My daughter has an ovarian tumor

[4Q Basket Case]

The solution exists in Europe, and every other Western country other than the US - you have socialized medicine for everyone and privatized medicine for those who can afford it or wish additional coverage. We have a close friend who is a doctor in the UK. When we talk to him he makes it clear - yes, there are waiting lists for socialized services, but at least they are available to everyone. And there are no waiting lists for privatized services.

People want to pretend that there is only one or the other. Unless you are in Russia or China, that is not true. In western countries, they have both. Whatever we adopt in America will also have both. But the tens of millions with no care today will get care, and the middle class will no longer have to fear bankruptcy from a single bad illness in the family.

Which is pretty much what Obamacare, as originally passed, was.
- Everybody has to participate in an insurance plan
- You can do that with private insurance (usually through an employer, occasionally purchased as an individual) or
- You can do that through the exchange
- There are subsidies for low income people

When Congress lifted the individual mandate, young people who weren’t covered by an employer left the program in droves, knocking the actuarial underpinnings out from under the program.

 

[B1GTide]

Which is pretty much what Obamacare, as originally passed, was.
- Everybody has to participate in an insurance plan
- You can do that with private insurance (usually through an employer, occasionally purchased as an individual) or
- You can do that through the exchange
- There are subsidies for low income people

When Congress lifted the individual mandate, young people who weren’t covered by an employer left the program in droves, knocking the actuarial underpinnings out from under the program.

Sorry, not even close. You do not have to pay one cent to be covered in any western country except America.

 

[4Q Basket Case]

Sorry, not even close. You do not have to pay one cent to be covered in any western country except America.

The fact that the federal government might start paying for everything doesn’t mean that medical services all of a sudden become free.

One way or another, the taxpayer will foot the bill. You can do it through higher taxes, into a program administered by the government. Or you can pay it to an insurance company.

Given the track record of all levels of government in administration, I think you’ll get better results for less money by paying it to an insurance company

 

[B1GTide]

The fact that the federal government might start paying for everything doesn’t mean that medical services all of a sudden become free.

One way or another, the taxpayer will foot the bill. You can do it through higher taxes, into a program administered by the government. Or you can pay it to an insurance company.

Given the track record of all levels of government in administration, I think you’ll get better results for less money by paying it to an insurance company

You are intentionally missing the point.

 

[Go Bama]

Given the track record of all levels of government in administration, I think you’ll get better results for less money by paying it to an insurance company

I used to think this.

Insurance companies by their nature are in business to pay as little as possible. They may say a procedure is unnecessary, limit the amount that can be charged for a procedure, say a procedure has already been performed when it hasn't, say they don't see a problem when it is obvious, make it difficult to appeal a claim, keep your office staff on hold indefinitely, lose the claim or say they never received it, ask a doctor to write a narrative to describe the condition, and on and on and on.

There are hundreds of insurance companies. The only way to know what a patient's benefit allows is to call the company, but even then they may give you one answer on the phone and a different answer when the claim is filed.

Dental insurance used to pay for bite wing x-rays twice a year. Now, most will only pay once per year. This saves the insurance companies a massive amount of money, but it is not in the best interest of patients.

The other side of the same coin is the medical teams will have meetings to figure out how to get as much as possible from the insurance companies. So whether or not the patient needs the procedure, it may be performed just to get the money. In dentistry there continues to be a shift toward large national dental companies that are run like big business. The focus is on money, not patient care.

I agree government has proven to be poor at administration. My experience is the current system of insurance companies is a bigger nightmare that continues to get worse and worse.

 

[Jon]

Speaking of cost & "in network" I just got off the phone with the hospital. My doc had called me to tell me what they charge for a surgury that I've needed for years, but that doesn't include the hospital or anesthesiologist cost, so I called the hospital to find out. They will not give me the cost, or even a ballpark figure. They told me I have to schedule surgery, then call them to see if I can afford it, and pay a portion up front - but they cannot tell me how much that will be.
It's ridiculous. All hospitals do it - but we pre-paid for my c-section with the doc, then had to pay $500 up front when we walked in the door to have it (surprise!!)

I used to think this.

Insurance companies by their nature are in business to pay as little as possible. They may say a procedure is unnecessary, limit the amount that can be charged for a procedure, say a procedure has already been performed when it hasn't, say they don't see a problem when it is obvious, make it difficult to appeal a claim, keep your office staff on hold indefinitely, lose the claim or say they never received it, ask a doctor to write a narrative to describe the condition, and on and on and on.

There are hundreds of insurance companies. The only way to know what a patient's benefit allows is to call the company, but even then they may give you one answer on the phone and a different answer when the claim is filed.

