Tired of insurance denying medications- mandating adverse effects

[InkedDOc]

Just fed up with having to place patients on medications which I know will result in either inefficacy or poor outcomes. Insurance dictates too much. Please consider signing if you agree.

The White House

President Biden and Vice President Harris promised to move quickly to deliver results for working families. That’s what they’ve done.

petitions.whitehouse.gov

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[clausewitz2]

Just fed up with having to place patients on medications which I know will result in either inefficacy or poor outcomes. Insurance dictates too much. Please consider signing if you agree.

The White House

President Biden and Vice President Harris promised to move quickly to deliver results for working families. That’s what they’ve done.

petitions.whitehouse.gov

You need Congress or your state legislatures to act, the case law on this is pretty clear re: health insurance not being liable for bad outcomes related to most denials.

 

[tr]

This is just a tiny smoldering corner of the unsalvageable dumpster fire that is the for-profit health insurance industry. The whole thing needs to be eliminated.

If you want to do something useful, call your congressperson and tell them to support Pramila Jayapal's Medicare For All bill.

 

[clausewitz2]

This is just a tiny smoldering corner of the unsalvageable dumpster fire that is the for-profit health insurance industry. The whole thing needs to be eliminated.

If you want to do something useful, call your congressperson and tell them to support Pramila Jayapal's Medicare For All bill.

Consolidated hospital systems are much bigger driver of costs than the insurance industry. Break up the multi-billion dollar "charities" and the balance of bargaining power shifts significantly.

 

[Shikima]

Another means in which to negate what insurance companies do is to go cash only and develop relationships with drug reps for samples.

 

[Merely]

This is just a tiny smoldering corner of the unsalvageable dumpster fire that is the for-profit health insurance industry. The whole thing needs to be eliminated.

If you want to do something useful, call your congressperson and tell them to support Pramila Jayapal's Medicare For All bill.

Will this hurt physician income?

 

[whopper]

I don't mind some of what they do. E.g. if they want me to try 2 generics before an expensive $800/month antidepressant, I get it. The science backs up the expensive stuff isn't so much more effective for many people. But if a few meds were tried and failed, heck yeah they should be able to be tried and not denied on the more expensive stuff, and that's when they start ticking me off when they deny it.

They also tick me off when they make me talk to a doctor on the phone to justify further hospital treatment, the patient is obviously dangerous, and they deny coverage.

 

[PikminOC]

This is just a tiny smoldering corner of the unsalvageable dumpster fire that is the for-profit health insurance industry. The whole thing needs to be eliminated.

If you want to do something useful, call your congressperson and tell them to support Pramila Jayapal's Medicare For All bill.

You think Medicare will cover these meds? Lol

 

[NickNaylor]

Will this hurt physician income?

Of course it will - Medicare doesn't pay particularly well, thus if many or most of your patients are having their care paid for by Medicare, it will hit your - or your hospital's - pocketbook.

 

[Sushirolls]

Just fed up with having to place patients on medications which I know will result in either inefficacy or poor outcomes. Insurance dictates too much. Please consider signing if you agree.

The White House

President Biden and Vice President Harris promised to move quickly to deliver results for working families. That’s what they’ve done.

petitions.whitehouse.gov

I need examples. Similar to whopper, there are typically generics worth using first. What I usually see are ARNP starts of branded drugs either outpatient and inpatient, and when they transfer to me I'm left holding the hot potato that shouldn't have been baked in the first place. I do agree with sentiments from Whopper it is frustrating to get them covered after trying several other combinations.

 

[Sushirolls]

This is just a tiny smoldering corner of the unsalvageable dumpster fire that is the for-profit health insurance industry. The whole thing needs to be eliminated.

If you want to do something useful, call your congressperson and tell them to support Pramila Jayapal's Medicare For All bill.

Supporting this horrible idea is like telling a woman with fibrocystic breasts she needs radiation, chemo, and then at the end of it still doing a bilateral mastectomy. Bad idea on so many levels.

 

[PikminOC]

Of course it will - Medicare doesn't pay particularly well, thus if many or most of your patients are having their care paid for by Medicare, it will hit your - or your hospital's - pocketbook.

And under one payor they can drive fees even lower...

 

[Ironspy]

My state has an online complaint system for the attorney general’s office health insurance division. I fill it out while I wait on hold for the prior auth so it takes no extra time. You have to get patient consent Bc you’re sharing some of their PHI but i’ve had a lot of luck expediting things this way.

