I write about America’s health care system, and I got caught up in it
nakedcapitalism.com
nakedcapitalism.com
Seniors write in about how they’re eating dog food to pay for their medicine, I forward the letter to insurance doctors, who deny it because they “have to try these 3 drugs before you can get what works”.
Made me realize this whole country is broken and those at the top are morally bankrupt.
Why use a $1000 per month branded drug unless you know the $5 per month generic drug doesn’t work?
It’s reasonable to expect people to exhaust lower cost alternatives, that are reasonably expected to work, before stepping up costs.
The problem is, you won't be able to hammer down the health of the patient to the lowest cost option, only the most effective.
This also happens if the employer switches insurance.
So no it isn’t as innocent not as simple as saving costs for generics. This makes sense for the first time the patient seeks treatment. This doesn’t make sense if the patient already has a treatment plan that works and the insurance company decides they want to do the whole pony show again, fucking in peoples life for months.
A [relatively] well known exception is anticonvulsants. My younger brother paid for that with his life. I hope the FDA figures out how to properly evaluate generic equivalence.
They shouldn’t have, though. Injections (what I’m on now) work better. They’re easier to maintain the correct dose, you don’t have to worry about getting it on your partner/kids, you only take it once every week or two…and it’s maybe $20 a month.
That’s not just a few dollars saved. There are probably hundreds of thousands of men out there that take it. I see there’s a generic gel now but it still costs anywhere from $60-$150 a month.
Too bad it’s $1,000 a month. We’re all paying that so people can avoid sticking themselves with a needle.
We don’t spend 100x on a drug because a doctor “has a feeling”.
The insurance requirements are typically quite limited for 1st line failures. Doctor just needs to prescribe then 2 weeks later attest that it didn’t work.
Seems reasonable to save the healthcare system thousands of dollars when tens of dollars would do?
Maybe you're talking about different medicines that people are using (like different insulins), the generics use the same formula as the original.
The only sane response to that is “okay, I won’t give my kid either of those; we’ll just stick with OTC lotions”. Which is exactly what they intended.
You lost me there. What makes it immoral? Money is an asset allocation tool, so why is it morally wrong to use it for medicine the same way we do for food and housing?
Genuine question. I have a hard time understanding what sets medicine apart from everything else when people think healthcare should be universally free, but not food, water, clothing, housing, etc. especially considering those other things are more directly necessary for survival.
If you have cancer though than basicall the market cannot find a price, and it would tend towards to: 'give me all you have'.
Yes it can... there is more than one oncologist in the world. Competition exists.
As for if youre talking about the chemo drugs, you don't have to use the latest-and-greatest on-patent treatment. There are now decades of drugs that are off patent. They may not be as good, but then again, it is your life so many choose to pay for the new better ones. If it was illegal to pay more for better drugs than they would never exist (and don't talk to me about government funding; not a single socialized medicine country has innovated any drug of value in the past 50 years, and yes, they do steal from us in the USA by taking our IP and not paying for it).
Changing housing situations is exactly as easy as changing hospitals and emergency rooms no? Since the latter are mostly decided by where you live. In fact, most mid to large cities feature many hospitals near any given residence, so it is actually easier. I would also point out that the demand curve for housing, energy and food are far more inelastic than for medicine.
> If you have cancer though than basicall the market cannot find a price, and it would tend towards to: 'give me all you have'.
Why couldn't the market find a price? Cancer actually seems like the worse example possible. The people I've known who've been diagnosed with cancer have shopped around for care from many different hospitals. It would seem that cancer would be the perfect candidate for market forces to lower prices since a diagnosis generally affords a bit of time to find and decide on treatment options. Even in the extreme case of 'you have months to live' people tend to spend a few weeks collecting different opinions.
that's before even getting into pharma. which can charge millions of dollars for life saving/changing drugs for single course treatments. hell take a look at what happened with epipens. there is no protection against profiteering via nebulous 'markets' when your choices are 'purchase or die'.
This account, or at least should account, for a very small minority of interactions with healthcare facilities. Saying that's why the whole market is defunct is recklessly reductionist.
> markets don't deal with this situation well.
They don't deal with it at all. Imagine if some people needed bread or they'd die, would that change the price on the shelf? No, because the bread didn't get there because of that niche market, it got there because most people eat it. It is the same with healthcare. If a hospital exists because people routinely visit the doctor, some people needing their life saved isn't going to suddenly change prices.
