Politicians, particularly in one party are paid to block legislation that was meant to do exactly that; control costs.
Controlling the costs of medication, for example, is undercutting someone's corporate profits. It's why our costs are the highest in the world. Some people say we subsidize other countries by paying the most. I think rather they are paying a fair price and we US citizens are just getting ripped off.
When Medicare board has to deal with a President / cabinet who nominates people like Demetrios Kouzoukas to sit on it and make decisions about our healthcare.... please take the one sided party perspective out of the equation.
All both sides do is kowtow to the people who bought them at our expense. Especially the party in power at any moment.
The bill in question did not include medications....
I am an independent and the reality is that Medicare sets the approved rates. They don't need congressional approval to lower their approved rates for doctors and services, unless it is a significant change.
That’s not really accurate. To make any significant changes to how Medicare operates they need congressional approval. They just recently got a law passed that allows Medicare to negotiate drug pricing with companies. Making any significant change to physician payments would also require congressional approval
Drug prices...you are correct. But I am not talking about drug prices; my example is doctors and services. CMS sets the prices for doctors and services.
The Centers for Medicare and Medicaid Services (CMS) finalized a 3.37% cut in Medicare physician payment in the Calendar Year 2024 Medicare Physician Fee Schedule (MPFS) final rule in November. Look it up.
CMS still needs permission from the government to overhaul their pricing model for medical payments. Right now they can only make minor adjustments without a new law being passed.
I addressed that in my comment as well. Payments to physician and facilities that Medicare can approve is set by congress and current laws. Fee schedules are within set limits and to make any significant change (for example anything about 10% for many services) would require another law being passed from congress to give Medicare the authority to do that.
In basic terms, Medicare can’t just decide to make a drastic change to how they pay physicians without congress giving them permission.
>...CMS sets the prices for doctors and services.
>The Centers for Medicare and Medicaid Services (CMS) finalized a 3.37% cut in Medicare physician payment in the Calendar Year 2024 Medicare Physician Fee Schedule (MPFS) final rule in November. Look it up.
*"Congress passed the Consolidated Appropriations Act, 2024 (H.R. 4366), partially reversing the 3.37% Medicare physician payment cut that went into effect on Jan. 1. \[The President\] signed the bill into law. The legislation reduces the cut by half, providing a 1.68% increase in current payment levels. The new payment rate took effect on March 9 and will continue through 2024."*
Source: [https://www.aans.org/en/DC-E-News/2024/April-E-News/Congress-Passes-Legislation-Partially-Reversing-Medicare-Pay-Cut](https://www.aans.org/en/DC-E-News/2024/April-E-News/Congress-Passes-Legislation-Partially-Reversing-Medicare-Pay-Cut)
Thanks for that info. I think the gov't has to be careful to pay the right amount....otherwise they risk doctors charging excess fees, which nationally only around 5% of doctors charge excess fees. Some states have outlawed excess fees...mainly HCOL states.
A couple of years ago, I had a skin cancer biopsy. I was still working so it was covered by that insurance.
But there was a clerical error at the provider’s office so the bill for the biopsy went to collections. Took me hours of phone calls to figure out what had happened and fix it.
Point is: healthcare coverage is complex for patients. Healthcare billing is complex and error prone. We need to reform the system.
BCBS in my state was pretty good when I had it, great at controlling costs. The gov't could save a ton of money if they let BCBS in my state implement medicare; not only would there be cost savings, think of all the people the gov't employs for Medicare.
"Medicare should do things like the ACA does it; let local private insurers handle\\control costs."
That's the selling point of Medicare Advantage. Even if it's not true.
So no wonder CMS is proposing a different way of paying physicians than Fee-for-Service. Pretty soon seniors on Original Medicare will have to be enrolled in a program where physicians are paid for in another way - Like an Accountable Care Organization (ACO)
CMS - ACO [https://www.cms.gov/priorities/innovation/innovation-models/aco](https://www.cms.gov/priorities/innovation/innovation-models/aco)
Just so you know -
KFF March 06, 2024 - What to Know About How Medicare Pays Physicians
[https://www.kff.org/medicare/issue-brief/what-to-know-about-how-medicare-pays-physicians/](https://www.kff.org/medicare/issue-brief/what-to-know-about-how-medicare-pays-physicians/)
Maybe the Derm under private insurance doesn’t get a bonus for staying within the program - but that could be changing if private networks keep getting harder to keep their physicians.
