I despise Trump but would vote for him over someone who wants to take my family's insurance away

[wolfpup]

@survinga

In the “almost all” reference, I think I had a $35 co-pay.

In your “not much” question (I love how people demand that I have perfect knowledge, but no one else gets these kinds of questions), I don’t know exactly what they paid, but it was such that I never heard them utter anything at all about cost. And I know they have the same insurance I have, since we work together, so again “almost all” of their costs were covered, as we don’t have high deductible plans and coverage on major illnesses is very good. Maybe over a year or two, they paid out a few hundred bucks…These are anecdotes to answer your questions of course, but many people on this board use anecdotes.

FTR, I have never argued that private insurance as implemented in the USA doesn’t work most of the time for most people, nor has anyone else AFAIK. But this glosses over the big issues of its systemic deficiencies and the horror stories stemming from the many, many cases where it doesn’t work. The three major objections to it are (a) the lack of universality, (b) the enormous and unnecessary costs and complexities inherent in the system, and (c) the bureaucratic interference with medical practice, including claim denials, treatment downgrades, and other forms of meddling.

Your well-meaning proposals could eventually address point (a), and good regulation could make a dent in point (b), but only a dent, but nothing in the private system can address point (c), and that’s the most important one of all, because it threatens not only people’s financial solvency, but their very lives.

I simply cannot emphasize enough how different it is – and how important it is – that when I go to the doctor, or to the ER, or get admitted to a hospital, money is simply not part of the process. Payment in full to the providers is simply taken for granted and never affects the patient or their treatment. I think this is actually a hard concept for Americans to understand because it’s so alien to them.

[wolfpup]

@Northern_Piper

Why on Earth would the government want to limit your coverage options? Because government is inherently eee-vil and wants people to suffer? With all due respect, you’re thinking like some Americans who think government can’t be trusted to provide basic services, like health-care.

Northern Piper, now that you’ve clarified your comments, I think we’re in agreement on pretty much everything. As to the above, I think it’s a misinterpretation of what I meant, which was that if there’s only one source of insurance (real insurance, like auto insurance, not health care) then you don’t have as many different coverage options and rates to choose from as when you have many different insurance companies.

My point, in the context of this thread, is that any payer for health care coverage has a fundamental moral duty to pay for any health care you need, period, no exceptions, so it’s fundamentally different from the conventional idea of insurance. Throw in uniform community-rated premiums where everyone pays exactly the same for the same guaranteed coverage for everything medically necessary (as determined by a doctor, not the insurer) and there is then essentially no difference between different insurers. That’s pretty much single-payer.

[Aspenglow]

@Translucent_Daydream

My cursor must have jumped. The two people with insurance at my work are on Medicare because they are over 65 years old. Sorry that was jumbled. When I lived in Oregon I was on the state program and that was the only time I’ve been insured in the past 10 years I think. That was the only time my wife has had insurance either.

You’re kind. I misunderstood you and that was pointed out by kenobi 65. Thanks for being magnanimous.

[Northern_Piper]

I’ve gone throughtbtg thread and it looks like the OP has gone. That’s too bad, because I have a genuine question: what is so good about the OP’s plan that he doesn’t want to give it up? And I mean details, not a vague “choice” issue. And as others have pointed out, I’m curious if it’s an employer plan, chosen by the employer?

[kenobi_65]

@Northern_Piper

And as others have pointed out, I’m curious if it’s an employer plan, chosen by the employer?

I’m guessing so, though the OP did also say, “For the record, I support the ACA.”

The odds alone are that the OP is getting insurance through their employer. From the Kaiser Family Foundation site that I linked to earlier, here are the proportions for source of health coverage, among all U.S. residents:

• Employer: 49%
• Medicaid: 21%
• Medicare: 14%
• Non-Group (that is, ACA policies and anything else one buys on one’s own): 7%
• Other Public (mostly military and VA): 1%
• Not Insured: 9%

[Novelty_Bobble]

@survinga

In your “not much” question (I love how people demand that I have perfect knowledge, but no one else gets these kinds of questions), I don’t know exactly what they paid, but it was such that I never heard them utter anything at all about cost. And I know they have the same insurance I have, since we work together, so again “almost all” of their costs were covered, as we don’t have high deductible plans and coverage on major illnesses is very good. Maybe over a year or two, they paid out a few hundred bucks…These are anecdotes to answer your questions of course, but many people on this board use anecdotes.