Dental insurance used to pay for bite wing x-rays twice a year. Now, most will only pay once per year. This saves the insurance companies a massive amount of money, but it is not in the best interest of patients.

The other side of the same coin is the medical teams will have meetings to figure out how to get as much as possible from the insurance companies. So whether or not the patient needs the procedure, it may be performed just to get the money. In dentistry there continues to be a shift toward large national dental companies that are run like big business. The focus is on money, not patient care.

I agree government has proven to be poor at administration. My experience is the current system of insurance companies is a bigger nightmare that continues to get worse and worse.

I consulted for a computer reseller years ago, early 2000's. They brought me in because their core business was failing and they wanted to figure out new markets. One of the things they wanted to explore was selling medical software to physician offices and groups. I had about a few of the biggest players at the time come in a pitch me on why I should sell their stuff. Wow it was slimy. Every vendor said something to the effect of "well it is technically illegal for our software to recommend every test that we know medicare and all the major private insurers are likely to cover by patient here is how we get around that". This was their pitch to docs, "select this condition from the dropdown menu and we show you everything medicaid will pay for," not here is what the condition recommends. It hasn't been about patient care for a long, long time.

For your biz, several years ago I needed a new dentist. Went to my insurer, found out the practices locally I could go to and booked an appointment. Dentist had a brand new doc working there who I took a liking to right away. She was 5-6 years into her practice but new to Atlanta having moved here for her husbands work. About 15-20 mins in the guy who ran the practice came in and she showed him what was up with my eval and he proceeded to check me out and claim I needed surgery and just a litany of stuff I had no need for, I could see it in her eyes like "omg I can't believe what scum this guy I am working for is". I told him we address that all later but I was just here for the cavity I needed filled but I would schedule a follow up. I never followed up. I did go to her linked in a few months later and learned that she had quit and opened her own practice. I still go to that practice even though it is a good 15 miles out of my way (and that is a LOT in Atlanta traffic) and I still like her quite a bit. I also pay out of network for the privilege

 

[Padreruf]

I consulted for a computer reseller years ago, early 2000's. They brought me in because their core business was failing and they wanted to figure out new markets. One of the things they wanted to explore was selling medical software to physician offices and groups. I had about a few of the biggest players at the time come in a pitch me on why I should sell their stuff. Wow it was slimy. Every vendor said something to the effect of "well it is technically illegal for our software to recommend every test that we know medicare and all the major private insurers are likely to cover by patient here is how we get around that". This was their pitch to docs, "select this condition from the dropdown menu and we show you everything medicaid will pay for," not here is what the condition recommends. It hasn't been about patient care for a long, long time.

For your biz, several years ago I needed a new dentist. Went to my insurer, found out the practices locally I could go to and booked an appointment. Dentist had a brand new doc working there who I took a liking to right away. She was 5-6 years into her practice but new to Atlanta having moved here for her husbands work. About 15-20 mins in the guy who ran the practice came in and she showed him what was up with my eval and he proceeded to check me out and claim I needed surgery and just a litany of stuff I had no need for, I could see it in her eyes like "omg I can't believe what scum this guy I am working for is". I told him we address that all later but I was just here for the cavity I needed filled but I would schedule a follow up. I never followed up. I did go to her linked in a few months later and learned that she had quit and opened her own practice. I still go to that practice even though it is a good 15 miles out of my way (and that is a LOT in Atlanta traffic) and I still like her quite a bit. I also pay out of network for the privilege

I had a similar experience with a dentist here in Charleston...would not give me a price, but would up paying 5,000 for a tooth/bridge. I've decided to go to the MUSC dental school...

 

[Go Bama]

I consulted for a computer reseller years ago, early 2000's. They brought me in because their core business was failing and they wanted to figure out new markets. One of the things they wanted to explore was selling medical software to physician offices and groups. I had about a few of the biggest players at the time come in a pitch me on why I should sell their stuff. Wow it was slimy. Every vendor said something to the effect of "well it is technically illegal for our software to recommend every test that we know medicare and all the major private insurers are likely to cover by patient here is how we get around that". This was their pitch to docs, "select this condition from the dropdown menu and we show you everything medicaid will pay for," not here is what the condition recommends. It hasn't been about patient care for a long, long time.