> that's before even getting into pharma. which can charge millions of dollars for life saving/changing drugs for single course treatments. hell take a look at what happened with epipens. there is no protection against profiteering via nebulous 'markets' when your choices are 'purchase or die'.
Totally agree. The issue there is regulation and how we allow companies to be a position of no competition. If the government stepped in and payed those prices for you, it wouldn't solve the problem.
sadly its not. you're in pain? you need to visit a medical facility to figure out whats wrong. without knowing how serious it is it can lead to a life long issue. again you don't really have choices here. pay the healthcare tax or risk long term issues.
there is a reason preventative medicine is cheaper (overall) than delaying care until a condition has progressed.
the capitalists idea of a market simply doesn't apply to healthcare.
> If a hospital exists because people routinely visit the doctor.
this isn't true. we fund hospitals in rural areas because there literally isnt enough people to keep one operating via patient care.
you're also asserting that if the populace can't sustain the healthcare system then it shouldn't be available to people. which is fairly cruel and immoral.
I don't see how that is a congruent thought. The 'sadly it's not' doesn't follow from your statement after. If you are in pain without knowing how serious it is, you would likely get opinions from several doctors. You're not going to walk into the first hospital you find and say "I'll pay anything you ask just fix me."
> the capitalists idea of a market simply doesn't apply to healthcare.
You still haven't made a logically coherent argument as to why it doesn't. The vast majority of healthcare transactions are made between two lucid and consenting parties.
> this isn't true. we fund hospitals in rural areas because there literally isnt enough people to keep one operating via patient care.
That backs my point, right? Those hospitals aren't funded by emergency care either, which means the point about costs being a one sided negotiation while the other party is dying is still inaccurate.
> you're also asserting that if the populace can't sustain the healthcare system then it shouldn't be available to people. which is fairly cruel and immoral.
I don't think recognizing the limits of a given resource is cruel or immoral, it's reality. Us not having perfectly clean energy is killing us all, but it isn't cruel and immoral, it's a problem that needs solving. If a town can't afford a hospital, and you want to live in a town with a hospital, move, right? I don't see any reason why taxpayers should pay so a small mountain town in the middle of nowhere can have a staff of doctors and nurses to support a population of 100 people. If someone wants to live in the mountains of Oregon, I don't see how we have a responsibility to pay for a medical care facility to follow them up.
> You're not going to walk into the first hospital you find and say "I'll pay anything you ask just fix me."
these two statements are functionally equivalent. by running around paying every hospital for opinions you're literally saying 'I'll pay anything you ask just fix me'. It also tracks with my statement that medical pricing isn't influenced by rational markets which are what is required for a capitalist free market to 'work'. people need to be able to say 'this is unnecessary' which never happens in health care.
In healthcare you have two modes: 1. I can afford the care, price is fairly immaterial make me better. 2. I can't afford the care, doesn't matter what the price is.
> that backs my point, right? Those hospitals aren't funded by emergency care either, which means the point about costs being a one sided negotiation while the other party is dying is still inaccurate.
not sure how you get to this idea. the point is you're hung up on the dying aspect which is basically immaterial. I can torture you and get you to say anything I want. medical care is basically the same thought process for those who need care. The only thing that prevents people from paying any price is literally not being able to afford it. Otherwise people will 100% bankrupt themselves to make pain go away.
Given that the majority of bankruptcies in the US are due to health care just proves this point.
There is no way to make this kind of market work in a 'free' market system.
> I don't see any reason why taxpayers should pay so a small mountain town
we already do. you can argue whatever you want but as a society we've already mandated this level of access. for the same reason we've mandate fire and police coverage. its a public safety issue and a tax payer in bum fuck no where have the same right to have their taxes ensure they're covered as joe shmoe in NYC.
There are MANY reasons why this is economically a good thing via 2nd/3rd order effects that more than pays for itself.
> I don't think recognizing the limits of a given resource is cruel or immoral, it's reality.
every country with universal coverage disagrees with you. I'm not going to belabor this point further. Reality has proven otherwise. The US system is just completely dysfunctional. and thinking otherwise DOES make you cruel and immoral. If you want to discuss how to make a healthcare system that works, fine, but I'm not going to moralize with you on a clearly disgusting world view.
No you're not. You can choose which hospitals you're getting opinions from.
> In healthcare you have two modes: 1. I can afford the care, price is fairly immaterial make me better. 2. I can't afford the care, doesn't matter what the price is.
