Tired of insurance denying medications- mandating adverse effects

[Sushirolls]

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.

The freedom I speak to is more cultural. For instance in the US we have this entire concept of 'coming of age' and discovering one's identity, and culturally we accept and even expect people to make poor choices in youth.
You spend time with East Asian cultures and the over riding culture is 'do what your parents tell you.' Places like India, where poppy readily grows, doesn't exactly have the level of opioid use disorder as the US.
Yes my assertions have holes, and you can even point out other substances like alcohol. Please just try see what I'm saying about the cultural nuances of the US comparative to others.

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[clausewitz2]

The freedom I speak to is more cultural. For instance in the US we have this entire concept of 'coming of age' and discovering one's identity, and culturally we accept and even expect people to make poor choices in youth.
You spend time with East Asian cultures and the over riding culture is 'do what your parents tell you.' Places like India, where poppy readily grows, doesn't exactly have the level of opioid use disorder as the US.
Yes my assertions have holes, and you can even point out other substances like alcohol. Please just try see what I'm saying about the cultural nuances of the US comparative to others.

I don't see how most of that explains the cost of our healthcare system, but regardless I do 't think anything you are identifying as uniquely American separates us that much from Western Europe. The UK and Scandinavia have even worse binge-drinking than us and are still beating us. Also, if we are talking about finding identity, I will just point out that existentialism came from France.

 

[whopper]

If you want to get into healthcare systems....

I actually agree that a system some free-market competition can have some advantages for everyone. Problem is it ain't happening in our system. When was the last time you actually picked your healthcare? Most of the time it's picked for you by your employer. Most of the time that employer didn't explain to you how it works, nor did you have options. Most of the time my own patients with insurance don't even know how it works. "What I have a deductible? What's that?"

So when someone argues our system is great cause it's a free-market system, what a load of dung. A free-market system would be more on the order of something like car insurance, where they offer their plans, they compete, and you pick the one you feel is best for you while the company also helps you to understand what's covered and what's not.

Add to the above that in systems with a socialized government single-payer system, there too still exists private insurance but the private insurance company has to do a job well enough for you the consumer to actually want to buy it when you already have the government insurance as an option. So the private insurance actually has to do a good job and not the crappy job we typically see in the US such as trying to get out of services and products they already promised they'd cover. And the fact of the matter is in many of these countries the person is content with their government healthcare.

Then add to the problem that private companies are expected to pay for their employees insurance? WTF especially in this era of through the roof costs? Wouldn't that cut into business and harm many fighting to stay afloat? The current system we got now was started by Nixon and it's different era but the rules haven't adapted.

Hey I'm all for seeing if a free-market system works better but that requires competition and choice for consumers. We don't got that now, so why are the people arguing to keep the current system claiming it's so free-market when it's not? Someone from the Left could criticize me but I just said above in first world countries they get better outcomes, and they can still get private insurance. Someone from the Right could criticize me but what I'm proposing is a system with even more free-market forces vs the current status quo.

And even aside from insurance, hospital costs are uncontrolled and not in balance with competition. E.g. hospitals just do what they do and give you the bill later. They don't tell you your options, don't tell you they're charging you hundreds of dollars for an IV bag that cost them less than $1. Where's the free market in that?

 

[VA Hopeful Dr]

If you want to get into healthcare systems....

I actually agree that a system some free-market competition can have some advantages for everyone. Problem is it ain't happening in our system. When was the last time you actually picked your healthcare? Most of the time it's picked for you by your employer. Most of the time that employer didn't explain to you how it works, nor did you have options. Most of the time my own patients with insurance don't even know how it works. "What I have a deductible? What's that?"

So when someone argues our system is great cause it's a free-market system, what a load of dung. A free-market system would be more on the order of something like car insurance, where they offer their plans, they compete, and you pick the one you feel is best for you while the company also helps you to understand what's covered and what's not.

Add to the above that in systems with a socialized government single-payer system, there too still exists private insurance but the private insurance company has to do a job well enough for you the consumer to actually want to buy it when you already have the government insurance as an option. So the private insurance actually has to do a good job and not the crappy job we typically see in the US such as trying to get out of services and products they already promised they'd cover. And the fact of the matter is in many of these countries the person is content with their government healthcare.

