but you might have to get a generic shingles vaccine.
Currently there is no generic shingles vaccine approved in the US, only brand name Shingrix.
Currently, without insurance, Shingrix is $201+ in my market via GoodRx.
I enjoyed the word play, just wanted to get that out there: Shingrix is the only option.
Gotta love big pharma.
You can read a whole bunch about my real-life experiences with both Health Insurance and Medical Billing in the pit thread I started.
There are people actively (and in some cases of posters here) proudly engaged in fraudulently pushing costs to the patient in contravention of the legal requirements of ACA.
The providers negotiate low reimbursement rates with the insurers. The insurers market high deductible plans to employers. Then the insurers and providers have an incentive to bilk the patient within that deductible window by “creative upcoding and re-coding”. The insurer doesn’t care what the provider bills the patient below the $3000 deductible.
They are playing the game of staying just on the right side of obvious bad faith. If you fight hard enough and escalate to the insurance regulator they will back down. Their business model depends on many or most patients giving up and paying the bills.
Oh, I’m in the middle of something similar myself. My son had a minor procedure done, and the Dr. quoted and charged something like $300 for it, but the day surgery center billed a different code than the Dr. quoted, and is trying to charge us five times that, and getting them to talk to each other and change it is proving difficult to say the least.
My point wasn’t that the system isn’t ripe for abuse, or that there are a lot of unscrupulous people who will happily make a buck when it means someone else will suffer. All I was getting at was that having health insurance means you have insurance. It doesn’t mean everything’s covered under all conditions, etc… It’s not a healthcare Get out of Jail card, and doesn’t mean that everything’s covered, etc…
I kind of feel like if more people understood how similar it is to other insurance, and what that implies, especially as they age, they might be a lot less pleased, and more willing to consider other options. I mean, when you’re 25, insurance is pretty much what most people need. But when you’re 55, it’s a different story for many.
Not advocating one system or another, but this article seems relevant - as mentioned, health treatments are triaged and rationed, no matter what system:
She wrote on Facebook: “If you’re reading this, then it means I’m no longer here, I can’t say to a better place as that is impossible!”
Enhertu is available in Scotland, and 19 other European countries, but not the rest of the UK, and a Welsh government spokesperson said it relied on independent advice from health assessment body NICE, which called it too expensive for the NHS to fund.
-snip-
Enhertu can give patients with a specific type of incurable breast cancer an extra six months to live on average.
-snip-
Rachel’s oncologist from Swansea Bay health board applied for specialist funding, but was refused.
The health board said at the time it “carefully considers all requests for the funding of treatments that fall outside normal treatment protocols” and takes NICE recommendations into account.
Many countries have private insurance and universal coverage. It’s an almost unique feature of the American version that you can go to a doctor and then engage in a months or years long battle over paying for something.
Health insurance IS supposed to be a get out of jail free card for healthcare with very, very few exceptions. It’s absolutely fucking ridiculous that something as routine as a hairline fracture or a colonoscopy should result in endless litigation on a routine basis. It’s stupid and evil and doesn’t happen anywhere else.
If insurance companies and doctors in the Netherlands did 5% of the shenanigans I’ve experienced in just the last ten years they’d be shut down.
There is literally nowhere in the world where if I went to the ER with a dislocated shoulder, I would be battling the hospital and my health insurance provider for three years because the insurer wouldn’t pay until I cooperated to THEIR satisfaction in pursuing recompense from the tennis facility or my where I sustained the injury or my playing partners. And by “cooperated” they mean perjure myself. And this was not some fly-by-night insurer. It was one of the biggest in the country and a non-profit to boot.
The idea that this is all just a misunderstanding of how insurance works plays right into the hands of the scammers telling you this is the best we can do.
This sounds like the fiction promulgated by the health insurance industry that they are your “partners” in health care, and I vehemently disagree with this characterization. They are no such thing. They’re basically useless parasites that contribute negative value to the health care process by intruding into the doctor-patient relationship in order to limit treatments, deny claims, and otherwise control costs. This is a foundational problem and fatal flaw with insurance as a model for funding health care. Your doctor is the one closest to your case, knows you and your medical history and, as long as they’re ethical and competent, is the person looking after your best interests, not the insurance bureaucrat. Insurance bureaucrats are not your friend; more often than not, they’re your enemy and their incentives tend to run counter to your best interests.