No it doesn't. I've shopped around for PCP. It wasn't like that at all. Do you think every doctor works in an inner city ICU or something? I'm not sure where you're pulling this view from.
> Given that the majority of bankruptcies in the US are due to health care just proves this point.
What point does it prove? I don't really see what point you're making. Is it the US system has major problems? If so, I agree. Is it that nationalized healthcare is the best choice? I haven't seen you make an argument for that at all other than conjuring your own personal ethical code.
> these two statements are functionally equivalent
I'm trying to make a coherent point, so that makes sense.
> not sure how you get to this idea. the point is you're hung up on the dying aspect which is basically immaterial...
So you agree with me now? Emergency care doesn't play a major role in the market?
> we already do. you can argue whatever you want but as a society we've already mandated this level of access
I'd like to see the mandate you're referencing. Sounds like you actually agree with codifying qualifying circumstances for care ;)
> every country with universal coverage disagrees with you
No they don't. Countries with nationalized healthcare routinely ration care. They recognize limited resources same as us, just through a bureaucratic system a oppose to a market system. Just because it's a man with an office deciding if you get to see the doctor rather than your bank account doesn't make it morally superior.
> If you want to discuss how to make a healthcare system that works, fine
This is the discussion I've been getting at the whole time. You're the one constantly conjuring some vague sense of morality as opposed to discussing which models may work better than others.
you clearly don't understand how hospitals work. getting opinions costs money. just visiting and taking their time costs money.
you can get a hospital to quote you the cost of a procedure. but to actually get a doctor to diagnose you takes time, resources, and tests. this costs money. and without doing said work you have no idea what procedures to get a quote for.
and frankly the only reason to get multiple opinions is if the current doctor has failed to resolve your problem.
no one jumps doctor to doctor unless there is something wrong with the current one like a lack of progress on resolving the issue.
> You're the one constantly conjuring some vague sense of morality as opposed to discussing which models may work better than others.
without understanding the moral outcomes of an economic system makes any such discussion meaningless. You should checkout Albert Hirschman https://www.ias.edu/press-releases/albert-o-hirschman-1915%E...
Proof? Services not typically covered, like plastic surgery or cosmetic dermatology. Clearly listed and even advertised prices for their services, openly discussed up front.
But if the govt reimbursement rate for an annual checkup is $x, why would anyone need to list that price up front, or have reason to ever charge any less?
The US has a rule about “usual & customary price”. That’s a legal definition and providers can’t charge any customer more than that.
If you’re looking to price discriminate, you set your U&C price as high as possible, maybe 2-5x what you’d accept. That way if you find a customer willing to pay 4X, you’re not running afoul of the law.
For everyone else, you negotiate a much more reasonable net price, typically through insurance.
The people who get screwed in the end are ones without insurance. They get billed the imaginary number nobody ever intended anyone to pay.
And indeed the US has many such services, though they are often overwhelmed, or performed through a complex set of nonprofits combining govt funds with donor money as best they can to provide good support. Sometimes they are overwhelmed specifically because of externalities related to the for-profit insurance healthcare system. The high and often unpredictable cost of any medical situation, means people with tight budgets become sicker before getting care, if they ever get it, leading to a higher percentage of bad outcomes, up to and including job loss and homelessness for the individual, and knock-on effects for the rest of their family. This puts extra pressure on the parts of the support system that do exist - those already mentioned, and, of course, the police, who end up getting called to many situations that could have been prevented by the people involved having better services to begin with, to meet their health, food, and housing needs.
Isn't it though? "This thing should be free for everyone all the time" is a lot different than "we should help people out a little if they're down on their luck". Temporary housing, food banks, etc are the latter, and I'm all for the same with medicine. The fact that food and housing are subject to markets makes it easier for organizations to carry out such missions, which is one of the barriers you mention in your second paragraph when you talk about the complexities of dealing with insurance companies.
And creating a public market necessarily diminishes the private, driving up costs, as purchasers are now competing with government for the same supply.
Medicine is a scarce resource at this point, and, generally speaking, giving care to X often means Y won't get it. The fundamental problem with medical care is supply, lowering barriers for demand isn't a solution to that.
That last bit is exactly what we're in disagreement about, and I haven't seen a good case for it yet.
> In the U.S. system denials of care by insurance companies are not done so another person can get said care
True.
> They are done to increase profit margins
Indirectly, sure. Its a business where money out must be less than money in.
> and profiting from denying someone care is immoral.
