U.S. Budget & OBBB | OCT 1 - Gov’t Shutdown Begins

[ZenMode]

My mother retired from being a medical administrator in one of the poorest counties in NC and she could tell you on any given moment at any given time what percentage of their deliveries were Medicaid and what the outstanding balance was from the State of NC on those claims. Routinely, those kinds of hospitals and clinics have to borrow funds for ongoing operations with future due Medicaid payments as collateral. Everyone in medicine knows those numbers about their facility or practice. This is EPSECIALLY true in rural counties.

I can assure you that if the practice she ran found out their Medicaid reimbursements were going to be cut by even 10-15%, they would have ceased operations the following week. They are also to this day the only OB/GYN practice in Edgecombe County and the only OB physicians with admitting privileges at the local hospital. If that practice closes, there isn't a single doctor to deliver a baby in the entire county.

In order for this hospital to make a truly informed decision, they'd have to know:

• Nearly precisely how many patients they'll be losing
• How much revenue those patients generate now and will in the future
• How much money they'll be subsidized from the government which means they ..
• Need to know how many medical facilities will be closing around the country....
• ...How much the remaining facilities will receive which means they also....
• Need to know how the federal government calculates subsidies.

Are you telling me they knew that within hours of the bill passing?

Also @superrific

 

[lawtig02]

My eye surgeon is from Serbia. She did a perfect job repairing my detached retina. I love her

My spine doctor is Asian and his humane approach and treatment has been a godsend. I love him

The dentist who did a wonderful on my root canal had brown skin and was likely from somewhere in the Middle East. I love him


My primary care physician is from India and my only complaint is that she is too diligent in taking care of me, but I love her


Bottom line is I don't give twowhether I see a 'murican doctor for care. I'm pretty sure they will not surpass my current doctors.

Just to be clear, I agree completely. I just have a hunch MAGA does not.

 

[superrific]

The whole point of the medicaid expansion under the ACA was to insure as many people as possible under the premise that insured patients cost the system far less than uninsured.

I think this is a bit too strong. That was one of the points, not necessarily the main one. I mean, you're right; there was also more going on.

IIRC, Insured patients do not cost the system less than uninsured people. It's that their care is delivered at a fraction of the cost. So while we pay as much per insured as uninsured, we are delivering a lot more care in the first instance. It's the same way that Caleb Love scored about as many points as Tyler Hansbrough. One of them was a bit more efficient than the other . . .

Now, there are also distributional issues as to who pays in each case, and yes that was a significant issue under ACA and that's why some of the obscure financing provisions were in there.

 

[finesse]

I think this is a bit too strong. That was one of the points, not necessarily the main one. I mean, you're right; there was also more going on.

IIRC, Insured patients do not cost the system less than uninsured people. It's that their care is delivered at a fraction of the cost. So while we pay as much per insured as uninsured, we are delivering a lot more care in the first instance. It's the same way that Caleb Love scored about as many points as Tyler Hansbrough. One of them was a bit more efficient than the other . . .

Now, there are also distributional issues as to who pays in each case, and yes that was a significant issue under ACA and that's why some of the obscure financing provisions were in there.

Well, insured patients who get diagnosis and care early instead of waiting like many uninsured who wait until they are forced to do something are probably a bit cheaper. That's just a feeling though as is my prediction of a better overall outcome.

 

[TangledUpInBlue06]

Also, you should have proof of losses - either the losing tickets or contemporaneous receipts (something that very few people have).

Dealt with this in my law school clinic. IRS dinged the client for unpaid taxes on something like $80k of gambling winnings. The client didn't have half that to his name. Kind, elderly gentleman who just socialized with his buddies at the racetrack most days. He of course lost as much (probably more) than he won, but the issue was proving it. Figured out he had some kind of card issued by the track that he loaded money on and used to place bets. Got the racetrack to send us the record of transactions on the card. Those records came in the day I graduated and after I passed the case on to a new student attorney. Always been curious how is turned out.