Anecdotes are fine and thanks for that, I guess the bit that is important is

we don’t have high deductible plans and coverage on major illnesses is very good

which leaves open the possibility that others do not have that level of coverage.

[Translucent_Daydream]

I don’t understand some of the problems people have with governmental health care. The best health care I ever had when when I lived in Oregon, and that was Medicaid (the poor people stuff.) When we had to go to the doctor, it was just “go to the doctor” it wasn’t “do I have the $40 dollar co-pay today” or “whats my deductible at right now” or anything like that. The paperwork to get it started was pretty ominous, but it seemed like the paperwork was more to do with the private company that was administering it. It was first Moda health out of the Portland area then it was something else when we had to move to Salem.

The wife and I used to have Blue Cross PPO about ten years ago though an employer in Texas. It was $625 a month for both of us with a $8000 out of pocket and $40 co-pay. When my wife had medical problems, we had to go to the doctor 17 times (yes, for real 17 times, twice a week) before he would order a test to determine she had cancerous legions growing throughout the inside of her abdomen. The test was a “cut you open and find out whats cookin’ in the oven” type of surgery. The day before the surgery, we found out that the hospital doing the surgery would only admit her the following morning if we paid them $1,200 dollars up front, so we were going to have to cancel the surgery. My next door neighbor was a nurse over taking care of my wife while I was at work and over heard the wife telling me she was going to have to cancel the procedure, so she whipped out her credit card and paid the “pre-op fee”. I took a loan out from my work to cover her credit card charge, which is a whole other story that involved me throwing my boss’s computer monitor across the room and throwing a huge fit, but that’s another story of one of my bad moments. It took me 2 years to pay it off.

Anyway the next day she is under the knife for what they told me was going to be a 20 - 30 minute deal. 4 hours later, Doctor Dickhead comes into the room as white as his lab coat, and tells me that he is glad that the surgery happened, because they found all of these masses pulling on her insides and they had to remove them. He didn’t know how she was able to walk or anything like that. They were going to have to send off stuff for biopsies, but they were definitely malignant.

So we get her home and try to get her to heal up from this rush job procedure, and then the bills started. Turns out the doctor switched anesthesiologists an hour before the surgery to some guy that wasn’t covered by our insurance. So this guy sent us this $1,700 dollar bill with FedEx in an envelope. Then we found out that the doctor also switched the surgery from the hospital to a day surgery center attached to the hospital, so the insurance wouldn’t cover that either. And since the surgery went from “exploratory” to “oh shit you are loaded with weird tumors” the surgery wasn’t covered at all either.

So lets recap what we have spent so far (I sold almost all of the stuff I inherited from my grandfather to pay for this as we went):

17 doctor’s office visits at the $40 dollar co-pay over the course of about two 2 months = $680
Two months worth of insurance premiums = $1250
“Pre-op fee” whatever the hell that was = $1200
Doctor switcharoo not in my right flavor of Blue Cross/Blue Shield = $1700
The surgery center not in the hospital even though it was attached to it = $3250
The surgery itself (not sure still if it was the doctor or the hospital billing) = $6000

So we are up to a total of $14,080 and that isn’t all of the bills either that we got. This includes none of the copays for the medication that Dr. Dickhead kept throwing at my wife to see if it would “help her feel better.” I spent about 6 months on the phone with BC/BS trying to figure out how I was getting charged so much when I thought my limit of out of pocket was $8000 a year. Turns out, what I paid only had a portion applied to the deductible in some sort of Darth Vader percentage math that nobody was aware about.

We are still paying off the first surgery to this day. When she had the growths return, we were in Oregon on that evil government insurance. Her new doctor helped us look at the bills we were still paying for the first surgery. Besides a bunch of cussing, she had no idea why we got stuck with it. But the new surgery wouldn’t cost us a dime, and we didn’t have to pay any copays or pre-op fees or anything like that. It was covered by the evil no good insurance.

Why is the employer insurance better in this situation? Even though we technically had a “choice” with Dr. Dickhead, he was the only one in the network in our area so it really didn’t feel like a choice.

Why was the co-pay necessary?
Is that a deterrence to keep you from going to the doctor? It made most of my prized family possessions evaporate, thats for sure.
Why can the doctor change locations on the surgery and his buddies in the room and have my bill change? I never authorized any of those changes.

