...but I apparently don't know the proper incantation to get that to work. It would also be interesting is someone had concrete side-by-side examples of what Medicare/Medicaid pay vs. what everyone else pays for several different "common" items.
> It would also be interesting is someone had concrete side-by-side examples of what Medicare/Medicaid pay vs. what everyone else pays for several different "common" items
No payer (including Medicare) pays a single price across the board - even Medicare pays different amounts to different providers in different regions, etc. So there is no one single price for each payer that we could compare, and it'd be hard to find true apples-to-apples comparisons between them, short of polling individual practices and asking them what they received last month (which is hardly rigorous).
Remember that these are often treated as closely guarded secrets - if they were truly public, the AMA couldn't charge for access to CPT codes, and it would be harder for Medicare and private payers to negotiate the minimum rate for each provider. It's the same reason you'd be hard-pressed to ask most companies to make all of their individual salary data public.
The reason we know that Medicare pays so little, though, is that (a) it's no secret - even Medicare doesn't really try to hide it, (b) Medicare has to publish aggregate data, and we know from the aggregate data that they reimburse 7% less than COGS on average, and (c) it's statutorily mandated.
The first column are the number of points a given service is assessed for, the second is what the publicly-mandated insurances that most Germans are covered by will pay, and the third is the private rate: private insurance or straight-up cash. Doctors and other providers can choose to charge higher than the usual 2.3 multiplier for private patients, and they can choose to only accept private patients, but most accept the public insurances, too.
I can confirm that these are the current prices - I'm privately insured with the highest legal annual deductible (1200 EUR) and pay those bills out of pocket.
Result: Visits to my Hausärztin (primary care doctor) are somewhere in the 30-70 EUR range, full price. Just about everything in healthcare is startlingly cheap in Germany compared to the US (dentistry is only somewhat less expensive than in the US). About 10 years ago, I paid less for the same procedure without participation from my insurer than a friend did in the US after her insurance paid its portion - and I had a night in the hospital, while she was an outpatient!
> Are you saying that Medicare/Medicaid reimbursement rates aren't public information?
Private insurer rates are definitely not public information, for any definition of "public".
Medicare reimbursement rates are sort of public, but not at the level of granularity you want. And a portion of that is because the question is not easily defined. For a given CPT code, Medicare might pay one of many different rates, depending on factors such as the geographic region, whether the provider operates in a CAH, whether the provider qualifies as a DSH, etc. That level of granularity is not easily accessible, and without it, there's no way to give meaningful example individual comparisons without running the risk of cherry-picking non-representative examples simply due to availability bias.
(Also, Medicare and Medicaid can't be lumped together. Medicare is a single, federal program that is administrated in four parts. Medicaid is a set of 50 different programs run at the state level, each of which can be administrated in more ways than I can count. The one thing that they all have in common here is that, like Medicare, they pay abysmal rates to providers, but the relationships that they have are even more complex - even in a single state, like New York, there are literally hundreds of different ways that Medicaid services can be provided, depending on the type of plan chosen.
Source: founded a company that had to abstract all of this complexity for patients, who were disproportionately on Medicare or Medicaid)
Yes, I'm willing to give up on the comparison to private insurance/transactions. So now I'm just wondering how to get a hold of Medicare reimbursement rates. We know that they vary by location, and other factors. But it must boil down somewhere, to a lookup table or a formula or the guy processing the forms who rolls a dice and multiplies by the last 3 digits of the medical code to come up with the reimbursement, etc.. Or is it all based on trust, and Medicare just pays 70% of any invoice that gets submitted to them? (And they send auditors out every once in a while in order to keep up appearances)
I am familiar with NY medicaid. They do publish a way to calculate the Medicaid default rate. Insurers do not have to pay exactly this but it provides a decent base line. Here is a basic description of how inpatient pricing works.
Each year the state publishes the set of hospital rates and intensity weights for each DRG (Diagnosis-Related Group) and severity combo (currently using weights developed in 2014). So a DRG of 460 (Renal Failure) with a severity 2 has a weight of 0.7393. Now the actual cost will depend on which hospital you go to since each hospital has a different base rate. For example each Mount Sinai hospital has a base rate of $8,743.45 while Niagara Falls memorial hospital has a base rate of $5,558.99. Each hospital also has a per discharge rate. To calculate the default rate take the hospital base rate x DRG intensity weight + per discharge rate.
> Does anyone know how to look up what Medicare/Medicaid pays for particular procedures
Medicaid is separate state-run programs with different reimbursement policies in each state, and othe common federal rules governing the state programs include provider-specific (both cost and charges to the general public) limits, so, there is no simple “what rate Medicaid pays” for any service.
(And that's even before considering that in some states, a substantial portion of Medicaid is provided by private insurers who are paid capitated rates, not fee-for-sercice, by the states.)
Somehow I came across that G8709 was for prescribing antibiotics. I figure I should be able to plug that into something like:
https://www.cms.gov/apps/physician-fee-schedule/search/searc...
...but I apparently don't know the proper incantation to get that to work. It would also be interesting is someone had concrete side-by-side examples of what Medicare/Medicaid pay vs. what everyone else pays for several different "common" items.