Health Care and the alternative point of view

[disneysteve]

The price is not consistent- because to be given the answer, more than likely I will be asked which insurance plan I am on.

For example last year from 2008 to 2009 my kids were getting synagis shots. The shot in December was a different cost than the shot in January because the insurance plans changed.

This type of inefficiency needs to be corrected

its the same procedure
to the same patient
the cost should be the same

which insurance plan I have should not change the cost

I understand your point now. So you basically want to eliminate the insurance companies (which I certainly wouldn't have a problem with). That is the appeal of a single-payer system. You don't have a dozen different companies negotiating a dozen different contracts with each provider. The price is what it is and the payer pays that price. Done deal. What you can't do is have multiple payers who are in competition with each other and come in and fix the prices. That would probably qualify as restraint of trade or some such issue like that. Just as the individual providers have different overhead and financial needs, so do individual insurance companies. Some are small regional companies. Others are large national companies. Different overhead. Different business models.

[jIM_Ohio]

I understand your point now. So you basically want to eliminate the insurance companies (which I certainly wouldn't have a problem with). That is the appeal of a single-payer system. You don't have a dozen different companies negotiating a dozen different contracts with each provider. The price is what it is and the payer pays that price. Done deal. What you can't do is have multiple payers who are in competition with each other and come in and fix the prices. That would probably qualify as restraint of trade or some such issue like that. Just as the individual providers have different overhead and financial needs, so do individual insurance companies. Some are small regional companies. Others are large national companies. Different overhead. Different business models.

Insurance companies can exist
but they cannot have the same level of control they do now

they are the pool of money paying for things
but the prices they pay need some regulation


the overhead of the insurance companies should NOT effect the price the patient pays
it should only affect the profit of the insurance company

idealistic, I know
but that is what forums are for

In theory, there is no difference between theory and reality
in reality, there is a difference

[blankcheck]

Insurance companies can exist
but they cannot have the same level of control they do now

I think this is what the issue boils down to, and the concern is, if not them, then who? The government has answered "the government," which is how almost the whole world looks at it. However, since it's a relatively new concept in this country, it's incredibly difficult to swallow that. Hell, despite clear advantages, this nation doesn't support the metric system!

Back on topic...how so other insurance industries remain solvent, yet still remain a requirement for certain products? Car insurance and home insurance are not little things, yet they are mandated, anticipated, and accepted by society as a whole. What is their model? I'm not familiar with the nuts and bolts of those industries, and I suspect it's apples-to-oranges, but I'm not sure.

[creditcardfree]

We could tell you the cost of any vaccines we give or any lab tests we do. We can't tell you the cost of any test or procedure for which we have to refer you elsewhere to get like an x-ray or ultrasound because it depends where you go, which speaks to Jim's point. X-ray facility A doesn't charge the same price as x-ray facility B or C or D. Of course, medicine isn't unique in that regard. A gallon of milk costs a different price at each grocery store. I can show you intersections that have 4 gas stations and each charges a different price per gallon. That's what happens in a free market.

Remember, the majority of doctors are small business owners, so part of that free market system. If you want to fix prices, you need to totally change the nature of healthcare. You need to make me and every other doctor a government employee with a fixed salary and full benefits.

I appreciate your response. I haven't had much experience with needed to ask for the cost of services and it doesn't seem to be a topic with many doctors. As long as they know you do or do not have insurance seems to be the concern that comes across as a consumer.

I also don't think prices need to be fixed because we are a free market system. If I want a really good doctor and their skills demand a higher fee, I'd be willing to pay for their expertise. This of course is easier to figure out if you have time before needing services, much harder in an emergency...but then again I would be willing to pay more in an emergency situation.

Can I also just say, insurance billing practices at the very least need a huge overhaul!! It should not take years to bill someone for a proceedure, don't these doctors want their money at the time of service?

[disneysteve]

the overhead of the insurance companies should NOT effect the price the patient pays
it should only affect the profit of the insurance company

I guess that's true because if their overhead goes up, they can raise premiums. Now, however, they also negotiate new contracts with providers to adjust fee schedules. Keep in mind that the government already does the exact same thing with Medicare. There is a 10% Medicare pay cut to doctors pending as we speak.