Then add to the problem that private companies are expected to pay for their employees insurance? WTF especially in this era of through the roof costs? Wouldn't that cut into business and harm many fighting to stay afloat? The current system we got now was started by Nixon and it's different era but the rules haven't adapted.

Hey I'm all for seeing if a free-market system works better but that requires competition and choice for consumers. We don't got that now, so why are the people arguing to keep the current system claiming it's so free-market when it's not? Someone from the Left could criticize me but I just said above in first world countries they get better outcomes, and they can still get private insurance. Someone from the Right could criticize me but what I'm proposing is a system with even more free-market forces vs the current status quo.

And even aside from insurance, hospital costs are uncontrolled and not in balance with competition. E.g. hospitals just do what they do and give you the bill later. They don't tell you your options, don't tell you they're charging you hundreds of dollars for an IV bag that cost them less than $1. Where's the free market in that?

Bingo.

Private insurance works in certain European countries because often the care you get with the government plan sucks. So getting private insurance is an easier sell.

 

[splik]

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.)

I'm not sure where you got this, but it's just not true at all. On practically every measure, the US provides worse healthcare to the population as a whole than most every other developed country, and certainly compared the high price we pay for it. You must have seen the data. Even on measures where the US does well, are largely fantasy (for instance the US fares well for cancer mortality, but this is an artifact of over-aggressive screening and lead-time bias and detection biase - the numbers are heavily skewed by early diagnosis and detection of cancers that would never be a threat to life). But those words "as a whole" are very important. We often talk about a "US healthcare system" as a unitary entity, even though we know there is no US healthcare system but the care you get depends on whether you are a Veteran, in the military, a poor child, over 65, have ESRD or ALS, an American Indian, employed, developmentally disabled, and so on. So you have some people who get outstanding care, and other people who don't care care at all. And that inequality harms everyone. There are also huge geographical differences in the kind of care and cost of healthcare within the US. In fact, there is more differences in the quality, access, cost, and level of care people get in the US than between other countries. But our convuluted system is also a big part of the problem.

Part of the problem with substandard care is no even lack of care, but too much of it. Patients are overdiagnosed, overmedicated, overtreated, often with great iatrogenic harm which generates even more revenue for healthcare systems and further bloats the cost of healthcare. So much of what is done flies in the face of the evidence, and most professional societies in the US have been reluctant to produce evidence-based guidelines for fear of offending their members' sensibilities and undermining their bottom line (for instance, there is no reason an OB needs to deliver a baby from an uncomplicated delivery, and the old APA guidelines for bipolar disorder including psychodynamic psychotherapy etc). This is not to mention the utter quackery that many physicians (and non-physicians too) are peddling in this country that would not fly elsewhere (and homeopathy is quite popular in germany).

BTW, despite being a dyed in the wool socialist, I do not believe "medicare for all" is a workable or even desireable solution to the woes of healthcare in this country. We have had 55 years to make it happen - that ship sailed long ago. In addition, medicare is a sinking ship (different ship). For years it was barely held together by the SGR which was repealed at the behest of the AMA in 2015 and instead we have MACRA as a way of containing costs. But MACRA is a nightmare for many physicians (deliberately so, its purpose was to control costs) and to expand medicare to the whole of the population is just not a workable solution. Also medicare reimbursement tends to decrease every year- CPT codes we frequently use reimburse less than 5 years ago despite inflation and other increasing costs of healthcare. I do think medicare should be significantly expanded to cover everyone who cannot obtain insurance otherwise but it needs significant reworking in order to make feasible. The big elephant in the room when it comes to healthcare reforming is rationing. No politician is going to publicly talk about that because it is political suicide. But it is also the only way to provide universal healthcare: we can cover everybody, but not for everything. All health insurance companies exercise rationing (which is loosely what the thread was initially about), but when the government does it, people invoke talk of "death panels" and there is a level of scrutiny that does not occur in the private sector.