Again, this is the disagreement, and I'm not really seeing a good argument for that being the case. Some people should be denied care. I don't see why performing a necessary function shouldn't be profitable, especially when it's beneficial to everyone in times of scarcity, like now.
I am not more important than you or anyone else. I don’t deserve health care before you just because I have more money. That’s a perverse idea. Unfortunately too many Americans embody the Bible’s warning regarding the love of money.
> Police, most roads, and certain aspects of the legal system are free at the point of usage.
Sure, and those generally work well because the overhead is low. The per person cost of all of those services combined is extremely low compared to medical expenses. If giving everyone healthcare cost the same as giving every 911 service, this conversation wouldn't be happening.
> It’s bad to have for profit police, court system, and Air Force.
I think government and the monopoly on violence are generally good so long as the government is democratic, so sure.
> Some things ought not be profit driven
Totally agree. Executions and jails for instance. Anything were the service involves inflicting violence or removing rights is probably better left to a democratically elected organization.
> It’s quite disconcerting that someone sees no problem with a person profiting from denying healthcare. I should not be able to enrich myself by denying you health care. Tough decisions need to be made and the motive for the decision should not be profit.
You're confusing the role with the action. I think 'being the organization that prioritizes care' can be profitable and ethical. That's different from saying 'an organization should get paid for saying no to someone'. Those are two different things and you're assuming that you can't have the first without the second. The insurance company doesn't make money off 'saying no', it makes money off codifying rules that distribute healthcare and enforcing them on a set of people buying into those rules. When more people are denied they make more money, but they aren't 'denying to make money'. It's a different incentive structure from you're describing. Also, nobody in that scenario is 'denying care' they are denying paying for the care. You're still free to go receive the care and pay for it yourself. You can also find a charity and convince them to pay, or crowd fund. That's actually a benefit of the market driven system: there is no such thing as a 'hard' no.
> I am not more important than you or anyone else. I don’t deserve health care before you just because I have more money. That’s a perverse idea.
Totally agree. Having the ability to purchase something is not the same as 'deserving' that something. Two entirely different concepts that live in different systems. One is grounded in the philosophical idea of fairness, and the other in the physical process of voluntary exchange.
> Unfortunately too many Americans embody the Bible’s warning regarding the love of money.
Totally agree here too, as an agnostic, although that's kind of a tangent.
Anyway… I think both systems are very similar in the end. Rich (or even middle class) gets great service in premium facilities. Average folks get OK service with some downsides, likely paying out of pocket in various ways. The only difference may be poor people coverage which is subsidized by upper tier payers. Who themselves may never use public service and go to premium only.
Also, another major difference may be the big expensive procedures. Aside from the 1%, people would do the procedure in public hospital because it’s crazy expensive otherwise. But everything else leading up to it and recovery after it more likely to happen in premium market since it’s much more affordable.
EDIT: After further reading it appears that private health care is a murky area in some provinces. My above stated belief appears to be wrong at least in terms of how things actually work there. Here is my view. Private medical care should be banned.
On top of that, official medical staff wages were crap. People were forced either work for peanuts (IMO nurses and doctors jobs are damn hard and they have to be paid well), take money under table or... emigrate.
Now we have mixed system and it's definitely better than it was before. Doctors gets paid well. Elite doctors tend to work 2-3 days in private clinics and then 2-3 days in public hospitals so you can still get hold of them for free. Those who have an inch for premium services can pay local&legal, so local economy wins.
These seniors should vote for and advocate for a more expansive social safety net then.
Why don't I throw you in a cage, and then you can try voting for someone to advocate for your release.
The point is the seniors need help now, not being told to go organize. The healthcare system is broken, and until you get sucked into it, you don't understand the extent of it.
It's different for people less fortunate than ourselves. We all mostly work tech jobs with great pay and decent insurance. These people don't have that. A lot of them can't pay for food.
So yeah, I'm doubling down. Downvote away.
Why is it so hard to say the healthcare system is broken instead of blaming the seniors.
That dude's throwaway is doing real damage by normalizing the deflection of blame onto the patient.
They've spent their lives participating and interacting within the current political framework. Blaming all problems at the feet of "morally bankrupt leaders" is hyperbolic populist rhetoric to absolve personal responsibility.
Broad platitudes like "everyone should have access to healthcare" doesn't count
Most likely we need to reform the insurance industry, but systemic changes are definitely needed.
I get denied health insurance policy itself due to my physical disabilities against the local laws and regulations in my country[1]. That includes major International brands.
How can I put this gently, capitalism thinks I'm not worth living or saving.