Where do doctors and hospitals fit in? Would you say the same thing for us, that our overhead can't affect the prices we charge for our services? If my staff demands raises, I have to pay them more but can't turn around and charge my patients more. If my property taxes go up, I can't pass those costs on to patients? If my insurance costs rise, I just have to eat that cost?

[creditcardfree]

If we are still in a free market, all providers should be able to pass on some of their overhead to the patient. Insurance companies that are publically traded also have a duty to their shareholders to make a profit. I think it comes down to us consumers to determine what we really want for our healthcare, if we demand it, whatever IT is, then the providers, doctors, hospitals and insurance companies will provide. Okay...maybe idealistic. What we have now seems to be a reflection of our demands, or lack thereof!

[maat55]

The free market is no panacea. Look no further than the last recession, brought about by Wall Street greed.

Improperly regulated Wallstreet. This does not justify government takeover of the economy.

[maat55]

Here is an excerpt from a thoughtful article "Why We Must Ration Health Care" that was posted several months ago from the New York Times. Hopefully it will make you think and add to the discussion.
http://www.nytimes.com/2009/07/19/ma...agewanted=1&em

I fully agree with rationing when it comes to government provided healthcare. This is why I do not agree with government provided healthcare. In a free country, you decide by how you prioritize your finances. Some will afford it, some will not, but the lowest price will come from the free market and not the government. I don't won't to be at the mercy of the government, I could live with my own failure.

[markusk]

The price is not consistent- because to be given the answer, more than likely I will be asked which insurance plan I am on.

For example last year from 2008 to 2009 my kids were getting synagis shots. The shot in December was a different cost than the shot in January because the insurance plans changed.

This type of inefficiency needs to be corrected

its the same procedure
to the same patient
the cost should be the same

which insurance plan I have should not change the cost

You are forgetting that the hospital bought the medication, synagis in this case, from a drug manufacturer. Medications are bought in large purchase agreements at a time (by duration or quantity) and each batch can change in price -- purchasing agreements between hospital(s) and drug manufacturers change. This is even more true of the same generic brand medication that are made by different companies. I was told by a pharmacist, hospitals often "get the best deal" and will shop around all the time. So its possible that synagis "cost" was different not because the insurance changed but because the cost of the drug changed in that time.

The same procedure to the same patient by the same physician at the same hospital does have the same cost. Its the insurance companies that differ in how much they pay for the same service/study. When one insurance company keeps lowering its payments, that insurance company is "dropped" and patients are told their insurance are no longer accepted by that physician.

[markusk]

I fully agree with rationing when it comes to government provided healthcare. This is why I do not agree with government provided healthcare. In a free country, you decide by how you prioritize your finances. Some will afford it, some will not, but the lowest price will come from the free market and not the government. I don't won't to be at the mercy of the government, I could live with my own failure.

I am somewhat confused as to your reasoning. Rationing is okay if the government provides healthcare, so this is the reason why you do not agree with government providing healthcare? The article is just about rationing whether by a single payer (England was the example in the article) or by a for-profit insurance company.

If a new drug comes into the market, there is no "lowest price." There is just one price set by the sole pharmaceutical company who owns the patent, and unless you have insurance, most likely you will not be able to afford it. In this not so hypothetical example, the insurance company is now "on the hook" for the cost of this new drug, so they may try to deny the medication because it is "experimental" or raise premiums for everyone or try to find a way to "drop" the person's insurance or hope the person dies as soon as possible, or go bankrupt.

We are all at the mercy of someone. Some people don't want to be at the mercy of the government not realizing (or unwilling to admit) that we are already at the mercy of the pharmaceutical/insurance industry.

At a certain level, I guess its a matter of choosing your evil. On the one hand is a faceless bureaucracy that can be inefficient, existing only to perpetuate itself and not necessarily to delivering healthcare. On the other hand is a faceless bureaucracy that exists only to make a profit, and not necessarily to delivering healthcare.

[disneysteve]

I appreciate your response. I haven't had much experience with needed to ask for the cost of services and it doesn't seem to be a topic with many doctors. As long as they know you do or do not have insurance seems to be the concern that comes across as a consumer.