 

[PsyDr]

I might have some inside information on this. (Love me yet?)

1) It’s really good idea to request every insurance’s treatment guidelines and keep them on file. Some might say that if you have the rules in front of you, playing the game gets very easy.

2) It's a great idea to get the name of the relevant physician reviewing things.

3) @Ironspy is 100% correct. Complaining to the state insurance has some real teeth.

 

[FlowRate]

Consolidated hospital systems are much bigger driver of costs than the insurance industry. Break up the multi-billion dollar "charities" and the balance of bargaining power shifts significantly.

And what's a major driver of consolidation? Medicare ACO's.

 

[whopper]

A trend I've noticed is several PCPs just give out the expensive stuff first. It's seemingly as if they just do what the drug-rep tells them. Again, I think it's actually a good thing to try cheaper generics first especially in this newer age of SSRIs being cheap, and several atypical antipsychotics being available for less than $100.

A colleague of mine tried a patient on Nuplazid on a patient first. WTF? The antipsychotic did work but the patient had no Parkinson's sx whatsoever, nor did the insurance pay for it. He closed his practice and referred her to me, and while I liked the guy I was frank with the patient-"I don't know why he put you on a medication that costs over $2700 a month when there's others your insurance will cover that I have no reason to believe will not work other than that they haven't been tried on you." I changed her to Risperidone costing her less than $10 a month and it worked just as well.

When I told her this she flipped out and demanded her meds not be changed. Her family talked her into at least trying my recommendation.

After the Risperidone worked I told the family, "I just saved you the price of a college tuition per year." But it's not just the cost to the patient. In terms of the entire system, we physicians could save the system billions if we made good economic choices---> cheaper meds, but only so if they are of about the same quality of which there are several.

Back in the era of SSRIs and all atypicals being expensive, the price at that time for many was justified even with the expensive stuff being tried first. SSRIs and atypicals do have significant benefits for the majority over the older TCAs, MAO-Is and typical antipsychotics. Plus back in that era even those then generic meds were much more expensive. Remember it wasn't until about 10 years ago that the first about $10 a month meds came out. Before then most generics were still expensive. Many today still are. Generic Aripiprazole is still hundreds of dollars a month. Same with Clomipramine, a TCA.

These days it's completely worth trying Escitalopram or Citalopram first as an antidepressant. While Trintellix does have superiority in studies over SSRIs it's not that much and IMHO if I were the patient I'd rather try the $10 a month stuff first vs the $800/month stuff when the latter only has a few percentage points of difference in efficacy. Same with the newer atypical antipsychotics. That said I do have plenty of patients on the more expensive stuff, but I try this stuff only when the cheaper stuff was tried and failed or very limited success with the newer stuff working much better. I just tried a patient on Rexulti whose tried over 10 meds and she's had the best reaction to that med out of all the ones she's tried with complete remission of symptoms. On other meds she's never had complete remission and spent several years living with chronic suicidal ideation while on a mixture of Lithium, Latuda, Escitalopram, and that regimen was the best she had for years until the Rexulti was tried, plus she's tried Risperidone, Depakote, Olanzapine, Sertraline, Fluoxetine, Venlfaxine, etc. Of course in that situation the more expensive med is justified.

 

[calvnandhobbs68]

I get the reasonable 'try generics first, cheaper equivalent meds' first but there are also plenty of examples of insurance companies just straight scamming us/patients. Denying hospital stays or billing retroactively is of course the big one. I wish I could just go "nah, I think your massage sucked so I'm not gonna pay for it, thanks for the massage though!"

I recently had a patient with ADHD where the insurance literally did not cover any extended release stimulant class. None. I spent probably 20 minutes bouncing around the stupid ass insurance phone tree, then spent more time trying to figure out which of the 20 plans my patient had, then they didn't even have the formulary on their website (even though the insurance person said they did), then spent another 10 minutes while the insurance person finally found the formulary and spelt out every stimulant they would cover, none of which were extended release. Hey thanks for not contributing to medication abuse in our country insurance companies! Don't give me the bull**** "well what would happen if the gov'ment was the only insurance company huh?" Medicaid covers Adderall XR.

