SAD state of Healthcare

[Smallsteps]

My husband came home with the brochures for sign-up for new insurance ... (it is a real pain that many private companies seem to switch plans every year just when you get use to the last one. )
In today's presentation the sales rep told employees and had handouts that stated that .....88% of first time diagnosis are WRONG ........
and that when using the new plan for next year employees are required to consult with this companies healthcare "advisors" for a second opinion....not only on diagnosis but all treatments as well ........not a second appointment or tests............
but simply some various levels of medical training nurses / doctors deciding on looking over charts if they feel YOUR doctor who may know you and examined you was WRONG ..... and in their world that is happening 88% of the time??

My husband stood up and really questioned the information given ........ since 88% seemed a really high for missed or wrong diagnosis.
He then asked "why the company would not eliminate these incompetent providers from their list ...... if that was an accurate estimate of false diagnosis"
.
Guy was stammering that that was not what he was saying ........but my husband said "you have it in writing ....... certainly you did not think that through or thought that was a smart idea for legal reasons".

He also questioned the idea that their 'Advisors" paid for by that insurance company ........will not simply push the CHEAPEST treatment option for all conditions,.......... and if they were experts why would they choose to just work for insurance company instead of the front lines of healthcare treating patients each day.

The rep for insurance company just stood there stammering confused as to why anyone would question this process.
I guess many employees now are asking if this group is REALLY the way for the plan to go. including CEO and the board of directors.

In casual observation of TV ads ...
I also have noticed more and more companies jumping into the the GOOD RX type game ..... If drug company can afford to sell for ( example from commercials ) $8.90 instead of $67.00........................... then perhaps why not lobby to take out the middle man markup to save ALL people the money?
Now Good RX is offering direct ( cash only not taking insurance) online visits for much cheaper then average office visit ......

I am still not sure how all these virtual visits work as far as if a doctor is licensed in the your state. IF taking insurance most of them credentialed the providers for license and past issues.............. but private pay are these companies really paying for Dr from each state ?

This is bypassing some safety IMO for patients ..... I did credentialing and some doctors who lets say are NOT the cream of the crop were eliminated from practicing in some vigilant states but is that being monitored if you see a virtual DR who ships drugs directly to your home ?

All the ads for like items Singlecare / etc say they are COUPONS to get lower drug prices by bypassing your insurance and paying directly.
But Coupons would be a once or twice deal not a consistent price do you find out each month what price you will pay unless you swap where you are buying it all the time etc.
If pharmacy A has it at $6.00 for two months the jumps to $40 ...... so you look on app and find pharmacy B or C has it at X amount and you chase the best price all over town or internet sites?

So where is the money for all involved?? .... if you switch to different pharmacies ....Do the various pharmacies all in turn pay rebates to companies like Good Rx or Singlcare etc for directing customers to them ?
I suppose them selling your data will help pay for all these ADS as well .........

So you pay less by NOT using insurance but if you bypass it.......... how does insurance keep track of treatments / prescriptions.?
Seems that they would benefit if the patient went around them to buy directly cheaper...... Does insurance have vested interest in these pay direct programs?

I am seeing commercials ( all paid for by PHARMA ) insisting do NOT put off treatment for ( insert condition) simply because covid restrictions............... I would imagine their demand is shrinking .... as people are not going in and being prescribed the various Drugs .... thus limiting profits for the drug producers.

One especially pushy one, I have seen is even promoting ........if YOUR DR is not seeing many people call us and we will set you up with one of Our preferred doctors...... Code words for those sure to prescribe said drug.

This is a sad state of healthcare ........

[amarowsky]

it's ridiculous all the hoops average people have to go through to "not feel like your getting screwed" from your health insurance provider.

FYI, I rarely feel this way about the healthcare worker themselves. Although I would be surprised if there were 0 issues on this side. The lion's share of my gripe is with insurance companies. And that aside from collective bargaining with individual companies & health care providers , provide ZERO benefit to the consumer, yet are requisite if you wish to be insured. (only exemptions is if you are one of the 40 million people on medicare/medicade, or one of the 100,000 wealthy enough people that could afford to pay the Cash sticker price at point of care places.).