[1] https://abishekmuthian.com/insurers-are-putting-the-lives-of...
- What did the insurer expect to happen, in order for this person to keep getting their medicine?
- Why did those things not happen?
- Whose job was it to make sure those things happened?
- Did that person know it was their job?
- ...etc.
I get that it was about prior authorization, but whose job was it to make sure the prior authorization happened? Why didn't that person do it in a timely fashion? Why isn't there an understanding within the insurer's system that Type 1 Diabetes is a life-long condition and not something that will just go away when the insulin runs out?
Was there a "happy path" here or does a scenario like this invariably degenerate into a scramble involving dozens of calls and day-destroying last-minute errands?
This statement about what a prior authorization is is also incorrect:
> They’re essentially requirements that a physician get approval from an insurance company before prescribing a treatment.
Doctors need no approval from anyone to prescribe. A prior authorization is approval from the insurance company that they agree with the treatment option and will pay for it (subject to deductible/copay/oop max).
The theory here is that the end user has no idea what they are getting since they are not knowledgeable about medicine. Doctors could be prescribing unnecessarily expensive medicine or treatment, so the managed care organization (MCO, or insurance company) “manages” the healthcare for the uninformed buyer by having the healthcare professionals employed by the MCO double check things.
In this specific person’s case, it looks like the biggest delay was in getting a doctor’s appointment when he needed both a new MCO and a new doctor. Technically, you can pin this on undersupply of doctors, MCOs tied to employer, MCOs not hiring good people and causing unnecessary delays, incompatible electronic documentation systems that do not talk to each other, and I could go on and on.
Ideally the doctor should be able to see what medications the MCO will cover on their computer while the doctor is seeing the patient so before they even leave the doctor’s office.
Another concern in the long list of concerns is the MCO is not necessarily the one deciding the rules for what treatment/medications to pay for or not. Many, many times it is state government (e.g. Medicaid), federal government (e.g. Medicare/Tricare), or other entity that is actually paying for the healthcare who will hire the MCO and give them the rubric on how much to pay for people’s healthcare/what treatment courses or brands of medications will be covered. This is how poor people (Medicaid) can be restricted access to healthcare by limiting the reimbursement for their healthcare so fewer doctors accept it while older people or members of military get access to better healthcare because their healthcare gets reimbursed at higher prices (Medicare/Tricare).
The system allows for a lot of opacity to allow for a lot of price segmentation while also providing political cover for such decisions due to the complexity of understanding it.
1. Wait for prior authorization and allow our appointment to be canceled and rescheduled (for the fourth time, having already wasted several weeks)
2. Pay out of pocket
We decided to pay out of pocket, since we knew that the prior authorization could delay us by an arbitrary amount of additional time and had recently read that the insurance might not even help us anyway.
The twisted thing is that you can't just get the operation done and let the prior authorization work itself out later. It truly has to be prior or you get stuck paying out of pocket, even if the operation is obviously medically necessary.
This structure seems expressly designed to screw the patient over. Maybe it doesn't prevent the doctor from prescribing, but it has a similar impact in the end.
And regardless of my anecdote about prior authorization, there is the question of why someone with Type 1 Diabetes is being denied their medicine. I feel like the only potentially valid excuse would be if the insurer literally didn't know the person had Type 1 Diabetes.
I have had doctors collect payment, and then refund me once they get paid by the MCO.
One more thing that would help here is decoupling employers from your MCO. That way, when you change employer and location at the same time, it does not mean you change your MCO. If the person who wrote the article had the same Blue Cross Blue Shield MCO (or other MCO part of a nationwide network) with old and new employer, then he would have had no reason to seek out a new doctor and new medication.
While insurance tied to your employer sucks, I think the best thing to do here is for the law to iron out the data interchange between MCOs. In a "marketplace" like the US, insurers must be under a dire legal obligation to transfer your data in a comprehensive and timely fashion to whoever is currently administering payment for your care. Especially when lifesaving medication is involved.
The patient should not be held hostage by the incompetence of MCOs at communicating medical data.
I forgot to respond to this in your prior reply. The answer here is because insulin is not just insulin. There are many different formulations and brands with many different prices.
Even the federal government does not want to pay for all of them:
https://www.healthline.com/diabetesmine/new-medicare-program...
So one could say it is about money, or how much extra money is politically available to spend for the marginal benefit (population wise) of certain insulin.