Also, when I'm talking to someone in the "pharmacy" department of an insurance company, why am I having to spell out dextroamphetamine letter by letter because the "pharmacy" person doesn't know wtf the word is? I'm tired of having to run my medical decisions by or argue about medication coverage to people who can't even say the medications I'm prescribing.

 

[LadyHalcyon]

Probably not helpful for the general purpose of this thread, but I have several patients on Vyvanse who have Medicaid. There is a Shire Cares program that will cover 100% of the cost if you can prove your insurance won't cover it and you fall within a certain financial bracket

I get the reasonable 'try generics first, cheaper equivalent meds' first but there are also plenty of examples of insurance companies just straight scamming us/patients. Denying hospital stays or billing retroactively is of course the big one. I wish I could just go "nah, I think your massage sucked so I'm not gonna pay for it, thanks for the massage though!"

I recently had a patient with ADHD where the insurance literally did not cover any extended release stimulant class. None. I spent probably 20 minutes bouncing around the stupid ass insurance phone tree, then spent more time trying to figure out which of the 20 plans my patient had, then they didn't even have the formulary on their website (even though the insurance person said they did), then spent another 10 minutes while the insurance person finally found the formulary and spelt out every stimulant they would cover, none of which were extended release. Hey thanks for not contributing to medication abuse in our country insurance companies! Don't give me the bull**** "well what would happen if the gov'ment was the only insurance company huh?" Medicaid covers Adderall XR.

Also, when I'm talking to someone in the "pharmacy" department of an insurance company, why am I having to spell out dextroamphetamine letter by letter because the "pharmacy" person doesn't know wtf the word is? I'm tired of having to run my medical decisions by or argue about medication coverage to people who can't even say the medications I'm prescribing.

 

[tr]

Supporting this horrible idea is like telling a woman with fibrocystic breasts she needs radiation, chemo, and then at the end of it still doing a bilateral mastectomy. Bad idea on so many levels.

Really, you think the current system in the US is a benign, neutral condition like fibrocystic breasts? You like staying on the phone for hours with insurance companies to justify your medical decisions to some bureaucrat? Having to employ an army of billers and coders to fight to get paid, that's good, cool, neutral? People going bankrupt because they got sick, that works for you? Most expensive health care in the world for middling to bad health and longevity, yeah that's ok too?
Cool cool.

 

[deleted407021]

Really, you think the current system in the US is a benign, neutral condition like fibrocystic breasts? You like staying on the phone for hours with insurance companies to justify your medical decisions to some bureaucrat? Having to employ an army of billers and coders to fight to get paid, that's good, cool, neutral? People going bankrupt because they got sick, that works for you? Most expensive health care in the world for middling to bad health and longevity, yeah that's ok too?
Cool cool.

But the income of a group of historically very well-compensated and well-regarded professionals that makes up less than half a percent of the US population will likely go down some...

 

[Merely]

But the income of a group of historically very well-compensated and well-regarded professionals that makes up less than half a percent of the US population will likely go down some...

Go down some? In other countries it’s 1/2 of what we make here..yeah that’s unacceptable

 

[deleted407021]

Go down some? In other countries it’s 1/2 of what we make here..yeah that’s unacceptable

What would you say to a decrease of 5 to 10%?

 

[MBBSMOM]

But the income of a group of historically very well-compensated and well-regarded professionals that makes up less than half a percent of the US population will likely go down some...

Canada has universal healthcare and doctors there are paid almost the same as doctors in the US. The average salary for a psychiatrist in Canada is 225k while here in the US it's around 227k.

 

[FlowRate]

Really, you think the current system in the US is a benign, neutral condition like fibrocystic breasts? You like staying on the phone for hours with insurance companies to justify your medical decisions to some bureaucrat? Having to employ an army of billers and coders to fight to get paid, that's good, cool, neutral? People going bankrupt because they got sick, that works for you? Most expensive health care in the world for middling to bad health and longevity, yeah that's ok too?

We have the highest quality healthcare in the world and best health outcomes, as already pointed out itt, when you remove automobile accidents. LMK if euro countries have a pill that fixes that. Maybe you could get behind a petition to shrink the US so it'll be more convenient to build public transportation?

I get the reasonable 'try generics first, cheaper equivalent meds' first but there are also plenty of examples of insurance companies just straight scamming us/patients. Denying hospital stays or billing retroactively is of course the big one. I wish I could just go "nah, I think your massage sucked so I'm not gonna pay for it, thanks for the massage though!"

