SAD state of Healthcare

[LivingAlmostLarge]

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).

Oh i'm terrified. I know my DH is too with his job switch. We aren't sure what is going to happen with our medical insurance. With a startup its looking dicey. But it's the gamble we are willing to take. It would make small businesses a lot more attractive if healthcare was decoupled to employment.

[disneysteve]

But do they add any value towards your health? Other than enable access?

That's not really the point of health insurance as it currently exists. But yes, they do reimburse me for part of our gym membership (at least pre-Covid when going to the gym was a thing). I'm sure they probably offer various other sorts of programs or classes, smoking cessation, weight loss, that sort of thing, but nothing that I've ever looked into getting.

[HundredK]

We have Kaiser HMO as our healthcare, which sounds great, $20 for anything, right? Except I have learned over the years that it's never ideal to have your doctor and your insurer be the same company. It means all they want to do is cut costs, and actual healthcare is always secondary to that. With Kaiser, if you don't go in already knowing what you want and demand repeatedly to have it done, it will not be done. They will sit there at their computer in the exam room, type type typing away, until the computer tells them the lowest cost treatment and then they will insist that is the best thing. It's so frustrating. It must be frustrating for doctors too. Insurance companies have way too much power.

[ua_guy]

We have Kaiser HMO as our healthcare, which sounds great, $20 for anything, right? Except I have learned over the years that it's never ideal to have your doctor and your insurer be the same company. It means all they want to do is cut costs, and actual healthcare is always secondary to that. With Kaiser, if you don't go in already knowing what you want and demand repeatedly to have it done, it will not be done. They will sit there at their computer in the exam room, type type typing away, until the computer tells them the lowest cost treatment and then they will insist that is the best thing. It's so frustrating. It must be frustrating for doctors too. Insurance companies have way too much power.

The computer thing in the exam room has really taken off in the last 10 years. Byproduct of most providers moving to an electronic health record. Some providers do a better job of minimizing screen time and making the patient feel like the focus rather than the screen. I bet DS can speak to his experience there.

Private managed care has always been a slice of hell it seems, unless you are mostly healthy and only need routine visits. My mom is dealing with that now. Medicare with an advantage plan through Kaiser. Have to follow Medicare's rules, plus Kaiser's little fun house of cost-saving measures on top of that. I don't wish the experience on my worst enemies.

[disneysteve]

The computer thing in the exam room has really taken off in the last 10 years. Byproduct of most providers moving to an electronic health record. Some providers do a better job of minimizing screen time and making the patient feel like the focus rather than the screen. I bet DS can speak to his experience there.

Blame this on the government. A number of years ago, they mandated that doctors switch to EHR. The first couple of years there was an incentive payment for doctors who switched. Then it changed to a penalty for those who didn't switch. So most switched to get the extra money and avoid the pay cut. It was rolled out very poorly (big surprise) and there were literally hundreds of different EHR programs on the market, none of which could communicate with each other. Over time, the market has consolidated and there are now just a handful of major players and there is a lot more interoperability, though it's still not perfect.

I think a provider staring at a computer while in the exam room with a patient is outrageously rude, but that's become the norm. Me? I refuse to do that. When I walk into an exam room to see a patient, I focus my attention on the patient. I don't touch the computer. I do all of my computer work at the workstation outside of the exam room before and after I see the patient - not during the visit. My turn around times are excellent. My patient satisfaction survey scores are excellent. It is quite possible to be fast, efficient, and good without using the computer in front of the patient.

Many providers think they're doing a good job by working on the computer at the same time they're supposed to be listening to the patient, but multitasking doesn't exist. You can't actually do two things at once, so the end result is always that you're not doing either of them as well as you could be.

[disneysteve]

I'm not all that familiar with Kaiser so I can't speak to their philosophy, but there is a lot of movement toward practicing evidence-based medicine (EBM). That means actually adjusting treatment practices, prescribing habits, testing, and more based on the latest data about what actually works best and at the best price. Many, many, many things that are done in medicine are done out of habit even in cases where research has proven them to be ineffective or less effective than other alternatives.

It's much easier for large systems like Kaiser to put those newer practices into place. It's tougher to get some 50 or 60-year-old private practitioner to change their habits. I can tell you that personally, since moving from a small private practice to a large healthcare system practice, I've changed many things that I do because we're frequently informed about the latest information. In fact, we actually started an EBM committee within our urgent care staff and at our monthly meetings we do a presentation on a particular topic to highlight the latest and best practices.

[amarowsky]

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.

They will cover the visits for asthma related care from the doctor's office. They will just not provide any $ support for the daily required Rx, to care for the asthma. The price was insane! $400+ per month, for just advair. I'm fortunate that my asthma has been becoming more and more mild w/ my weight loss. But I know many are not disciplined, able bodied enough, or have the time/resources to get healthy. (cheaper & quicker to eat like crap these days).

