Medical Costs Bankrupt Patients; It's the Computer's Fault 637
nbauman writes "Don't get cancer until 2015. The Obama health reform is supposed to limit out-of-pocket costs to $12,700. But the Obama Administration has delayed its implementation until 2015. The insurance companies told them that their computers weren't able to add up all their customers' out-of-pocket costs to see whether they had reached the limit. For some common diseases, such as cancer or heart failure, treatment can cost over $100,000, and patients will be responsible for the balance. Tell me, Slashdot, how difficult would it be to rewrite an insurance billing system to aggregate a policyholder's out-of-pocket costs? 'A senior administration official, speaking on condition of anonymity to discuss internal deliberations, said: "We knew this was an important issue. We had to balance the interests of consumers with the concerns of health plan sponsors and carriers, which told us that their computer systems were not set up to aggregate all of a person's out-of-pocket costs. They asked for more time to comply."'"
Re:That's funny (Score:5, Informative)
Having worked firsthand in the medical data field, I'm actually more inclined to believe them. It's pretty easy for a billing system to say "You haven't met your deductible" or "You've paid about enough"... but as I understand it, the legislation requires that each patientis cost be tracked on a per-patient basis - not per-policy or even per-insurer. That means the records have to be combined from every participating hospital, correlated with information from every other insurance provider, and deduplicated accurately, before they can be added.
There are many people with multiple health insurance policies, who go to several healthcare systems, or have incorrect identification data in their records. What's being asked is not simply adding a few numbers in a bill, but rather merging trillions of records with few errors, across hundreds of formats from thousands of providers.
I wish them luck, and I'm glad I'm not in that field any more.
Not as fast as one would hope. (Score:5, Informative)
So what is the opposition party alternative? Repeal.
That will limit the out of pocket costs when? Never.
Plus it will eliminate the various positive effects that the ACA is already having.
Basically the people that are screwing up here are the beneficiaries of the higher out of pocket costs, our Medical Insurance Overlords.
Insurance Systems Suck (Score:3, Informative)
Easy answer on this one from someone who has worked in the insurance industry for a few years... the systems suck.
I am not defining 'suck' from the standpoint of performing because they do what they need to... however they become so bloated with complexities that even minor changes seem daunting. No person or team in my organization knows how the systems work from end-to-end and even the vendors need to use reverse engineering to resolve issues because of the complexities.
Not unusual for an insurance company to build a new system to support new plans because integration of the benefit rules into an existing system is not worth the pain. In the end the company ends up with several systems and IT silos built up around them.
The system at my current work will not be able to handle tracking co-payments over any period of time. The jobs that run overnight to price claims and track this sort of thing are already running at capacity.
On top of all this the executive management in this industry tend to be incredibly conservative and avoid risks like the plague.
Real-time processing required (Score:5, Informative)
Step 2 is an immediate response, step 4 is handled in batch processing nightly. So far so good. Except that the Affordable Care Act makes it *illegal* to make a patient pay more than the annual limit. The authorizer and/or the pharmacy can be charged for forcing the patient to pay above the annual limit. This means that the authorizer must be aware of limit of each patient and be able to respond in real-time so that neither they nor the pharmacy will be sued. The insurance company doesn't have that information available real-time, nor do they make it available to the authorizer.
It is a computer issue, but as simple as everyone thinks. Putting individual insurance files on-line so that the out of pocket expenses can be tracked real-time isn't trivial. Now, maybe the Insurance companies were hoping the law wouldn't be implemented so they didn't do the hard work necessary to get set up, or maybe the rules were only written as to how to handle the annual limit must be handled.
Just remember, the last time companies put together a real-time on-line credit/debit system, the government decided that they charged too much to support the infrastructure, and started regulating it. That was the Durbin amendment to Dodd-Frank, which put a fixed limit on per swipe fees - regardless of what the infrastructure and support costs actually are.
jerry
Re:A cynic's view (Score:3, Informative)
All you need to know is that's not true [politifact.com].