I mean, help me understand why that is the better system. I’m not the smartest guy around so I don’t try to have lofty opinions on things, but the only thing that was different to me in both versions of health care is that BC/BS made a shit ton on money from me and didn’t do their damn job. The evil government stuff just paid for the health care.

[bump]

@campp

I believe there is a formal appeal process. Whoever decided it was not “necessary” will have to prove their medical credentials that proves they know what they are talking about. That’s part of the Regulatory dept at the Ins Co. They cannot get out of that one, since the denier is usually some hourly schlub. Anyway, this is how I’ve seen these stories get worked out. It will likely involve legal action however. He should win.

I know in the workers comp world, the initial triage person for this sort of utilization review(UR) is usually a RN. They basically sort them into two piles- clearly medically necessary (i.e. a cast for a broken leg, stitches for a cut, etc…) or ones that have questionable stuff.

The questionable ones go out to a third party UR provider for review for medical necessity. Who it goes to is subject to a whole host of state/federal rules as to specialty, licensure, etc…

Anyway, this third party provider reviews the case documentation against the relevant treatment guidelines, tries to contact the original provider to discuss their rationale for that particular treatment, and makes their determination based on all that.

Now in this case, assuming the UR process for a regular insurance claim is similar, I’d guess that one of four things happened:
[ul]
[li]the triage nurse messed up[/li][li]the reviewing physician messed up (didn’t contact the original surgeons for background)[/li][li]the original surgeons flubbed their documentation[/li][li]the original surgeons didn’t follow the proper treatment guidelines (i.e. freestyled it without regard to the accepted treatment for the condition).[/li][/ul]

Any of those could cause a review to fail when it shouldn’t. If I had to guess, I’d bet it was the original surgeons botching the documentation or not following the treatment guidelines (doctors in general have a ornery streak and are know-it-alls and don’t like being told what to do).
** used to be the IT product manager/business relationship manager for my old employer’s worker’s comp UR review business unit, so I’m pretty familiar with the worker’s comp side of that business.

[Translucent_Daydream]

@bump

I know in the workers comp world, the initial triage person for this sort of utilization review(UR) is usually a RN. They basically sort them into two piles- clearly medically necessary (i.e. a cast for a broken leg, stitches for a cut, etc…) or ones that have questionable stuff.

The questionable ones go out to a third party UR provider for review for medical necessity. Who it goes to is subject to a whole host of state/federal rules as to specialty, licensure, etc…

Anyway, this third party provider reviews the case documentation against the relevant treatment guidelines, tries to contact the original provider to discuss their rationale for that particular treatment, and makes their determination based on all that.

Now in this case, assuming the UR process for a regular insurance claim is similar, I’d guess that one of four things happened:
[ul]
[li]the triage nurse messed up[/li][li]the reviewing physician messed up (didn’t contact the original surgeons for background)[/li][li]the original surgeons flubbed their documentation[/li][li]the original surgeons didn’t follow the proper treatment guidelines (i.e. freestyled it without regard to the accepted treatment for the condition).[/li][/ul]

Any of those could cause a review to fail when it shouldn’t. If I had to guess, I’d bet it was the original surgeons botching the documentation or not following the treatment guidelines (doctors in general have a ornery streak and are know-it-alls and don’t like being told what to do).
** used to be the IT product manager/business relationship manager for my old employer’s worker’s comp UR review business unit, so I’m pretty familiar with the worker’s comp side of that business.

Can you help me understand this in a little bit of an easier way? They way I took it is that its “your doctor vs. the doctor that the insurance company has”?

It would seem to me that there is one of these doctors in this scenario that would have your medical interests in mind, because, um, he is your doctor and is looking at you in person? The other doctor is the “doctor of your insurance company’s money”?

[bump]

@Broomstick

Yes, basically, that’s it - there’s always a formal appeals process, but it’s lengthy, full of paperwork and red tape, if you don’t get ALL the forms and fill them ALL out completely and carefully you can be summarially denied (again), and yes, it’s very much a feature and not a bug - the insurance company wants to delay paying as long as possible. Even better if the patient gives up, or is too tired/sick to continue

Let’s not get too pissy about it; under a universal health care system, it’s likely that the doctors will have less discretion about how they can treat a patient- if they want to get paid, they’ll have to adhere to specific treatment guidelines, even when they don’t necessarily agree with them.

Or go through the same sort of review process to see why they didn’t follow the procedures; the only difference is that it won’t involve the patient’s pocketbook, but it may well involve the way they’re treated and their outcome.