From year to date, I'm down about 30 lbs and dropping. It seemed most wise to improve my health, so I can hopefully rely on medicine less. Thankfully this has been working. At 6'2 I've reduced my weight from 240's to about 220 on the dot. My goal is to be at or under 200 lbs , steadily by the time I'm 40. And I'm turning 34 in Month or so, so I'll making progress. Ideally.... With the weight loss, I'll be able to go w/o the asthma medicine eventually I hope. (although mine is allergy triggered, but exacerbated when I weight more. I've been as high as 270 lbs, back in 2018).

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?

Sorry this was meant to be tounge and cheek. Her (my wife's) company is a privately owned corporation, by an American. (She actually went to school w/ the CEO's daughter). I was making a dumb joke that American's working in corporate office of a very large plastics manufacturer, are likely to get cancer or a heart attack. So that was their priority. (dumb joke )

[disneysteve]

They will cover the visits for asthma related care from the doctor's office. They will just not provide any $ support for the daily required Rx, to care for the asthma.

That's totally bizarre. I've never heard anything like that before. So they'll pay for you to seek treatment for asthma, but won't pay for the actual treatment itself? What an outrageously odd policy.

Do you have any idea if it applies to other conditions? Like will they cover you seeing your doctor and getting diagnosed with high blood pressure but not cover those medications either? I can't imagine how they justify not covering any asthma medication.

From year to date, I'm down about 30 lbs and dropping. It seemed most wise to improve my health, so I can hopefully rely on medicine less.

That's awesome! Congratulations. Healthcare in this country would be so much better and cheaper and more accessible if everyone would adopt that mindset.

[Snicks]

Blame this on the government. A number of years ago, they mandated that doctors switch to EHR. The first couple of years there was an incentive payment for doctors who switched. Then it changed to a penalty for those who didn't switch. So most switched to get the extra money and avoid the pay cut. It was rolled out very poorly (big surprise) and there were literally hundreds of different EHR programs on the market, none of which could communicate with each other. Over time, the market has consolidated and there are now just a handful of major players and there is a lot more interoperability, though it's still not perfect.

I think a provider staring at a computer while in the exam room with a patient is outrageously rude, but that's become the norm. Me? I refuse to do that. When I walk into an exam room to see a patient, I focus my attention on the patient. I don't touch the computer. I do all of my computer work at the workstation outside of the exam room before and after I see the patient - not during the visit. My turn around times are excellent. My patient satisfaction survey scores are excellent. It is quite possible to be fast, efficient, and good without using the computer in front of the patient.

Many providers think they're doing a good job by working on the computer at the same time they're supposed to be listening to the patient, but multitasking doesn't exist. You can't actually do two things at once, so the end result is always that you're not doing either of them as well as you could be.

Well, yes we can blame the government, but then people want MORE govt heavy handedness.

[Snicks]

Honestly, Medicine has become like any other industry. Follow the dollars. In the old days, they used to admit people the night before to get them ready for surgical procedures and they could have good medical management, control of their BP, blood sugars, etc. Now, that is rarely done and I think we are the worse for it. There are still some people who would benefit from staying overnight prior, but it won't be PAID for so it's not done. A lot of the real care is simply not done or left up to the patient/family who may or may not understand what is needed.

[amarowsky]

That's totally bizarre. I've never heard anything like that before. So they'll pay for you to seek treatment for asthma, but won't pay for the actual treatment itself? What an outrageously odd policy.

Do you have any idea if it applies to other conditions? Like will they cover you seeing your doctor and getting diagnosed with high blood pressure but not cover those medications either? I can't imagine how they justify not covering any asthma medication.

That's awesome! Congratulations. Healthcare in this country would be so much better and cheaper and more accessible if everyone would adopt that mindset.

Well if your considering the "syntax" then yes, it is on the list of covered conditions (asthma). But they classify treatment for the medicines under (2) columns. One is "preventative medicine" that is no cost and does not require deductible to be satisfied. This list is from the ACA list, so from what I can see it covers aspirin, fluoride, tobacco cessation stuff, vaccines, bowel medicine, folic acid , and then 2 pages of women's contraception like medical supplies. https://www.caremark.com/portal/asse...ntive_List.pdf <---- link if it shows.

column 2) = "maintenance drug list". THis has a lot of medicines on it, including my asthma. But at the top of the list it says, "Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes. Due to the large number of available medicines, this list is not all inclusive. Please note that this list does not guarantee coverage and is subject to change. Your prescription benefit plan may not cover certain products or categories, regardless of their appearance on this list. Where a generic is available, it is listed by the generic name. If no generic is available, then the brand name appears. This list represents brand products in CAPS and generic products in lower case". I looked, and I it says it covers "asthma medicine". But the cost is much more expensive than paying Outside of insurance, with Cash..... Sticker price for the medicine at the pharmacy is $400 per month for Advair, or any of the generics (i think the 2 generics mite be +/- $20 from the $400). Now if I buy the medicine w/ cash, outside of insurance, the sticker price drops from $400 --> $100. With my insurance the sticker price drops from $400 --> $320. Making the insurance, a much more expensive avenue for me to pursue.
https://www.caremark.com/portal/asse...t_DrugList.pdf <--- maintenance list steve. If you can take a look. My medicine is on here, but it's way more costly than cash.