That's ignoring the fundamental cosmic absurdity of this entire system, with its pretense to be some kind of competitive private market with the usual benefits of such. When in reality, insurers are just a bunch of hogs at the trough that you're shuffled between as you change employers. The private market does not seem to create any sort of incentive for efficiency or a better consumer experience.
It does make life easier for providers and patients when there is one system that provides quick definitive answers rather than back and forth. On that front, there is much improvement to be made in electronic communications between healthcare providers and MCOs.
On a positive note, this is happening via electronic prescriptions and integrated EMRs. I have seen my kids’ doctor pull up covered medications in their system and then quickly sending the electronic prescription to the pharmacy.
> But I'm sure this would create other problems and snarl the system with even more complexity.
There is absolutely no reason for employers to be involved in your healthcare. They currently are able to use it as a leash around your neck because paying for MCOs via your employer means you get to purchase with pre tax dollars. Paying yourself means you have to pay with post tax dollars. I am looking at my box 12 code DD total, and for me that is $32k of insurance premiums I was able to pay with pre tax dollars.
More importantly, it gives employees an additional hurdle and fear of changing employers, because what if they have to go through what the person who wrote this article did? Maybe they should not shop around to see if they can sell their labor at a higher price, and just stick to their current employer. Another unnecessary chip for employers to have over employees in the US.
This is horrifying to contemplate... do employers just love that chip so much that they see it as worth all the terrible customer experience and inefficiency it causes? Do they lobby to keep it this way?
Let us let businesses pay for MCOs with pre tax dollars. But not individuals, that would be undesirable….why?
Let us let businesses select retirement fund options for employees, and then let employees save $21k to $50k per year of pre tax money if they invest in their employer’s retirement savings options (401k).
Let us only let individuals save $6k pre tax in their own retirement account, without the meddling of employers. Let us go one step further and phase this benefit out if one employee works for an employer with 401k and the other does not.
As of 2020, let us let employees pay for student loans with pre tax money if they pay through their employer. But not students who pay themselves.
Let us pay for public transit with pre tax money, but only if via employer.
And so on and so forth. You see TONS of laws that explicitly give an upper hand to employees of well funded employers, effectively giving a competitive disadvantage to employees of poorer employers (small businesses, immigrants) and simultaneously incentivizing those who do work for well funded employers to not seek other options, such as starting their own small business.
And if they want to grift their employees by giving them bad fund options because of some kickback the fund provider gives them, they can.
Which self insured employers pay for directly.
So the barriers to switching aren't necessarily good for the employer either, because the more reliant someone is on their health insurance, the more they cost the company, and the less likely they are to ever leave.
I am in favor of the US federal government to spend money on R&D for medicines resulting in fewer patented medications resulting in lower cost medications. And also reforming the process to becoming a doctor because obviously people want more doctors. Not necessarily making doctors less qualified, but the whole spend your 20s torturing yourself is unnecessary, along with wasting 4 years on a bachelors.
To the consumer, the experience is the same - they can’t get a necessary drug before spending hours or days playing telephone tag with their doctors office and insurance company. Often, this happens for a drug they’ve taken their whole life. Insulin, thyroid hormone, etc.
Well said overall, but the supply of doctors isn't the issue here (regardless of if it's a separate, bigger problem).
1) This case is what mid-levels are ideally suited for. Routine and can be seen within a day or two. Would have moved the whole timetable forward.
2) It's the supply of doctors participating in any given insurance plan or govt reimbursement scheme, not overall supply.
It's pretty easy to find a doctor to see same-day if you pay cash (either straight cash or front cash and submit your own reimbursement).
Which is itself more an issue about regulation being so burdensome and costly that doctors can't afford it without joining a large group or hospital owned practice. Especially the cost of required electronic records.
Which is why it seems like all the small private practices are being bought out by hospitals. Because they either are, or their docs are retiring, or they are opting out of all insurance and govt plans and going concierge/prepaid/membership/cash-only.
What I'm curious about is #1: why couldn't this person get in to see a mid-level sooner? They rarely book more than a few days out.
It's exactly the type of issue that they are meant to help with to reduce demand on the doctors and get patients seen quicker. A routine refill without any nontypical complexities or changes to report.
Did approval specifically require a physician? That would be more of a system problem that needs resolving.
https://www.healthline.com/diabetesmine/new-medicare-program...
The whole thing is performance politics to distract from the "insurance" companies running everything from medicine regulations to your kids playgrounds (so they don't hurt themselves and need care).
https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...