Seems like price tables could pretty much make most of the insurance industry obsolete.... If we didn't have to pay those THOUSANDS of salaries for bill collectors, insurance adjusters, lawyers, all the data input people to manage these billions of transactions, and of course the non-stop advertising we see on TV that we have to pay. Just saying.... if you cut all of this out, it would give our medical workers a lot more time to deal with client/patients. And give client/patients less time distracted on the phone either fighting for coverage or on hold w/ your insurance/billing, and more time considering our health or just spend doing more fruitful things.

Flipping hate health insurance for essential health things.... (emergency room, routine visits, or mid level urgent care stuff).... Just another greedy mouth to feed between me and my doctor.

[amarowsky]

All the ads for like items Singlecare / etc say they are COUPONS to get lower drug prices by bypassing your insurance and paying directly.
But Coupons would be a once or twice deal not a consistent price do you find out each month what price you will pay unless you swap where you are buying it all the time etc.
If pharmacy A has it at $6.00 for two months the jumps to $40 ...... so you look on app and find pharmacy B or C has it at X amount and you chase the best price all over town or internet sites?

So where is the money for all involved?? .... if you switch to different pharmacies ....Do the various pharmacies all in turn pay rebates to companies like Good Rx or Singlcare etc for directing customers to them ?
I suppose them selling your data will help pay for all these ADS as well .........

So you pay less by NOT using insurance but if you bypass it.......... how does insurance keep track of treatments / prescriptions.?
Seems that they would benefit if the patient went around them to buy directly cheaper...... Does insurance have vested interest in these pay direct programs?

I am seeing commercials ( all paid for by PHARMA ) insisting do NOT put off treatment for ( insert condition) simply because covid restrictions............... I would imagine their demand is shrinking .... as people are not going in and being prescribed the various Drugs .... thus limiting profits for the drug producers.

One especially pushy one, I have seen is even promoting ........if YOUR DR is not seeing many people call us and we will set you up with one of Our preferred doctors...... Code words for those sure to prescribe said drug.

This is a sad state of healthcare ........

Forgot to even mention. Our insurance changed in early 2019 (went from Mine <----> to my wife's companies plan).

Our old plan covered asthma patients. This new one doesn't (I'm a mild asthmatic). Just sucks... I use to get my medicine covered under our old Rx plan. Their new insurance plans don't cover asthmatics (looks like her or I would have to find a Different occupation or company, if we want to keep breathing properly).

So under this plan to cover my advair (or generic) it is $400 month w/ insurnace Rx card.

Thankfully, if I just buy it Cash , w/ a Good Rx coupon, it's only $100 a month. <----- *This is meant to support your post*. The fact that, cash + coupon, is cheaper than Insurance Rx price....

This is a joke, and a system that NO PERSON WOULD ENVISION IS A GOOD IDEA. I can't imagine the young man/woman who dreamed that one day, "I could put a system into motion. That you would be able to pick the job that is perfect fit based on you: Education, experience, interests, and HealthCare you will need to live". <----- This is meant to be hyperbolic. Because it's a non-sense relationship (one's employer, employing industry with one's relationship to their doctor).

I am away no able minded person would have planned for such an awfully constrained outcome, and it naturally unfolded by poor management. It's just an awful design, that stifles innovation and true entrepreneurial risk taking (the stuff the moves the needle of progress the MOST, especially when we need it.).

[amarowsky]

sorry I get soo heated up.... Just hate that I KNOW I'm getting screwed....

It's this 95% distrust in the pricing of an entire system, that has given me enough cause to lose 20 lbs PERMANENTLY since 3/20 covid lockdown. I would just 100% prefer to never go to the doctor. But because that's non-sense, I'll go my plan B, remove 95% as much reason to go to doctor as possible.

So now I do 3-4 miles walks 4-5 times a week, eat a lot less, sleep more, and generally am more concerned with avoiding the doctor. I have enough money to go there.... I eventually will trust the doctor with any of their moves...... Just the thought, or damn near inevitability, that I'll have to be screwed around on some costs, pay $20 to use a hotpad, or $10 for tissues, or some total bull**** charge, is enough to make me want to do everything I can to avoid it.

It's like that Liar you know at work, that you HAVE to work with sometimes.... You have no option but to work w/ the person. But you know they're lying, or full of ****, and just want to avoid them. So you will do Extra work to avoid them. This is now how my relationship is w/ healthcare. And it sucks.... I wish I could have a more authentic trust. But I just now, that before, and after I see my doctor, billing/insurnace/someone in their system is gonna try their best to extract more of my wealth (my time) than they Ought to. <--- I can't wait until we change our system some how, to make this feeling go away. (FYI, It's almost the same feeling when an Airline changes your plans on you, At your own expense, without your consent. Helpless..... and lied to).