 

[superrific]

In order for this hospital to make a truly informed decision, they'd have to know:

• Nearly precisely how many patients they'll be losing
• How much revenue those patients generate now and will in the future
• How much money they'll be subsidized from the government which means they ..
• Need to know how many medical facilities will be closing around the country....
• ...How much the remaining facilities will receive which means they also....
• Need to know how the federal government calculates subsidies.

Are you telling me they knew that within hours of the bill passing?

I guess we're doing this again?

1. They do not need to know "nearly precisely" how many patients they are losing. For one thing, all they need to know is whether it's too many. Think of it this way: if our football team is down 52-10 headed into the fourth quarter, we don't know precisely how many points we will end up with but we know we're going to lose.

Second, for high revenue businesses like hospitals, statistical projection methods work very well. If you have a million customers, and then next week you have 900,000, that's what you need to know. If it's 893,356 or 913,122 doesn't matter.

Third, in budgeting and all business analysis, the standard practice is to run projections on different base cases. for instance, in financial projections: you might run the numbers assuming a best case scenario of 3% interest rates going forward; an average case of 4%, and a worst case of 5%.

Put all these together and companies have a very good financial picture. They don't know exactly what will happen, but they know the likelihood. They can tell you with quite a lot of precision what their chances of survival are. For instance, they might know that they have a 10% of surviving. That's a piss poor likelihood.

2. You don't think the hospitals know each others' finances, roughly speaking? They do. They have trade associations. There are consultants who gather data. They know the reimbursement schedules, and the population in various areas. They know the doctors' salaries and staff salaries.

They might not know exactly which hospitals will close but they can predict accurately that it would be between X% and Y%.

Note: I don't know this for sure about hospitals per se, but I know this for a fact for other big businesses and I see no reason hospitals would be different given that they hire the same MBAs.

3. They do not need to know exactly how the government will calculate subsidies if they know it's not enough. I've read where the stabilization fund would have to be north of $200B. So no matter what the subsidy calculation, it's not going to cut it.

4. They know within HOURS because they've already modeled it. Hospitals employ hundreds or thousands of people in administrative/analyst roles. What do you think they do all day? Just because you pick your nose doesn't mean that's what everyone does.

 

[superrific]

Well, insured patients who get diagnosis and care early instead of waiting like many uninsured who wait until they are forced to do something are probably a bit cheaper. That's just a feeling though as is my prediction of a better overall outcome.

Like I said, the care delivered to insured patients is much cheaper. But because of that, they get more care, meaning that they are overall as or more expensive but the experience improvement dwarfs the cost.

It's like a basketball team where the leading scorer drops 20 a game shooting 35% from the field. The second leading scorer drops 15 a game with 55% shooting. The second leading scorer is clearly the better offensive player (all else being equal) but the first still scores more. Doesn't win more though.

 

[ZenMode]

I guess we're doing this again?

1. They do not need to know "nearly precisely" how many patients they are losing. For one thing, all they need to know is whether it's too many. Think of it this way: if our football team is down 52-10 headed into the fourth quarter, we don't know precisely how many points we will end up with but we know we're going to lose.

They aren't "down" anything. They aren't trying to overcome a deficit. They're a hospital with a budget.

Second, for high revenue businesses like hospitals, statistical projection methods work very well. If you have a million customers, and then next week you have 900,000, that's what you need to know. If it's 893,356 or 913,122 doesn't matter.

Your range is "nearly precisely", IMO.

Third, in budgeting and all business analysis, the standard practice is to run projections on different base cases. for instance, in financial projections: you might run the numbers assuming a best case scenario of 3% interest rates going forward; an average case of 4%, and a worst case of 5%.

Ok.

Put all these together and companies have a very good financial picture. They don't know exactly what will happen, but they know the likelihood. They can tell you with quite a lot of precision what their chances of survival are. For instance, they might know that they have a 10% of surviving. That's a piss poor likelihood.

This is circular. In order to be precise, they have to be precise with the variables that go into the estimate.

