Health Care and the alternative point of view

[cptacek]

That is fine. We can disagree on the appropriate level of government involvement in the economy. From my standpoint, additional involvement of the government (bailouts, seizures and setting compensation levels) leans towards "taking over the economy" and from your standpoint it doesn't. But the government has recently become more involved, which is what I was trying to point out.

Back to health care.

[jIM_Ohio]

You aren't allowed to see what your plan covers? Is that true? How are you supposed to make a decision at open enrollment time if you don't have that info?




I'm not sure I agree. I think who is ordering the drug makes a big difference. If some mom and pop pharmacy is ordering one vial they are going to pay a different price than a regional chain ordering 100 vials and that will be different than the big national prescription benefit manager (PBM) ordering 10,000 vials. The first will pay full list price. The second may get a small discount. The third will get a big corporate bulk discount. Do you think that should change? Pretty much every business I can think of offers bulk discounts for bigger customers.

This is the whole reason behind drug formularies. They drive me crazy, of course, because Plan A might cover Drug X as the preferred product for diabetes, for example, while Plan B covers Drug Y as the preferred product. Then a sales rep for Drug Z will come see me and tell me that his company's drug is the cheapest in the class. But I proceed to find out that neither Plan A nor Plan B covers Drug Z so even though it might be cheaper at the retail level, the insurance companies have negotiated better deals with the manufacturers to get Drugs X and Y cheaper for their customers.


This I agree with 100%. Insurance companies do not care what is in the patient's best interest. They are for-profit, publicly-traded companies. They care what is in THEIR best interest.

Steve- you might know this better than me, but it was my understanding in case of Synagis that everyone was ordering the drug ahead of time.

No one keeps it on inventory (maybe a hospital does, but not sure).

If you want another curve, check this out

Cigna is my health plan
Medco is my prescription provider

If I need a prescription, it gets billed thru medco
so when Synagis was prescribed, cigna routed us to medco
medco says they cannot do synagis because its a shot (and not a medicine) and our plan documents said that Synagis was given thru cigna
they would route us back to cigna, and cigna would say they offer me no prescription coverage

eventually cigna realized the error of their ways and covered the shot (it was cigna and not medco authorizing the shots). Cigna still had to order them and ship them to pediatrician though.

My point is that I lit into my HR department because the timeliness of the transition was about 15 days.

Meaning my kids needed the shot within 15 days of Jan 1 to maintain immunization schedule, and NO ONE was doing customer first level of service, and my HR department told me I was NOT cigna's customer, and I could NOT see the plan documents so I could just skip the phone run around and go to the person which could give me results.

[jIM_Ohio]

I'm not 100% sure of this but I don't think it is the pharmaceutical companies that just decide to sell the drugs cheaper in Canada. I'm sure if it was up to them, they'd charge just as much in Canada as they do in the US. The difference in Canada is that the government controls everything and sets the prices. It isn't a free market system.

I agree with Steve
they do not set a low price point by choice
they set that price by negotiating with canadian health care providers (government).

[disneysteve]

Cigna is my health plan

my HR department told me I was NOT cigna's customer

These two statements are just mind-boggling. Cigna insures you but doesn't consider you to be their customer and won't speak to you directly when you have questions or issues with your coverage. Amazing. And we wonder why things are so screwed up in the health insurance field.

[cptacek]

These two statements are just mind-boggling. Cigna insures you but doesn't consider you to be their customer and won't speak to you directly when you have questions or issues with your coverage. Amazing. And we wonder why things are so screwed up in the health insurance field.

The employer is the customer. This wouldn't happen if we bought directly from the insurance company instead of through the employer.

[disneysteve]

The employer is the customer. This wouldn't happen if we bought directly from the insurance company instead of through the employer.

I'm a physician and I've never heard of anything like that. I get my insurance through my employer, too - always have - but anytime I have a question or issue with my insurance, I call the insurance company. Nobody at my office would be able to answer my questions.

[cptacek]

Hey, I understand. I think it is mind blowing as well. But the employer is paying for the service and providing it to jIM as a benefit. The insurance company doesn't have any contact with jIM until a bill comes in, and then, most likely, only has contact with the doctor's office, not jIM himself. The contracts and the negotiating prices and everything else is between the employer and the insurance company.

[jIM_Ohio]

The employer is the customer. This wouldn't happen if we bought directly from the insurance company instead of through the employer.