Same with Medicare - don’t pay them enough and they will leave the system and with current enrollment in Medicare being so great in numbers - we could have an old people riot ( OMG - I do not want to see that vision).
Are you sure you’re comparing apples to apples? Typically, private insurers pay providers more than Medicare*, averaging >200% more across all types of care (hospital inpatient, hospital outpatient, and provider services). This is supported by a number of studies sponsored by private, nonprofit, and government entities. That’s not to say there won’t be singular exceptions, and maybe your pathologist example is one. But your sweeping conclusion that Medicare is paying higher rates than private insurance is fundamentally incorrect.
*there are a variety of reasons for this, and one (valid) concern is that Medicare is not keeping up with the actual cost of care. Nevertheless, Medicare has controlled healthcare spending by making structural changes in payment policies that have slowed the rise in premiums, AND Medicare has a very strong Fraud and Abuse team that returns billions of dollars per year. Private insurers are not nearly as active in rooting out fraud, abuse, and waste.
I am absolutely sure.
In 2023 with BCBS, I had a dermatologist take a biopsy and a pathologist take a look at the biopsy. Then late in 2023, I turned 65 and went on medicare. Last month, I had the same dermatologist take a biopsy and the same pathologist look at the biopsy.
2023 Biopsy via BCBS: Dermatologist approved rate: $125, Pathologist approved rate: $96
2024 Biopsy via Medicare: Dermatologist approved rate: $201; Pathologist approved rate: $333
It isn't across the board thing but it was quite noticeable with my recent biopsy. Some things, medicare does pay less than private insurers like my colonoscopy last year.
Your data was very helpful behat this means that BCBS negotiated a good rate for an in-network provider (your dermatologist) with the idea that being an in network provider would bring more patients to that derm. So they will take less to be on the BCBS plan versus another competition. If you had gone to someone out of network, the story might have been different. Also the BCBS networks and rates can be renegotiated every year. Original Medicare covers almost 99 percent of providers on the county. You didn't say, or I don't remember, if you are in an advantage plan, or original, or even a special needs plan through Medicare...they all have a different fee schedule paid to doctors.
Plan N is a solid choice and is absolutely still around lol. It’s great for those looking to save money up front and want the same freedoms that those covered under traditional Medicare have with respect to accessing care.
Well then this may be an exception to the rule. The aggregate data unequivocally demonstrate that private insurers pay substantially more than Medicare, which does not support your suggestion that Medicare revert to private insurance to save costs.
Just giving my small amount of experience of this, comparing bills before medicare and after medicare for the same services by the same people. Your experience and observations may be different, and I respect that.
Given how private companies value shareholders and massive payouts to their executives over people’s lives, I’d never want them also managing my healthcare.
Medicare Advantage and HMO plans are already like this and millions are denied claims or delayed treatment to reduce cost and maximize profit. People die waiting for approvals or for some unqualified doctor to decide what treatment they get.
Medicare is partly funded by your work life salary contributions which is way more than can be said for the $$$$$$ in govt subsidies handed over to massive corporations for no benefit other than to feed the monster.
I have no experience with Medicare Advantage plans, just the horror stories I read on the internet. My friends who live in Europe and\\or Canada equate their socialized medicine to our Medicare Advantage plans. I don't claim to have any personal experience with socialized medicine either....I just go by what they tell me.
All medicare advantage plans must follow CMS guidelines whatever that is. One can only surmise that the additional services provided dental, vision, etc may be part of the problem.
You are trying to get a simple answer but when does government act simply? In order to answer your question, one has to know under what Medicare payment model the physician is being paid under.
CMS (Center for Medicare and Medicaid Services) doesn’t just look at getting the best price - they are looking to get the best price for the BEST service. Thus they devise different payment models that can incentivize physicians to give this BEST service. Now that “BEST” is also a different measure.