That said a solo psychiatrist in PP could potentially do quite well with medicare if it weren't for all the MACRA nonsense (its hard to do in PP because you have to have electronic records and other onerous requirement). In my area, a psychiatrist working 35 clinical hrs/ week, with a 100% show rate, for 48 weeks a year, seeing 10 new pts (99205) and 50 30min follow ups (99214+90833) would gross $613, 780 in a year. Imperfect model, but shows that medicare is not all doom and gloom.

 

[futuredo32]

im assuming this is sarcasm?

People with the financial means come to the US for healthcare because they want better quality care than they can get where they are living. Mick Jagger is a recent example, he's in the US for cardiac surgery and paying cash instead of getting it done in the UK "for free"

 

[clausewitz2]

People with the financial means come to the US for healthcare because they want better quality care than they can get where they are living. Mick Jagger is a recent example, he's in the US for cardiac surgery and paying cash instead of getting it done in the UK "for free"

I suggest reading splik's post again; the critical part is the idea that some people get fantastic care and some get essentially none.

Our hospital has a fancy floor of the transplant wing catering to rich foreigners. This is not where Joe Schmoe Cirrhotic ends up when his liver fails.

 

[splik]

People with the financial means come to the US for healthcare because they want better quality care than they can get where they are living. Mick Jagger is a recent example, he's in the US for cardiac surgery and paying cash instead of getting it done in the UK "for free"

mick jagger lives in LA lol. quality of care is not something measured by where celebrities go get their care. when we are evaluating a nation's health care outcomes we are really looking at how the average person fares with the care in their locality. most people just want their local hospital and the doctors in their area to provide them with timely, affordable, effective, quality care. also I think jagger was in NYC at the time (where his 32yr old gf lives), which is why he had his TAVR there. I am sure he would have had it at Cedars-Sinai if he were in LA, or the Heart Hospital in London if he were in London and sick. really sick people don't usually have the luxury to fly off to wherever for their treatment. Also he is probably not entitled to free healthcare on the NHS because he doesn't pay taxes and doesn't live in the UK (though he has a home in London).

thankfully, most health policy wonks don't make their assessments on healthcare based on the activities of celebrities or the super rich. rich people's idea of what "the best" is, is often questionable, and I think it is well know that "VIP" patients tend to get worse care for various reasons.

Do people really think american healthcare is the bees' knees? It's definitely overpriced. My institution charges over $1000 for an initial evaluation with me (for my services alone, this does not include facility fees). I can tell you the better insurances pay all or most of this. on the flip side, medicaid might pay $80 for an initial psychiatric evaluation in some places. US healthcare is a tale of extremes. And this is the problem. We don't measure a country by how the most privileged are served (as they will do well, regardless), but by how we care for the most vulnerable.

 

[VA Hopeful Dr]

I'm not sure where you got this, but it's just not true at all. On practically every measure, the US provides worse healthcare to the population as a whole than most every other developed country

This is somewhat false: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30994-2/fulltext

We do quite well in a number of measures:

TB - 100, perfect score

URI, diphtheria, tetanus, whooping cough, measles - 100 across the board

Breast cancer - 100

Cervical cancer - 86, which is better than most of Europe outside of Scandinavia.

Uterine cancer - 99

Colon cancer - 93 which is middle of the OECD countries

Testicular cancer - 96 which is upper half of OECD

Hodkin's - 100

Nonmelanoma skin cancer - 3rd place at 92

As for lead-time bias and over-aggressive screening, we have just decreased our recommendations for cervical and breast cancer screenings. We don't screen for testicular, skin cancer, Hodkin's, or Uterine. For colon cancer, the EU says first line is FOBT which has roughly identical mortality to colonoscopies but results in higher grade cancers at diagnosis. Whether that's a fair trade economically I don't know (I suspect not), but I'll gladly pay for a colonoscopy q10 years if I can catch it at stage 1 v. state 2/3.

Peptic Ulcer - 95

Appendix - 100

Hernia - 99

Gallbladder - 94

Epilepsy - 100

A very large factor in some of the metrics we don't do well in (CV disease for example) is our developed world leading rates of diabetes and obesity.

