Health Care Spending
CalGal -- Monday, July 22, 2002 -- 12:53:11 AMIt is my considered opinion that governments everywhere make dreadful spending decisions on health care. Try and talk me out of it.
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Agree.
Community rating, agree.
Because we are conservative financial services company owned by an even more conservative world-wide insurance company. While I see cost shifting for this employer to be feisable, I don't see eliminating offering health plans as a possibility at this time.
Here's someone who essentially agrees with both of us, and give some reasons why we are in the current health insurance climate that we are in right now. (Courtesy of Infotrack at EH Butler Library, SUNY-College at Buffalo).
Oh, come on. You believe them? He believed them? Don't be silly. It's much simpler than that. Why offer incentives for good health when it's much simpler to turn down everyone?
If it were advantageous for health insurance companies to push individual insurance, they'd do so.
I acknowledge that this is current practice for many insurance companies. It shouldn't be, but it is.
Do I believe any of them--I'm not stupid. Do I believe that HHS is a labyrinthine organization that would give out contridictory answers to different people and that the federal laws and HHS rulings are written so poorly that most insurance companies legal teams don't want to land in court so they say "it's not legal" Yeah, I believe that's happening.
The majority of constraints on insurers come from the states, not the fed. That's why the NY Atty General has been having a field day the past two weeks suing and arresting insurance firms and brokers. All insurers are mostly regulated by the states--California is a case in point--they have more regulation on the issuance and content of health policies than almost any other state.
There must be a better way--you and I agree on that. The insurance companies need to be more creative in their offerings and do better at risk assessment--like the car insurance companies--so that individuals and families can make better purchasing decieions on their healthcare. Federal and state regulations need to be clear and clearly communicated. Some states need to loosen their regulations so that more insurers will come into the state to do business, thereby creating a more competitive market, which should drive some pricing down. The employers who are not constrained by unions also need to continue to move costs to employees (if they've already started, and start if they haven't) to make those individuals true consumers of healthcare. The employers, as you said, could even offer financial incentives with the pool of money they're currently spending on healthcare. (Some already do, but they are few and far between).
Gladwell makes and interesting observation in his article:
Another thing that seems to be needed is a Consumer Reports for healthcare and prescription drugs. People need a plain-english reference tool so that when they go into their provider they can ask intelligent questions about their treatment. I'm not sure how to get to that, considering the number of drugs, policies, and types of coverages, but more information will only help the consumer in the end.
Thanks for posting a link to that article and making the highlight. My team is currently crafting copy around this issue for the next open enrollment period, and I've forwarded the link to our head of HR and benefits management rep.
One of my relatives is in hospice for lung cancer. They don't expect her to live much longer than 4 more months.
She fell and broke her hip last week and has insisted on a hip replacement. Medicare is paying for the replacement and the following physical therapy. Costs are expected to run over $100,000.
I love my cousin, but I really do not think this is a good allocation of resources.
I don't know. I assume that whereas private insurance companies retain the right to refuse this sort of treatment, it nevertheless falls under the category of procedures that Medicare pays for routinely. They wouldn't turn down a hip replacement for a healthy 65-year-old, so they're not going to turn it down for a terminally ill 82-year-old.
I am assuming that Medicare doesn't get to pick and choose which services it will provide to which patients. If a service is provided, it must be provided for everyone.
That's ridiculous. She's in hospice, for chissakes. Doesn't hospice = palliative care? IMO, a hip replacement != palliative care. It should really be set up so that you can have one or the other, but not both -- IOW, if she were still agressively treating the lung cancer, fine, go ahead with the hip replacement as though you're assuming the cancer treatment's going to work. But once hospice is started, it should be another story.
It sort of half-assedly is. She had to leave hospice for the hip replacement, and she can't go back until the rehab is done. She will almost certainly die first. I honestly don't understand why she wanted it done, unless she was overcome by huge gushing waves of denial.
TennCare never was in good shape. It was and is poorly managed and abuses were rampant.