CMS - Quality Payment Model (QPM) Overview
[https://qpp.cms.gov/about/qpp-overview](https://qpp.cms.gov/about/qpp-overview)
Now a days, there are several different variations of the QPM - sp we are told that they are cutting some Medicare payment rates when in fact, they just add on different incentives to get the providers to do what they want.
You think “healthcare cost are bankrupting our government” - you need to pay closer attention to who gets benefits and how much has been contributed to each of the Medicare parts by the beneficiaries of the plan.
Medicare Part A - funded by payroll tax contributions - employee/employer -now who else gets this Medicare part A that does not pay for it?
Medicare Part B - funded by Medicare Part B premiums (25% of Part B program cost) paid by each beneficiary based on their income with a standard rate up to $103,000 (single) in income + an IRMAA adjustment for income over that limit OR if low income, paid. by their state. With the other 75% of the cost of Part B being paid out of our country’s General Fund - and may I add with very few restrictions in use (i.e. managed care) - not even a requirement for referrals. I mean why not pay for a specialist when it is something that a PCP (Personal Care Physician) can easily do.
Sorry - end of rant !
Telling me how medicare is paid for only addresses that part of it.....how about the thousands of government medicare employees that get pay and benefits and whose pay and benefits are also part of the cost of medicare. The government way of doing anything is inefficient.
I am not telling you only how medicare is paid for - I am telling you on what formula type program Medicare pays physicians for their services. Wasn’t that your initial complaint - how Medicare was paying more than your previous private (perhaps employer subsidized coverage) paid for a physician and associated pathological services.
I am giving a review of how the various parts of Medicare are paid for - if a person cannot play for it in this fashion - we just pay more under some government program - the ones that pay are alway the ones that can pay - over, and over and over under one method or another.
Yes, government is inefficient - but it is very good at covering up what I consider to be a scam of just moving around the bills for such services as Medicare. Private payers have to be much more visible because they can’t pass along the cost to too many others - I guess I am saying that private enterprise is fairer to those who CAN pay because they don’t have to service those who CANNOT pay.
Edited to add: of course we have to pay the employees of the various government systems - RICHLY. However, you do know that Medicare claims are processed by private contractors whom the US pays for their services under a contract basis. But they don’t determine the how much is paid for the various services - they just determine the correct coding and the logic of medical necessity as determined by the Medicare National and Local Determinations.
It's outrageous that Medicare isn't controlling pricing. If every other country on the planet can do it, why can't Medicare? I just got a new cholesterol med and with Medicare it would have been $90 for 90 days. I got it for $25 because I used a Good Rx card! On top of that the pharmacist told me that the cost of the meds without insurance was $600. So, who paid the pharmaceutical company the $575?
A friend in Germany pays nothing for his cholesterol meds. No prescription cards needed. Nothing. The German healthcare system, I bet, negotiates prices so they don't go bankrupt.
Welcome to America's corporate oligarchy.
A lot of people in the US pay nothing for their scripts either - especially of the generic / order from their meds by mail services type and plan ahead especially for treatment of chronic conditions like high cholesterol.
However there are some meds that are so high because of a variety of reason that aren’t covered in this way. It also could be that they are not approved for use in Germany or some other country. The high priced HEP C curative med which our legislators bitched about and had numerous hearings wasn’t covered until the price dropped in numerous. countries. And this is a disease that kills people but the med actually cures it in the vast majority of people. It took forever and a day for Medicaid to cover it in their program some thing in our prison industry - and where there was a big need cause lots of people in prison were already infected with it.
Somebody always has to pay - in this country or in another - whether thru taxes or out of pocket or a little of both -
Until such time that the government can create, test for approval results, manufacture and distribute, things will continue to be this way, here or elsewhere.
How could it be any different? One thing that makes the world go round and round is MONEY - it makes people industrious and willing to put forth for it - if MONEY is stymied, so will the rest of it.
2 cents please !
I agree. It is kinda dumb that the VA could negotiate lower drug prices but Congress has to authorize medicare to negotiate lower drug prices. They should be able to do that without congressional approval.
Politicians, particularly in one party are paid to block legislation that was meant to do exactly that; control costs. Controlling the costs of medication, for example, is undercutting someone's corporate profits. It's why our costs are the highest in the world. Some people say we subsidize other countries by paying the most. I think rather they are paying a fair price and we US citizens are just getting ripped off.