Technically it's insured. Because I'm paying for insurance, which the sole purpose is to indemnify high costs. But in this case, the insurance I pay for is effectively failing at it's only task. Because it's making it MORE expensive, and for many old people, predatory, to get their Rx. I know a lot of people who are not informed enough, to search Good Rx or a similar coupon system, to drop the sticker price of medicines that are too high.

It's abbohrent.... that we have "sticker" prices on medicine that is the gateway for people to get to "baseline" or "zero". And those have to be cunning enough to either negotiate, fortunate enough to not worry about money, fortunate enough to hold a job in an industry that pays their employee's high insurance income (don't kid yourself, this is a substitution for wages & corporate write offs) , old/empoverished/disabled enough to be one of the 40 million to qualify for national healthcare, or sacrifice pursuing my preferred line of work, to accept one in a corporate environment that will ensure me enough to not be financially destitute.

The worst part, is i'll likely get a part time job at UPS. even though I don't really need the money... It's just an insurance policy for Insurance. Because I can get really good insurance working part time there. So incase my wife get laid off, her company goes under, or some other reason. We're not left with a random accident destroying over a decade of responsible saving, debt payment, and hard work. And w/ out insurance, I'm 1 twist of fate, from loosing everything to a relentless assault of medical bills. (already was there once w/ my amputation.... no fowl play. So this can happen to ANYONE. You better hope you have a corporate job when you get hurt, or be married to someone w/ one).

I'll keep playing their game, because I have too much to lose. But this stupid game and system, is costing us a lot of progress and innovation. And I think it's profit and greed, at the core, of this decaying system of inefficiency.

[amarowsky]

Well, yes we can blame the government, but then people want MORE govt heavy handedness.

Not agreeing or disagreeing w/ this. But in your opinion, do you think the "for profit" medical system we have in the USA has been responsible with their pricing to their clients/patients, in relation to profit?

I recall Steve always mentioning a Healthcare fund he has had for a long time that has consistently outperformed the S&P (if I'm recalling properly). I just fear that the level of greed that is "acceptable" and "encouraged" within the strongest ownership class (those who are quite wealthy, primarily through stocks) is spiraling out of control. And short term profit goals for these hospitals, are a terrible terrible motivator for a "healthy - society". Healthy being, physically, mentally, and ideally financially.

What would be an ideal step in the right direction, for our healthcare system to take? (in your opinion Snicks ) feel free to list a few things. w/ some context. (good chance for us to grow our opinions)

[disneysteve]

Well if your considering the "syntax" then yes, it is on the list of covered conditions (asthma).

So the plan does cover asthma treatment and medications but it sounds like the prescription plan sucks. That makes a lot more sense than what you were initially saying. The employer probably took the cheapest, bottom of the barrel plan to offer employees. That's unfortunate. Is there any option to upgrade to a better plan? Even if the premium is higher, you might come out ahead if it covers your meds at a better price.

[disneysteve]

Honestly, Medicine has become like any other industry. Follow the dollars. In the old days, they used to admit people the night before to get them ready for surgical procedures and they could have good medical management, control of their BP, blood sugars, etc. Now, that is rarely done and I think we are the worse for it. There are still some people who would benefit from staying overnight prior, but it won't be PAID for so it's not done. A lot of the real care is simply not done or left up to the patient/family who may or may not understand what is needed.

Surely there is some truth to this, but on the other hand it also ties in to what I said earlier about evidence based medicine. For example, the reason that people get discharged right after surgery rather than spending a couple of days in the hospital "recovering" like they did years ago is that we've found that outcomes are better with earlier discharge. Post-op infection rates are lower. Getting people up and moving around faster is better than having them sitting in that hospital bed. I'm not familiar with pre-op data but I wouldn't be surprised to learn that the same is true there. Spending a day in the hospital before surgery probably raises your risk of catching some infection that you wouldn't have been exposed to at home.

[ua_guy]

Honestly, Medicine has become like any other industry. Follow the dollars. In the old days, they used to admit people the night before to get them ready for surgical procedures and they could have good medical management, control of their BP, blood sugars, etc. Now, that is rarely done and I think we are the worse for it. There are still some people who would benefit from staying overnight prior, but it won't be PAID for so it's not done. A lot of the real care is simply not done or left up to the patient/family who may or may not understand what is needed.

I understand this point through the concept of "medical necessity." You are correct that health insurers have really clamped down on procedures and treatment they deem unnecessary for either health outcomes or cost containment because it just isn't necessary. If a patient demands a test but there's no medical indication for it, no, the insurer (paying the bill) isn't going to pay for it. And I think to your point about prior hospitalization to a surgery, does anyone really want to stay in a hospital bed the day before a surgery? When things can be managed through outpatient visits or even telehealth? Hospitals are awful places and the couple times I've had surgery, my two biggest questions are - how long does the surgery last, and what's the soonest I might be able to go home?

What are some examples of "real" care that isn't done, or left up to the patient/family in this "new" model?