I recently had a patient with ADHD where the insurance literally did not cover any extended release stimulant class. None. I spent probably 20 minutes bouncing around the stupid ass insurance phone tree, then spent more time trying to figure out which of the 20 plans my patient had, then they didn't even have the formulary on their website (even though the insurance person said they did), then spent another 10 minutes while the insurance person finally found the formulary and spelt out every stimulant they would cover, none of which were extended release. Hey thanks for not contributing to medication abuse in our country insurance companies! Don't give me the bull**** "well what would happen if the gov'ment was the only insurance company huh?" Medicaid covers Adderall XR.

Also, when I'm talking to someone in the "pharmacy" department of an insurance company, why am I having to spell out dextroamphetamine letter by letter because the "pharmacy" person doesn't know wtf the word is? I'm tired of having to run my medical decisions by or argue about medication coverage to people who can't even say the medications I'm prescribing.

Honestly I have never had this experience. I'm only in residency and yes sometimes I have to submit prior auths, but they're usually approved. While the experience you describe sounds super frustrating, I'm not sure why it's more common in some places but not others. But that fact alone means that the solution to your problem is not only single-payer.

 

[VA Hopeful Dr]

Canada has universal healthcare and doctors there are paid almost the same as doctors in the US. The average salary for a psychiatrist in Canada is 225k while here in the US it's around 227k.

Because if they didn't, you'd have a massive departure of Canadian doctors to the US. If our rates go down, they will do the same within 1 year.

 

[Merely]

We have the best health outcomes?? Someone just said that I def did not know that.....I thought we were like 30th or something

 

[splik]

We have the highest quality healthcare in the world and best health outcomes,

im assuming this is sarcasm?

 

[MedMan80]

Because if they didn't, you'd have a massive departure of Canadian doctors to the US. If our rates go down, they will do the same within 1 year.

Absolutely, they tried this 1-2 decades ago and there was an exodus of CDN doctors to the US, primary care exodus hurt them the most. So in response, FM residency is now 2 years in Canada and they are very well compensated.

 

[VA Hopeful Dr]

We have the best health outcomes?? Someone just said that I def did not know that.....I thought we were like 30th or something

Nope, our outcomes are actually quite good

 

[MedMan80]

Nope, our outcomes are actually quite good

How does the quality of the U.S. health system compare to other countries? - Peterson-KFF Health System Tracker

The coronavirus pandemic has resulted in millions of cases across the globe. The United States has one of the highest death rates due to COVID-19 across the world, and its mortality rates will likely increase. Due to different approaches to containing the virus across countries – as well as the...

www.healthsystemtracker.org

Doesn't look good to me

 

[calvnandhobbs68]

We have the highest quality healthcare in the world and best health outcomes, as already pointed out itt, when you remove automobile accidents. LMK if euro countries have a pill that fixes that. Maybe you could get behind a petition to shrink the US so it'll be more convenient to build public transportation?

Honestly I have never had this experience. I'm only in residency and yes sometimes I have to submit prior auths, but they're usually approved. While the experience you describe sounds super frustrating, I'm not sure why it's more common in some places but not others. But that fact alone means that the solution to your problem is not only single-payer.

It depends on how you cut the data as noted above. We do somewhat better on some measures, somewhat worse on other measures. If you spend a bit of time on the healthcaresystemtracker.org website you get a better appreciation for some of the subtleties involved in this. However, the big problem with all this is that we spend literally TWICE as much per capita on healthcare than most other developed countries and this gap has widened since the 1970s. We're not getting twice the benefit (or anywhere close to that) so many people (including myself) view this as a bit of a problem. Where exactly all this excess expenditure is going is a matter of constant debate

I'm glad you've never had this experience and it is extremely frustrating. There was no way to submit a prior auth in this situation, they just straight up wouldn't cover it. I'm glad that your prior auths are usually approved, I'm probably 50/50 with initial approval (after wasting plenty of time gathering all the info for prior auths, the frustration for the patient going to the pharmacy and finding out that the prior auth is required, etc etc) and have had to call to try to get a prior auth rejection overturned multiple times.

No single fact means that the solution to the problem is a universal government healthcare plan option. Lots of little facts add up to that.