Weirdly, we're pretty bad at leukemia (doesn't separate out kids from adults). No idea why. Even weirder is that German is significantly worse at that than we are. That tells me there's something strange going on with leukemia.


That all said, you're not wrong about our bizarre hodgepodge of ways people get care. That and our huge size and very diverse population makes it difficult to apply lessons from elsewhere here.

 

[Merely]

This is somewhat false: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30994-2/fulltext

We do quite well in a number of measures:

TB - 100, perfect score

URI, diphtheria, tetanus, whooping cough, measles - 100 across the board

Breast cancer - 100

Cervical cancer - 86, which is better than most of Europe outside of Scandinavia.

Uterine cancer - 99

Colon cancer - 93 which is middle of the OECD countries

Testicular cancer - 96 which is upper half of OECD

Hodkin's - 100

Nonmelanoma skin cancer - 3rd place at 92

As for lead-time bias and over-aggressive screening, we have just decreased our recommendations for cervical and breast cancer screenings. We don't screen for testicular, skin cancer, Hodkin's, or Uterine. For colon cancer, the EU says first line is FOBT which has roughly identical mortality to colonoscopies but results in higher grade cancers at diagnosis. Whether that's a fair trade economically I don't know (I suspect not), but I'll gladly pay for a colonoscopy q10 years if I can catch it at stage 1 v. state 2/3.

Peptic Ulcer - 95

Appendix - 100

Hernia - 99

Gallbladder - 94

Epilepsy - 100

A very large factor in some of the metrics we don't do well in (CV disease for example) is our developed world leading rates of diabetes and obesity.

Weirdly, we're pretty bad at leukemia (doesn't separate out kids from adults). No idea why. Even weirder is that German is significantly worse at that than we are. That tells me there's something strange going on with leukemia.


That all said, you're not wrong about our bizarre hodgepodge of ways people get care. That and our huge size and very diverse population makes it difficult to apply lessons from elsewhere here.

When you have to literally cherry pick specific diseases to show how good our outcomes are, that probably is a sign that you’re on the wrong side of the debate..

 

[VA Hopeful Dr]

When you have to literally cherry pick specific diseases to show how good our outcomes are, that probably is a sign that you’re on the wrong side of the debate..

I had a larger post in SPF where I address every single metric that study used, feel free to address the post I made there as I'm not going to retype the whole thing. But the snark is always appreciated, even if clearly misguided.

The short version is that if we had similar rates of obesity, diabetes, SIDS, and child abuse rates as Europe, all of our our outcomes would be similar to theirs.

 

[calvnandhobbs68]

I had a larger post in SPF where I address every single metric that study used, feel free to address the post I made there as I'm not going to retype the whole thing. But the snark is always appreciated, even if clearly misguided.

The short version is that if we had similar rates of obesity, diabetes, SIDS, and child abuse rates as Europe, all of our our outcomes would be similar to theirs.

I somewhat agree with that but preventative medicine is still medicine. Putting actual amounts of money into real sustainable programs to decrease rates of these diseases is healthcare.
Cutting down on private insurance companies is part of that. Right now private companies are incentivized to try to deny as much coverage as possible and kick the ball down to Medicare, who then gets to pick up the results of 30 years of uncontrolled obesity, HTN, DM, smoking, etc etc. It shows in how much preventative medicine is actually reimbursed or covered at all. A universal insurance plan which is forced to cover you from birth to death has much more incentive to prevent you from developing preventable diseases, vs insurance companies who know that every time you switch employers/schools/age out of your parent's plan/become eligible for Medicare they get to pass the costs along to another company.

 

[Merely]

I had a larger post in SPF where I address every single metric that study used, feel free to address the post I made there as I'm not going to retype the whole thing. But the snark is always appreciated, even if clearly misguided.

The short version is that if we had similar rates of obesity, diabetes, SIDS, and child abuse rates as Europe, all of our our outcomes would be similar to theirs.

