working on a project in an area of healthcare where there was massive Medicare fraud decades ago. Medicare now requires extensive documentation for each claim and the paperwork is so onerous that providers have exited the market and it's very, very difficult to access care.

[nradov]

Right, CMS plays whack-a-mole with Medicare claim fraud. When they catch on to a systemic pattern they clamp down in a way that creates extra burdens for everyone, and then the fraudsters move on to something else.

[da_chicken]

They waste billions on fraudulent claims because they don't fund the program well enough to have compliance enforcement or auditing.

Also, I'm not going to trust a podcast owned and operated by Stacey Richter, who also just so happens to be the co-president of Aventria Health Group and QC-Health.

[AnthonyMouse]

> They waste billions on fraudulent claims because they don't fund the program well enough to have compliance enforcement or auditing.

These are synonyms for having higher overhead, right? If you pay a billion dollars in claims with ten million dollars in administrative costs then your "administrative overhead" is 1%, even if half the claims are fraud. If you increase "administrative costs" to a hundred million to get rid of the fraud, in practice you just saved 410 million dollars but now your "administrative overhead" is up to 20%.

[apical_dendrite]

There's another reason. The harder you make it for a provider to get reimbursed for a service (in order to cut down on fraud), the more difficult it is for legitimate patients to access that service. Medicare patients are elderly. Many of them aren't able to chase after doctors to get the services they need.

[nradov]

Trust is irrelevant. You can verify all of the statements made by Brian Machut on that podcast with independent sources if you like.

[CWuestefeld]

This isn't even close to true. Keep in mind that Medicare, together with Medicaid (which operates under much of the same administrative rules), account for nearly half of medical spending. So basically, if a provider doesn't want to play by their rules, they MUST deal with Medicare. That is, the government is nearly a monopsony in this industry.

There's a common, misleading, claim that Medicare is more efficient because they spend far less than commercial insurance on overhead like claims processing. This claim is true. But the impression that it gives is absolutely the opposite of reality. The reason that Medicare doesn't spend as much on admin is that they offload all of this work onto the providers. Every hospital in America has a "Medicare Reimbursement" team. A moderate-sized hospital is going to have something like 2 FTEs focusing just on the reimbursements from Medicare and Medicaid. And that's a lot more work than just filing the right forms for each case. There's a ton of additional work. Each spring they have to file a HUGE "Medicare Cost Report", requiring a couple of months of work to get all the data in place for it. (Source: my wife was "Director of Reimbursement" at various hospitals for quite a few years, before going into consulting.)

That Medicare Cost Report that I mentioned is, beyond a huge effort sink, the source of many other evils. Because of the amount of work that's needed to gather and collate all this data, hospitals naturally structure their Accounting around the way Medicare wants them to report. The thing is, that's largely orthogonal to the way a rational person would do cost accounting. The result is the common criticism about how widely varying the cost of a given specific line-item is between hospitals: they don't really know how much a given procedure costs because that's not how they track their expenses, so they apply some allocation heuristics, and every hospital does that a bit differently.

There are also various perverse incentives in the system. For example, Medicare is smart enough to know that it costs more to deliver care in NYC or SF and so forth. Every locale has a Cost Index that scales how much they expect to need to pay. This leads to hospitals needing to show that their expenses are higher so they should be classified into locale X rather than neighboring locale Y.

Another one my wife told me about her hospital: Medicare realized that a lot of UTIs were hospital-acquired, and they rationally said that they would no longer pay for UTI treatments unless the hospital could prove that they were not hospital acquired. Well, maybe that wasn't rational, because with Medicare/caid being such a huge portion of their business, they changed their policy to test for UTI for everyone at admission, so that they could furnish the proof demanded. Think of all that wasted lab work...

So no, Medicare is NOT more streamlined and efficient. It's absolutely, 180-degrees, the opposite of that.

[Retric]

> nearly half of medical spending

> something like 2 FTEs focusing just on the reimbursements from Medicare and Medicaid

2FTE’s vs what?

The question isn’t is this free, the question is how large is the total staff including price negotiations, doctors, and IT time spent handling billing issues, and is Medicare more or less than 50% of the total.

I am ware of one hospital and 2 medical clinics where the difference is very much in favor of Medicare.

[gamblor956]

2 FTEs vs a department. Most hospitals have entire departments to handle insurer coding and some even have departments just to handle insurer disputes.

[CWuestefeld]

to handle insurer coding

Coding is a different layer. Everything needs coding, whether for gov't or commercial payers. So the folks doing this coding can't be separated out for commercial. In fact, it's kind of the opposite:

CPT codes (for procedures) - these are defined by AMA, but mandated by CMS (i.e., Medicare/caid). Because the gov't mandated them, the commercial payers adopted them too.

HCPCS codes (equipment and supplies) - defined by CMS.

ICD-10-PCS codes (hospital inpatient stuff) - defined by CMS.

[gamblor956]

And yet my point still stands. Hospitals employ more people to handle private insurer coding than they do to handle Medicaid.

[CWuestefeld]

2FTE’s vs what?

versus nothing. Hospitals don't have to maintain a whole team for UnitedHealth, or for Anthem, etc.

This is my point. Medicare cooks the books to look more efficient by offloading their administrative costs onto providers. Other payers can't do that because, even if huge, they don't operate at the same scale.

Think about it: we often hear on the news about disputes about contracts when a local hospital's agreement with some insurance company comes up for renewal. They play hardball, getting local news to run stories on how many people will be affected if they can't come to terms. But you'll never hear this in the context of Medicare/caid. Hospitals have leverage to negotiate with commercial payers, but not with the government.

[nradov]

Depending on the size of the health system it may not be a team of multiple FTEs but they absolutely do expend significant resources on managing differences between commercial payers. They all have different rules about covered services, step therapy, prior authorization, hospital admission, etc. Sometimes those differ significantly even between health plans offered by a single carrier.

[apical_dendrite]

This isn't really true anymore (if it was ever true). Providers are spending a huge amount of time dealing with prior authorizations and appeals for private insurance.

I work in this area and you're right that Medicare can require a huge amount of paperwork from providers. And a hospital will have far more than 2 FTEs for this (it's called Revenue Cycle Management).

[sixothree]

Many providers report that dealing with Medicare has clear rules they can follow while dealing with private payers causes a huge burden.

[mwwaters]

Medicare has overhead, but you’re not saying whether it is more than commercial insurance. The admin expense/profit portion of commercial insurers also don’t take into account provider admin costs (not to mention the huge amount of time patients can deal with denials, appeals, etc.)

[tptacek]

It's further the case, regarding Medicare expense ratios, that their admin costs are low relative to private insurance because the median private insurance customer incurs far lower medical costs, leaving admin as a higher fraction.

[tptacek]

It can't be both: either insurers are incentivized to authorize as much care as possible so as to fit more money through the 20% opening, or they're incentivized to deny care to minimize their expenses. Which is it?

[Retric]

What do you mean elevators go up and down clearly someone only wants to go in one direction. If they are below 80% they want costs to increase, over 80% costs better decrease.

The ideal long term strategy is to drive everyone’s costs to go up slowly over time slightly faster than inflation. Adding administrative burden to medical institutions is a perfect way to achieve that, but clearly that never happens…