US health care companies will usually not cover OTC drugs, no matter how medically necessary they are. I would say never, but I did get iron covered. 40+ years ago
The unintended consequence of this is that physicians will prescribe newer drugs that need a prescription over older drugs that can be gotten OTC. And will prescribe medicine even when other approaches might work as well.
I suspect that the opposite happens in Canada. I know they have far more drugs available OTC.
I have never had a doctor ask me if I have a prescription drug plan. They give me a prescription, and it’s then up to me to get it.
The pharmacy I go to was able to switch a drug that I was getting on to my drug plan. I don’t know how they were able to do that; made some sort of application to the drug plan. I never saw the application or had to sign it or anything.
I’d be willing to bet that if a doctor orders/prescribes something outside of the standards or off the formulary, he’s got to justify that or not get paid. I can’t imagine the Canadian system just lets their doctors do whatever, and they get paid regardless.
Let’s not talk about your opinion. I’ve given you the federal statute that applies.
Please give me a cite that says professional standards for doctors in Canada are enforced by the single-payer system, and not by the medical regulatory body. That’s the body which enforces medical standards, not the single-payer.
Come on, he only billed 40,000 15-minute visits in one year. That works out to 192 hours of visits per week. Can you guess how many hours actually exist in a week? Hint, it is less than 192. Fuck this guy and his pill pushing (I’m assuming Purdue Pharma loved him and probably visiting with him often).
Here’s a pretty good representation of how our system works, courtesy of South Park (it’s not far off the mark):
Each entity in the chain of health care services operates in a silo and little to no incentive to align their goals to good health outcomes for patients. And the point about health insurance companies making it easy to pay to and hard to get paymemt from, is apt.
I had been looking for a letter rebutting a claim filed by a pediatric oncologist, and sure enough, I finally found it. UHC, of course, and the YTer reads it, with identifying information redacted, at about the 11 minute mark.
You’re leaving out a further complication, probably because you’re Canadian and I’m sure this would truly never come up under your system.
Remember, it is NOT the individual American choosing a health policy in the vast majority of cases, it is their employer making that choice. There can be considerable differences between these policies.
So… there is the list of procedures/medications/etc. the insurance company views as useful/effective/non-experimental and then the employer can, to a rather large degree, pick and choose on that menu for the services they will pay for.
So, for example, in the 1990’s I worked for a clinic that would NOT cover normal labor and delivery for a pregnancy. If you had a zero complication natural childbirth the cost was all on you. It would, however, cover the cost of labor and delivery if there were complications. Surprise, surprise, all of a sudden all the pregnant women at work had “complications” during their labor and delivery. I don’t think that’s legal anymore, but I’m not sure - this sort of thing has been “solved” 
by a patchwork of legislation covering various situations. Another one I used to see when I worked for the Evil Insurance Empire was non-coverage of high school, college, or organized sports. If your kid broke a leg skateboarding down your driveway you were covered. If he broke his legs playing high school football the entire cost was on you. Oh, and in 2002 the Evil Insurance Empire wrote a clause into the policy for its own employees that it wouldn’t cover any injuries as a result of a terrorist act. That was - eventually - changed but it sure didn’t sit well.
So it’s not just the insurance company calling these shots, it can also be the employer. As another example: the insurance company might be just fine with cochlear implants but maybe an employer decides to save money by not covering them. This omission will probably be buried in the fine print of the full policy rather than mentioned in the “summary” normally handed out to people. As long as no one tries to get one likely no one will notice, and depending on circumstances it might be years before anyone notices. Or maybe never. Or maybe next week. But in the end there will probably be no coverage for a cochlear implant for anyone covered under that policy.
You’re quite right — none of that would ever have occurred to me.
The employers have no role in determining access to Medicare services in our system. Supplementary stuff (prescriptions, glasses, dental), yes, but not coverage of issues like pregnancy and broken legs.
That wasn’t just the company you worked for and it wasn’t just for organized sports. Health insurance companies won’t pay if someone else is liable. They won’t pay if you got hurt at work - that’s the responsibility of the worker’s comp insurer. My kid gets hurt playing on a Little League team - my insurance company wants to know what kind of insurance the Little League has when they would just pay if I said it was a bunch of kids playing rather than something organized. I trip on my neighbor’s broken sidewalk and get hurt- they want to know about the neighbor’s homeowners policy. Injured in a car accident - someone’s auto insurance should be paying. My son got assaulted once - they wanted to know if we knew who the perpetrator was. That’s another cost that isn’t often taken into account - how much does it cost for different insurance companies to fight over who covers an injury? I’m 95 % sure this is not an issue in most other countries.
