Jim Henderson wrote:

> 
> IMO a big part of it is denial of preventative care because the doctor is/
> was "out of network" or some other bizzare reason.  So rather than 
> prevent us from getting sick, they'd rather things get bad enough that we 
> have to go for a major visit.
> 
> On a smaller scale, I went to get my teeth and gums cleaned.  The dentist 
> said that my gums were bad enough that he wanted me to see a periodontist 
> for my cleanings for the next year.
> 
> But my insurance company doesn't cover *preventative* periodontal care; 
> it's only covered if I've had periodontal surgery, which means I hadn't 
> let things get *bad enough*.  So the incentive is to let things get worse 
> so I need surgery, then I can get my teeth cleaned.
> 
> And of course my dentist didn't know this about my plan (how could he 
> keep track of everyone's plan's limitations?), and my read of the plan 
> was that it as covered.
> 

> And when they get worse, that drives the costs up.  I'm know the 
> insurance company saved about $500 by not paying out on my claim, but if 
> I'd let it get to the point where I needed surgery, it sure as hell 
> would've cost them more than $500.
> 
> This is what pisses me off when people who aren't in favour of universal 
> health care say "we don't want a bureaucrat dictating what we can and 
> cannot have" - because we already *have* that.
> 

Yes, well understanding exactly what we have, ie. how such decisions are 
being made, and how it malfunctions is a big part of the problem.  The 
question does become, can something government-run really do better.

I can speculate about the anedotal examples you offer, (and I can match 
them, and so can others I know), and try to extrapolate from there and 
form ideas how free enterprise falls short.

I would suppose it is more cost effective for insurance companies to try 
and expunge demographic groups from the insurance roles. I would suppose 
it is easier for them to quantify the costs from groups based on 
demographics or certain ailments, than for them to try and quantify the 
cost effectiveness of various preventative or alternative treatments, in 
detail, across a broad range of ailments.  Otherwise, if the anecdotes 
you, I, and everyone else can offer are true, there should be an 
incentive for an insurance company to make good decisions around these 
issues.  But only if the cost of determining such good decisions costs 
less than what is saved.  Also it would seem true that a company could 
enter the market with some success by covering such treatments.

So one wonders now much it would cost to identify such cost saving 
improvements. And if a government run program could really contaon cost 
any better.

Also if many cost saving improvements would even gain traction with the 
public. Especially without the support of doctors.  To be honest many of 
my personal stories of excessive costs seem to point directly at the 
physician.*  I can see how insurance companies are incentivised to 
contain costs.  I don't see why doctors necessarily are.


*A urologist who tried to rush me into expensive surgery as a fertility 
treatment. When the mundane, and cost free solutiion, cooler baths, was 
arrived at by my chiropractor, he actually tried to schedule surgery 
before the effectiveness of the mundane solution could be confirmed with 
test results.
*An alternative treatment, not covered by insurance, for a back ailment 
that allowed my boss's mother to walk out of the office unassisted, 
having entered using crutches
*Recently a doctor prescribing Nexium to my 21 year old son for acid 
reflux.  Nexium is the most heavy-duty of the available breed of 
medicines for that ailment, and, the most expensive of that breed by at 
least a factor of two.  The treatment plan was: 'use as needed.' Huh?

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