 

[clausewitz2]

It depends on how you cut the data as noted above. We do somewhat better on some measures, somewhat worse on other measures. If you spend a bit of time on the healthcaresystemtracker.org website you get a better appreciation for some of the subtleties involved in this. However, the big problem with all this is that we spend literally TWICE as much per capita on healthcare than most other developed countries and this gap has widened since the 1970s. We're not getting twice the benefit (or anywhere close to that) so many people (including myself) view this as a bit of a problem. Where exactly all this excess expenditure is going is a matter of constant debate

I'm glad you've never had this experience and it is extremely frustrating. There was no way to submit a prior auth in this situation, they just straight up wouldn't cover it. I'm glad that your prior auths are usually approved, I'm probably 50/50 with initial approval (after wasting plenty of time gathering all the info for prior auths, the frustration for the patient going to the pharmacy and finding out that the prior auth is required, etc etc) and have had to call to try to get a prior auth rejection overturned multiple times.

No single fact means that the solution to the problem is a universal government healthcare plan option. Lots of little facts add up to that.

Adjust our expenditures for income per capital and while still on the expensive side we look much more like relative leaders of the pack rather than a ridiculous outlier. I would question the idea that the gap has been widening since the 80s; there seems to be a secular trend since that time towards higher costs as a function of GDP in all developed countries and our cost growth rates these days don't look that unusual. Still not sure just that initial gap opened up, though.

 

[tr]

Adjust our expenditures for income per capital and while still on the expensive side we look much more like relative leaders of the pack rather than a ridiculous outlier. I would question the idea that the gap has been widening since the 80s; there seems to be a secular trend since that time towards higher costs as a function of GDP in all developed countries and our cost growth rates these days don't look that unusual. Still not sure just that initial gap opened up, though.

Can you be a practicing physician and doubt that our health care costs are out of control?

I am literally incentivized by my institution to drive up health care costs. We have an RVU target, i.e., a billing target. Nobody has any interest in tracking my patient outcomes or other markers of quality of care (yes, very difficult to identify appropriate indicators, different issue for a different day). All they are interested in is how much I can charge the patients. There are discussions on this board every day about how to maximize billing - i.e., cost - for a given episode of care. Multiply this by a million practicing physicians and you have a huge cost problem, totally leaving aside the exploitative pharma bros and bloated insurance actuarial costs and everything else.

Capitalist systems are structured to maximize profit and they are great at it. And that's what we have. A health care system that maximizes profit, with other outcomes falling where they may.

 

[FlowRate]

im assuming this is sarcasm?

Once you control for various factors like smoking, obesity, and car accidents, no. Do you really think that the actual care we provide is substandard, as a whole, compared to any other country? (Honest question, you have more international experience than I do.)

Can you be a practicing physician and doubt that our health care costs are out of control?

I am literally incentivized by my institution to drive up health care costs. We have an RVU target, i.e., a billing target. Nobody has any interest in tracking my patient outcomes or other markers of quality of care (yes, very difficult to identify appropriate indicators, different issue for a different day). All they are interested in is how much I can charge the patients. There are discussions on this board every day about how to maximize billing - i.e., cost - for a given episode of care. Multiply this by a million practicing physicians and you have a huge cost problem, totally leaving aside the exploitative pharma bros and bloated insurance actuarial costs and everything else.

Capitalist systems are structured to maximize profit and they are great at it. And that's what we have. A health care system that maximizes profit, with other outcomes falling where they may.

There are also competitive pressures to reduce cost. Insurance negotiations, prior auths, CMS RVS, cash practice, surgical centers, patient choice.

No single fact means that the solution to the problem is a universal government healthcare plan option. Lots of little facts add up to that.

Actually the funny thing about lamenting prior auths/insurance approval while advocating for single payer is that either way you're still going to do prior auths--or just not be able to prescribe the drug you want, at all.

 

[clausewitz2]

Can you be a practicing physician and doubt that our health care costs are out of control?

I am literally incentivized by my institution to drive up health care costs. We have an RVU target, i.e., a billing target. Nobody has any interest in tracking my patient outcomes or other markers of quality of care (yes, very difficult to identify appropriate indicators, different issue for a different day). All they are interested in is how much I can charge the patients. There are discussions on this board every day about how to maximize billing - i.e., cost - for a given episode of care. Multiply this by a million practicing physicians and you have a huge cost problem, totally leaving aside the exploitative pharma bros and bloated insurance actuarial costs and everything else.

Capitalist systems are structured to maximize profit and they are great at it. And that's what we have. A health care system that maximizes profit, with other outcomes falling where they may.

