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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Jim Charter wrote:
> But can you really blame the Health Insurance Industry for 
> everything?

Absolutely not.  If so, then regulation would be an answer.  However, 
part of the problem is systemic, which is why reform is needed.

One of the problems is billing, for instance.  Insurance companies are 
experts at negotiating discount rates for their large volume in order to 
drive their costs down.   The government funds (Medicare and Medicaid) 
look at bills and say, "We'll pay X% of these." Care providers are 
experts at padding bills in order to drive their costs up.

The end result is that, between private insurance & government funds, 
the healthcare industry gets the funds they need to operate, but it's 
only a percentage of their claimed prices.  This doesn't hurt the 
healthcare industry (they still get the money they need), the government 
(they pay what they can and then say "enough") or the insurance 
companies (they negotiate their discounts, remember?).

It hurts people without insurance, because they're left paying the 
inflated sticker price which they can't afford.

...Chambers

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On Sun, 30 Aug 2009 17:01:35 -0400, Jim Charter wrote:

>  To be honest many of
> my personal stories of excessive costs seem to point directly at the
> physician.*

Oh, sure - part of that comes from the physician's sponsorship by the 
drug companies.  I lucked out and found a very *good* allergist who 
doesn't believe in just alleviating the symptoms (though I do take a 
couple of drugs to alleviate symptoms from my allergies) but also getting 
at addressing the root cause.

The thing that impressed me about him was that he took me off Advair (for 
asthma) when it became apparent that it wasn't necessary or having a 
significant effect - he's given me an albuterol inhaler for emergencies, 
which I've used maybe 3 times (and had to have replaced because it 
expired).  He's very much into not prescribing things that aren't 
necessary - as opposed to my PCP, who handed me a bunch of samples and 
said "try these".  Needless to say, I've switched PCPs.

Jim

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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.

Post a reply to this message

Chambers wrote:
> Jim Charter wrote:
>> But can you really blame the Health Insurance Industry for everything?
> 
> Absolutely not.  If so, then regulation would be an answer.  However,
> part of the problem is systemic, which is why reform is needed.
> 
> One of the problems is billing, for instance.  Insurance companies are
> experts at negotiating discount rates for their large volume in order to
> drive their costs down.

The other dirty trick is by not paying any doctor who charges less than
their rate to anyone not covered. In certain areas where there is only
one insurance company, either because there is only one major employer
or from state regulation, this can lock people out of receiving care.
And most doctors could not get by by only seeing patients without that
insurance.

>   The government funds (Medicare and Medicaid)
> look at bills and say, "We'll pay X% of these." Care providers are
> experts at padding bills in order to drive their costs up.
> 

Ask the care providers if they know what it costs. Sure, they know what
the machine cost to a few significant digits. And they often know what
the costs to operate it are, or the costs of the medicines they
prescribe. But the overhead that the hospital gets, to pay for the
stacks of paperwork or for profit, are often completely unknown. If you
find out what it costs, try to even find details on what the big
companies pay.

Finding the actual X% that the government pays is not too tough. They
factor in regional costs compared to national, and pay extra for clinics
serving the low-income bracket. The details are at
http://www.cms.hhs.gov/PFSlookup/ along with a way to lookup the amount
they pay for certain specific procedures.

> The end result is that, between private insurance & government funds,
> the healthcare industry gets the funds they need to operate, but it's
> only a percentage of their claimed prices.  This doesn't hurt the
> healthcare industry (they still get the money they need), the government
> (they pay what they can and then say "enough") or the insurance
> companies (they negotiate their discounts, remember?).
> 
> It hurts people without insurance, because they're left paying the
> inflated sticker price which they can't afford.
> 
> ...Chambers

I heard or read somewhere, that the best advice for someone without
insurance was to ask the management at a doctors office what they would
charge if you paid in cash, up front. Most doctors don't even know what
the office charges, but management knows what it costs to go through
stacks of paperwork.

Did that for an eye exam last year, after they quoted me the price they
would gladly bill my insurance, paid something like $50 for the whole
work up.

Post a reply to this message

Chambers wrote:
> Shay wrote:
>> But that's still not precisely what we're arguing about. The precise 
>> thing we're arguing about is how to decide /when/ the rights of he 
>> many should outweigh the rights of the few. You believe the majority 
>> should decide when the majority's rights should impede upon the 
>> minority's. That's where I can't see your logic. I believe with the 
>> system you propose, two people will too often (always?) elect to eat 
>> the third.
> 
> Why can't we just say that, in some instances, the rights of the many 
> outweigh the rights of the few, and in others the rights of the 
> individual are paramount?