It’s funny to me because you’re treating diabetes, obesity as uncontrollable risk factors that we just have to accept rather than outcomes in and of themselves. Maybe there’s a reason they have lower rates of diabetes, obesity, etc....

 

[VA Hopeful Dr]

It’s funny to me because you’re treating diabetes, obesity as uncontrollable risk factors that we just have to accept rather than outcomes in and of themselves. Maybe there’s a reason they have lower rates of diabetes, obesity, etc....

So tell me, how do we cure obesity?

There is a reason why they have lower rates of those things, and its not something that I as a FP can fix.

 

[VA Hopeful Dr]

I somewhat agree with that but preventative medicine is still medicine. Putting actual amounts of money into real sustainable programs to decrease rates of these diseases is healthcare.
Cutting down on private insurance companies is part of that. Right now private companies are incentivized to try to deny as much coverage as possible and kick the ball down to Medicare, who then gets to pick up the results of 30 years of uncontrolled obesity, HTN, DM, smoking, etc etc. It shows in how much preventative medicine is actually reimbursed or covered at all. A universal insurance plan which is forced to cover you from birth to death has much more incentive to prevent you from developing preventable diseases, vs insurance companies who know that every time you switch employers/schools/age out of your parent's plan/become eligible for Medicare they get to pass the costs along to another company.

But that's not actually what happens. Nothing that I do in the treatment of people with HTN, DM, smoking, whatever is denied by insurance. Chantix, SGLT-2s, Lyrica, diabetes ed, glucose testing supplies, even some of the newer weight loss drugs.

The insurance companies know that keeping diabetes and hypertensives well controlled saves money. Heck, they pay me more if I can show I'm doing a good job making that happen.

 

[futuredo32]

mick jagger lives in LA lol. quality of care is not something measured by where celebrities go get their care. when we are evaluating a nation's health care outcomes we are really looking at how the average person fares with the care in their locality. most people just want their local hospital and the doctors in their area to provide them with timely, affordable, effective, quality care. also I think jagger was in NYC at the time (where his 32yr old gf lives), which is why he had his TAVR there. I am sure he would have had it at Cedars-Sinai if he were in LA, or the Heart Hospital in London if he were in London and sick. really sick people don't usually have the luxury to fly off to wherever for their treatment. Also he is probably not entitled to free healthcare on the NHS because he doesn't pay taxes and doesn't live in the UK (though he has a home in London).

thankfully, most health policy wonks don't make their assessments on healthcare based on the activities of celebrities or the super rich. rich people's idea of what "the best" is, is often questionable, and I think it is well know that "VIP" patients tend to get worse care for various reasons.

Do people really think american healthcare is the bees' knees? It's definitely overpriced. My institution charges over $1000 for an initial evaluation with me (for my services alone, this does not include facility fees). I can tell you the better insurances pay all or most of this. on the flip side, medicaid might pay $80 for an initial psychiatric evaluation in some places. US healthcare is a tale of extremes. And this is the problem. We don't measure a country by how the most privileged are served (as they will do well, regardless), but by how we care for the most vulnerable.

I believe he has dual citizenship. But the point was many people who can afford to do so come to the US for better healthcare. Some from the US go to other countries for less expensive healthcare. I'm not talking about the measure of a country, that's another topic (as if this thread hasn't been derailed enough), but do you really hear about people with money going outside the US for better healthcare?

 

[MBBSMOM]

I believe he has dual citizenship. But the point was many people who can afford to do so come to the US for better healthcare. Some from the US go to other countries for less expensive healthcare. I'm not talking about the measure of a country, that's another topic (as if this thread hasn't been derailed enough), but do you really hear about people with money going outside the US for better healthcare?

Rand Paul went to Canada to get hernia surgery .

 

[splik]

I believe he has dual citizenship. But the point was many people who can afford to do so come to the US for better healthcare. Some from the US go to other countries for less expensive healthcare. I'm not talking about the measure of a country, that's another topic (as if this thread hasn't been derailed enough), but do you really hear about people with money going outside the US for better healthcare?