With the recent laws regarding mandatory coverage of emergencies while out of network, it seems to qualify for the definition of “insurance”, as you are protected from expenses above $17.4k per calendar year per family.
The fact that most Americans probably cannot afford this is a separate matter, but it is more insurance than it has ever been in the US.
The US is pay $400 to $1,200 per person per month from age 0 to 64, and then pay up to $8,700 individual / $17,400 family per calendar year.
At age 65, the government starts paying for your hospital care assuming you or your spouse paid Medicare taxes for at least 10 years, and you then have to buy a nebulous blend of subsidized care / insurance for other things like medication, doctor visits, etc.
Given that this applies to in-network costs only, as you noted above, it seems very inaccurate to describe it as genuine protection. Any random provider in your current care situation can be out of network, it is very hard to know or have any control over especially in a crisis situation, and it is these providers that usually end up billing you through the nose.
It would be irresponsibly misleading to call your life insurance "protection" if the insurer just rolls a dice or consults the day of the month to determine if they'll pay your claim.
https://www.cms.gov/nosurprises
https://www.hhs.gov/about/news/2021/07/01/hhs-announces-rule...
For non emergency care, it should be easy to login to insurance company’s website and see if doctor or doctor group is in network or out of network.
Insurer websites have lied to us in the past, claiming X was in network (zero cost!) and then sending us a denial resulting in a giant out of network bill for that exact X. Same service, same provider.
Truly incompetent and evil system. Fills me with rage.
Now I feel like I will have to screenshot and archive every digital representation that is made to us about whether X will be covered and be prepared to initiate a lawsuit over it.
In the meantime we will simply not be paying the bill. I've been thinking about doing this for many other medical bills we receive as well. It's all so arbitrary and uncontrollable. I simply don't feel I have an obligation to pay a bill in a made-up amount for made-up reasons I have nothing to do with.
I am a very reliable bill payer and normally see it as a basic matter of personal responsibility, but this broke me.
It won’t help you now, but before any expensive visit, you should call your insurer and confirm they are in-network (doctor and clinic). A note will be made in your file as proof.
Your example is leagues of laws and regulation on top of a scam, a pyramid model that affords top care for those who can afford modest premiums and really do get expensive care for $5 copay, at the cost of everybody else who has to fight their employer via federal politics for the right to go bankrupt.
Indeed, I would say that using insurance to pay your insulin bill is coming out on top of the scam, because some books are getting cooked (+/- paper costs) at the expense of mutual indemnity (taxes, social security). An insulin user is a health insurance voter, but that is a weak expediency for actually fixing the price of insulin and ending the tyranny of insurance companies over healthcare, and it turns whole populations into do-or-die partisans.
Thanks, Obama!
Yes, thanks for getting the only legislation passed in the past 30+ years that expanded access to healthcare.
FYI, ACA is what made it possible for people to even purchase healthcare coverage without an employer. And also, taxpayer funded healthcare (“public option”) was preferred by the Obama administration, but had to be whittled down to meet the compromises needed since there was basically zero support from across the aisle.
The tax benefits of health coverage via employers is a separate matter, and while it should have been addressed, I am not surprised nor would I blame Obama for that, since it was already hard enough to get what we currently have passed.
As an analogy in the case above the car owner is having their insurance company pay for their gasoline - where you are referring to an insurer paying for a car accident.
I can see their point now, but at the time I was thinking relative to other taxpayer funded healthcare systems.
This is also a consequence of our legal/tort system. At one of my business, a person claims to have stepped on a landscaping rock and damaged their ankle or knee or something. They took pictures of this roughly 2in x 2in x 2in rock in the parking lot, maybe a foot away from the curb that separated the landscaping rocks and the parking lot surface.
This lawsuit has been going on for 3 years now, and I can only assume $10k+ in lawyer time has been spent asking the employees if they saw a rock there and when they last checked the parking lot to see if it was clear of rocks, etc.
With the courts accepting cases like these, and businesses needing to protect themselves from cases like these, it is no wonder as a society, we end up wrapping ourselves in insurance. Specifically in this case, the person or family suing has been found to have a history of these types of lawsuits. And yet still, the case drags on.
Wife was on some serious (and expensive) medical treatment. After many months, the medical provider was at the final stages of the treatment. As usual, the provider needs insurance approval for arcane codes that constitute that segment of the treatment.
Get this, the medical provider applies for approval using a FAX. There is no acknowledgement or online tracking. And the authorization is received back using FAX. What a joke!
