Jim Charter wrote:
> 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 don't have to speculate about government healthcare, I am on it. Long
time disability, and a long boring story. The difference between the two
are night and day, really.

When I was on my parents private insurance, I saw the tables of
paperwork they had to do to make sure that things got covered. Now, I
will admit that desks were a lot taller back then, so my memory is
probably skewed a bit.

Now the same test, that was done several times when I was younger and
resulted in paperwork to approve and cover, was performed with no
paperwork passing through my hands. None. I did not have to justify
anything, the doctor did that. My GP had sent me to a specialist over a
disorder that they could not handle, and the specialist thought the test
would be informative, and as far as I know no abnormal paperwork was
done by them either.

It was informative, and by ordering injections of radioactive isotopes
they determined that there was nothing that really needed to be done. As
the specialist said, he could have tossed around CAT and MRI scans, and
lots of blood work and sonograms, and who knows what else. Sure, an
expensive test looks like more work up front, but that alone saved them
from running the other tests every 6 months for the next 3 years.

To add to the cost savings, no one had to be hired to peruse the
paperwork and stamp it with a big red 'denied'.

> 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.
> 

That assumes new companies can even enter the legal minefield that the
major insurance companies have made to protect themselves.

> 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.
> 

The government already does a pretty good job at containing the costs.
Medicaid/Medicare have prices that they will pay hospitals on most major
procedures. These are not usually negotiable, if I understood what the
hospital staff was explaining. But then again, neither are the prices
that major insurers will pay. They set them and if the hospital wants to
have anyone visit it in that state they had better take those prices.

> 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.
> 

The doctors really aren't. They don't need to be, but they are often in
the best position to know what the best treatment would be. Often, not
always. I would still trust most of their opinions over someone sitting
in an office building completely detached from the patient.

> 
> *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.

Surgeons, I don't trust any of 'em. When dealing with any specialist,
tell them up front that any invasive procedure will be performed by
someone at another clinic after a second opinion. What how quick they
will offer simpler solutions.

> *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?

Could be that the doctor knows that, while an over the counter medicine
for the same costs some $20 a month, a prescription may only cost the
patient their copay amount. Or, the doctor is on the christmas card list
of the drug company behind that pill.

That is a whole other area of needed reforms, though.

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