[ua_guy]

I googled "88% of first diagnosis is wrong", and sure enough, in a list of junk links and fake news, I found the morsel of truth which was twisted and bludgeoned to fit a narrative. The statistic refers to a 2017 study conducted by the Mayo Clinic based on a sample of 286 patients between January 2009 and late December 2010. Patients sought a second opinion and diagnosis were compared. In the study abstract, it says this:

In 12% (36/286) of cases, referral diagnoses were the same as final diagnoses. Final diagnoses were better defined/refined in 66% (188/286) of cases; but in 21% of cases (62/286), final diagnoses were distinctly different than referral diagnoses. Total costs for cases in category 3 (different final diagnoses) were significantly higher than costs for cases in category 1 (P = .0001) and category 2 (P = <.0001).

If anyone has interest in a starting point for this reading, here: https://newsnetwork.mayoclinic.org/d...cond-opinions/

So, what it really says is that a total of 78% of diagnoses (12% same diagnosis, 66% better defined) were pretty good. In 21 % of cases, the second opinion revealed diagnoses which were distinctly different and were much more costly diagnoses to treat. So we're actually talking about 21% "wrong diagnosis" which is actually a distinctly different diagnosis. But I did not read where it said the second diagnosis was incorrect. I'm not a doctor but I know people can have many conditions which present related and comorbid symptoms. All of which is to say, there is value in getting a second opinion.

I don't know about you, but when I see my doctor, I understand that he's not going to get it right every time, on the first try. I can lean on a statistic like 78% of diagnosis being basically the same with a second opinion, where maybe better definition or clarity is added to the diagnosis. I think that's pretty dang good, actually.

As for the rest of the meandering casting of doubt and questions in the OP's post, this is why I'm supporting single-payer nationalized healthcare. The existing model is too complex for people to understand and big pharma has been allowed far too much rope with its price gouging and pricing models for different types of consumers.

My elderly parents are having to deal with Kaiser Permanente managed care (Medicare advantage) and it makes me want to scream. We're trying to get a second opinion for a very involved surgery that my mom requires from a neurosurgeon. They denied the request and it equates to a part-time job trying to understand and appeal the denial. Even if it was approved, there are many restrictions on where she can go, who she can see, so, instead she's taken my advice which is, if you have the money to do it, just do see a doctor you trust, and pay out of pocket. And that is what she is doing. I was elated to hear she has an appointment at one of the highest regarded teaching hospitals, UW Medicine, for early January.

[disneysteve]

88% of first time diagnosis are WRONG

That's BS, pure and simple. For a health insurance provider to actually put that in their printed materials is criminal. No way would I do business with a company like that.

employees are required to consult with this companies healthcare "advisors" for a second opinion

Under what circumstances? Before surgery? Only for specific conditions? Requiring a second opinion before elective surgery might not be an awful idea, or perhaps before beginning cancer treatment. But the times when a 2nd opinion should be required should be pretty limited.

I am still not sure how all these virtual visits work as far as if a doctor is licensed in the your state.

You do need to be licensed in the state in which you are practicing telehealth. Telehealth was already around but Covid probably advanced the field by a good 5 years or more when nearly all doctors were forced to start doing it since they had to close their offices to most or all in-person visits.

My urgent care started doing telehealth. I haven't done it yet myself but we have several providers doing it. When you call in, you're getting the very same people you would get if you walked in the door for an in-person visit. They aren't lesser providers in any way. If they feel your condition can safely be handled by phone, they do. If they think an in-person exam is warranted, they refer you to one of the physical urgent care sites, or the ER if appropriate.

I am seeing commercials ( all paid for by PHARMA ) insisting do NOT put off treatment for ( insert condition) simply because covid restrictions

Unfortunately, many people have been delaying necessary medical care because of fear of Covid. I think it's important to let people know that that isn't a good idea. Healthcare facilities are taking every precaution they can to keep people safe. It's not perfect but you're a lot less likely to catch Covid at your doctor's office or the hospital than you are going out to dinner or visiting your family for Christmas.