You know I definitely get what you're saying, and I think I share your disquiet about how billing is gamed. I don't want to defend the current structure of our healthcare financing particularly and there are other developed countries that do a much better job. I would dispute the idea that health insurers are making boatloads of money (the industry on a whole has something like a 2% profit margin most years, which is also the profit margin of Rubbermaid, not a fantastically lucrative venture). There is clearly a cost issue in this country that is unique to us.

Capitalist systems certainly do attempt to maximize profit; the major check on this without external intervention is other people wanting a piece of the pie. If profits are excessive one of the places to look is who is rent-seeking most successfully; in the case of our system it is largely healthcare systems who are increasingly monopolistic. It is also somewhat disastrous that we decided to determine the basic units of reimbursement by asking a bunch of people whose pay is tied to those units to decide what would be a fair reckoning of how much they ought to be reimbursed.

I would say thought that other developed countries use fee for service models with private insurers much better and less proportionately expensive results. Germany is an example that even delivers most care through private hospitals and clinics but still has great outcomes for much less money; they even have the weird link between employment and health insurance we do. The Netherlands is a good example of a FFS system that also has specialist reimbursement similar to the United States.

These countries achieve this in a number of ways. Germany for instance says you will have public health insurance and cannot get private insurance unless your income is above a certain amount. Premiums are often a percentage of your income rather than a fixed amount. Cleverly one way they insure public health insurance is functional is requiring all public employees to have public health insurance; if we made it so Congress-critters had to have Medicaid I imagine the impetus to reform would be much greater. The details of how you structure the system end up mattering just as much for the day to day as broad, theoretical categories like fee for service v. single-payer.

Moving billing away from FFS has its advantages to be sure, but it is not without downsides. Capitation provides a natural incentive to do as little as possible or required for the largest number of patients if you want to maximize revenue. Outcome-based payment is inevitably going to incentivize cherry-picking reasonably healthy people and trying to avoid the trainwreck cases; any propensity risk-score you try to introduce to even this out is inevitably going to create some category of people who are a) actually not that bad off but who score highly who everyone will want to poach and b) people who don't score highly but are going to be very complicated to care for.

I'm not opposed to single-payer in principle but I don't like how some people treat it as a magic solution that is going to fix all of our problems. Real change is never 100% positive. You have to figure out what trade-offs are worth it.

 

[Amygdarya]

We have the highest quality healthcare in the world and best health outcomes, as already pointed out itt, when you remove automobile accidents. LMK if euro countries have a pill that fixes that. Maybe you could get behind a petition to shrink the US so it'll be more convenient to build public transportation?

Honestly I have never had this experience. I'm only in residency and yes sometimes I have to submit prior auths, but they're usually approved. While the experience you describe sounds super frustrating, I'm not sure why it's more common in some places but not others. But that fact alone means that the solution to your problem is not only single-payer.

I share the geography with you and I've seen cases of meds coverage being denied even in my however many months of intern year. The most egregious case was a patient with severe psychotic disorder who gets seriously violent with his family when psychotic, who was, after many antipsychotic trials, finally stabilized on Invega and started on Invega Sustenna before discharge, only to find out right after discharge that their insurance would absolutely not cover it. I remember both resident and attending spending hours on the phones talking to the insurance company (don't remember which), filing prior auth and being denied, denied, denied. So the patient had to be switched back to their pre-hospital regimen that they easily decompensate on.
I mean, my co-interns and I are even discussing a project to ensure our inpatients don't get stabilized on meds they'd be denied after discharge (I know this is backasswards but the idea is that at least they won't decompensate right away after being switched to a different regimen after discharge).
So I don't know, maybe you've just been lucky that you haven't had these experiences.

 

[whopper]

I recently had a patient with ADHD where the insurance literally did not cover any extended release stimulant class.

Agree.

As a clinician I'd rather have the pt take the ER class cause less chance of abuse and side effects. ERs are more expensive but this is a case where IMHO the more expensive med is the better option for the majority.

And yes insurance companies will usually deny payment for the ERs.

 

[VA Hopeful Dr]

Can you be a practicing physician and doubt that our health care costs are out of control?

