Obamacare failing?

[LivingAlmostLarge]

I can't get a flu shot at pharmacy unless they bill it through my medical. Instead I have to wait and call around to a dr office because Aetna won't cover it at a pharmacy. Yes so my kiddo who has insurance now her appointment with pediatrician is November for a well check and shot. I'm calling every office to find one that takes our "premium" coverage now through a company.

I solidly will argue that we've proven in this country people want socialized medicine or else Medicare would go away. Medicare runs more efficiently that all others. It also covers with less hassle than a normal insurance company.

CCF I see you pointing our Tricare from the military but ask a family who has insurance they buy and see if they wouldn't leap to tricare? I think they would because it's likely to be cheaper and still easier than jumping through hoops of your insurance you buy. When you buy your own insurance the insurance company has you hostage. They don't care about your 1 voice. At least with Tricare/medicare you have a larger voice.

Obamacare was doomed to fail because what healthy person wants to pay to subsidized sick people? And sick people who know they need care are the first to sign up when insurance companies are forced to insure them after denying coverage all those years. It's not profitable to only have sick people that's not how insurance works. You need healthy people to balance the risk pool.

As for pharma, well even medicare can't negotiate with them. And arguing that socializing health insurance will prevent innovation? Not really. Maybe they'll just make less profit. You know that the US is the only country that pharma really makes a profit on? The same drug bought across the border is over the counter earlier, cheaper, etc. But why not gouge the US? Because sales at 90% of the cost.

But i think if the US reformed it to single payer and instead invested in RD and like they used to with grants it would still drive innovation. People doing the academic research and even the pharm research aren't driven by money. Many do it because it's their passion. Many innovations are collarborations where the private industry is funding academic labs because they have no money. Try giving them money and see what happens. It's a chicken and egg. If the US even had a semblance of negotiating power pharma companies would still make a large profit.

[creditcardfree]

CCF I see you pointing our Tricare from the military but ask a family who has insurance they buy and see if they wouldn't leap to tricare? I think they would because it's likely to be cheaper and still easier than jumping through hoops of your insurance you buy. When you buy your own insurance the insurance company has you hostage. They don't care about your 1 voice. At least with Tricare/medicare you have a larger voice.

I don't doubt that people would sign up if they had smaller copays and premiums. It sounds wonderful and to some degree it is, and like all of you I'm grateful for insurance and believe we all should have some form so that we don't become financial bankrupt and can get service.

Why don't you think I'm hostage with Tricare? You don't think I have to pay out of pocket for some procedures? What hoops do you think we don't have jump through? Just trying to understand your point of view.

There are only 1.3 million service members, so while that is more than one, it makes up only .05% of the population. That's not as big of a voice as you might think.

[disneysteve]

One problem that I've seen with Tricare is that not many doctors accept it. There are probably more if you're in the vicinity of a military base, but other than that, providers are few and far between. We have a handful of patients with Tricare and it's very hard to find specialists to refer them to. They often need to travel up near McGuire AFB to see a doctor.

[creditcardfree]

One problem that I've seen with Tricare is that not many doctors accept it. There are probably more if you're in the vicinity of a military base, but other than that, providers are few and far between. We have a handful of patients with Tricare and it's very hard to find specialists to refer them to. They often need to travel up near McGuire AFB to see a doctor.

Thank you for confirming what I have said on this before. For the last 9 years we were no where near a military base (Army Reserves don't have large posts!) LAL knows I'm not a fan of government insurance and Tricare is the reason why. Doctor's aren't interested in accepting it. They don't get compensated well enough. I've noticed that many that do seem to be doing out their desire to be of service to military members and their families. They aren't covering their costs.

[disneysteve]

Doctor's aren't interested in accepting it. They don't get compensated well enough.

To be honest, I have no idea how the compensation is. I think doctors tend to decide which insurance plans to accept based on two main factors. Compensation is one but patient volume is the other.

For example, in my office, we accept a few plans that are a pain in the butt to deal with but they are major players in our area so we really need to accept them or we pass up hundreds of potential patients. On the other hand, why go through all of the hassles of getting credentialed with TriCare, setting up an account with their online portal to submit claims and do referrals and whatever else just so we can take care of 5 or 10 patients? It isn't worth the trouble no matter how good the compensation might be. If we were down the street from a military base, sure, but we are 40 miles from the nearest base.