In practical terms, this’ll mean that a doctor who’s practiced for decades and knows what condition X looks like and that medication Z is most effective for patients of a specific type, will now have to go through the medical theater of trying other medications first, instead of just cutting to the chase and prescribing treatment Z right off the bat. Or they’ll make you go through physical therapy and various conservative (and cheap) treatments before finally resorting to surgery, even if they knew it was the right treatment all along.

The good news is that it won’t cost the patient anything.

[Translucent_Daydream]

@bump

Let’s not get too pissy about it; under a universal health care system, it’s likely that the doctors will have less discretion about how they can treat a patient- if they want to get paid, they’ll have to adhere to specific treatment guidelines, even when they don’t necessarily agree with them.

Or go through the same sort of review process to see why they didn’t follow the procedures; the only difference is that it won’t involve the patient’s pocketbook, but it may well involve the way they’re treated and their outcome.

In practical terms, this’ll mean that a doctor who’s practiced for decades and knows what condition X looks like and that medication Z is most effective for patients of a specific type, will now have to go through the medical theater of trying other medications first, instead of just cutting to the chase and prescribing treatment Z right off the bat. Or they’ll make you go through physical therapy and various conservative (and cheap) treatments before finally resorting to surgery, even if they knew it was the right treatment all along.

The good news is that it won’t cost the patient anything.

Stupid people like me would find that this type of rationing doesn’t have the same angering effect of an insurance company that is taking 35% of my monthly pay - pretax - and then not paying my claims.

I feel like if there is some sort of system in play that isn’t there to ensure the profits of some rich board of assholes, but to make sure that unnecessary triple tests that the doctor can bill for and make more money aren’t the norm.

As it is now, unnecessary tests are a profit center of doctors and hospitals. And our medical spending per citizen is way out of whack with what other countries are spending on their citizens, and they have better out comes.

One of these systems has protections for profits cooked into them, and one does not. I’m just saying it seems like you are missing a bigger picture here.

Also, since when has anyone I know gone to a doctor and the doctor isn’t actively googling your symptoms anyway? The last time I went to a doctor, I got to see what they were typing away at on their little computer tablet because the doctor stood in front of a mirror. That bastard was googling “sinus drainage and fever”.

[slash2k]

@bump

In practical terms, this’ll mean that a doctor who’s practiced for decades and knows what condition X looks like and that medication Z is most effective for patients of a specific type, will now have to go through the medical theater of trying other medications first, instead of just cutting to the chase and prescribing treatment Z right off the bat. Or they’ll make you go through physical therapy and various conservative (and cheap) treatments before finally resorting to surgery, even if they knew it was the right treatment all along.

The good news is that it won’t cost the patient anything.

That’s already what happens now, and it costs me plenty.

I’ve got good employer-provided insurance with a prescription plan administered by CVS/Caremark. There’s a formulary (they call it the “Preferred Drug List”) of approved medications, and RIGHT NOW this means that a doctor who’s practiced for decades and knows what condition X looks like and that medication Z is most effective for patients of a specific type, will now have to go through the medical theater of trying other medications first, instead of just cutting to the chase and prescribing treatment Z right off the bat, because medication Z either costs a whole lot more or simply isn’t covered at all for patients who don’t have prior approval from the prescription drug manager (and you don’t get that prior approval unless your doctor can document why the preferred drug is contraindicated [“it’s not the best choice for this patient” is NOT an acceptable reason] or was tried and didn’t work).

There’s a whole list, regularly updated, of “Medications Requiring Prior Approval for Medical Necessity”; if you are taking a medication that is on the preferred list and it gets moved to the prior approval list, then the insurance company requires you to stop taking it and try one of the currently-preferred drugs before they will continue paying for your medications (that happened to a friend on asthma meds; it took MULTIPLE trips to the ER before the insurance company relented and decided that maybe the doctor really did know what she was doing).

Since that is the current system, why is a government system that does something similar such a bogeyman? At least with a government system, there is likely a legislator whose constituent services staff can intervene; who can intervene when the corporate bureaucrat decides you really don’t need that expensive anti-psychotic anymore?

[Translucent_Daydream]

@slash2k

At least with a government system, there is likely a legislator whose constituent services staff can intervene; who can intervene when the corporate bureaucrat decides you really don’t need that expensive anti-psychotic anymore?