For your biz, several years ago I needed a new dentist. Went to my insurer, found out the practices locally I could go to and booked an appointment. Dentist had a brand new doc working there who I took a liking to right away. She was 5-6 years into her practice but new to Atlanta having moved here for her husbands work. About 15-20 mins in the guy who ran the practice came in and she showed him what was up with my eval and he proceeded to check me out and claim I needed surgery and just a litany of stuff I had no need for, I could see it in her eyes like "omg I can't believe what scum this guy I am working for is". I told him we address that all later but I was just here for the cavity I needed filled but I would schedule a follow up. I never followed up. I did go to her linked in a few months later and learned that she had quit and opened her own practice. I still go to that practice even though it is a good 15 miles out of my way (and that is a LOT in Atlanta traffic) and I still like her quite a bit. I also pay out of network for the privilege

I see this all the time. Courses are offered on how to sell high priced dentistry. Instead of giving a patient their options, just give them the high priced option. Have a patient fill out a questionnaire which asks on a scale of one to ten how important is your dental health (almost everyone says 10), then offer the patient only the big ticket procedures. Use a laser to detect cavities that cannot otherwise be seen, but cheat on the reading to find more cavities. I've seen dentist refer patients to an oral surgeon rather than pull a tooth because the OS will charge as much as a root canal. I've seen countless teeth get endodontic treatment (root canal) that absolutely did not need endo. I've seen doctors do crown preps on teeth with absolutely nothing wrong with them.

Most dentists are very ethical people who make a good living by treating their patients fairly. I would steer completely away from the guys with the biggest offices that do the most advertising.

Jon, it sounds like your 15 miles is well worth the drive.

 

[Padreruf]

I see this all the time. Courses are offered on how to sell high priced dentistry. Instead of giving a patient their options, just give them the high priced option. Have a patient fill out a questionnaire which asks on a scale of one to ten how important is your dental health (almost everyone says 10), then offer the patient only the big ticket procedures. Use a laser to detect cavities that cannot otherwise be seen, but cheat on the reading to find more cavities. I've seen dentist refer patients to an oral surgeon rather than pull a tooth because the OS will charge as much as a root canal. I've seen countless teeth get endodontic treatment (root canal) that absolutely did not need endo. I've seen doctors do crown preps on teeth with absolutely nothing wrong with them.

Most dentists are very ethical people who make a good living by treating their patients fairly. I would steer completely away from the guys with the biggest offices that do the most advertising.

Jon, it sounds like your 15 miles is well worth the drive.

I had an ex-bil who was convicted of welfare fraud in NC and lost his license...he post dated and mislabeled work in order to get paid by the government...Alabama gave him a license 2 years later...

 

[NationalTitles18]

I used to think this.

Insurance companies by their nature are in business to pay as little as possible. They may say a procedure is unnecessary, limit the amount that can be charged for a procedure, say a procedure has already been performed when it hasn't, say they don't see a problem when it is obvious, make it difficult to appeal a claim, keep your office staff on hold indefinitely, lose the claim or say they never received it, ask a doctor to write a narrative to describe the condition, and on and on and on.

There are hundreds of insurance companies. The only way to know what a patient's benefit allows is to call the company, but even then they may give you one answer on the phone and a different answer when the claim is filed.

Dental insurance used to pay for bite wing x-rays twice a year. Now, most will only pay once per year. This saves the insurance companies a massive amount of money, but it is not in the best interest of patients.

The other side of the same coin is the medical teams will have meetings to figure out how to get as much as possible from the insurance companies. So whether or not the patient needs the procedure, it may be performed just to get the money. In dentistry there continues to be a shift toward large national dental companies that are run like big business. The focus is on money, not patient care.

I agree government has proven to be poor at administration. My experience is the current system of insurance companies is a bigger nightmare that continues to get worse and worse.

It's very much the same on the medical side. I'm sick and tired of wrestling with insurance companies to get patients the care they NEED.

But if the patient has Medicare I order the test and guess what happens...

It gets done. Period. No hassling. No wrestling. No prior authorization. No damn peer to peer with a doctor on the other end of the phone who is literally paid to deny proper care.

I'm ready for Medicare for all with supplemental insurance of your choice. Just fix the stupid donut hole for prescriptions and a few other things and let's do it.

Right now private insurance is, by and large, much worse than Medicare.

 

[TIDE-HSV]

It's very much the same on the medical side. I'm sick and tired of wrestling with insurance companies to get patients the care they NEED.

But if the patient has Medicare I order the test and guess what happens...

It gets done. Period. No hassling. No wrestling. No prior authorization. No damn peer to peer with a doctor on the other end of the phone who is literally paid to deny proper care.

I'm ready for Medicare for all with supplemental insurance of your choice. Just fix the stupid donut hole for prescriptions and a few other things and let's do it.

Right now private insurance is, by and large, much worse than Medicare.

I had barely started practicing when Medicare came in and I was representing dozens of doctors in the first couple of decades. All I heard in meetings was how Medicare was ruining the practice of medicine, they weren't being paid enough, etc. Over the years, I noticed a subtle change in attitude...