I am literally incentivized by my institution to drive up health care costs. We have an RVU target, i.e., a billing target. Nobody has any interest in tracking my patient outcomes or other markers of quality of care (yes, very difficult to identify appropriate indicators, different issue for a different day). All they are interested in is how much I can charge the patients. There are discussions on this board every day about how to maximize billing - i.e., cost - for a given episode of care. Multiply this by a million practicing physicians and you have a huge cost problem, totally leaving aside the exploitative pharma bros and bloated insurance actuarial costs and everything else.

Capitalist systems are structured to maximize profit and they are great at it. And that's what we have. A health care system that maximizes profit, with other outcomes falling where they may.

You're looking at it the wrong way.

Medicare/insurance has rules for coding/billing. Doctors have historically been WAY undercoding our work. Maximizing billing actually means "billing appropriately for the work you did".

My employer (in fairness, I am FP) has lots of quality measures. It would be harder to do for psychiatry since you don't have numeric things like BP or A1c.

Totally agree about drug prices and greedy middle men.

 

[calvnandhobbs68]

Actually the funny thing about lamenting prior auths/insurance approval while advocating for single payer is that either way you're still going to do prior auths--or just not be able to prescribe the drug you want, at all.

It would cut paperwork down by probably 20x the amount it is right now even if there was a prior auth to fill out. Right now you have basically little to no idea if one of the hundreds of insurance plans that exist in this country will cover what medication you’re prescribing your patient without doing serious legwork yourself.

Also, did you read what I wrote? We already aren’t getting to prescribe drugs we want with private insurance companies. I don’t get where this idea comes from that private insurance companies don’t want to control their costs too....except for them “saving money” means being able to give more money back to investors.

 

[FlowRate]

It would cut paperwork down by probably 20x the amount it is right now even if there was a prior auth to fill out. Right now you have basically little to no idea if one of the hundreds of insurance plans that exist in this country will cover what medication you’re prescribing your patient without doing serious legwork yourself.

Also, did you read what I wrote? We already aren’t getting to prescribe drugs we want with private insurance companies. I don’t get where this idea comes from that private insurance companies don’t want to control their costs too....except for them “saving money” means being able to give more money back to investors.

Well, I did, and that was exactly the point--neither situation fixes the "doctors can't do what they want for their patients" problem. I'm not arguing one is better than the other so much as a more balanced view, similar to clausewitz. As for whether it would mean less paperwork/time, maybe it would. That problem could also be fixed in ways that are similarly authoritarian to singlepayer without going full singlepayer (uniform formularies.) There are numerous ways well-intentioned bureaucrats can design apparently straightforward interventions without actually being able to predict the unintended (it's in the name) consequences.

I've gone off the rail a tad. I guess if I had a point or goal in this discussion it's that I think the world of political discource would be better if we were all able to start from a position of recognizing that no one option is as simple or effective as we think. It's easy to see the problems with our current healthcare system because we live in it. There's a bit of religious fervor for singlepayer that I would wager is lost when you live in that sort of system. Could single payer potentially fix some of our problems? Yes. But I'm not convinced (explicitly--in the sense that I haven't decided one way or the other) that the problems it creates are worth the transition.

 

[whopper]

You're looking at it the wrong way.

Medicare/insurance has rules for coding/billing. Doctors have historically been WAY undercoding our work. Maximizing billing actually means "billing appropriately for the work you did".

Lots of people want to blame doctors.
Doctors are actually making less money these days compared to years ago and it's not like we make money off of the 50 cent IV bag that the hospital charged you $600.
Insurance companies, hospitals, pharmaceutical companies, medical device companies, etc are usually the people cashing in.

Given that doctors that accept insurance MUST ACCEPT THE PAY FROM THE INSURANCE COMPANY AT A GIVEN RATE, the only way we can manipulate the pay is if we see less patients per unit time to see more and make more. E.g. instead of seeing a patient for 30 minutes we see them for 15. I do know many docs that do this in a manner I find inappropriate but in terms of the big system that's not the real stinker of healthcare problems and costs.

 

[FlowRate]

Lots of people want to blame doctors.
Doctors are actually making less money these days compared to years ago and it's not like we make money off of the 50 cent IV bag that the hospital charged you $600.
Insurance companies, hospitals, pharmaceutical companies, medical device companies, etc are usually the people cashing in.

Given that doctors that accept insurance MUST ACCEPT THE PAY FROM THE INSURANCE COMPANY AT A GIVEN RATE, the only way we can manipulate the pay is if we see less patients per unit time to see more and make more. E.g. instead of seeing a patient for 30 minutes we see them for 15. I do know many docs that do this in a manner I find inappropriate but in terms of the big system that's not the real stinker of healthcare problems and costs.