I hear a familiar refrain a lot from better off people that is something like “thats what lawyers are for” or “man just get a lawyer.”

I am not sure these same people have been poor and sitting in the legal aid office begging someone not to look at them like a piece of sub human garbage, but a decent person needing help fighting the wealthy in a system skewed for the wealthy.

Those same “why don’t you get a lawyer” people are never going to see the pitch forks and torches coming for them either.

[Novelty_Bobble]

@bump

Let’s not get too pissy about it; under a universal health care system, it’s likely that the doctors will have less discretion about how they can treat a patient- if they want to get paid, they’ll have to adhere to specific treatment guidelines, even when they don’t necessarily agree with them

Doctors (in the UK at least) have a wide discretion about how they treat a patient and they don’t “paid” in the way you seem to suggest above. There is also an independent body that assesses treatments for effectiveness against cost.

In the USA do the doctors have the latitude to prescribe any threatment they like and the insurance companies will definitely cough-up?

[Euphonious_Polemic]

@Translucent_Daydream

I don’t understand some of the problems people have with governmental health care. …<payment horror story follows>

I mean, help me understand why that is the better system. I’m not the smartest guy around so I don’t try to have lofty opinions on things, but the only thing that was different to me in both versions of health care is that BC/BS made a shit ton on money from me and didn’t do their damn job. The evil government stuff just paid for the health care.

As I understand it, if you had Universal Health care, and a single government insurer, you would not have FREEDOM, and would be in the grip of SOCIALISM. So this would be terrible.

That’s really all I’ve ever gotten from supporters of the status quo.

[Euphonious_Polemic]

@bump

Let’s not get too pissy about it; under a universal health care system, it’s likely that the doctors will have less discretion about how they can treat a patient- if they want to get paid, they’ll have to adhere to specific treatment guidelines, even when they don’t necessarily agree with them.

Yeaaaaa… you might want to check into what ACTUALLY happens in a UHC country, and just how treatment guidelines are arrived at (hint; it involves actual physicians who are experts in their field, not insurance company middlemen)

[Novelty_Bobble]

@Euphonious_Polemic

Yeaaaaa… you might want to check into what ACTUALLY happens in a UHC country, and just how treatment guidelines are arrived at (hint; it involves actual physicians who are experts in their field, not insurance company middlemen)

For those interested, in the UK this is handled by this organisation, NICE

[PatrickLondon]

Wandering off-topic a little, but NICE provides clinical guidelines for doctors on the effectiveness of particular treatments and protocols for how to use them, and rulings on the cost-effectiveness of different treatments that don’t *prevent *doctors from using them, but rather require local NHS organisations to provide them if the doctor prescribes them within the guidelines and protocols.

True, local NHS organisations have some flexibility in determining the thresholds at which they will allow for some treatments, which in recent times of financial stringency have led to some reductions in free services, e.g.,
https://www.bionews.org.uk/page_144287
https://www.southportvisiter.co.uk/news/southport-west-lancs/ccg-withdraw-funding-free-treatments-13771922

but (a) there is strong representation from local GP practices in the local CCGs that manage NHS funds and (b) they have to go out to public consultation on priorities before coming to such decisions

But of course any country can set up its public services how it wishes - there is no one and only model for UHC.

[Translucent_Daydream]

@Euphonious_Polemic

As I understand it, if you had Universal Health care, and a single government insurer, you would not have FREEDOM, and would be in the grip of SOCIALISM. So this would be terrible.

That’s really all I’ve ever gotten from supporters of the status quo.

There has to be some sort of fear of it that they have of something besides that.

Are they afraid that too many people will actually be getting health care that they won’t be able to go to the doctor? Are they afraid that there will be some sort of shortage? If it is truly only 8% of people that are going without insurance that will get it and then have access, I don’t think that would be the problem.

Are they afraid that people will immigrate to the country just to get the sweet medical benefits? I don’t know if that is a problem or not, thats for people above my pay grade to decide.

Are they afraid that it will somehow cost them more? I had no idea how expensive and bullshit my insurance was until I had to use ours.

RANT It seems like from the middle sometimes seems like one side sees the other as either rednecks or hippies. I don’t see a whole lot of either in the real world. END RANT

[Euphonious_Polemic]

For some, it may be that they don’t want to pay for something that the UNDESERVING will benefit from. There are various definitions of “undeserving” out there, depending on one’s point of view.