We are talking at cross-purposes. My contention is that we do not measure a nation's healthcare provision by where wealthy foreigners go. No one is saying that there aren't fantastic physicians and surgeons (many of them foreign trained) in the US, or that the US does not have some top notch hospitals, and access to the latest healthcare innovations. My point is this is irrelevant to evaluating health care systems, which we measure by how the average person and the most vulnerable fare. And the US fares very poorly there. The fact that there is very top notch care available is meaningless if it is not an option for the many.

Americans are flocking in droves to India for their healthcare. Does that mean that India has better healthcare than the US? No, it does not, but it is much more revealing than where the ultra rich might go to get their care.

As an aside, it is also a symptom of the disease that foreigners are coming to get expensive care in the US, because it adversely impacts access for US citizens. Where I work, local people are sometimes bumped off for rich chinese foreigners people who give a $200k "tip" to get their children seen in our psychiatry clinic. And this is a public institution.

 

[MBBSMOM]

When you have to literally cherry pick specific diseases to show how good our outcomes are, that probably is a sign that you’re on the wrong side of the debate..

Yep out of all the developed countries we have the highest maternal mortality rate .

 

[VA Hopeful Dr]

Rand Paul went to Canada to get hernia surgery .

At a place that is quite famous for doing nothing but hernia surgery. Gawande mentions them in his first book.

 

[futuredo32]

We are talking at cross-purposes. My contention is that we do not measure a nation's healthcare provision by where wealthy foreigners go. No one is saying that there aren't fantastic physicians and surgeons (many of them foreign trained) in the US, or that the US does not have some top notch hospitals, and access to the latest healthcare innovations. My point is this is irrelevant to evaluating health care systems, which we measure by how the average person and the most vulnerable fare. And the US fares very poorly there. The fact that there is very top notch care available is meaningless if it is not an option for the many.

Americans are flocking in droves to India for their healthcare. Does that mean that India has better healthcare than the US? No, it does not, but it is much more revealing than where the ultra rich might go to get their care.

As an aside, it is also a symptom of the disease that foreigners are coming to get expensive care in the US, because it adversely impacts access for US citizens. Where I work, local people are sometimes bumped off for rich chinese foreigners people who give a $200k "tip" to get their children seen in our psychiatry clinic. And this is a public institution.

We are on two different pages. You are concerned about helping the least while I am discussing where to get the best care. If it's a concern for you, why not speak out against the "Tips?"

 

[tr]

BTW, despite being a dyed in the wool socialist, I do not believe "medicare for all" is a workable or even desireable solution to the woes of healthcare in this country. We have had 55 years to make it happen - that ship sailed long ago. In addition, medicare is a sinking ship (different ship). For years it was barely held together by the SGR which was repealed at the behest of the AMA in 2015 and instead we have MACRA as a way of containing costs. But MACRA is a nightmare for many physicians (deliberately so, its purpose was to control costs) and to expand medicare to the whole of the population is just not a workable solution. Also medicare reimbursement tends to decrease every year- CPT codes we frequently use reimburse less than 5 years ago despite inflation and other increasing costs of healthcare. I do think medicare should be significantly expanded to cover everyone who cannot obtain insurance otherwise but it needs significant reworking in order to make feasible.

I totally agree that there are improvements that could be made to Medicare. However it would be much easier to make these improvements operating from a base of universal coverage. Medicare is at a financial disadvantage to private insurers because it covers the oldest and often sickest patients. If we could take all the healthy young people whose premiums are currently swelling the coffers of private insurers and bring them under the Medicare umbrella, Medicare would have a lot more financial room to maneuver. Once that is done it would be easier to make other improvements.

I don't love everything about HR1384 (the Jayapal bill). For example they have a fee-for-service reimbursement approach which is basically a setup for unnecessary procedures. But there's nothing to say that couldn't be fixed later once people realize how awful it is.

I think the most important thing right now is to create a system of universal coverage. That is the most important step. Other changes can be made incrementally. Medicare happens to already be up and running, so logistically the most direct way to achieve universal coverage is to expand this existing program, rather than having to start over from scratch.