[LivingAlmostLarge]

I've found that when you buy your own insurance, the cheap plan many dr like Tricare don't take it either. They say "oh we don't take that". We really struggled finding anyone who could take us in. I've found that the better your insurance the more choices you have. Based on what your employer provides for. When you buy your own it's very, very limited, especially when you pay OOP for everything.

[creditcardfree]

I've found that when you buy your own insurance, the cheap plan many dr like Tricare don't take it either. They say "oh we don't take that". We really struggled finding anyone who could take us in. I've found that the better your insurance the more choices you have. Based on what your employer provides for. When you buy your own it's very, very limited, especially when you pay OOP for everything.

I believe that. The doctor's don't want to play with the little unknown insurance companies. Sometimes particularly for office visits and small procedures, I wish one could just pay the doctor and skip the insurance!

[disneysteve]

Just to give you a tiny taste of what drives doctors crazy:

I saw an 11-year-old boy for an annual physical.
American Academy of Pediatrics, Centers for Disease Control, and the state of New Jersey all recommend or require 11 year olds to get a tetanus vaccine and a meningitis vaccine. In fact, if they don't get them, they can be banned from school until they do. So as part of his physical, we gave him both vaccines.

His insurance company denied the tetanus vaccine as unnecessary and not a covered benefit.

Isn't it wonderful how they can deny something that is in every set of guidelines and even legally required by the state? Must be nice to have that kind of power.

[LivingAlmostLarge]

like I said our insurance is supposedly good but all vaccines needs to be placed through medical billing not pharmacy. So we can't go to a CVS or Walgreens. It has to be a dr office which makes getting shots a pain. I plan on getting the kids shots at a hospital because getting into the pediatrician is impossible. Or I can pay OOP and then get reimbursed. Yes jumping through hoops.

Last year we stockpiled I'll admit my DK allergy pens and asthma medications. We didn't want to pay $300+/month. But our insurance before we left the company covered everything with a $10 copay. We got our money's worth. Having filled it with 3 month scripts both as a traveling and regular and school supplies the drs wrote us multiple scripts in 3 month with refills so we could "drop"it everywhere. Only way insurance pushed it through. Even now I have to drop it at school still and buy extras. Thankfully again we have insurance we aren't buying.

We didn't and wouldn't qualify for the subsidy last year or this year even with DH working part-year. So we were footing everything OOP. It was not fun. We tried to avoid dental, vision, and dr visits unless absolutely necessary.

I don't think that paying for our own insurance is the answer personally. It makes people less likely to go in for preventative care.

[Spiffster]

Just to give you a tiny taste of what drives doctors crazy:

I saw an 11-year-old boy for an annual physical.
American Academy of Pediatrics, Centers for Disease Control, and the state of New Jersey all recommend or require 11 year olds to get a tetanus vaccine and a meningitis vaccine. In fact, if they don't get them, they can be banned from school until they do. So as part of his physical, we gave him both vaccines.

His insurance company denied the tetanus vaccine as unnecessary and not a covered benefit.

Isn't it wonderful how they can deny something that is in every set of guidelines and even legally required by the state? Must be nice to have that kind of power.

A few years back I went to my PCP to get a physical. My wife noticed that I have a sinus dysrhythmia so I had mentioned this to my doctor. He recommended an EKG to make sure things were normal (they were). I month later I got a bill stating that United Healthcare refused to cover the EKG stating it was "Not a proven medical procedure"... Like it went to a witch doctor, and this was some kind of strange ritual I had performed... I wish I was kidding.

Picked up the phone and called the clowns at UHC. They said it must have been a mistake, and they would take care of it. Off the phone in a matter of minutes... turns out they did nothing, and I got another notice from my PCP a few weeks later. Again, I called customer service and they had no record of my last call but said (again) that they would handle it... and again, I got another notice threatening collection this time. So a third time, I call UHC and demanded to talk to a manager, who yet again, told me it was a mistake and they would take care of it. The bill was FINALLY paid.

Universal healthcare? Yes please... if it will cut these shysters out of the loop, then Im all for it.
Will the government do better, lol... likely not, but at least I know profit will not have priority over my health.

[tripods68]

Our health care system is ultimately heading towards single-payer system as a replacement for Obamacare.