My wife didn't hear about the treatment for 3 weeks. Under pressure, she called her insurance. Insurance says, they didn't receive any request for authorization.
Why the fuck didn't the medical provider follow up? Exact question asked by my wife. Medical provider's explanation was that they faxed and were just waiting on insurance. They just sat on their fat bums while the time was running out.
So, wife patiently asked medical provider to apply for authorization again. The provider said they sent another request right away.
Another week later, wife had to call insurance again to find out that they STILL DID NOT receive any request.
Distraught wife asked insurance rep to call the medical provider immediately. Of course the call went to voice mail.
Wife then called the medical provider and left a scathing voicemail, threatening to sue. Only then this system worked miraculously. It still took a day for the medical provider to figure out what was wrong with their fax system. It still required my wife to follow up with insurance asking if they received the authorization request. Then 3 days later, the insurance provider approved the authorization and my wife had to call the medical provider again to confirm that the authorization was received.
All good now? Ohhh Noooo. Now the medical provider placed an order for medication that needs to be shipped from a pharmacy in another state. And they do place it. Now my wife gets a call from the shipping pharmacy to schedule a delivery. The delivery happens after 3 days.
Wife checks the delivery. Oops, it is missing a few items required for treatment. Guess what she needs to do to get the missing items delivered? You guessed it. Have the medical provider do the authorization process ALL OVER AGAIN.
Oh, and every call to the medical provider goes to a voicemail to which they take a minimum of 8 hours to reply and every call to insurance has a 30 min elevator music. Imagine all this 10 times in 3 weeks and that was just one round of shipping and nervousness.
Fuck American Healthcare.
France is starting.
Someone in the US should get funding for this. It's a 300M people's "market".
American healthcare is what I would wish on my enemies.
Any book about their systems ?
If you are going from America, you can't go wrong in any major Asian country. India has the benefit of having English speaking doctors.
QC = not dying, not having more side effects ..
when you say pure free market, I'd like to know how you get access to this market and who ensure you're not "selling" bad stuff/practice/ideas
When a medical professional does "the maybe not completely ethical thing", word spreads and they lose future patients to competition. Business declines. The professional loses standing in the community and current employer would terminate their employment. Future employers need good references. They are socially shunned and have legal proceedings on them.
The doctors there are like chefs in a restaurant. The quality of their work determines their standing and future business. Medical facilities are like restaurants. The quality of their service matters.
One thing to note though is that you want to visit medical professionals in cities and not some rural village doctor. Rural doctors are more likely to have "quality control" issues more as their reputations are not discoverable easily without learning local languages.
I'm sorry but this erodes my sympathy significantly. Learn about the options that exist if your first choice treatment isnt available. Learn about mitigation when no treatment is available. This is your life, act like its your responsibility already.
Science can help, alloxan destroys the islets of Langerhans, it is used to create diabetic mice. Go ahead, take a dose, lead by example. The Walmart insulin comes up here on this website from time to time, and the overall conclusion is that long-acting insulins prevent blood sugar excursions.
I am. I expect to be dead before the decade is out, the doctors offer ways to make that more comfortable but shorter. I disagree with their priorities and am thus on my own for other treatment options.
"I do not need to know about other options" seems inexcusable to me, and seems to be what the author assumes is the correct attitude towards their treatment.
I have no love for pharma price gouging, but if insulin was free, everybody would be stuck on the 1921 formulation.
In most countries insulin price is around $30. I remember it was cheap in US too.
Seems like another problem created by US kleptocracy. Make something prohibitively expensive, and "solve" problem by providing handouts to cover costs.
On top of the national mandatory health insurance, there's also optional private health insurance and private hospitals and such, but even for those the prices are nowhere near the insane numbers I see whenever US healthcare is discussed, and I frankly can't understand how people aren't revolting over there.
Edit: I just remembered that diabetes is recognised as a long term condition, so you would be 100% reimbursed by the public insurance scheme.
In short we haven’t come to a consensus as to derivation of the engineering axiom, you can have 1) broader access 2) quantity/quality 3) affordability —-pick two
That's seriously f'ed up.
If you don't believe that's the purpose of the new regulation you are insufficiently cynical. Where's the revolution?
Here's a page going through the story.
An Arm and A Leg is a really interesting podcast partially funded by Kaiser Health News that does similar stories to this one, going through the ridiculousness of the whole US Healthcare system and how people have successfully navigated it.
https://armandalegshow.com/about-x/partners-and-supporters/k...