The following is a partial extract from another post I made on this subject:
Every health care system has to control costs. UHC systems control costs through overall policy and primarily through fee schedules. Commercial health insurers primarily control costs by micromanaging each individual case, which necessarily means that they are always meddling in the doctor-patient relationship. In UHC, the physician and their patient are the final arbiters of appropriate treatment protocols. With private insurance, the insurance company bureaucrats are the final arbiters, approving or denying treatment as they see fit, often for mercenary reasons and to the detriment of the patient, and potentially costing the patient their life or degrading their quality of life.
The renowned late health care economist Ewe Reinhardt made this point many times, and is quoted in this paper [PDF] from which I provide this excerpt:
It is Reinhardt’s assertion that the absence in the United States of an overall program of budgetary control over medical expenditures, as is characteristic of the prominent European systems, results in unparalleled micro-management at the clinical level to achieve cost control unattainable on a larger scale. He writes that “…if the bureaucrats cannot somehow impose upon the healers an overall budget constraint ex ante, then they will sooner or later be driven to control their outlays on an ongoing basis, by monitoring each and every transaction for which they pay – that is, by second guessing both the providers’ clinical and pricing decisions” (Reinhardt, 1988). This appropriation of the clinical dimension of autonomy would be regarded as intolerable by physicians in other medical care systems. He suggests that “European and Canadian physicians would be appalled at the numerous intrusions into clinical decisions now routinely made by these external monitors in the United States. They probably would rise up in arms over that loss in clinical autonomy” (Reinhardt, 1988).
This is wrong, too. The basic principle in the single-payer systems in Canada is that, with very few exceptions, all procedures generally provided by doctors and hospitals are covered if the doctor deems them to be medically necessary. It cannot be otherwise, because the foundational principle is that no one should ever be denied medically necessary health care.
Seems that “medically necessary” is the operative term, and not any different than “approved treatment”. I see this:
Medically necessary services are not defined in the Canada Health Act. The provincial and territorial health care insurance plans consult with their respective physician colleges or groups. Together, they decide which services are medically necessary for health care insurance purposes.
So it’s not up to individual doctors at all. A doctor, quack or not, pushing a treatment that hasn’t been declared “medically necessary” isn’t necessarily going to be covered.
I’m sorry , I just don’t buy that any individual doctor can decide what’s medically necessary no matter what . Can an individual Canadian doctor decide that a particular generally accepted treatment is necessary for a particular patient - I’m sure that happens. Can a doctor bill Canadian Medicare for treating a cancer patient with laetrile or a COVID patient with Hydroxychloroquine and get paid. The patient won’t get a bill, I understand that (and that’s a big improvement over the US) , but that doesn’t mean the Canadian single-payer system will pay Dr. Oz for quackery.
No, your conclusion here is very misleading, but maybe I wasn’t clear enough, or you may be misunderstanding the Canada Health Act (CHA). Health care policy is a provincial responsibility. The purpose of the CHA is to set out a basic framework of foundational principles that every province and territory must follow. One of those five foundational principles is “Comprehensiveness”, and this is what mandates coverage of all services generally provided by doctors and hospitals. The actual schedule of services is within the jurisdiction of each province, but it must be comprehensive and not selective, meaning that if it’s a medically recognized procedure available in a hospital, it must be covered.
I did not mean to imply that a doctor can arbitrarily deem any quack treatment to be “medically necessary”. What I’m saying is that the doctor is the sole gatekeeper to insured medical services, that the schedule of these services must be comprehensive, essentially encompassing everything that hospitals generally do, and that the doctor-patient collaboration is the sole determiner of what treatment the patient receives. Crucially and most importantly, there are no arms-length bureaucrats second-guessing what treatments the patient is allowed to receive. This is what I mean when I frequently refer to the single-payer insurance plans here as “unconditional”. There is no adjudication of individual claims in the sense of conventional insurance.
I hope it’s clear from the above what I was actually saying.