Because the individual doesn't have any say in the "why can't we just 
say..." The Constitution is his only defense against the many.

> 
> I'm not arguing for an ideal here, I'm looking at what should be done in 
> this specific instance.

If this were allowed, *every* specific instance would lead to majority 
benefit at the cost of minority rights.

"""
A democracy cannot exist as a permanent form of government. It can only 
exist until the voters discover that they can vote themselves largesse 
from the public treasury. From that moment on, the majority always votes 
for the candidates promising the most benefits from the public treasury 
with the result that a democracy always collapses over loose fiscal 
policy, always followed by a dictatorship. The average age of the 
world's greatest civilizations has been 200 years.
  -Alexander Tytler (unverified)
"""

  -Shay

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Shay wrote:
>> I'm not arguing for an ideal here, I'm looking at what should be done 
>> in this specific instance.
> 
> If this were allowed, *every* specific instance would lead to majority 
> benefit at the cost of minority rights.

You should always avoid absolutes.

;)

> """
> A democracy cannot exist as a permanent form of government. It can only 
> exist until the voters discover that they can vote themselves largesse 
> from the public treasury. From that moment on, the majority always votes 
> for the candidates promising the most benefits from the public treasury 
> with the result that a democracy always collapses over loose fiscal 
> policy, always followed by a dictatorship. The average age of the 
> world's greatest civilizations has been 200 years.
>  -Alexander Tytler (unverified)

I guess the US is ripe for destruction then.  Good luck in the new world 
order.

Oh, by the way... what's the age of the United Kingdom?

...Chambers

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Sabrina Kilian wrote:
> I heard or read somewhere, that the best advice for someone without
> insurance was to ask the management at a doctors office what they would
> charge if you paid in cash, up front. Most doctors don't even know what
> the office charges, but management knows what it costs to go through
> stacks of paperwork.
> 
> Did that for an eye exam last year, after they quoted me the price they
> would gladly bill my insurance, paid something like $50 for the whole
> work up.

I'm glad that worked for you.  If I find myself without coverage again, 
I'll remember that.

My father in law works for Safeco, so I've heard some real horror 
stories about people's lives being ruined by medical bills that were 
denied coverage.

I know those instances aren't the norm, but they happen far too often to 
be acceptable.

...Chambers

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Chambers wrote:
> 
>> """
>> A democracy cannot exist as a permanent form of government. It can 
>> only exist until the voters discover that they can vote themselves 
>> largesse from the public treasury. From that moment on, the majority 
>> always votes for the candidates promising the most benefits from the 
>> public treasury with the result that a democracy always collapses over 
>> loose fiscal policy, always followed by a dictatorship. The average 
>> age of the world's greatest civilizations has been 200 years.
>>  -Alexander Tytler (unverified)
> 
> I guess the US is ripe for destruction then.  Good luck in the new world 
> order.

How long do you think we can continue to borrow from the future?

> 
> Oh, by the way... what's the age of the United Kingdom?

The government or the title?
As a democracy?
As a "great civilization"?

Questions for a historian, I suppose. And subjective even then.

I'm more interested what position you would take on *my* words. What 
protection would you give to the few when the many are "just say(ing)" 
that their own rights rights outweigh those of the few? How would you 
protect those protections against the next occurrence of "just say(ing)"?

  -Shay

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Shay wrote:
> How long do you think we can continue to borrow from the future?

I hate to tell you this, but it's impossible to not borrow exponentially 
more money from the future over time, the way the money system is now set 
up. Everyone owes everyone money, and there's no way to pay it all back. 
It's mathematically impossible to pay back all loans. There's more money 
owed than there is existent, and the only way to make more money is to 
borrow it.

> I'm more interested what position you would take on *my* words. What 
> protection would you give to the few when the many are "just say(ing)" 
> that their own rights rights outweigh those of the few? How would you 
> protect those protections against the next occurrence of "just say(ing)"?

The rights of the few cannot be protected from the majority in practice, 
except by having the few in a different sovereign organization with its own 
military force. You have to look at each attempted infringement and decide 
if it's sufficiently worthwhile to make people pay for it.

-- 
   Darren New, San Diego CA, USA (PST)
   Understanding the structure of the universe
    via religion is like understanding the
     structure of computers via Tron.

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