Re:A cynic's view (Score:5, Informative)
http://www.leadertelegram.com/blogs/tom_giffey/article_c9f1fa54-d041-11e1-9d01-0019bb2963f4.html [leadertelegram.com]
I was curious to know how the length of the Affordable Care Act compared with other major pieces of legislation. Take, for example, the Wisconsin state budget (officially known as Act 32) signed into law last July by Gov. Scott Walker. The PDF of the budget, as approved, is 532 pages long. I cut and pasted the text into my word processor, and learned the budget ran to 409,629 words (give or take -- the figure includes some page headers and other extraneous verbiage). How long is the Affordable Care Act? By my count, it’s 418,779 words (again, that’s approximate).
In other words (pardon the pun), a law refashioning one of the major sectors of the U.S. economy is only slightly longer than a law setting the two-year budget for one of the 50 states.
http://www.fourmilab.ch/uscode/26usc/ [fourmilab.ch]
The complete Internal Revenue Code is more than 24 megabytes in length, and contains more than 3.4 million words; printed 60 lines to the page, it would fill more than 7500 letter-size pages.
Part of The Big Lie strategy is repeating a lie over and over again till it's common enough people start to believe it. Don't fall for that type of dishonest stupidity.
Re:A cynic's view (Score:5, Informative)
Ezra Klein of the Washington Post says THIS:
There’s a Politico story making the rounds that says that members of Congress are engaged in secret, sensitive negotiations to exempt themselves and their staffs from Obamacare.
Well, they were secret, anyway.
The story has blown up on Twitter. “Unbelievable,” tweetsTPM’s Brian Beutler. “Flat out incredible,” says Politico’s Ben White. “Obamacare for thee, but not for me,” snarks Ben Domenech. “Two thumbs way, way down,” says Richard Roeper. (Okay, I made the last one up).
If this sounds unbelievable, it’s because it is. There’s no effort to “exempt” Congress from Obamacare. No matter how this shakes out, Congress will have to follow the law, just like everyone else does.
Based on conversations I’ve had with a number of the staffs involved in these talks, the actual issue here is far less interesting, and far less explosive, than an exemption. Rather, a Republican amendment meant to embarrass Democrats and a too-clever-by-half Democratic response has possibly created a problem in which the federal government can’t make its normal contribution to the insurance premiums of congressional staffers.
Maybe.
See? This is getting boring already.
Here’s how it happened: Back during the Affordable Care Act negotiations, Sen. Chuck Grassley (R-Iowa) proposed an amendment forcing all members of Congress and all of their staffs to enter the exchanges. The purpose of the amendment was to embarrass the Democrats. But in a bit of jujitsu of which they were inordinately proud, Democrats instead embraced the amendment and added it to the law. Here’s the relevant text:
The only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are — (I) created under this Act (or an amendment made by this Act); or (II) offered through an Exchange established under this Act (or an amendment made by this Act).
(Snip)
But no one is discussing “exempting” congressional staffers from Obamacare. They’re discussing creating some method through which the federal government can keep making its current contribution to the health insurance of congressional staffers.
“Even if OPM rules against us,” one staffer said, “it’s inaccurate to imply that any talks are aimed at exempting federal employees from routine mandates of ACA since any talks are about resolving the unique bind that the Grassley amendment puts federal employees in.”
This isn’t, in other words, an effort to flee Obamacare. It’s an effort to fix a drafting error that prevents the federal government from paying into insurance exchanges on behalf of congressional staffers who got caught up in a political controversy.
All you really need to know about Obamacare is: republicans lie, republicans lie, republicans lie.
Re:A cynic's view (Score:5, Informative)
You'd be amazed how difficult it actually is to track accumulated values (like out-of-pocket payments) in most insurance software. It's not just "SELECT SUM(claims.oop) WHERE claims.member = X" -- it should be, but it's not. And the process in place is so fragile that any change at all might well break the whole thing.
There's also the problem of the system not being able to accommodate things like a legislative limit that's different from the contract limit, or a contract that changes after initial implementation -- if you don't assign a new group number to the members you can't apply new limits to them. And you can't assign a new group number without a new contract entry. And there is no new contract because the change was legislative not contractual. And you can't just update the old policy entry because it would apply retroactively to all old claims.
It's all stuff that any one with 2 credits in database administration could fix in like 4 minutes, but it's all baked in to 40 years of COBOL, intermixed with business logic, writing fixed-width data to ASCII "tables", and no one is willing to risk changing anything unless God and his wife both sign off on it.