[amarowsky]

I googled "88% of first diagnosis is wrong", and sure enough, in a list of junk links and fake news, I found the morsel of truth which was twisted and bludgeoned to fit a narrative. The statistic refers to a 2017 study conducted by the Mayo Clinic based on a sample of 286 patients between January 2009 and late December 2010. Patients sought a second opinion and diagnosis were compared. In the study abstract, it says this:

In 12% (36/286) of cases, referral diagnoses were the same as final diagnoses. Final diagnoses were better defined/refined in 66% (188/286) of cases; but in 21% of cases (62/286), final diagnoses were distinctly different than referral diagnoses. Total costs for cases in category 3 (different final diagnoses) were significantly higher than costs for cases in category 1 (P = .0001) and category 2 (P = <.0001).

If anyone has interest in a starting point for this reading, here: https://newsnetwork.mayoclinic.org/d...cond-opinions/

So, what it really says is that a total of 78% of diagnoses (12% same diagnosis, 66% better defined) were pretty good. In 21 % of cases, the second opinion revealed diagnoses which were distinctly different and were much more costly diagnoses to treat. So we're actually talking about 21% "wrong diagnosis" which is actually a distinctly different diagnosis. But I did not read where it said the second diagnosis was incorrect. I'm not a doctor but I know people can have many conditions which present related and comorbid symptoms. All of which is to say, there is value in getting a second opinion.

I don't know about you, but when I see my doctor, I understand that he's not going to get it right every time, on the first try. I can lean on a statistic like 78% of diagnosis being basically the same with a second opinion, where maybe better definition or clarity is added to the diagnosis. I think that's pretty dang good, actually.

As for the rest of the meandering casting of doubt and questions in the OP's post, this is why I'm supporting single-payer nationalized healthcare. The existing model is too complex for people to understand and big pharma has been allowed far too much rope with its price gouging and pricing models for different types of consumers.

My elderly parents are having to deal with Kaiser Permanente managed care (Medicare advantage) and it makes me want to scream. We're trying to get a second opinion for a very involved surgery that my mom requires from a neurosurgeon. They denied the request and it equates to a part-time job trying to understand and appeal the denial. Even if it was approved, there are many restrictions on where she can go, who she can see, so, instead she's taken my advice which is, if you have the money to do it, just do see a doctor you trust, and pay out of pocket. And that is what she is doing. I was elated to hear she has an appointment at one of the highest regarded teaching hospitals, UW Medicine, for early January.

TY for doing the legwork to cut out the b.s. click bait firepower from the title. Dropping from 88% --> 21% (distinctly wrong diagnosis).

FWIW, 21% wrong diagnosis is still pretty freggin poor.... I get health outcomes are no guarantee, as every body is unique and responds differently as far as input/output. But 1/5 of experts (Doctors) have diagnosis that are in conflict seems like a pretty high margin of error.... In other industries, this type of diagnosis would be a coffin nail for the company providing the services in a competitive market.

Couldn't agree more to the out of pocket stuff.... We both have explained, in this thread, how using $$$ outside of insurance has been our answer for some peripheral examples of healthcare.

Medical Staff Member questions: (i'd love your input, as I do not work in this field).
1)What do our medical staff (any patient facing healthcare professional) members think of insurance?
2)How much does interaction with insurance, increase or decrease your ability to serve the health of your clients?
3)Would it be better with more/less/all/none interaction with insurance?
4)If you are in the position/authority/approver/oversight to account for medical transactions, would you prefer them to be/not to be involved with an insured / un-insured person w/ funds?


***Please assume everyone w/ cash is able to pay for their services in the above hypothetical questions. Intent is to extract the perceived "support" healthcare insurance provides to the client/doctor relationship. Or in the event there is little to any support/value added, how much their involvement is costing the "doctor <--> Client/patient relationship".

[disneysteve]

Our old plan covered asthma patients. This new one doesn't

What do you mean by this? Do you mean they just don't cover your Advair? There are several perfectly good alternatives to Advair.

[disneysteve]

So, what it really says is that a total of 78% of diagnoses (12% same diagnosis, 66% better defined) were pretty good. In 21 % of cases, the second opinion revealed diagnoses which were distinctly different and were much more costly diagnoses to treat. So we're actually talking about 21% "wrong diagnosis" which is actually a distinctly different diagnosis.