Another thing that probably didn’t occur to you , @Northern_Piper is that many employers self-insure. My insurance card says Well Known Insurance Company and Second Well Known Insurance Company on it. But they don’t actually provide my insurance. My employer is self-insured and those companies just administer the benefits while my employer actually pays the benefits. Which means that my “coverage” can be very different from the coverage actually provided by those companies in their own policies. In my case, the benefits are likely better than the commercial policies but that won’t be the case with all self-insured employers. I know that my doctor was surprised that my insurance covered the colonoscopy prep I preferred - apparently most don’t.
You beat me to posting about self-insured companies. About 3/4 of large (500+ employees) U.S. companies are now self-insured. As @doreen notes, they use a third-party health insurance company (like a United Healthcare or Blue Cross and Blue Shield) to manage claims – and, importantly, provide access to their “in-network” doctors and hospitals – but self-insured companies themselves are the ones who are paying for the claims (and managing the risk pool, either directly or through a third-party company).
That’s my experience. Yes, if it’s a Workplace injury, it’s covered by Workers Comp, but when you get rushed to hospital with a workplace injury, “who pays?” is secondary to getting treatment right away.
Years ago when I was involved in some personal accident litigation work, if compensation was recovered after a car accident, some of it might go to the medicare system. But now that our auto accident insurance is 100% no-fault, for both the vehicle and the individual, I don’t think it matters any more.
But your basic point is correct: our medicare system is not an insurance company, it’s a public service, so there’s no claims against other insurance companies for medical care.
Just like if you call the cops because you’ve been assaulted, the cops don’t try to sue the accused person for their expenses; fire services don’t try to find someone to sue for the cost of putting out the fire on your house.
Police, fire, health care - they’re all public services paid out of tax dollars.
Last April, while walking to my office from the train station, I slipped on a patch of ice, fell to the pavement, and broke my right elbow. All told, the total cost for the injury (ER visit, pre-surgery stuff, surgery, physical therapy, post-surgical follow-up visits) came to about $50K.
Thank goodness for having fairly good health insurance (I only had to pay a smallish fraction of that), but the insurance company sent me several letters, wanting an exact description of exactly where it happened, on whose property, and whether or not I was on the premises of my job.
Finally, after the third time I replied with, “It happened in the middle of Washington Street, where it crosses LaSalle Street. Take it up with the City of Chicago,” they finally stopped bothering me about it; I have to guess that they did not bother the city, either.
It’s ridiculous to talk about “moral hazard” in the context of health care. It’s not like free soda; nobody wants to have to receive any health care at all. Lots of fully insured Americans die every year because they didn’t bother to show up for the free annual checkups that could have diagnosed their condition while it was still treatable.
There is a difference between “nobody” and “almost nobody”. But it’s the tiny sliver of abusive people that will drive costs up for everybody.
If you stack up boxes of Ozempic in the doctor’s office with a sign that says “take one if you need it!”, someone will stop by to grab all of them and build furniture out of them or use them for fireplace fuel or something.
There’s a reason why basically everyone has co-pays, even in single-payer UHC countries like Canada. What other reason would there be for them?
That’s not to say that co-pays are the only possible mechanism for reducing the moral hazard, but it’s an extremely common one.
I think the obstacle should be “is a doctor prescribing the medication?”. I oppose any proposal to just stack up piles of free meds.
I’m going to need a cite for the claim that “co-pays are virtually universal”.
So you’re agreeing that there needs to be some obstacle (even a tiny one) to receiving medication?
I’ll ask again: why are co-pays virtually universal (even in fully nationalized health care systems like the NHS) if not to reduce the moral hazard?
Whoa! I think I just discovered the secret of time travel!
I’m approaching retirement and I’ve never paid a doctor bill or a hospital bill in my entire life. Lived in three different provinces. What co-pay are you talking about for Canada?
You presumably pay for medication out of pocket. The co-pays are for the various plans for prescription coverage (as I linked to above).
Clearly, paying a normal price for medication is another way of avoiding the moral hazard. The most effective one, in fact.