Re:A cynic's view (Score:4, Informative)
I completely agree. That said, the billing systems already have this function built in. Hospitals and other health care providers want to track what they're owed and by whom.
Stating their systems don't have this functionality is a bald faced lie. Congress should try some due diligence.
Re:A cynic's view (Score:5, Informative)
A board that reviews health care expenses and recommends cuts in specific areas isn't new with or unique to Obamacare. Every insurance company has one, and they feed off of an existing, independent board that recommends prices for the entire medical industry (and which is sometimes wildly off the mark in terms of current costs).
Unlike Obamacare, every insurance company also has employees (doctors, yes, but not the ones treating the patient) who can decide that a given treatment isn't worth the cost associated with it and deny its coverage, thereby in some cases sentencing the patient to death. That nearly happened to my then-86-year-old grandfather who was denied coverage for a triple bypass because he was already beyond his life expectancy. It wasn't until it was pointed out--twice--to the insurance company that he was still working 40 hours per week that the surgery was approved, by which time he was in the ICU on oxygen. It was his employer-provided insurance that tried to nix the surgery. This was about 2005. He lived another five years or so after the surgery.
I'm not entirely certain how the insurance-company doctors making such decisions will fare under Obamacare, but I expect that they'll still be around.
Re:Yeah.. (Score:4, Informative)
Re:A cynic's view (Score:5, Informative)
Just so you know, every time you write a check in the united states, the format that it needs to get converted into follows the x937 spec. Each record is in ebcidic but requires a big-endian record header except for the records with image data in them, where the image data is required to be little-endian. The medical systems running our nations hospitals make banking look sane.
There's your 10 minutes of terror for the day.
Re:A cynic's view (Score:5, Informative)
Part of the reason for the resistance is lost institutional knowledge. These are old systems, probably poorly commented and poorly documented. They've been modified and patched a thousand times over to handle corner cases, odd hardware based bugs, new interfaces, new regulations and new laws, as well as mashing with new insurance companies, new plans, old plans, outdated data and new data and 50 states worth of independent regulations. How much money and how much time do you suppose it would take to rewrite that entire 30 year history, including refactoring all of the data such that is accessible back to the beginning, in a modern language, with modern technologies and can guarantee that it is 99.99% exactly the same functionality for all possible input combinations?
For reference, the state of North Carolina recently overhauled their Medicaid billing system. They are months and billions of dollars behind in payments from this change over, and the project was already over due and over budget.
Just Sad (Score:4, Informative)
Re:Just curious (Score:5, Informative)
Wrong on so many counts.
The executive branch has the authority (granted by Congress) of delaying implementation of laws if there are implementation issues that require a delay to work out. It happens fairly often, though usually without the whining that's accompanying this instance. Which is odd, because it was Republicans asking for the delays, and causing the problems that lead to the delays, so it's nonsensical for them to complain about having been given the delay they asked for.
The waivers are a part of the ACA, to give states flexibility in how they implement healthcare reform, as long as they meet or exceed the targets for cost and coverage. And since Republicans were asking for the waivers via the mechanism defined in the ACA, I'm not sure how they'd justify complaining that they were given the waivers that they asked for. Or that it's somehow an exception to the ACA.
And the price support that Congressional staff is receiving for healthcare bought through the exchange is exactly the same as the price support that they are receiving for their current healthcare. Surely you're not arguing that people should lose their existing healthcare benefits from their employer.
So all of your examples of illegal acts are legal.
Care to try again? Perhaps after some more research...
Re:That's the beuaty of it (Score:5, Informative)
Tell me more about how great this works and procedures aren't rationed or wait listed.
It's worked well for me in Australia so far.
Last time I needed it, I went to the hospital (severe abdominal pains), they admitted me immediately. Within 20 minutes I was in a bed and being checked over. Within half an hour, I was on pain relief and monitoring. Overnight, I had a diagnosis and initial treatment so I could leave the hospital. The following week I was given a schedule for follow-up surgery, which I duly attended and which solved the problem.
The sole bureaucratic action I had to make was to present my Medicare card when I first attended the hospital, and even that was optional, if I didn't have it with me. I paid nothing, was treated promptly and got well.
How about you tell me what you think is wrong with it?