This was part of problem solving, and the above statement over simplified my situation.

My employer hires hewitt to administer our benefits. This means when I called in November to ask questions about what was covered, we called 3 different people (from 2 companies).

First time I called to verify Synagis was covered, I spoke with cigna.
I did not write down a person's name date or similar

Second time wife called, and I gave her the 800 number on company benefits website- turned out that was a Hewitt number (I did not know that at time).

Wife checked with someone, wrote down name, date, employee ID number
wife verified by talking with supervisor on same phone call- name date employee number documented

both of those were to Hewitt, which apparently did not have access to plan documents.


fast forward to January
we called Jan 2 to get Synagis scheduled between Jan 15 and Jan 25. Cigna told us it was NOT covered under our plan.

wife then called cigna back, told them of above conversation and supervisor conversation
cigna replied back with no record of above conversation

I then called my benefits department and they called cigna on my behalf
cigna reiterated they had no record of conversations

I then escalated to my HR department (keep in mind this is corporate HR, not benefits specialists) and they said their hands were tied.

On these calls, I asked many questions over and over- one of which was "tell me the process I follow to get Synagis shots, and refer me to a web site to tell me the procedure"

The reply was this, Cigna's web site did not have Synagis on it. I could find out what it was, but not how to get it under my plan.

I asked my corporate HR department what the plan was, and they said I was NOT ALLOWED to see plan documents.

they went on to add I was NOT the customer, my employer was, and therefore I am not allowed to see plan specifics.

Yet the people on the phone- none of them worked for my employer- so none of them knew anything about my situation- they could reply with corporate mumbo jumbo, and tell me what to do, but it was a 3 person hand off.

I would ask cigna for synagis
they said that is prescription, call medco

I call medco and they said they don't administer synagis, call your employer
my employer says they don't administer benefits, call Hewitt

Hewitt then says you get health care thru cigna, call them

NO ONE was doing what was in best interest of the patient


None of the health care reform addresses these inefficiencies- they are trying to get more people coverage, but if this is the coverage they get, they would be better off without it, and let medicaid pick up the tab on the kids getting the Synagis.


So most of my opinions presented earlier in thread have this problem getting solved differently.

1) I believe in the current health insurance system there are gross inefficiencies with patient care. My #1 goal is to root out these inefficiencies (like above).
2) The best way to root out the problem above is make the patient the customer, and give them rights to have full access to all treatment information (prices, administration procedures, choices for treatment).

Examples of #2:
a) I should be able to go to my insurance carrier's website and type in my treatment (Synagis) and get a definition and a cost for a specific procedure. The insurance company should offer costs for various forms (like nurses coming to house, ordering medicine and shipping to pediatrician) with a list of risks and costs for each type of procedure.

b) If I type in the disease (RSV) I should be able to look up a treatment (Synagis) and get same information.

c) I should see the costs before I pay (Cigna was good at this once we got hang of what was going on)

d) Keeping anything a secret from the patients and patients parents needs to be outlawed, to point where I should be able to sue Hewitt and Cigna for not making speedy decisions and adding complications to the health care treatment.


Give me the ability to sue, and I am sure cigna would change their procedures within 2 days.


3) Disclosing costs might root out inefficiencies of the higher cost for same treatment. If it does not, I suggest fixing prices until it occurs (this is controversial whenever I suggest it anywhere).

4) My doctor and myself should not have to sort thru different insurance plans- meaning my doctor did not know what my insurance did or did not cover, and this led to delayed treatment. There needs to be a way of saying- Synagis is preventative care, and if you qualify, the doctor can perscribe any one of 3-4 ways to get the treatment. Putting 6 month preemies in a waiting room filled with disease during cold and flu and RSV season is pure stupidity on hands of insurance company. My doctor needs the authority to override that insurance plan's decision.

[disneysteve]

But the employer is paying for the service and providing it to jIM as a benefit. The insurance company doesn't have any contact with jIM

Most people who have insurance in this country fit that description - covered through their employers. I don't know the stats but I'm sure the portion of people who buy their own coverage is a minority. We deal with this every single day in the office. Whenever there is any issue with coverage, we direct the patient to call the member services number on their card. In fact, we often have them do it while in our office to straighten out a problem or get a question answered. I've never run into a situation where the patient couldn't call his insurance company with questions about his policy. Learn something every day.