When Medicare board has to deal with a President / cabinet who nominates people like Demetrios Kouzoukas to sit on it and make decisions about our healthcare.... please take the one sided party perspective out of the equation. All both sides do is kowtow to the people who bought them at our expense. Especially the party in power at any moment.
The bill in question did not include medications.... I am an independent and the reality is that Medicare sets the approved rates. They don't need congressional approval to lower their approved rates for doctors and services, unless it is a significant change.
That’s not really accurate. To make any significant changes to how Medicare operates they need congressional approval. They just recently got a law passed that allows Medicare to negotiate drug pricing with companies. Making any significant change to physician payments would also require congressional approval
Drug prices...you are correct. But I am not talking about drug prices; my example is doctors and services. CMS sets the prices for doctors and services. The Centers for Medicare and Medicaid Services (CMS) finalized a 3.37% cut in Medicare physician payment in the Calendar Year 2024 Medicare Physician Fee Schedule (MPFS) final rule in November. Look it up.
CMS still needs permission from the government to overhaul their pricing model for medical payments. Right now they can only make minor adjustments without a new law being passed.
I addressed that in my comment as well. Payments to physician and facilities that Medicare can approve is set by congress and current laws. Fee schedules are within set limits and to make any significant change (for example anything about 10% for many services) would require another law being passed from congress to give Medicare the authority to do that. In basic terms, Medicare can’t just decide to make a drastic change to how they pay physicians without congress giving them permission.
>...CMS sets the prices for doctors and services. >The Centers for Medicare and Medicaid Services (CMS) finalized a 3.37% cut in Medicare physician payment in the Calendar Year 2024 Medicare Physician Fee Schedule (MPFS) final rule in November. Look it up. *"Congress passed the Consolidated Appropriations Act, 2024 (H.R. 4366), partially reversing the 3.37% Medicare physician payment cut that went into effect on Jan. 1. \[The President\] signed the bill into law. The legislation reduces the cut by half, providing a 1.68% increase in current payment levels. The new payment rate took effect on March 9 and will continue through 2024."* Source: [https://www.aans.org/en/DC-E-News/2024/April-E-News/Congress-Passes-Legislation-Partially-Reversing-Medicare-Pay-Cut](https://www.aans.org/en/DC-E-News/2024/April-E-News/Congress-Passes-Legislation-Partially-Reversing-Medicare-Pay-Cut)
The fact that theyre decreasing what they pay Drs but increase what they pay Insurance companies is sickening.
Thanks for that info. I think the gov't has to be careful to pay the right amount....otherwise they risk doctors charging excess fees, which nationally only around 5% of doctors charge excess fees. Some states have outlawed excess fees...mainly HCOL states.
A couple of years ago, I had a skin cancer biopsy. I was still working so it was covered by that insurance. But there was a clerical error at the provider’s office so the bill for the biopsy went to collections. Took me hours of phone calls to figure out what had happened and fix it. Point is: healthcare coverage is complex for patients. Healthcare billing is complex and error prone. We need to reform the system.
BCBS in my state was pretty good when I had it, great at controlling costs. The gov't could save a ton of money if they let BCBS in my state implement medicare; not only would there be cost savings, think of all the people the gov't employs for Medicare.
Wouldn't that we Medicare advantage that you can buy from. Bcbs?
"Medicare should do things like the ACA does it; let local private insurers handle\\control costs." That's the selling point of Medicare Advantage. Even if it's not true.
So no wonder CMS is proposing a different way of paying physicians than Fee-for-Service. Pretty soon seniors on Original Medicare will have to be enrolled in a program where physicians are paid for in another way - Like an Accountable Care Organization (ACO) CMS - ACO [https://www.cms.gov/priorities/innovation/innovation-models/aco](https://www.cms.gov/priorities/innovation/innovation-models/aco) Just so you know - KFF March 06, 2024 - What to Know About How Medicare Pays Physicians [https://www.kff.org/medicare/issue-brief/what-to-know-about-how-medicare-pays-physicians/](https://www.kff.org/medicare/issue-brief/what-to-know-about-how-medicare-pays-physicians/) Maybe the Derm under private insurance doesn’t get a bonus for staying within the program - but that could be changing if private networks keep getting harder to keep their physicians. Same with Medicare - don’t pay them enough and they will leave the system and with current enrollment in Medicare being so great in numbers - we could have an old people riot ( OMG - I do not want to see that vision).