2. You don't think the hospitals know each others' finances, roughly speaking?

Knowing, so specifically, the finances of all medical facilities, All around the country, who could be impacted to the point of closure or needing subsidies? Absolutely not. That a silly claim.

They do.

BS

They have trade associations. There are consultants who gather data. They know the reimbursement schedules, and the population in various areas. They know the doctors' salaries and staff salaries.

Ridiculous claim.

They might not know exactly which hospitals will close but they can predict accurately that it would be between X% and Y%.

BS again

Note: I don't know this for sure about hospitals per se, but I know this for a fact for other big businesses and I see no reason hospitals would be different given that they hire the same MBAs.

Well, no shit.

3. They do not need to know exactly how the government will calculate subsidies if they know it's not enough.

Again, circular. You have to know how it's calculated to know it's not enough.

I've read where the stabilization fund would have to be north of $200B. So no matter what the subsidy calculation, it's not going to cut it.

You're again assuming detailed knowledge on all kinds of variables that there's no reason to believe they know.

4. They know within HOURS because they've already modeled it. Hospitals employ hundreds or thousands of people in administrative/analyst roles. What do you think they do all day? Just because you pick your nose doesn't mean that's what everyone does.

It's all just circular reasoning. You assume they know X, which makes them able to know Y, Even though you are assuming that they know X to start with.

 

[wmheel1287]

In order for this hospital to make a truly informed decision, they'd have to know:

• Nearly precisely how many patients they'll be losing
• How much revenue those patients generate now and will in the future
• How much money they'll be subsidized from the government which means they ..
• Need to know how many medical facilities will be closing around the country....
• ...How much the remaining facilities will receive which means they also....
• Need to know how the federal government calculates subsidies.

Are you telling me they knew that within hours of the bill passing?

Also @superrific

Of course they know how many patients they will lose to a sufficient extent..and it doesn't need to be precise. If the facility is already struggling and is 70-80% Medicare/Medicaid, any distruption at all is enough.

Future prognostication of use based on past trends is pretty straightforward in the medical world.

Furthermore, you’re ignoring the fact that in many states (including and especially NC), almost EVERY practice and hospital in rural areas is owned by the same conglomerates. For example, you would have to look pretty hard to find a hospital or major practice east of I95 not owned by UNC Health or Vidant (formerly ECU Health). The same is true in the Triangle of UNC/Duke/Wake Med. Within an hour of Greensboro its all Moses Cone/Wake Forest. Everything west of GSO is Atrium Health.

They all know minute by minute what each practice, provider, and hospital is doing, where the patients come from, how they pay, and what their expected usage is.

 

[superrific]

1. You missed the point of the analogy. You can be uncertain about the precise effects in the future and yet certain that it will not be enough.

For instance, I don't know how much money I would raise if I went door to door in my neighborhood asking for donations. I'm certain it wouldn't be enough to cover a $5000 gambling debt I owe to the mafia because the government wouldn't let me deduct my losses.

2. Do you understand probability? You don't, evidently. If I say that I have a 50% of succeeding at something, I don't know exactly what will happen the next time I try. But if I try 10 times, I'll probably succeed between 3 and 7 times. If I try 10000 times my success rate will be very close to 50%. Get it? You can model all the factors you say are unknown and use that to make the projection.

It's amazing what people can do with skills and a lot of computing power.

3. How is it a ridiculous claim to note that hospitals receive reimbursements according to a published schedule? That they know how much doctors are getting paid because they see job listings and ask doctors how much they are making and get employment reference letters etc. etc. Population is publicly available data. Medicaid spend is publicly available. What is it that you think they can't possibly know?

 

[kickazzz2000]

They aren't "down" anything. They aren't trying to overcome a deficit. They're a hospital with a budget.

Your range is "nearly precisely", IMO.

Ok.

This is circular. In order to be precise, they have to be precise with the variables that go into the estimate.