[disneysteve]

My doctor needs the authority to override that insurance plan's decision.

Many times, I have appealed an insurance company decision that I disagreed with and I'm almost always successful in getting it done the right way. Sometimes, it takes faxing one pretty simple form stating the reasons for my decision. Other times, I need to call and speak directly to their medical director. But there is always some way for the doctor to contest the decision. Of course, sometimes the answer is still no.

[feh]

Most people who have insurance in this country fit that description - covered through their employers. I don't know the stats but I'm sure the portion of people who buy their own coverage is a minority. We deal with this every single day in the office. Whenever there is any issue with coverage, we direct the patient to call the member services number on their card. In fact, we often have them do it while in our office to straighten out a problem or get a question answered. I've never run into a situation where the patient couldn't call his insurance company with questions about his policy. Learn something every day.

I don't know how widespread this is. I get insurance through my employer, and when we have questions, we communicate directly w/ the insurance company.

[jIM_Ohio]

Most people who have insurance in this country fit that description - covered through their employers. I don't know the stats but I'm sure the portion of people who buy their own coverage is a minority. We deal with this every single day in the office. Whenever there is any issue with coverage, we direct the patient to call the member services number on their card. In fact, we often have them do it while in our office to straighten out a problem or get a question answered. I've never run into a situation where the patient couldn't call his insurance company with questions about his policy. Learn something every day.

DS-

part of the issue in our situation was "who covers this procedure".

Synagis is an immunization
yet according to the insurance company it is a prescription

what regulated this are the plan documents
but I don't have access to those -covered that before

so calling the 800 number was just like being treated like a hot potato

800 number to insurance company
they transfer me to prescription provider (new company)
they transfer back to insurance company (new person).

I don't have the time to spend 3 hours on the phone with these people

Its OK for a specific form of treatment (whether from doctor or me) to be rejected. But so few people involved wanted to do what was best for the patient (get them timely immunization shots)

The problem is not necessarily "who gives you your insurance"- its that regardless of who gives it to you, the insurance companies have so many plans and so many customers they prefer to treat you like a number and not a person which needs medical care.

That needs to be addressed with reform before more people are insured with tax dollars (IMO).

And I agree the doctor's office can help...
but to me the issue was "specifically how is the medication given to patient"

Because under old insurance plan nurses were coming to our house
under new plan they would not let that happen, so by time pediatrician was involved, it was to schedule them giving the shots within a 2-3 day window once we knew the shots were at the office.

[disneysteve]

the insurance companies have so many plans

This is something we deal with all the time, and patients often don't understand that. Patients get angry when my receptionist asks to see their insurance card to verify their benefits. They say they have Aetna, what else do we need to know? We explain that Aetna offers dozens of different plans with different copays, different requirements for choosing or not choosing a primary doctor, different drug benefits, different provider networks, etc. Just saying, "I have Aetna" really tells us very little.

[geojen]

jIM, I can symapthize with the Synagis situation. We had the same problem getting our son's shots covered with our first insurance company as well. It took our Doctor and a Synagis rep repeatedly calling the insurance company. Finally, my doctor faxed them a letter saying that if DS didn't get the shots, and he got sick, we would raise high holy hell. That seemed to work.

Then, when I switched employers, I expected the same hassle. But the new insurance company just paid the bill, no questions asked. Now, I am not complaining about that, but obviously one company felt that it was medically necessary for DS to have the shot, and another didn't. Why wasn't my doctor's opinion the final word? I mean, that is what everyone has been railing about. "I don't want a beaurocrat standing between me and my health care." But, everyone knows that is what we already have. Doctor's need to be able to have the final say, period.

[disneysteve]

Why wasn't my doctor's opinion the final word?

As a doctor myself, I'll be the first to admit that doctors aren't always right and I have no problem with there being some oversight to see to it that doctors are making appropriate decisions and even to encourage/require doctors to practice cost-effective medicine. Doctors being pretty much in total control is what led to a lot of today's problems to begin with (which was all before my time but I've certainly heard stories).

Ultimately, though, what many insurance companies do amounts to nothing less than practicing medicine without a license. They make treatment decisions for patients that they have never seen or evaluated based on some cookbook list of criteria that may or may not have been met.

There needs to be less red tape and more communication between the doctor and the insurer, more of a collaboration and less of a confrontation.