Antipsychotics are a $12 Billion global industry, a large portion of it in the US. That's just one drug class. Doctors aren't seeing any kickbacks (illegal) for using expensive drugs.

A fun statistic from the internet: "while drug companies bring in 23% of health care’s U.S. revenue, they make 63% of the total profits."

Regulatory capture is quite effective.

 

[VA Hopeful Dr]

Lots of people want to blame doctors.
Doctors are actually making less money these days compared to years ago and it's not like we make money off of the 50 cent IV bag that the hospital charged you $600.
Insurance companies, hospitals, pharmaceutical companies, medical device companies, etc are usually the people cashing in.

Given that doctors that accept insurance MUST ACCEPT THE PAY FROM THE INSURANCE COMPANY AT A GIVEN RATE, the only way we can manipulate the pay is if we see less patients per unit time to see more and make more. E.g. instead of seeing a patient for 30 minutes we see them for 15. I do know many docs that do this in a manner I find inappropriate but in terms of the big system that's not the real stinker of healthcare problems and costs.

I don't disagree with any of this, but its not really germane to the point I was making.

 

[Sushirolls]

As Flowrate alludes to, single payer will create more problems then solves.

America has worse outcomes because we are still a free country. Free country where people make choices that lead to opioid UD, Tobacco UD, vehicle accidents, and sedentary life style choices that wreak metabolic havoc. I'd rather preserve freedom of choice, freedom for stupidity, then give it up to the government to start mandating lifestyle changes or a single health care entity. No thanks.

Freedom isn't free, and we need to be fighting to preserve it on all fronts and not drink the socialist koolaid.

 

[deleted407021]

As Flowrate alludes to, single payer will create more problems then solves.

America has worse outcomes because we are still a free country. Free country where people make choices that lead to opioid UD, Tobacco UD, vehicle accidents, and sedentary life style choices that wreak metabolic havoc. I'd rather preserve freedom of choice, freedom for stupidity, then give it up to the government to start mandating lifestyle changes or a single health care entity. No thanks.

Freedom isn't free, and we need to be fighting to preserve it on all fronts and not drink the socialist koolaid.

I’m not an expert, but I feel like obesity, alcoholism and car accidents are problems the world over and I can’t see how they’re related to the US being super extra “free”.

 

[clausewitz2]

I’m not an expert, but I feel like obesity, alcoholism and car accidents are problems the world over and I can’t see how they’re related to the US being super extra “free”.

If they are Mexico is more free than the US because they certainly have higher rates of obesity.

 

[calvnandhobbs68]

As Flowrate alludes to, single payer will create more problems then solves.

America has worse outcomes because we are still a free country. Free country where people make choices that lead to opioid UD, Tobacco UD, vehicle accidents, and sedentary life style choices that wreak metabolic havoc. I'd rather preserve freedom of choice, freedom for stupidity, then give it up to the government to start mandating lifestyle changes or a single health care entity. No thanks.

Freedom isn't free, and we need to be fighting to preserve it on all fronts and not drink the socialist koolaid.

Lol wut?

How are people free to have opioid dependence? Heroin and fentanyl are still illegal far as I know. People are just as “free” to use drugs in most other comparable countries (even more free in some of them). How are people not “free” to crash their cars in other countries?

Your post sounds like a bad country song.

 

[VA Hopeful Dr]

If they are Mexico is more free than the US because they certainly have higher rates of obesity.

False:

https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf

The World Factbook — Central Intelligence Agency

 

[clausewitz2]

False:

https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf

The World Factbook — Central Intelligence Agency

You're right. But it looks like if you go outside the OECD (only 35 countries after all), the South Pacific and Kuwait are the real bastions of liberty:

https://www.google.com/amp/s/www.valuewalk.com/2019/01/top-10-most-obese-countries-oecd-who/amp/

 

[VA Hopeful Dr]

You're right. But it looks like if you go outside the OECD (only 35 countries after all), the South Pacific and Kuwait are the real bastions of liberty:

https://www.google.com/amp/s/www.valuewalk.com/2019/01/top-10-most-obese-countries-oecd-who/amp/

Oh yeah no doubt, but they aren't the ones we're getting compared to in terms of outcomes.