 

[NationalTitles18]

I had barely started practicing when Medicare came in and I was representing dozens of doctors in the first couple of decades. All I heard in meetings was how Medicare was ruining the practice of medicine, they weren't being paid enough, etc. Over the years, I noticed a subtle change in attitude...

It's only gotten worse with time. It used to be that BC/BS was the best private insurance, but that's often not the case anymore.

 

[TIDE-HSV]

It's only gotten worse with time. It used to be that BC/BS was the best private insurance, but that's often not the case anymore.

I'm sure you know that BCBS of AL/TN is the administrator here for Medicare...

 

[NationalTitles18]

I'm sure you know that BCBS of AL/TN is the administrator here for Medicare...

I know it was as of about 5 years ago and I'm sure it hasn't changed.

 

[4Q Basket Case]

You are intentionally missing the point.

You have a PM.

 

[TIDE-HSV]

I don't want to overwhelm the thread with observations about the French system, but sometimes the contrasts force me. My daughter's GE doc just canceled her combined endoscopy/colonoscopy next week. She wanted to cancel only the colon part because it conflicted with her methotrexate regimen, which has finally given her some relief from the worst of the SPS symptoms. He insisted illogically that they were "one procedure" and had to be done together. If she wanted to split them, she'd have to wait another 3.5 months. She's hoping the oncologist she sees in about three weeks will give her a referral to a different GE doc. Sometimes, it helps to have a different perspective...

 

[Go Bama]

I don't want to overwhelm the thread with observations about the French system, but sometimes the contrasts force me. My daughter's GE doc just canceled her combined endoscopy/colonoscopy next week. She wanted to cancel only the colon part because it conflicted with her methotrexate regimen, which has finally given her some relief from the worst of the SPS symptoms. He insisted illogically that they were "one procedure" and had to be done together. If she wanted to split them, she'd have to wait another 3.5 months. She's hoping the oncologist she sees in about three weeks will give her a referral to a different GE doc. Sometimes, it helps to have a different perspective...

It's certainly not my field, but I've never heard of doing those procedures at the same time. It doesn't make any sense.

 

[TIDE-HSV]

It's certainly not my field, but I've never heard of doing those procedures at the same time. It doesn't make any sense.

Well, there is no connection except for the convenience of the imaging center. However, she said that, when she was scoped in Germany, they also did them simultaneously. Come to think of it, I actually requested it once, in order to get it over with. They turned me down...

 

[Chukker Veteran]

Blue Cross opened my eyes about how ethically they cover medicine. My family doctor gave me a sample, a month's supply of medicine a few years ago, it saved me about 50 bucks, so great. It was something I took every month.

The following month, my prescription for that medicine was denied. Evidently they monitor the number of pills you buy. By skipping a month using the samples, it gave Blue Cross an excuse to deny covering the medicine. They said I had not taken it as prescribed since I took a month off buying it at the drugstore. I spent a lot of time on the phone with them, trying to correct the problem, but was simply told to get over it. They would no longer cover the name brand medicine that was working well for me, I was left trying different generics trying to get the same benefit and went through several different ones, while the original that had been denied was working well when they stopped it.

I realize this is mighty small potatoes compared to what else is being discussed in this thread, but decided to tell my story anyway.

I've had several significant operations since then, the Blue Cross has been satisfactory. But I can't help but wonder when they will pull something else like that on me, when there is some real money at stake.

 

[B1GTide]

Blue Cross opened my eyes about how ethically they cover medicine. My family doctor gave me a sample, a month's supply of medicine a few years ago, it saved me about 50 bucks, so great. It was something I took every month.

The following month, my prescription for that medicine was denied. Evidently they monitor the number of pills you buy. By skipping a month using the samples, it gave Blue Cross an excuse to deny covering the medicine. They said I had not taken it as prescribed since I took a month off buying it at the drugstore. I spent a lot of time on the phone with them, trying to correct the problem, but was simply told to get over it. They would no longer cover the name brand medicine that was working well for me, I was left trying different generics trying to get the same benefit and went through several different ones, while the original that had been denied was working well when they stopped it.

I realize this is mighty small potatoes compared to what else is being discussed in this thread, but decided to tell my story anyway.

I've had several significant operations since then, the Blue Cross has been satisfactory. But I can't help but wonder when they will pull something else like that on me, when there is some real money at stake.

Yep - you have to know the "rules". My wife has a cousin who is a doctor. She has since sold her practice, but she used to get insulin pens as free samples and she offered them to my wife a time or two because of the cost of insulin. My wife had to explain to her that she couldn't take them because she couldn't order less insulin in a given month for the reasons that you cite. Insulin has a pretty short shelf life, so you can't even set it aside "just in case" - it would end up being wasted.