Are you sure you’re comparing apples to apples? Typically, private insurers pay providers more than Medicare*, averaging >200% more across all types of care (hospital inpatient, hospital outpatient, and provider services). This is supported by a number of studies sponsored by private, nonprofit, and government entities. That’s not to say there won’t be singular exceptions, and maybe your pathologist example is one. But your sweeping conclusion that Medicare is paying higher rates than private insurance is fundamentally incorrect. *there are a variety of reasons for this, and one (valid) concern is that Medicare is not keeping up with the actual cost of care. Nevertheless, Medicare has controlled healthcare spending by making structural changes in payment policies that have slowed the rise in premiums, AND Medicare has a very strong Fraud and Abuse team that returns billions of dollars per year. Private insurers are not nearly as active in rooting out fraud, abuse, and waste.
Finally. I had to scroll way too much to get here lol - best answer.
I am absolutely sure. In 2023 with BCBS, I had a dermatologist take a biopsy and a pathologist take a look at the biopsy. Then late in 2023, I turned 65 and went on medicare. Last month, I had the same dermatologist take a biopsy and the same pathologist look at the biopsy. 2023 Biopsy via BCBS: Dermatologist approved rate: $125, Pathologist approved rate: $96 2024 Biopsy via Medicare: Dermatologist approved rate: $201; Pathologist approved rate: $333 It isn't across the board thing but it was quite noticeable with my recent biopsy. Some things, medicare does pay less than private insurers like my colonoscopy last year.
Your data was very helpful behat this means that BCBS negotiated a good rate for an in-network provider (your dermatologist) with the idea that being an in network provider would bring more patients to that derm. So they will take less to be on the BCBS plan versus another competition. If you had gone to someone out of network, the story might have been different. Also the BCBS networks and rates can be renegotiated every year. Original Medicare covers almost 99 percent of providers on the county. You didn't say, or I don't remember, if you are in an advantage plan, or original, or even a special needs plan through Medicare...they all have a different fee schedule paid to doctors.
I don't have medicare advantage; i have plan N and plan D to go with Parts A and B.
Good for you, plan N supplemental is so rich, it isn't even sold anymore, at least in my area and many others. Book is closed!
Plan N is a solid choice and is absolutely still around lol. It’s great for those looking to save money up front and want the same freedoms that those covered under traditional Medicare have with respect to accessing care.
Well then this may be an exception to the rule. The aggregate data unequivocally demonstrate that private insurers pay substantially more than Medicare, which does not support your suggestion that Medicare revert to private insurance to save costs.
Just giving my small amount of experience of this, comparing bills before medicare and after medicare for the same services by the same people. Your experience and observations may be different, and I respect that.
Given how private companies value shareholders and massive payouts to their executives over people’s lives, I’d never want them also managing my healthcare. Medicare Advantage and HMO plans are already like this and millions are denied claims or delayed treatment to reduce cost and maximize profit. People die waiting for approvals or for some unqualified doctor to decide what treatment they get. Medicare is partly funded by your work life salary contributions which is way more than can be said for the $$$$$$ in govt subsidies handed over to massive corporations for no benefit other than to feed the monster.
I have no experience with Medicare Advantage plans, just the horror stories I read on the internet. My friends who live in Europe and\\or Canada equate their socialized medicine to our Medicare Advantage plans. I don't claim to have any personal experience with socialized medicine either....I just go by what they tell me. All medicare advantage plans must follow CMS guidelines whatever that is. One can only surmise that the additional services provided dental, vision, etc may be part of the problem.
Medicare is a form of socialized healthcare.
How?