If you call my office to schedule an appointment, you will be asked what type of insurance you have. That could come across as us only caring that you have insurance but there's more to it than that. We need to know that because my staff needs to confirm that we accept your insurance, confirm that your insurance is active and in effect and confirm that you have selected us as your doctors if your plan requires you to do so. You'd be surprised how many people tell us they have insurance and when we check we find out that it was terminated last month or 6 months ago.

If you say you have no insurance, you'll be told the fee for an office visit so that you know in advance and can come prepared to pay that amount.

[disneysteve]

You are forgetting that the hospital bought the medication, synagis in this case, from a drug manufacturer. Medications are bought in large purchase agreements at a time (by duration or quantity) and each batch can change in price -- purchasing agreements between hospital(s) and drug manufacturers change. This is even more true of the same generic brand medication that are made by different companies. I was told by a pharmacist, hospitals often "get the best deal" and will shop around all the time. So its possible that synagis "cost" was different not because the insurance changed but because the cost of the drug changed in that time.

This is all true. Even if your insurance didn't change, the price could have changed because they could have changed their formulary. That drug could have changed from a preferred drug to a non-preferred or from Tier 2 copay to Tier 3 copay. Lots of reasons why the price might have been different.

[creditcardfree]

In response to the above post. This seems like an example, where as consumers we use our insurance company as our basis for how much things costs, instead of looking at the cost of each product or service we are receiving prior to insurance coverage.

Also, great explanation about how drug costs can change.

[jIM_Ohio]

I think this is what the issue boils down to, and the concern is, if not them, then who? The government has answered "the government," which is how almost the whole world looks at it. However, since it's a relatively new concept in this country, it's incredibly difficult to swallow that. Hell, despite clear advantages, this nation doesn't support the metric system!

Back on topic...how so other insurance industries remain solvent, yet still remain a requirement for certain products? Car insurance and home insurance are not little things, yet they are mandated, anticipated, and accepted by society as a whole. What is their model? I'm not familiar with the nuts and bolts of those industries, and I suspect it's apples-to-oranges, but I'm not sure.

If I could sue my employer and insurance company for promises not kept (health care wise) then they can keep the control they have.

Otherwise, put control in hands of doctors and also require full price disclosure.

This means a regulatory agency similar to FDA, NTA or any of the 10-100 other agencies which exist to regulate business. Even life insurance has regulations, and I see no reason why Health insurance companies cannot be regulated more.

The form of regulation I suggest is something where prices are disclosed (for example list every procedure by code, with a range of prices for that procedure based on x,y and z variables.

One variable could be whether a doctor or tech did the test.
Another variable could be facility (hospital, military or office)
another variable could be quality (the resolution of the MRI).

All that data exists, the issue is it is not disclosed to the public. In addition employers are not required to give data to their employees.

True story

My kids are preemies- born 12 weeks early. One of main issues preemies deal with is something called RSV- its a type of virus which infects the lungs.

There is am immunization for this called Synagis. You have to qualify for it. My kids qualified. The immunization is given in 4-6 doses 30 days apart. It is very expensive (think $1000-$2000 per shot per kid, and its not something pediatrician's have in high supply).

In 2008 my kids were Born in March.
In August our pediatrician started the qualification process with wife's insurance company (kids were on wife's policy back then)
Shots started in late October. Wife's insurance had a nursing company come to house, give kids shots, and stay for 30 minutes before moving on. This worked REALLY well.

In November my open enrollment occured. We checked with HSA and they said immunizations were covered at 100%. It apparently was a third party which told me this (turns out I was not speaking to cigna, I was speaking to Hewitt, but that person did not disclose that at the time).

In January when it came time to have cigna issue the first shot (kids had received 3 doses October-December, might have been 4 doses).

Turns out Synagis was NOT covered under cigna (even though we had the name of the person, and date of two phone calls, and the person's supervisor name which told us it was covered 100% in November). My employer gave me 2 responses:

1) The Hewitt employee did not have access to plan documents to know the answer for sure
2) I am not allowed to see the plan documents myself, because I am not cigna's customer

Turns out my employer is cigna's customer (not me) and I am not allowed to see plan documents for what is or is not covered.