I won't go to a link that requires registration, but I'm judging from the title that the article is covering the staredown between Gov. Bredesen and TennCare's lobbyists.
The idea behind it was well-intentioned: create a health care plan that would charge on a sliding scale so everyone had some coverage. The problems were myriad: Some providers and participants saw the plan as a cash cow to be milked. The byzantine precert procedures made it a headache for people to get care and doctors and care groups to get paid. I could go on, but I think you see my point.
I think those problems would be present in a federal health care plan as well, rufus. In fact, I'd say they'd be exponentially larger because the feds are even more remote than the state, and the incentive to milk the cash cow is ever greater.
One thing I noted about the Tennessee plan was that they initially had no income limits on who qualified, so that it quickly became used by a significant portion of the population who didn't need its coverage (having either alternative coverage or the income to pay for such coverage). This must have been a political compromise to get the law enacted, but it should also be seen as one of the fundamental flaws of the program.
Another issue that struck me was that this sort of plan must include a detailed breakdown of what will or won't be paid for by it. I think again, the TennCare program only came to those kinds of detailed decisions after the system was well in place.
A state or federal sponsored health care plan could work, but only if it is limited to those of a certain income level and only to cover necessary procedures. Lizzie told a story recently about a relative who is terminal and yet was able to get either Medicare or her state Medicaid to pay for an expensive hip surgery procedure even though she may die before fully recovered. Now that is both unnecessary and wasteful of public resources, although certainly compassionate on the part of someone who approved it. These sorts of stories must be eliminated if we go for a national health care plan for the poor.
I'm really pissed -- we got a letter from our pediatric ENT that they will likely not be able to come to an agreement with our insurance company over reimbursements, and will therefore, no longer participate with our insurance company. I am very loyal to this doctor; he's taken care of both my kids and is the best doctor we've ever had. This is the first time we're facing not being able to have a doctor we want because of insurance restrictions. I know it's a first-world problem, but I'm angry nonetheless at either (a) the doctors' greed or (b) the insurance company's refusal to pay the standard wage. I think it's the latter, according to our local newspaper (this company's rates are the lowest in the region). However, I wonder about (a) because I know that the health care system in which these doctors work couldn't come to an agreement with another insurance company as well.
I lost my kid's ENT too. And I hate the new one--she's very forgetful. The old one left a fairly large clinic which was on the plan to start his own practice, and he didn't affiliate with our insurance. Now that our insurance company has been bought out, I wonder if he'll be back on our list? Hmm, I hadn't thought of that before. Must check.
I need to check for rheumatologists as well, although I'm not optimistic. I like mine when I finally see him, but it's always at least a 30 minute wait and often an hour or more. I walked out before seeing him (actually, his PA) last time and have not yet followed up in any way. As a specialty, it seems to be way overburdened and they all have too many patients and not enough time. Or so I hear anyway. But you know, my case could probably be managed by seeing my GP more often and only seeing the specialist once a year or so (I see him every 3-4 months now). They do blood tests to check for various things, and may adjust my medication based on those. They examine my problem joints. I used to alternate between a nurse-practitioner and the doctor. Now they seem to have me seeing the PA all the time, but when I see him, the doctor always comes in at the end (not the case with the NP), so I'm not sure how much of a savings there is as I'm still taking up some specialist time. And my copay is the same no matter who in the office I see--I'd be curious as to how it's billed to insurance.
The insurance companies all have incentive to drive down prices/costs. The fact that your doctor couldn't come to an agreement with multiple insurance companies may only mean that they were all low-balling him.
The pediatrician my mom works for has a hard time getting insurance companies to cover the straight cost of things line vaccinations. It makes it extremely difficult for him - he wants to accept people's insurance, but how can he run a business where he loses money on each transaction?
Write the insurance company a letter and tell them how pissed you are. My doctor almost dropped my previous insurance but then they worked something out and I'm pretty sure it had to do with pressure on the insurance company, not the doctor.
High Prices: How to think about prescription drugs.
The whole article is really interesting. The paragraph I copied was something that I didn't even know before I read the essay.