Sure, fine, but I consider your interpretation of the discussion here to be very misleading. There is in fact a schedule of approved services that isn’t up to individual doctors. Furthermore, the implication that the insurance plans are not involved is false. Sure, they’re provincial/territorial groups instead of for-profit corporations, but you can’t tell me that cost effectiveness never comes up in their decision-making process.
Yes, I get that once a doctor decides that a patient has condition X, it is totally within their discretion to use treatment Y, as long as Y is on the list of “medically necessary” treatments for X. But that is a non-trivial restriction. A significant number of insurance denials are for experimental or otherwise non-standard treatments that would likely also not be covered in Canada.
But this probably doesn’t come up at all if doctors are the ones not getting reimbursed, rather than patients being hit with enormous bills.
And for a recent example that’s becoming very important:
https://www.getmaple.ca/blog/semaglutide-ozempic-cost-in-canada/
Even though Ozempic has very clear benefits for weight loss (and its associated health problems), it’s not covered under any of Canada’s public drug plans, because using it for anything but type-2 diabetes is considered off-label.
The same is true of most US insurance plans as well, of course. And I expect this to change very soon in both places. But it does mean that a treatment with very clear benefits is not yet covered because it’s not yet an approved treatment.
There is no Canadian Medicare. Health delivery is a provincial responsibility.
Not misleading at all, because once again you’re ignoring the mandate for “comprehensiveness” and the foundational principle that medically necessary health care must never be denied, which is fundamentally different from the way insurance companies operate. I mean, you can call it an “approved list” if you want, but I have a copy of an older OHIP procedure and fee schedule, and it’s huge and basically covers everything that hospitals do, as mandated by the Canada Health Act.
Cost-effectiveness is quite properly a major concern. The crucial issue is how that’s achieved. Please read my post #227. What I’m telling you – and this is the crucial difference from the American insurance system – is that the single-payer insurance plans are never involved in individual billing claims (which the patient never even sees) and therefore there’s not even a mechanism for denying a claim. There are rare exceptions in very special cases.
Experimental treatments are, by definition, not standard or routinely available or even necessarily recognized as effective, and wouldn’t be expected to be on anyone’s fee schedule. They can be covered under Canada’s single-payer plans but this would be one of those rare examples of needing individual approval.
While it’s probably true that experimental treatments may be a recurring cause of claims denials by American insurers, you are surely not trying to make the case that claims denials are not a huge and general problem of epidemic proportions across the whole American health care system. The industry averages about one claim denial out of every six; UnitedHealthcare denies one in three! Do you seriously believe that “a significant number” of these are for experimental treatments?
I can’t speak to the situation with Ozempic, though I would point out that drug benefits are a different program from any of the single-payer plans and are governed by completely different rules that don’t fall under the mandates of the Canada Health Act. The points I’m making are with respect to the single-payer systems for medical procedures.
Do US insurance companies not have an approved list of treatments that they cover?
Because if they do, that is the same as the Canadien healthcare plans.
But if they then have an additional step, where they reject coverage that is already on their covered list, on a case-by-case basis as « not medically necessary » in the eyes of their accountants or AI, that has no equivalent in the Canadian system.
A two-step process for approvals, once globally for covered services, and then individual case-by-case, seems to me to be how the US insurers operate. Please correct me if I’m wrong.
Don’t confuse my posts with someone trying to defend the American system. It absolutely needs to be fixed and has some very serious moral hazards embedded in it. But when bump says:
… and you flatly say he’s “wrong”, despite it being clear that “medically necessary” is in fact just that sort of approved treatment list that the provincial insurance groups and doctor colleges hash out, I find that misleading.
You emphasize very strongly that every medical decision is between the patient and the individual doctor, but that’s just not the case, because the entire scope of what insurance pays for has been decided in advance. And it’s a motte-and-bailey style argument that “medically necessary” in an actual-physical-reality sense is the same as “medically necessary” in a “what Canadian healthcare will actually pay for” sense. They aren’t the same thing, as with Ozempic and I’m sure many other cases.
If “experimental” just means “not on the approved list”, then sure, it’s probably significant. Doctors here don’t have the same interest in ensuring their treatments are covered by insurance as they are in Canada. It’s up to the patient, so why not push the most aggressive treatment possible?