[DaveInPgh]

A few years back I went to my PCP to get a physical. My wife noticed that I have a sinus dysrhythmia so I had mentioned this to my doctor. He recommended an EKG to make sure things were normal (they were). I month later I got a bill stating that United Healthcare refused to cover the EKG stating it was "Not a proven medical procedure"... Like it went to a witch doctor, and this was some kind of strange ritual I had performed... I wish I was kidding.

Picked up the phone and called the clowns at UHC. They said it must have been a mistake, and they would take care of it. Off the phone in a matter of minutes... turns out they did nothing, and I got another notice from my PCP a few weeks later. Again, I called customer service and they had no record of my last call but said (again) that they would handle it... and again, I got another notice threatening collection this time. So a third time, I call UHC and demanded to talk to a manager, who yet again, told me it was a mistake and they would take care of it. The bill was FINALLY paid.

Universal healthcare? Yes please... if it will cut these shysters out of the loop, then Im all for it.
Will the government do better, lol... likely not, but at least I know profit will not have priority over my health.

Clearly UHC was in the wrong and should have handled things right the first time.

That being said, if my PCP threatened collection while I was battling the insurance company over an obvious mistake I would find another PCP.

[DaveInPgh]

Thanks to Obamacare, I literally took it up the rear at the cost of $1,000.

When Obamacare was passed, my company decided to change what healthcare plans would be available to employees. Prior to, I had UPMC and EVERYTHING was covered at 100% after copay. My company stopped offering that option, and I got stuck with a UHC plan that only covers 80% after I reach my annual deductible.

My first Colonoscopy while with UPMC cost me a $100 copay.

My Colonoscopy last year with UHC cost me a little over $1100.

[disneysteve]

My first Colonoscopy while with UPMC cost me a $100 copay.

My Colonoscopy last year with UHC cost me a little over $1100.

That's odd. I thought the current laws required preventative care like mammograms and colonoscopies to be covered. Even on my HDHP plan that covers absolutely nothing, those tests are covered 100% and are not subject to the deductible.

ETA: I checked on this. I was half-right.

A screening colonoscopy is covered 100%. However, "patients may be charged for some services. You may have to pay part of the costs of anesthesia, bowel prep kit, pathology costs, and a facility fee (where the procedure is performed)."

Also, and this is one of those things that really sucks about insurance in general, if anything is found during the screening colonoscopy, such as a polyp that they need to remove, it may get classified as a diagnostic colonoscopy for billing purposes. That depends on the individual insurance company policies. So basically, they can say they'll pay for the test as long as it turns out normal.

That reminds me of a policy some companies used to have years ago regarding emergency room visits. If you went to the ER for an injury and an x-ray showed you broke a bone, the visit was covered, since that qualified as an emergency. But if the x-ray was negative and nothing was broken, they wouldn't pay since a sprain isn't an emergency. Thankfully, they got rid of that policy.

[DaveInPgh]

That's odd. I thought the current laws required preventative care like mammograms and colonoscopies to be covered. Even on my HDHP plan that covers absolutely nothing, those tests are covered 100% and are not subject to the deductible.

ETA: I checked on this. I was half-right.

A screening colonoscopy is covered 100%. However, "patients may be charged for some services. You may have to pay part of the costs of anesthesia, bowel prep kit, pathology costs, and a facility fee (where the procedure is performed)."

Also, and this is one of those things that really sucks about insurance in general, if anything is found during the screening colonoscopy, such as a polyp that they need to remove, it may get classified as a diagnostic colonoscopy for billing purposes. That depends on the individual insurance company policies. So basically, they can say they'll pay for the test as long as it turns out normal.

That reminds me of a policy some companies used to have years ago regarding emergency room visits. If you went to the ER for an injury and an x-ray showed you broke a bone, the visit was covered, since that qualified as an emergency. But if the x-ray was negative and nothing was broken, they wouldn't pay since a sprain isn't an emergency. Thankfully, they got rid of that policy.

Here is what I found on their Preventive Care document.

A patient had a polyp found and removed at a prior preventive screening colonoscopy. All future colonoscopies are considered diagnostic because the time intervals between future colonoscopies would be shortened.

I did indeed have a polyp on my prior screening, but I am almost certain that wasn't the reason listed when the second one was not covered. Their current document shows screening starting at the age of 40, but I am pretty sure at the time of my procedure their policy was starting at age 50. I think I have the information in my files. There is no way their policy was age 40 at the time.

Regardless, per their document, they plan on screwing me over every time I have the screening.