The article had some suggestions that I thought were sensible. There has to be a financial incentive for the consumer of the drug. So, having the consumer pay the difference between the older and newer medication may be one way. The problem that wasn't addressed at was that there is often no incentive at all for a consumer to get an OTC medicine. If they have a generous prescription plan, why not get a scrip for Nexium instead of using Prilosec OTC?
My plan did require me to try OTC Zantac in increasing doses before I could get Prevacid (years ago). I had to do the dose on the package, then 2x and I think even 3x. However, they cheerfully allow me to get 800 mg of ibuprofen.
I am in the midst of exactly this right now. I use Zyrtec because Claritin doesn't work as well for me as Zyrtec. I can't say it is completely ineffective, but by comparison it is. Because of the improved effectiveness of Zyrtec, I also take significantly less - I take them only when needed rather than one a day. (Claritin takes 2-3 days to start working and doesn't work as well once it does start. Zyrtec works within 2-3 hours. Since it helps stave off eczema, I can't wait 2-3 days once I need relief, not to mention how irritating it is to walk around for 2-3 days with an allergy attack, waiting for the goddamned medicine to start working.)
My insurance company wants my doctor to call and explain all this to them before they'll let me renew Zyrtec. Which sucks, because I didn't try Claritin with this doctor, I tried it with the doctor when I lived across the country on a different insurance plan. So I'm not sure if my doctor can tell the insurance company that I've tried Claritin, since she has no knowledge of it.
Plus, Claritin OTC is less expensive than the $35/30 pills that is my Zyrtec copay. I get that the insurance company doesn't want to get ripped off, but I am smart enough to want to pay less for my prescriptions!
Mostly I think the policy would be good if it were for new prescriptions. Telling me after 6 years on a medication that works that I have to go back to one that doesn't, just in case, is pissing me off.
I wonder if giving incentives to the doctors is a way? Doctors are sometimes ill-informed about the medications they prescribe. How many patients are actually pushing for a script to Nexium over Prilosec?
If you had your records transferred from Old Doc to New Doc, New Doc can read your records and affirm that you tried Claritin.
Keep working with your MD to petition the insurance company to add Zyrtec to your Rx plan or for an exception for your use. You have already done what the plan is asking you to do--step through the basic (cheaper) medicines to the more expensive medicinces in a methodical way until you and your MD find one that works for you. You might also want to get the benefits person at your company (if this is employer-sponsored health insurance) involved. There are appeal processes that you can go through to get an exception for Zyrtec so it falls under a more affordable area on your Rx plan.
I am not advocating that everyone go through this pain, and it is a huge pain to go through a formulary appeals process, but rather that those who have already diligently worked with their MD through all the drugs on the formulary for any particular condition, and find that the non-formulary, brand-name drug actually DOES have the best affect will have the best chance of getting an exemption from your Rx insurance provider.
I don't see why insurance companies should pay for a more expensive medication just because a cheaper one doesn't "work". Pain experience is notoriously subjective. So if cheaper meds don't work for a person, why isn't it up to them to eat the additional cost?
How do you prove that you tried something, especially if its OTC? Do you have to submit receipts?
Pharmacies are a middleman, it turns out
The mom and pops are a done deal, it looks like. But it's interesting to see how the larger chains are fighting back.
I get long-term prescriptions through Caremark, and it's very convenient. Like Netflix for drugs. All I have to do to refill is go online or call in, and then send in my prescription once a year. It saves me and my employer money, and really, what's not to like?
It does suck that the mail-order business appears to be the death of the mom-and-pops, but weren't the big chains running them out anyway? Plus, mail order is for prescriptions of 90 days or greater, so scripts for stuff like antibiotics still get filled at the corner drug store. I guess that's not enough to keep them in business.
I want a mail-order option, but they don't allow it on our plan. We'd have to use a local pharmacy anyway for scheduled drugs.
I can refill a script a certain number of days early, and if I pay attention can build up a decent "buffer" of doses. It seems that it would be harder to do this on a mail-order plan, since I assume refills would come automatically.