Just as a for instance, I was diagnosed with Wolff-Parkinson-White syndrome and had cardiac ablation to fix it. In my case I was symptomatic, and insurance paid for almost all of it. I would expect that to be an approved treatment in Canada as well.
But it’s detectable even without symptoms. As far as I know, surgical treatment is not recommended in that case, and I’d guess it’s not on any approved list. But there’s nothing stopping an American doctor from recommending treatment. They might well push it. If the patient is treated and the claim denied, whose fault is that? The insurance company for the denial? The doctor for pushing a treatment that probably wasn’t really necessary (though still not “experimental”)? The patient for actually undergoing the procedure? Who knows, but I’ll bet a lot of medical debt is for just this kind of thing.
Another significant category is simple error. Which implies that the raw denial rate is probably not very useful. If a large portion of those claims were accepted after fixing the errors, then the true denial rate may not be nearly as high.
There is the problem that insurance providers may use small technicalities to deny claims and hope that the claimant doesn’t go through the effort to fix or otherwise fight the denial.
Of course! And approved drug lists and all that. They will definitely try to deny anything not on their lists, although exceptions are sometimes possible.
My point really is that when Canadians describe their system, it sounds very alien at first and sorta incomprehensible how it actually functions at all. But look into it more and it is not really that different except for a few key details.
For example, the US wouldn’t have to adopt UHC to fix the two-step denial process you mention. We could just make a law that says whatever the approved treatment is, that’s that, and companies don’t get to make out-of-band rejections. Heck, maybe that’s already law and it’s just not enforced.
Just to expand on that a bit more, according to this site, these are the main reasons that private insurers deny claims. None of them apply to Canada’s single-payer plans, with the possible exception of #4, and then typically only because it’s something like cosmetic surgery that isn’t medically necessary, or some new treatment of unproven efficacy. The other reasons for claims denials simply don’t apply to single-payer:
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Paperwork errors or mix-ups
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Questions about medical necessity (“You need the service, but you haven’t convinced your health insurer of that”.)
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Cost control (The insurer wants you to try a different, usually less expensive, option first) – or will only pay for a less expensive treatment.
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The service just isn’t covered by your plan. (The requested service isn’t a covered benefit. This is common for things like cosmetic surgery or treatments not approved by the FDA. It could also happen if it’s a service that doesn’t fall within your state’s definition of the Affordable Care Act’s essential health benefits, if your plan is obtained in the individual or small group market. The specifics will vary from one state to another, but examples could be services like fertility treatments, vasectomies, acupuncture, or chiropractic services.)
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Provider network issues. (Depending on how your health plan’s managed care system is structured, you may only have coverage for services provided by healthcare providers and facilities that are part of your plan’s provider network.)
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Missing details (Perhaps there was insufficient information provided with the claim or pre-authorization request.)
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You didn’t follow your health plan’s rules. (Let’s say your health plan requires you to get pre-authorization for a particular non-emergency test, and you got the test done without getting pre-authorization from your insurer. Your insurer has the right to deny payment for that test—even if you really needed it—because you didn’t follow the health plan’s rules.)
As the above list of top reasons for insurance claims denials should hopefully help to illustrate, the difference between single-payer and private health insurance is really fundamental and absolutely not just “a few key details”. It’s a whole different world, structurally completely different, with entirely different goals and priorities.
This red herring has already been discussed several times. No, you couldn’t do that. Insurance companies would rightfully rebel at this level of government interference in one of the most fundamental aspects of their business and their primary method of cost control.
Meanwhile they have no problem themselves interfering in a doctor’s clinical autonomy and the doctor-patient relationship, which is just one of many problems intrinsic to the private health insurance industry, along with the inability to effectively control costs, limited provider “networks”, and the whole problem of massive bureaucracy that health care in America entails. It takes a lot more than a few tweaks to fix a system that is fundamentally broken from the top down.
I don’t see how. Much of that list is the same as in Canada. Yes, only “medically necessary” procedures are covered (where “medically necessary” is defined somewhere else). Some services (dental, etc.) just aren’t covered at all. Canadian drug plans will automatically give you only generic versions of drugs when available for cost reasons. Etc.