Knowing, so specifically, the finances of all medical facilities, All around the country, who could be impacted to the point of closure or needing subsidies? Absolutely not. That a silly claim.

BS

Ridiculous claim.

BS again

Well, no shit.

Again, circular. You have to know how it's calculated to know it's not enough.

You're again assuming detailed knowledge on all kinds of variables that there's no reason to believe they know.

Have you never run a business?

 

[heelinhell]

Just to be clear, I agree completely. I just have a hunch MAGA does not.

I agree with you that MAGAs may recoil if they don't see an old white male MD enter their exam room.

I'm just saying based upon my experience over the last 5 years and encountering medical folks, I like and feel comforted seeing "ethnic" medical folks entering my exam room.

 

[wmheel1287]

Have you never run a business?

Yeah... this kind of bill watching is part of the gig for sure. NC had proposed legislation in the General Assembly that would have cut the required continuing education of every licensed profession in the state by 50%. CE accounts for 21% of my revenue. Had the bill become law, I would have cut 2 admin staff, 2 moderators, and one instructor. I would have made those moves the moment the governor signed the bill. Thankfully it died in committee on June 12.

 

[lawtig02]

Have you never run a business?

Zen? Run a business???

 

[WaynetheDrain]

I don't know why you guys bother with Zen. He's utterly irredeemable as a human being and willfully misinformed about every topic. His only goal is to play devil's advocate in defense of Trump, and he's completely nonplussed by the reality that no facts are ever on his side.

Fuck him. Seriously.

 

[p5mmr9]

I think this is a bit too strong. That was one of the points, not necessarily the main one. I mean, you're right; there was also more going on.

IIRC, Insured patients do not cost the system less than uninsured people. It's that their care is delivered at a fraction of the cost. So while we pay as much per insured as uninsured, we are delivering a lot more care in the first instance. It's the same way that Caleb Love scored about as many points as Tyler Hansbrough. One of them was a bit more efficient than the other . . .

Now, there are also distributional issues as to who pays in each case, and yes that was a significant issue under ACA and that's why some of the obscure financing provisions were in there.

Generally speaking, uninsured delay treatment (additional cost if the delay worsens the diagnosis), seek ambulatory and emergency care at a higher rate (additional cost), and either default on medical debt (additional cost) or just don't pay entirely (additional cost). They are also generally charged more which feeds into the previously noted issues. The cost to the system is when these debts and payments are defaulted as medical care cost increases for everyone. Yes - insured will seek more treatment, but that treatment tends to be preventative which is fairly inexpensive compared with hospitalization. The "unpaid care" component is really where the cost to the system becomes inflationary to the whole.

Hospitals charge more for unisured:

Study: Hospitals Often Charge More to Insured than Uninsured for Same Services

A highly selective liberal arts college in the heart of Hartford, Connecticut, Trinity prepares students to be leaders unafraid of forging new paths.

www.trincoll.edu

Unpaid debt is rolled into the healthcare system as a whole:

Spending on Health Care for Uninsured Americans: How Much, and Who Pays? - Hidden Costs, Values Lost - NCBI Bookshelf

More:

The Uninsured and the ACA: A Primer - Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act | KFF

The Uninsured and the ACA: A Primer provides information on how insurance has changed under the ACA and more recent policy changes, how many people remain uninsured, who they are, and why they lack health coverage. It also summarizes what we know about the impact that a lack of insurance can...

www.kff.org

 

[p5mmr9]

Regardless, I think everyone agrees pulling insurance from patients is a net negative financially. The actual numbers are debatable.

 

[Geisterfahrer]

No one but you said criminal liability.

What’s the basis for civil liability?

 

[donbosco]

I don't know why you guys bother with Zen. He's utterly irredeemable as a human being and willfully misinformed about every topic. His only goal is to play devil's advocate in defense of Trump, and he's completely nonplussed by the reality that no facts are ever on his side.

Fuck him. Seriously.

Practice for the outside world?

 

[ZenMode]

Have you never run a business?

I've run a business within a larger business. I didn't start either one.