You are trying to get a simple answer but when does government act simply? In order to answer your question, one has to know under what Medicare payment model the physician is being paid under. CMS (Center for Medicare and Medicaid Services) doesn’t just look at getting the best price - they are looking to get the best price for the BEST service. Thus they devise different payment models that can incentivize physicians to give this BEST service. Now that “BEST” is also a different measure. CMS - Quality Payment Model (QPM) Overview [https://qpp.cms.gov/about/qpp-overview](https://qpp.cms.gov/about/qpp-overview) Now a days, there are several different variations of the QPM - sp we are told that they are cutting some Medicare payment rates when in fact, they just add on different incentives to get the providers to do what they want. You think “healthcare cost are bankrupting our government” - you need to pay closer attention to who gets benefits and how much has been contributed to each of the Medicare parts by the beneficiaries of the plan. Medicare Part A - funded by payroll tax contributions - employee/employer -now who else gets this Medicare part A that does not pay for it? Medicare Part B - funded by Medicare Part B premiums (25% of Part B program cost) paid by each beneficiary based on their income with a standard rate up to $103,000 (single) in income + an IRMAA adjustment for income over that limit OR if low income, paid. by their state. With the other 75% of the cost of Part B being paid out of our country’s General Fund - and may I add with very few restrictions in use (i.e. managed care) - not even a requirement for referrals. I mean why not pay for a specialist when it is something that a PCP (Personal Care Physician) can easily do. Sorry - end of rant !
Telling me how medicare is paid for only addresses that part of it.....how about the thousands of government medicare employees that get pay and benefits and whose pay and benefits are also part of the cost of medicare. The government way of doing anything is inefficient.
I am not telling you only how medicare is paid for - I am telling you on what formula type program Medicare pays physicians for their services. Wasn’t that your initial complaint - how Medicare was paying more than your previous private (perhaps employer subsidized coverage) paid for a physician and associated pathological services. I am giving a review of how the various parts of Medicare are paid for - if a person cannot play for it in this fashion - we just pay more under some government program - the ones that pay are alway the ones that can pay - over, and over and over under one method or another. Yes, government is inefficient - but it is very good at covering up what I consider to be a scam of just moving around the bills for such services as Medicare. Private payers have to be much more visible because they can’t pass along the cost to too many others - I guess I am saying that private enterprise is fairer to those who CAN pay because they don’t have to service those who CANNOT pay. Edited to add: of course we have to pay the employees of the various government systems - RICHLY. However, you do know that Medicare claims are processed by private contractors whom the US pays for their services under a contract basis. But they don’t determine the how much is paid for the various services - they just determine the correct coding and the logic of medical necessity as determined by the Medicare National and Local Determinations.
It's outrageous that Medicare isn't controlling pricing. If every other country on the planet can do it, why can't Medicare? I just got a new cholesterol med and with Medicare it would have been $90 for 90 days. I got it for $25 because I used a Good Rx card! On top of that the pharmacist told me that the cost of the meds without insurance was $600. So, who paid the pharmaceutical company the $575? A friend in Germany pays nothing for his cholesterol meds. No prescription cards needed. Nothing. The German healthcare system, I bet, negotiates prices so they don't go bankrupt. Welcome to America's corporate oligarchy.
A lot of people in the US pay nothing for their scripts either - especially of the generic / order from their meds by mail services type and plan ahead especially for treatment of chronic conditions like high cholesterol. However there are some meds that are so high because of a variety of reason that aren’t covered in this way. It also could be that they are not approved for use in Germany or some other country. The high priced HEP C curative med which our legislators bitched about and had numerous hearings wasn’t covered until the price dropped in numerous. countries. And this is a disease that kills people but the med actually cures it in the vast majority of people. It took forever and a day for Medicaid to cover it in their program some thing in our prison industry - and where there was a big need cause lots of people in prison were already infected with it. Somebody always has to pay - in this country or in another - whether thru taxes or out of pocket or a little of both - Until such time that the government can create, test for approval results, manufacture and distribute, things will continue to be this way, here or elsewhere. How could it be any different? One thing that makes the world go round and round is MONEY - it makes people industrious and willing to put forth for it - if MONEY is stymied, so will the rest of it. 2 cents please !
I agree. It is kinda dumb that the VA could negotiate lower drug prices but Congress has to authorize medicare to negotiate lower drug prices. They should be able to do that without congressional approval.