That doesn't surprise me at all. Keep in mind that when a primary care provider refers a patient to a specialist, they very often don't have a firm diagnosis. They just have a general idea of what's wrong, enough to know which type of specialist to send the patient to for further work up and treatment. It's typically the specialist that will do the work up, labs, imaging studies, etc. to make the actual diagnosis. Obviously, given much more data, they often come up with a different answer than what the PCP initially suspected.

I love when people twist data to make it sound like doctors are all incompetent.

[amarowsky]

What do you mean by this? Do you mean they just don't cover your Advair? There are several perfectly good alternatives to Advair.

It does not cover any asthma medicine..... Weather is be WIXELA, Advair, Albuertal (CRAZY expensive now) , or any of the several generics available. All $400 + per month ($1200 for my 3 month supply). Looks like my wife's boss's company bought a different bundle of insurance. (it's an American company, so my BITTER assumption is they're more of a cancer/heart attack company).

Kinda SICK, that you have to get lucky enough that your employer's healthcare Venn diagram overlaps with your personal health condition.... But I'm always free to get a job elsewhere.... That seems to be the only option to express my "freedom & liberty" while also preserving my "liberty to breath properly"....

Keep in mind, I'm intentionally being provocative and hyperbolic. Because of how poor the logic is, that resulted in the system we have now. It's just an evolution of corporate decision making.... And utterly resonant of a lot of our beaurocratic frustrations... I can afford these unfortunate solutions, but I assume many can not.

[disneysteve]

Medical Staff Member questions: (i'd love your input, as I do not work in this field).
1)What do our medical staff (any patient facing healthcare professional) members think of insurance?
2)How much does interaction with insurance, increase or decrease your ability to serve the health of your clients?

Dealing with insurance companies is one of many reasons that I finally left family practice and switched to urgent care where I don't need to deal with them at all.

Personally, I like my insurance just fine. We have a very good plan through our hospital system. But many insurances are quite lousy and very difficult to deal with both as a patient and as a provider.

When I was in family practice, we often faced long delays in treatment because of having to fight with the insurers to cover the necessary care. That's just bad all around.

[amarowsky]

Dealing with insurance companies is one of many reasons that I finally left family practice and switched to urgent care where I don't need to deal with them at all.

Personally, I like my insurance just fine. We have a very good plan through our hospital system. But many insurances are quite lousy and very difficult to deal with both as a patient and as a provider.

When I was in family practice, we often faced long delays in treatment because of having to fight with the insurers to cover the necessary care. That's just bad all around.

Personally, I like my insurance just fine. <----- What do you really like about your insurance? (do they provide any other value to you, other than indemnification from costs?)

[disneysteve]

It does not cover any asthma medicine

I've been in practice for 27 years and have never heard of an insurer not covering a specific, and very common, condition like asthma. Are there other things they don't cover as well or is it just asthma? That's bizarre.

I would definitely choose another option.

I'm not sure what your comment about it being an American company means. All of our insurance companies are American. Every single one of them covers asthma as far as I know, except yours apparently. What company is this?

[disneysteve]

Personally, I like my insurance just fine. <----- What do you really like about your insurance? (do they provide any other value to you, other than indemnification from costs?)

Good coverage. Large provider network. Low out of pocket costs. Reasonable premiums.

[amarowsky]

Good coverage. Large provider network. Low out of pocket costs. Reasonable premiums.

Seems like "Good coverage. Large provider network." = it is usable at the healtcare places you would hope. Which I can get, if you're accepting a lot of your income in the form of insurance, you would want to be able to use it places. But do they add any value towards your health? Other than enable access?

Even auto insurance will offer you tows, vacation info in some cases, rental car incase you need, and in some cases discounts for other places. To try and flesh out my point, I'm saying they provide additional support other than indemnification of your "car's health". Not an apples to apples at all, just saying, healthcare doesn't do anything but indemify cost and keep a network (which health stores you can spend your money at).

Based on your comments to (thank you for replying BTW). Seems they are more of a "calorie, time, and $$$ waster" in the actual patient to doctor relationship. And if they could be replaced by a reasonable price table, there would be Little to no need for it. Because cost & "where your money is accepted" [cash] is ubiquitous.

Seems like we only need insurance because of insurance & lawyers (drive up the price to extract wealth from the typical people).