When it comes to errors/missing details, obviously Canadian doctors are no more perfect when it comes to paperwork than American doctors, so the main difference is in who has the responsibility to fix the error. That’s a major difference in patient convenience but again, that could be improved with a change in the law. And probably not that big a deal anyway in the grand scheme of things. Errors can be corrected; it just takes time.
And yet we passed the ACA, which is frankly far more invasive than some of the differences we’re talking about.
Insurance companies of all kinds are good at figuring out how much they need to charge. That’s their entire business model, and the fact that they’re less profitable than other industries demonstrates this (successful companies make better predictions and can undercut their competitors on premiums). Force all of them to be consistent in how they approve treatment and the premiums will adjust to compensate. Up or down! No one’s going out of business here.
Where did I say anything would take a few weeks? My point is that we can get 90% of the benefits with relatively small adjustments, not a total rip-it-to-shreds revamp.
The reason I got into what Canadian provincial health care did or didn’t cover is because when a statistic like this is stated
Most Americans are going to think that the supplemental health insurance is about covering the doctor and hospital visits. But from the article above, that isn’t the case at all. And when I see that some part of that private insurance is for dental and optician care, I feel like the statistic is misleading. That’s why I posted this poll about what people expect from healthcare insurance
I would love to see a breakdown of what exactly those private insurance policies are covering.
I didn’t say “a few weeks”, I said “a few tweaks”, echoing your statement that US health care can be fixed just by changing “a few key details”. As reflected in this article today I was just looking at in the aftermath of the UnitedHealthcare CEO shooting, the US health care system is fundamentally broken in ways that are much more profound than you seem to realize, and is generating increasing public hostility over issues that are not amenable to simple fixes.
It’s getting really frustrating for me trying to explain how profoundly different the Canadian single-payer system is while you continue to argue that a few changes here and there can make the American health insurance system look much the same. It can’t. That’s why, except for small-potatoes supplemental coverages, Canada sent the private health insurers packing rather than trying to regulate them.
We have a system where there is no cost to the patient for all medically necessary procedures – no co-pay, no deductible, no “claim” at all in the insurance sense – you just receive the service and then you go home. With total per-capita health care costs less than half of those in the US, far better average life expectancy, and a foundational principle of guaranteed universal access at no cost. You can’t achieve such profoundly fundamental changes just by tweaking private insurance a bit. You either have to revamp the way the entire industry works and tightly regulate it as a unified entity, or get rid of it altogether.
There’s a lot of stuff in your post that I could argue with but as I said, I’m getting tired of this. Just for a few examples, you don’t appear to appreciate the expansive scope of the medical procedures that single-payer unconditionally covers regardless of cost. You claim that “Canadian doctors are no more perfect when it comes to paperwork than American doctors”, but this completely misses the point that when the “paperwork” in question is completely standardized in single-payer and managed entirely by providers through highly automated processes, the potential for error becomes vanishingly small. The difference in administrative costs is a really big factor here. Doctors’ offices in the US have administrative staff solely to handle insurance-company billing that are just not needed here.
And for yet another example, you cite the ACA as being “more invasive” than the things we’re talking about, but you couldn’t be more wrong. The ACA was practically written by the insurance industry and offers them new markets in exchange for some minor regulation, whereas the problems I’m talking about can only be fixed with such a complete revamping of the entire industry along with tight regulation that there would literally be no difference between one health insurer or any other, which is exactly the case in Germany’s statutory insurance scheme and is effectively single-payer with a different implementation.
I haven’t had supplemental insurance since I retired, and as I said earlier, never felt any need for it, and also some things have changed in recent years. But off the top of my head, supplemental is for amenities like fully private hospital rooms rather than the more common semi-private, eyeglasses, prescription drugs for those between 25 and 65 who don’t get public drug coverage, and dental which used to be a big deal, but a national dental program is now being phased in separate from the single-payer systems.
Some of these recent changes, and taking into account the fact that prescription drugs are price-controlled in Canada and generally much cheaper than in the US, makes supplemental insurance relatively unimportant for most people who don’t automatically get it anyway as a minor employment benefit.