So we forked over $1000-$2000 per shot per kid for next 3 months (needless to say we hit the out of pocket max on the HSA/HDHP within 2 months).

The way Synagis is shipped, you order it in viles of a given volume. My kids would get weighed in on Tuesday, the weight is sent to cigna, then they ship the number of viles based on weight. We would get weighed on Tuesday for a shot on Thursday or Friday (for example).

So if each vile was 10 ml (I am making that number up, I do not know volumes they used).
and one kid needed 11 ml, cigna would bill us for 2 viles, even though 9ml of the second vile is going to be thrown away.

The nursing company would weigh kids before the shot, measure the needle, and inject (less is wasted).


My comment is the pricing for this should be consistent regardless of who insures me.
My comment is I should be able to choose who gives my kids the shot (the nursing company is much more efficient)
My comment is I need to see plan documents before changing insurance companies if the current system is in place

any or all of those reforms are needed
keeping current system and then adding more people and tax dollars to it does not improve the system for me.

[jIM_Ohio]

You are forgetting that the hospital bought the medication, synagis in this case, from a drug manufacturer. Medications are bought in large purchase agreements at a time (by duration or quantity) and each batch can change in price -- purchasing agreements between hospital(s) and drug manufacturers change. This is even more true of the same generic brand medication that are made by different companies. I was told by a pharmacist, hospitals often "get the best deal" and will shop around all the time. So its possible that synagis "cost" was different not because the insurance changed but because the cost of the drug changed in that time.

The same procedure to the same patient by the same physician at the same hospital does have the same cost. Its the insurance companies that differ in how much they pay for the same service/study. When one insurance company keeps lowering its payments, that insurance company is "dropped" and patients are told their insurance are no longer accepted by that physician.

Slow down

we know how the synagis gets ordered

The price for synagis should not change (IMO) based on who is ordering it, because it is ORDERED and not inventoried. In addition in October the manufacturers of the immunization make the batch for the winter- this is not a one time shot, it is a series of dosages.

If two places manufacture it, I should be allowed to order it from wherever it is cheapest, not who my insurance company contracts with.

Part of the qualification process to get it validates this. You have to be a certain age (for example my kids were 6 months old in September, had they been 11 months, they might not have qualified. My kids were born 12 weeks early, had they been born 5 weeks early, its possible they would not have qualified. The NICU and pediatrician both informed us of this. The NICU told parents this every week (we had support group meetings, and RSV/ Synagis was brought up at each meeting. We were informed to starting checking with insurance then, and find a pediatrician which had experience with preemies which knew the procedure.

I can see the price changing from october to March based on the availability of the ingredients to make one batch vs another, as best I could tell, the unit price per vile stayed consistent throughout the treatment.

My issue with the Synagis is that a new insurance company controlled how it was delivered, and their way cost more (I was paying for something which had 90% of it thrown away). In addition the new insurance company put my kids at risk by requiring them to go to a doctor's office for a weigh in, and if any of you have ever had preemies, my kids would get sick the moment they were around other kids, so hospital waiting rooms for them increases their risk more than the immunization prevents a different risk.

No way the insurance company was doing what was in best interests of my kids, but they have procedures and plan documents which I am not allowed to see until deemed necessary. Had they told us this in November (when we asked during open enrollment) we would not have changed insurance companies.

Nothing in the process was based on patient first

Any suggestion I make, is in best interest of patient... the #1 thing is to take power away from the insurance companies. They cannot change treatment even if a different insurance company started treatment. They pay for the treatment, that is it. I pay them premiums, they pay my bills- withint certain limits or guidelines. They do NOT get to micromanage care, IMO.

My doctor needs control of the care (we did end up skipping a synagis shot in April with some discussion with pediatrician as to risks/rewards). I should have more control over how my kids are treated than my insurance company.

I am sure Steve has stories which HIPPA prevents him from sharing, but I can assure you that stories like this, where the insurance companies change treatment because of plan documents and internal procedures are quite common. This control they have needs to be reined in.